Research Blog #2 - Historical Background

History of the ER

Many people have a general idea of what services are provided in the Emergency Room (ER). I think of it to receive physical and phycological care in times of crisis. According to The American Academy of Emergency Medicine, "The field of emergency medicine evolved out of the necessity of caring for a rapidly growing population of patients seeking immediate and unscheduled medical care for emergency conditions." Although this source is describing emergency physicians, they say the following: 

"Emergency physicians in the U.S. emergency departments and sometimes other settings provide urgent and emergency care to patients of all ages, including definitive diagnosis of emergent conditions, prolonged stabilization of patients when necessary, airway management, and life-saving procedures using rapid sequence intubation and sedation. They use a multitude of diagnostic technologies including laboratory studies, bedside ultrasound and other sophisticated radiology, such as CT scan, and MRI...... In the U.S., emergency medicine fits extremely well into the overall medical system, and is clearly the most efficient way to provide emergency patient care" (National Library of Medicine)."

In other less wordy words, the emergency department provides critical care that can save lives (both in times of crisis and non-crisis). While the concept of providing emergency care is a concept as old as medicine, the modern idea of an emergency medicine as a specially is around 50 years old. Some early pioneers of the concept were Australia, Canada,  England, and the United States. Before the specialty was  more formally recognized in the 1960's, emergency rooms were vaguely disorganized. Emergency rooms and departments were staffed on a rotating basis by a wide variety of people. Medical students, physicians,   various specialists (typically only on-call), residents, and interns made up the staff. At least of half of ambulatory care was run my morticians and funeral homes, as they had the proper means by which to carry people horizontally (but they typically had minimally - if at all - trained staff). There was minimal coordination between hospital and pre hospital care. There were few - if any national organizations. This situation was bad for patients who got sick at the "wrong time" - the wrong time being when a specialist wasn't available (this problem was compounded when someone came in not during the work day, such as on holidays or in the middle of the night). And by the 1960's, it was becoming increasingly clear that emergency room visits were on the rise. Physicians were frustrated both by the lack of overall organization and lack of ability to treat all conditions they were seeing due to lack of specialized training.

But it took almost a decade for the emergency room to form in it's current iteration. In 1961, 4 physicians led by James D. Mills MD left their private practices to devote themselves to staffing an emergency room. That same year, an comparable effort led by  23 physicians happened in Pontiac, Massachusetts. This effort resulted in the creation of the Pontiac and Alexandria Plans for Emergency Medicine. This plan helped establish full time staffing rules for then new full time emergency room physicians and guidelines for emergency rooms (which would soon help specialists). And this was only the beginning.  In 1966, emergency department worked received the National Academy of Sciences' "White Paper: Accidental Death and Disability, the Neglected Disease of Modern Society", which described the terrible conditions of emergency departments all across the United States. This helped feed the 1966 Federal Highway Safety Act, which "set standards for ambulances and training" in the United States. In 1967, the American Medical Association (AMA) established on of the primer committees on emergency medicine. One year later in 1968, John Wiegnstein established the American College of Emergency Medicine (who went on to have their first conference the very next year in 1969 in Denver, Colorado with 14 faculty and 128 attendees!).

 In the 1970's, the field of emergency medicine really began to expand. In 1970, the first school of emergency medicine was created at University of Cincinnati by Bruce Janiak. Other programs were created in Los Angeles County by University of South California Medical Center (1971),  the Medical College of Pennsylvania (1972), University of Chicago (1972), and the University of Louisville (1973). At Evanston Hospital in 1973, RR Hannas created the first community hospital emergency medicine residency. 4 years after the founding of the ACEP, the American Medical Association (AMA) decided to recognize emergency medicine as it's own valid specialty. They were so excited, in fact, they created the AMA Section of Intrest: Emergency Medicine and overcame the protests of detractors.1973 saw two significant events happen. The first was the passage of the Emergency Medical Services Systems Act (Public Law 93-154), which funded local and national emergency medical services. The second was a provisional Council of Emergency Services - a branch in the AMA (which became permanent two years later in 1975. In 1974, the Emergency Medicine Resident's Association (EMRA) was created to provide a network for emergency practitioners. in 1976, the American Board of Emergency Medicine (ABEM) was created, and was fully recognized by 1979.

By 1980, Emergency medicine was gaining acceptance. The International Federation for Emergency Medicine (IFEM) had been established and provided and official definition that focused on the ability o take care of all types of acute illness and injury in patients of all age groups in all setting, both pre-hospital and in-hospital. While the early training programs were only two years long including an internship, by 1980 this period was standardized to an absolute minimum of 24 months of emergency medicine and 36 months of actual, total training. By the end of the decade, these programs had become even more rigorous, with many programs requiring  minimum of 36 months of emergency medicine training, with some programs even lasting four years. in 1980, ABEM issued the first board certification for emergency workers. Two years later in 1982, the Accreditation Council for Graduate Medical Education (ACGME) began issuing requirements. The Board of Certification of Emergency Medicine was created in 1987 to create a loophole for students who wanted to avoid training. in 1988, after a well publicized grace period, ABEM got rid of the practice track and began to require people to have training. In 1989, emergency medicine gained more respect with it's additions to many boards. 

The 1990's were a turbulent time for emergency medicine. In 1990 Gregory Daniel, a general surgeon practicing medicine in am emergency setting in Buffalo New York, sued many individuals and organizations (like ABEM) involved with the field of emergency medicine because he - along with numerous co-plaintiffs - believed that the closing of the training track was an illegal conspiracy to benefit the people on the newly established boards. In response, in 1991, the American Emergency Physicians (AEP) was created to provide certification for non-residency trained EMT professionals.   In 1992, John Kearney - under the alias 'The Phoenix' - wrote a book titled The Rape of Emergency Medicine and described how the corruption was negatively impacting medical care. Because of and in response to this, in 1993, the American Academy of Emergency Medicine (AAME) was formed. Their Job was to oversee fair practices in the field. In 1994, after a conference requested by SEAM, who was allowed to "officially" staff emergency rooms was officially changed from "board-certified emergency physician" to "qualified emergency physician"  after much lobbying.

In the last almost-two decades (the last 17 years since 2000), much has happened. in 2005, the Daniels lawsuit from the 1990's was dismissed, despite much protesting from the plaintiffs. AAEM and other certified organizations are trying to dismantle illegitimate organizations offering unrecognized certifications. Since 2000, there has been a lot of "corporate-ization", with many large contract management groups (CGM's) acquiring emergency medical contracts. As of fairly recently, around a third of practicing emergency room practitioners are working under contract with a CGM. Some organizations like AAEM believe that "corporate-ization" because it is bad for the public and for the staff, as they are now serving corporate purpose.  In 2010, there was an increase in training with the increase of legalized emergency rooms, which is good as it supports better care.

Sources

- "AAEM History." AAEM. American Academy of Medicne, n.d. Web. 20 Mar. 2017. <http://www.aaem.org/about-aaem/aaem-history>.

- About ACEP:1961: The First Full-time Emergency Physicians Emerge // ACEP." ACEP. American College of Emergency Physcians, n.d. Web. 20 Mar. 2017. <https://www.acep.org/About-Us/1961--The-First-Full-time-Emergency-Physicians-Emerge/>.
- Suter, Robert E. "Emergency Medicine in the United States: A Systemic Review." World Journal of Emergency Medicine. Second Affiliated Hospital of Zhejiang University School of Medicine, 2012. Web. 20 Mar. 2017. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4129827/>.