Reflections of an Original Emergency Room Doctor

In 1966, in a major medical school affiliated teaching hospital, I approached the end of my internship and eagerly scooped up emergency room (hereafter “ER”) work shifts, both for the experience and the $15.00 (under the table) reimbursement I was paid by the “relieved” doctor vacating the shift. The shifts were 12 hours long and chaotic. Organized medicine’s general pattern for dealing with unscheduled medical problems was simple: a room was designated and supplied to accommodate the medical staff, who would provide coverage on a rotating basis, i.e. every attending staff member, alphabetically chosen, would be in charge, either by physical presence or by telephone link, regardless of specialty. That was it. Nationwide, this model, with insignificant modifications, was entrenched. The attending doctor was seldom present.

When a patient showed up, whether a gunshot victim or a comatose patient found on the street, the charge nurse took vital signs and called the attending physician’s answering service. In those days of fixed telephone lines and no beepers, that was a formidable task. If it were Saturday afternoon, he might be fishing at a nearby stream or attending a local ball game; if Wednesday, he might be on the golf links.

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Presumably, his answering service knew how to contact him. Big presumption!

After chasing her doctor for a significant amount of time, the nurse was finally put through and might find out that the attending was a gynecologist, and not much help to the male patients. However, the gynecologist usually asked other doctors to handle his general surgery and to handle his neurology patients. Perhaps the nurse could track them down and ask them to consult for him. Again, the telephone charade would repeat itself, with new twists as the first physician had signed off and gone out of town and the other might not have privileges at your hospital.

In a teaching hospital, things were significantly better because there was always a crew of interns and residents who were physically present in the hospital 24-7, but perhaps not assigned to the ER as such, though they did go there and consult, if asked by the attending on whose service they were currently training.

My shift began on Saturday at noon and ended 24 hours later. That evening, several automobile accident victims and a knife attack victim showed up within 20 minutes. The ambulances unceremoniously screamed into our parking lot, unloaded their patients onto the waiting gurneys like sacks of potatoes, loudly announcing monosyllabic reasons for being there as, “car crash!” or “knife fight!” With screaming sirens and excessive speeds they left.

There was lots of blood smeared around the auto accident victims, from superficial wounds, it turned out, while the knife fighter was dry and quiet. Dr. H.W., chief surgical resident, came through the ER at this moment and, as was his custom, spent a moment to schmooze with the charge nurse.

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She walked him over to the fighter, who, though still very quiet, was now very pale. Without breaking stride, casting a quick but fixed glance at this patient’s neck, he bounded over to the cabinet, retrieved a scalpel, pair of gloves, and urinary catheter. In less time than it has taken me to type this, Dr. H.W. had made a stab wound in the patient’s chest, releasing a whoosh of air, and rammed the urinary catheter inside the chest cavity. I was at his side by this time. He looked at me disgustedly, and snapped, “tie that catheter down to the skin with a suture, hook it up to suction bottles, start an I.V. (intravenous) with broad spectrum antibiotic coverage, place the patient on oxygen, put him on my service with Dr. L. and review proper triage and intervention.” He then left. The charge nurse beamed. I was crushed, but very impressed and learned a lesson which stayed with me for my entire career.

This patient had a “Tension Pneumothorax,” a life-threatening, quickly impending disaster, which could be diagnosed by a careful look and could be cured in less than a few minutes. It did not call attention to itself like the many bleeding scalp and facial wounds on the surrounding gurneys. I got through my shift all right; more importantly, so did all of my patients. There was one more dramatic case which highlighted the mismatch of medical resources and patient need.

On Sunday, shortly before I was to be relieved, a somewhat tipsy member of the yacht club was brought into the ER skewed by a flagpole, from anus through his umbilicus. The aluminum spear point, tassel and all, was protruding from his abdomen by about six inches. The patient was conscious and talkative. The ER attending for Sunday was a dermatologist! Chastened by the previous night, I instructed

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the nurse to start polling the usual hangouts for an available general surgeon and started the I.V., oxygen, urinary catheter, and tracked down anesthesia coverage for the impending surgery. By the time the surgical team was assembled and ready to go, I had blood typed and cross-matched, necessary X-rays done, and anything else I could think of to speed the transit to the surgical suite. It seems my actions were atypical and unexpected but appreciated. This patient lived to sail his boat another day—although flagless, I might add.

This was not my first ER shift, but it dramatized the core problem more than the others. There was a complete disconnect between the presented medical problem and the resources available. It would soon become painfully apparent that the mismatch could be laid at the feet of the hallowed paradigm of medical teaching that had produced such valuable advances, namely, “longitudinal specialty study and research.” In the history of medicine, the field of general surgery and medicine gave way to area and organ specialties, which further sub-specialized into ever smaller fields of interest. For example, the HEENT (head, eyes, ears, nose, and throat) yielded the head to neurosurgeons at first, and EENT yielded eyes to ophthalmologists, who would further yield the retina to retinal sub-specialists, and so forth. However, who was looking at the whole patient? More particularly, presumably, each of these specialists and sub-specialists had the knowledge to deal expertly with a crisis in his field. How to mobilize that disseminated knowledge timely enough to benefit the patient in the ER? The answer shocked organized medicine to its roots. The vertical knowledge based teaching needed a paradigm shift in thinking. Simply put, a horizontally based body of knowledge, i.e., the emergencies of each specialty, needed to be organized and taught to postgraduate

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doctors.

At every level of patient care the resistance, emotional venom, and incredulity that were rampant during these formative years of emergency medicine was widespread. Though it would be easier to list those few that were supportive I will list some of the major opponents: The American Medical Association, most medical schools, the American Hospital Association, Blue Cross, Red Cross, ambulance services—it is a long list. They all had vested interests in the status quo, and fought the movement with power politics, press, and money. The burden borne by the early practitioners in our nation’s ERs was crushing. Underpaid, overworked, unrecognized, and trivialized by their peers who asked, “When are you going to smarten up and get a ‘real job?’” Looking back, I find it hard to imagine how so many of us survived it somewhat mentally and physically intact. Our patients, though, benefited and it was obvious that our presence and our personal efforts to self-educate in disparate fields such as anesthesiology, cardiology, trauma, pediatrics, medical emergencies, and others was signaling that we would persist, with or without help from above.

The current efficient, world-class system of dealing with medical emergencies owes its existence to a handful of physicians who stubbornly challenged the status quo. As I look back, it is difficult to imagine that we changed thinking, training, education, and medical decision making on a national level. The memory is a personal reward that I hold dear.

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