the history of emergency medicine
DESCRIPTION
TRANSCRIPT
“In the 1950s, both the presence and absence of health insurance drove people to emergency departments” – Brian Zink MD
The History of Emergency MedicineWhy we do what we do today
Steven Elsbecker D.O.
July 24th 2013
“Keep your sock game tight”
12/14/85 – 6/3013
Imagine……
Imagine…...
Objectives
Discover our roots
Review events in history that greatly impact our practice of EM today
Explore the early days of residency training in EM
Plant pride in your minds
Inception Style
The Pride Slide
“Emergency physicians are the jack of all trades and the master of none”
The Pride Slide
Well Trained Emergency Physicians are the masters of 4 areas
….and the jack of all trades
TRIVIA !!!!
Who said it?
“It blows me away that Emergency Medicine was one of the last specialties to be founded. It seems to me that it should have been the first. People get sick, and they need immediate attention.”
Was it
Judith Tintinalli
Joe Lex
Peter Rosen
Dale Carrison
The History of Emergency Medicine Part 1
The Timeline
The Early Days of Emergency Medicine
“While our specialty is only 50 years old, the attempt to deliver emergency care is, essentially, as old as medicine itself” – Robert Suter D.O.
Military Contributions to EM
Transition From GPs to EDs
Between 1940 and 1960, ED visits/year tripled
Increased availability of health insurance
24 hour coverage
DEMAND SKYROCKETED!
Staffing EDs in the 1950s and 60s
But those were the good ‘ol days…
But those were the good ‘ol days
…but
Not safe for patients
There was no specialized training for the delivery of acute care
Care was inconsistent at best
America Becomes Aware
In 1966 the National Academy of Sciences releases a white paper titled:
“Accidental Death and Disability: The Neglected Disease of Our Society”
Highlighted the poor state of emergency care
Led to a large influx in funding
America Got Hungry
The First Answer - The Alexandria Plan
In 1961, James DeWitt Mills MD and three others left their private practices
Started the first 24/7/365 Emergency Department in Alexandria, Virginia
Became known as the Alexandria Plan
more to come later….
The Founding of ACEP
1968
Vision: “Emergency Medicine should be practiced by qualified and certified emergency physicians”
TRIVIA !!!
In 1970, the first residency program got its roots. Where was this program founded?
The First Residency Program
1970
The First Department of Emergency Medicine
1971
Challenges Obtaining Specialty Status
During the early 1970s, other specialties attacked EM saying
It Becomes Official
1979
The ABMS approves Emergency Medicine as a specialty
The History of Emergency Medicine Part 2
Events That Defined Us
The Alexandria Plan
JL Dewitt James Mill
The Alexandria Plan
Gave up on images of James Mills
Nathan J Cleveland Cleveland State Basketball Player J’Nathan Bullock
The Alexandria Plan
In 1961, the Alexandria Plan laid the foundation for us to become what we are today
Evolution occurred in reverse order
TRIVIA !!!
Name the country in which Emergency Medicine was first recognized as a distinct medical specialty
TRIVIA !!!
United States – 1979
Canada – 1980
Australia – 1981
Hong Kong – 1983
Singapore – 1984
UK - 1986
EMTALA – That Which Defines Us
As part of the Consolidated Omnibus Budget Reconciliation Act, EMTALA was enacted in 1986
Its founding purpose was to prevent the transfer of unstable patients and the refusal to treat based on payer status
EMTALA – That Which Defines Us
EMTALA carries two provisions to Emergency physicians:
When a patient comes to a hospital seeking treatment, hospitals must:
Provide an appropriate medical screening examination
And
Provide necessary stabilizing treatment if an emergent medical condition exist
EMTALA – That Which Defines Us
EMTALA also defines what “comes to the hospital” means:
Coming to the hospital includes:
A patient coming onto a hospital’s campus or who is in an area or structure within 250 yards of the main buildings
A patient who presents to an ambulance owned by the hospital (regardless of that ambulance’s location at that time)
A patient who presents to any ambulance that is on the hospital in question’s property
EMTALA – That Which Defines Us
These “come to the ER” definitions were put in place for a reason
Young Chicago man 35 feet from the front door was refused care
TRIVIA !!!
For a beer….
What does EMTALA stand for?
Emergency Medical Treatment and Active Labor Act
EMTALA Cases
Woessner v Freeport Memorial Hospital
Man presented to hospital. Admitted for high fevers and left thigh pain. Sat in the ED for some time awaiting a bed. A physician eventually evaluated his blood results and recommended transfer to another facility for further evaluation. The patient's condition deteriorated and he nearly died upon arrival to the second hospital. He eventually required surgery and amputation of his left leg.
Both the hospital and physician were fined under EMTALA for not providing stabilizing therapy prior to transfer
EMTALA Cases
Williams v County of Cook
Patient presented to hospital, stating that she was in active labor. She alleged that she did not receive any exam and was told to wait in the waiting room.
After her baby’s feet began to protrude from her, she was taken back for delivery.
EMTALA Fines
What insurance class must you accept in order to be liable under EMTALA?
How much can a physician be sued for under EMTALA?
How much can a hospital be sued for under EMTALA?
The Good
The initial goal of EMTALA was to ensure fair treatment to patients, regardless of their ability to pay
Does it accomplish this goal?
The Bad
EMTALA mandates labor
EMTALA does not guarantee payment
EMTALA exposes physicians to an increased volume of high-risk patients
Limited risk however
… and the Ugly
EMTALA fines are not covered under malpractice insurance
Once fined for an EMTALA violation, you can lose your privilege to bill Medicare
Bye bye career
If all else fails….
Famous Emergency Physicians
Famous Emergency Physicians
Emergency Medicine’s Rise to Fame
TRIVIA !!!!
What does MASH stand for?
Mobile Army Surgical Hospital
EMTALA Discussion Questions
Could the legislators responsible for the creation of EMTALA have anticipated the complications we face today ?
EMTALA Discussion Questions
With the passage of the ACA, do you think that EMTALA should be modified? Do you presume that even more patients will seek medical care?
EMTALA Discussion Questions
To meet the definition of a medical screening exam, a hospital must provide consistent screening for similar patients regardless of payor status (ie 65 year old male with chest pain). In an ED with 20+ attendings, is it even possible to deliver consistent care?
THIS NEXT ONE IS CONTROVERSIAL
EMTALA Discussion Questions
EMTALA has been described, by some, as one of the only forms of slavery left in the US. Thoughts?
Resources
Schecter j, et al. Cobra Laws and EMTALA. http://emedicine.medscape.com/article/790053-overview
Zink, Brian. A Brief History of Emergency Medicine Residency Training. ERMA
Eitmann, N. EMTALA: Understanding its scope in Illinois. The Journal of the DuPage County Bar Association
Zibulewsky, Joseph. The Emergency Medical Treatment and Active Labor Act
(EMTALA): what it is and what it means for physicians. BUMC PROCEEDINGS 2001;14:339–346
Zink, Brian. HISTORY OF MEDICINE: Social Justice, Egalitarianism, and the History of Emergency Medicine. American Medical Association Journal of Ethics June 2010, Volume 12, Number 6: 492-494.
Suter, Robert. Emergency medicine in the United States: a systemic review. World J Emerg Med, Vol 3, No 1, 2012
Sullivan AF. Supply and demand of board-certified emergency physicians by U.S. state, 2005.
Acad Emerg Med. 2009 Oct;16(10):1014-8.
Richards, Eugene. The Knife and Gun Club: Scenes From an Emergency Room. April 1 1991
“Both the presence and absence of health insurance drive people to emergency departments. We are privileged to see both”