1. “In the 1950s, both the presence and
absence of health insurance drove people
to emergency departments” – Brian Zink MD

3. The History of Emergency Medicine
Why we do what we do today
Steven Elsbecker D.O.
July 24th 2013

4. “Keep your sock game tight”
12/14/85 – 6/3013

5. Imagine……

6. Imagine…...

7. 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

8. Inception Style

10. The Pride Slide
 “Emergency physicians are the jack of all trades and the master of none”

11. The Pride Slide
 Well Trained Emergency Physicians are the masters of 4 areas
….and the jack of all trades

14. 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

15. The History of Emergency
Medicine Part 1
The Timeline

17. 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.

18. Military Contributions to EM

19. Transition From GPs to EDs
 Between 1940 and 1960, ED visits/year tripled
 Increased availability of health insurance
 24 hour coverage
 DEMAND SKYROCKETED!

20. Staffing EDs in the 1950s and 60s

21. But those were the good „ol days…

22. 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

23. 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

24. America Got Hungry

25. 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….

26. The Founding of ACEP
 1968
Vision: “Emergency Medicine should be practiced by
qualified and certified emergency physicians”

28. TRIVIA !!!
 In 1970, the first residency program got its roots. Where was this program
founded?

29. The First Residency Program
 1970

30. The First Department of Emergency
Medicine
 1971

31. Challenges Obtaining Specialty Status
 During the early 1970s, other specialties attacked EM saying

32. It Becomes Official
1979
 The ABMS approves Emergency Medicine as a specialty

33. The History of Emergency
Medicine Part 2
Events That Defined Us

34. The Alexandria Plan
JL Dewitt James Mill

35. The Alexandria Plan
 Gave up on images of James Mills
Nathan J Cleveland Cleveland State Basketball
Player J‟Nathan Bullock

36. The Alexandria Plan

37. In 1961, the Alexandria Plan
laid the foundation for us to
become what we are today

38. Evolution occurred in reverse order

40. TRIVIA !!!
 Name the country in which Emergency Medicine was first recognized as a
distinct medical specialty

41. TRIVIA !!!
 United States – 1979
 Canada – 1980
 Australia – 1981
 Hong Kong – 1983
 Singapore – 1984
 UK - 1986

42. 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

43. 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

44. 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

45. 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

47. TRIVIA !!!
 For a beer….
 What does EMTALA stand for?
 Emergency Medical Treatment and Active Labor Act

48. 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

49. 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.

50. 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?

51. 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?

52. The Bad
 EMTALA mandates labor
 EMTALA does not guarantee payment
 EMTALA exposes physicians to an increased volume of high-risk patients
 Limited risk however

53. … 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

54. If all else fails….

55. Famous Emergency Physicians

56. Famous Emergency Physicians

57. Emergency Medicine‟s Rise to Fame

59. TRIVIA !!!!
 What does MASH stand for?
 Mobile Army Surgical Hospital

60. EMTALA Discussion Questions
Could the legislators responsible for the creation
of EMTALA have anticipated the complications
we face today ?

61. 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?

62. 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?

63. THIS NEXT ONE IS CONTROVERSIAL

64. EMTALA Discussion Questions
EMTALA has been described, by some, as one of
the only forms of slavery left in the US. Thoughts?

65. 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

66. “Both the presence and absence of health insurance drive people to
emergency departments. We are privileged to see both”