“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”