The Biology of Emergency Medicine
Peter Rosen, MD
Denver, Colorado
INTRODUCTION
Aristotle has often been misquoted as stating that all things must have a beginning, middle, and end. What he actually said was, «A whole is that which has a beginning, middle, and end.» I think it might be instructive to analyze emergency medicine as a whole to present my vision of the specialness of emergency medicine.
THE WHOLE
The BEGINNING «that which is not itself necessarily after anything else, and which has naturally something else after it…»
The history of emergency medicine is not yet written. But less important than who were the first physicians to restrict their practice to emergency medicine are the reasons for the appearance of the specialty.
It is hard to comprehend why it took so long for attention to be paid to the demands of the specialty. Certainly, since man took his first steps, there have been accidents and ailments that struck him down unawares. Doubtless, it takes a certain technology and willingness to intervene in natural disasters by an emergency response. Nevertheless, it is still an unaccountably late development in modern medicine.
The beginning cannot, therefore, be the onset of those medical conditions that would mandate a professional emergency response. In fact, when one analyzes emergency medicine in terms of its case load, one is quickly struck by the fact that true emergencies, i.e., the life or limb threat, are not what has produced the beginning of the field.
Even the urgent cases (nonlife or limb threat but requiring a response to prevent deterioration into true emergency) probably would not have produced the field. In fact, I believe that two events coincided to produce the beginning: first was increasing numbers of nonemergency patients in the emergency department; second, the initial financial support for these cases in the emergency department. The cause of the increased workloads is multifactorial: the disappearance of primary physicians; the demise of the housecall; the growth of urban populations; the increased expectations of the public («If you can put a man on the moon, why can’t you cure my cold?»); the initial willingness of third-party carriers to pay for emergency department visits but not office calls, and last, but not least, the captive presence of a physician in a predictable geographic area when the patient wanted to be seen: the interface with the medical delivery system. I’m sure that many other factors can be offered to explain this onset, but whatever the conglomeration of sociologic, technologic and medical events, in the late 1960s the crisis became ubiquitous, and the response produced emergency medicine.
The MIDDLE «that which is by nature after one thing, and has also another after it…»
It is hardly arguable that emergency medicine evolved along the only possible path or even that what we recognize as emergency medicine today is the form that it will assume over the next several decades. But as we all struggle to define our roles and responsibilities, it is worthwhile to pause and ask: Is there anything unique about emergency medicine that we can see in our struggle to define it as a special entity? That this was not done before the specialty had its beginning is not unique. While one can clearly distinguish between the allergist and the vascular surgeon, and readily understand the intellectual and technical concerns that separate them, the epistemological waters become very murky when trying to decide to whom to refer the facial fracture – oral, plastic surgeon, or otolaryngologist.
DEFINING THE SPECIALTY
Webster’s Dictionary defines a specialty as: «A branch of knowledge, science, art or business to which one devotes oneself whether as an avocation or a profession, and usually to the partial or total exclusion of related matters.»
What is there to emergency medicine to justify this definition?
First, there is the workload in and of itself. Not only did it produce the economic incentive for people to «exclude totally or partially related matters,» but its logistics began to shape the specialness of emergency medicine.
One of the specialty’s responsibilities is not only to separate the sicker from the less sick but to juggle several patients simultaneously. The emergency physician does not have the luxury of devoting all of his energy to a single case at a time.
To return to the separation of emergency, urgent, and nonemergency, clearly many of us choose emergency medicine because of the life or limb threat. The «cowboy case» makes our adrenaline flow and combating death is the intellectual and emotional challenge we sought in becoming physicians. But, in fact, as we examine our response to the emergency, our responsibilities are defined less by the definition of the disease state than by the level of life threat. As an analogy, the role of emergency medicine is to catch the climber who is falling from a precipice and return him to as much safety as can be readily achieved, but not necessarily to get him all the way back down to the valley. Nor does it matter how he fell. The life threat of the fall must be overcome before determining that his rope broke or that he was pushed by a jilted lover.
At times, that intervention can be lifesaving; at times, merely stabilizing as in volume replacement in the hemorrhaging patient.
And as we define our responsibilities, we get caught up in the uniqueness of our specialty. The dying organism behaves differently. Where we intervene in that death threat, in fact, sets the limits of our field.
Let us examine the dying patient. Despite the etiology, there are only a small, finite number of pathways to death: failure of respiration, failure of circulation – either via the pump or via the volume of the system, failure of the brain, or failure of metabolism. Although specific interventions must be made for specific causes – the response to the care coronary is different than to the respiratory failure from drug overdose – our specialty establishes adequate oxygenation, and does not teach better table manners to the former or personality control to the latter. Furthermore, the process of dying can be looked at grossly or microscopically. Not every patient with low blood pressure and rapid pulse has inadequate tissue perfusion. Correct assessment has to be the most important responsibility of our specialty.
Nor is our specialty confined to medical parameters alone. Emergency medicine has extended the arm of the physician to the field. In many areas we have been remiss in assuming the obligations of prehospital care. But as one reviews the literature, it is striking how inadequate and inappropriate is the field medical control of the intern or of the coronary care unit. The education, function, and quality control of prehospital care must, and will, be assumed by emergency medicine.
In addition, there are the sociologic aspects of the acutely dying to be dealt with. Much of the work on death and dying has been in the context of chronic disease. All preconceived lessons must be unlearned when calling out-of-state parents to inform them of their child’s sudden death.
To my mind, the hardest task in emergency medicine is the decision to send home a potentially life-threatened patient. The patient who is diaphoretic with clenched fist and an electrocardiogram (ECG) with ST elevations presents no problem in making a decision. Not so the patient who has had some chest pain, which is now gone, and no other clues to assist in the decision. Our awesome responsibility is deciding whether to intervene in this patient’s life threat or to send him home. I wish I could say I have always erred on the side of safety for the patient.
EMERGENCY MEDICINE’S UNIQUE BIOLOGY
To return to the classic acute myocardial infarction, the biology of emergency medicine does not demand proof of this diagnosis in the emergency department; it does demand stabilization. Until this lesson is learned, lives will be lost while ECGs are being run prior to placement of IV lines and administration of prophylactic lidocaine.
For a number of years, I have been saying that the emergency physician must be as good as the cardiologist in running an arrest. After several recent experiences watching cardiologists in charge of an arrest, I say they must become as good as the emergency physician.
It is time that we accept our role in medicine without apology and with the confidence that we can do the job well without calling for help until the next phase of care by the appropriate specialty. The days when the emergency physician functioned as a referring secretary and asked permission before intervening in a patient’s life threat, must, should, and shall come to an end.
Patients do not «belong» to physicians or services. Patients have problems that require care on many levels. The quality, appropriateness and timeliness of the initial care is the biology and responsibility of our specialty. No one who hasn’t trained for it, or practiced it other than full-time, is capable of rendering it. Merely because someone passed through an emergency medicine service as a student, intern, or medical resident does not give them the expertise of our specialty. It takes years of diligence, experience, and commitment to gain that expertise.
The limit of our specialty is, therefore, set by its unique biology, and that time continuum when other interventions become appropriate. These will vary with the degree of life threat, the need for future care, or the need for inpatient or follow-up care. But to a degree, to return to our analogy, the type of intervention relates to the distance to the valley. Certain life threats can be stabilized definitively within the emergency department. Others require special interventions, frequently dictated by how critical is time. For example, an extensive facial laceration must at times be referred to a surgeon because there are 20 other patients awaiting care.
EMERGENCY MEDICINE IN THE FUTURE
But is it enough to be involved in only one phase of life threat? The answer to that question is the shape of emergency medicine in the future. The degree of satisfaction or dissatisfaction in any field is the price tag or reward upon which continued participation hangs. I think emergency medicine «burn out» is more dependent on the psychic tension and stress of
dealing with death as a steady diet than a lack of being able to «play in the valley.»
A second component of our specialty is the urgent patient. Here, too, is a special pathophysiology that requires knowledge, technique, and commitments – the pathophysiology in acute exacerbation of a chronic disease or limited nonlife-threatening disease. Even if the patient is not seriously decompensating, that threat must be ruled out. The hardest mental change to create in new residents is to «assume the worst even if statistically improbable.» Nowhere in inpatient medicine does one learn that in early disease states, the threat to life, or well-being, hides itself. The responsibility is to describe or to deny that life threat rather than to place a specific label on a patient.
Many patients can be totally cared for within emergency medicine; many will require some follow-up. Again, the degree of service will depend on future definitions and may have much less to do with stated turf than how care is paid for. For example, at the city hospital or under national health insurance many cases are, or will be, seen in the emergency department which had been mandatory referrals to private offices.
Finally, there is the price tag of our specialty: the nonemergency patient. He, of course, tries our patience, stultifies our dreams of professional importance, produces voluminous letters of complaint, and of course, pays our extravagant salaries. But there is still something unique about the patient who demands a blood pressure check at 3 am.
But what is unique to the field in all three classes of patients is not just what is happening on the cellular level but the interface between health and disease, between patient and system, and between emergency system and the inpatient service.
No emergency patient, whatever the magnitude of his problem, is free from fear. «An emergency is an acute problem I have which I fear will turn into something worse,» said a student to me once. The sore throat that seemed a mild annoyance during the day, becomes diphtheritic choking (to the patient) in the middle of the night. The blood pressure check at 3 am is fear of impending stroke.
Moreover, the fear of the relatives must be part of the interface. Who can forget the panic of a caring person facing the awesome reality of an acutely injured and life-threatened relative? We all live on the brink of disaster and helping people on the wrong side of that brink is one of emergency medicine’s biologies.
Even when dealing with a nonemergency, it is still incumbent upon the emergency physician to eliminate all possible life threats and to try to discover what motivated this visit. Often, it is something other than the stated complaint. Sometimes the motive is never clear and the emergency department has to adjust to patients who will not seek medical attention anywhere else. We have frequently seen the phenomenon of patients who relate to an institution, and specifically the emergency department, rather than, and in preference to, an individual physician. This is becoming true not just for indigents who have been nurtured in a system of rotating house staff but also inadequately funded patients who simply possess what we call the supermarket mentality of medical care.
As one reviews the total commitment of the field, a new responsibility emerges that indeed requires special skills and knowledge – the ability to prioritize and appropriately treat each of these three categories.
We are poorly taught in medical school and residencies to distinguish sick from well. There are two great shocks for every emergency medicine resident: one, not every patient is sick, and two, many patients are much sicker than they first appear.
Not only must we learn the specialized skill of sorting and treating these categories but we must research the quality and quantity of care appropriate to each.
RESEARCH
Emergency medicine has yet to define to anyone’s satisfaction its research goals. That is hardly unique to emergency medicine in its present infancy. Is there a biochemical definition of death and dying? We still live with the legacy of the 1950s which insisted all medicine fit into the Krebs cycle. It will be very hard to produce this kind of research, not only because we lack the talent (at present at any rate), but also because the big and easy basic research dollar is now much harder to come by. Nevertheless, I do believe there is much basic laboratory research pertinent to our field, and given time and support, we will have a much easier time demonstrating our own unique biology. For example, let someone discover a solution that will carry and release oxygen and carbon dioxide and a trip to Stockholm awaits.
Unquestionably, there is great room for viable clinical research and inroads have been made. I personally believe that many of our most respectable clinical notions, doctrines, and fads will be overturned in the next ten years as appropriate emergency medical clinical treatment schedules are devised.
Systems research is presently fashionable in Washington but hopefully will produce something of a little higher quality than anecdotes about MAST suits or time schedules of patients appearing in emergency departments.
While we are talking about our middle, we must discuss education. Our concept of what constitutes a valid residency experience in emergency medicine is beginning to crystallize. There are three ingredients that appear critical: first, adequate patient pathology in the emergency department; second, an adequate attending faculty in the emergency department, and third, an adequate number of residents in the emergency department. If you don’t control your own service, you cannot develop into a proper specialist.
The one thing that has refined my vision of emergency medicine more than any other single factor is watching the evolution of self-confidence, specialty awareness, and poise of the emergency medicine resident who has acquired his training in the kind of residency described above. There is no substitute for online experience. You cannot learn emergency medicine on someone else’s service.
We don’t do a good job of educating the undergraduate in emergency medicine. That, too, is something that will require some time as well as commitment from the medical schools, nor is it unique to emergency medicine. At present, our best effort is in the senior elective but even this must be improved.
Education for the practicing physician is also in its infancy. Despite our efforts to stimulate continuing medical education programs, there doesn’t exist yet the slightest shred of evidence that CME effectively alters behavior, except in making curved parallel turns on the ski slope. Again, I believe in addition to didactics, laboratories, and workshops, we must develop some in situ emergency department teaching for the practicing physician.
I cannot leave the middle without comment on emergency medicine administration and service. Just as I believe that education best occurs in the emergency department, I believe that the field has suffered from too much administration divorced from the department – either because the director simply has not or does not now practice emergency medicine, or because he is assigned to the department with no commitment to the specialty. I cannot divorce service from administration, nor do I think anyone will ever comprehend the true responsibilities of the specialty unless they have amalgamated both areas.
AND FINALLY…
The END «that which is naturally after something itself, either as its necessary or usual consequent, and with nothing else after it…»
When involved in the middle, it is always difficult to foresee an end. Perhaps there is no situation that will negate emergency medicine’s ever being a whole, short of a nuclear holocaust destroying all mankind. But even should unforeseen technologies, sociologies, or economics produce an end to our specialty, we shall have had an unparalleled opportunity for intellectual and emotional career growth and development.
I shall close by quoting Oliver Wendell Holmes (Bartletts): «I find the great thing in this world is not so much where we stand, as in what direction we are moving: to reach the port of heaven, we must sail sometimes with the wind and sometimes against it – but we must sail, and not drift, or lie at anchor.»
REFERENCES
- Poetics Book 2 – Aristotle. Britannica Great Books, Encyclopaedia Britannica, 1952.
