“In the 1950s, both the presence and
absence of health insurance drove people
to emergency departments” – Brian Zink MD
The History of Emergency Medicine
Why 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 earl...
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 s...
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, ...
Military Contributions to EM
Transition From GPs to EDs
 Between 1940 and 1960, ED visits/year tripled
 Increased availability of health insurance
 ...
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 ac...
America Becomes Aware
 In 1966 the National Academy of Sciences releases a white paper titled:
 “Accidental Death and Di...
America Got Hungry
The First Answer - The Alexandria Plan
 In 1961, James DeWitt Mills MD and three others left their private practices
 St...
The Founding of ACEP
 1968
Vision: “Emergency Medicine should be practiced by
qualified and certified emergency physician...
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 Bullo...
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...
EMTALA – That Which Defines Us
 EMTALA carries two provisions to Emergency physicians:
 When a patient comes to a hospit...
EMTALA – That Which Defines Us
 EMTALA also defines what “comes to the hospital” means:
 Coming to the hospital includes...
EMTALA – That Which Defines Us
 These “come to the ER” definitions were put in place for a reason
 Young Chicago man 35 ...
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 ...
EMTALA Cases
 Williams v County of Cook
 Patient presented to hospital, stating that she was in active labor. She
allege...
EMTALA Fines
 What insurance class must you accept in order to be liable under EMTALA?
 How much can a physician be sued...
The Good
 The initial goal of EMTALA was to ensure fair treatment to patients,
regardless of their ability to pay
 Does ...
The Bad
 EMTALA mandates labor
 EMTALA does not guarantee payment
 EMTALA exposes physicians to an increased volume of ...
… and the Ugly
 EMTALA fines are not covered under malpractice insurance
 Once fined for an EMTALA violation, you can lo...
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 complicatio...
EMTALA Discussion Questions
With the passage of the ACA, do you think that
EMTALA should be modified? Do you presume
that...
EMTALA Discussion Questions
To meet the definition of a medical screening
exam, a hospital must provide consistent
screen...
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. Thoug...
Resources
 Schecter j, et al. Cobra Laws and EMTALA. http://emedicine.medscape.com/article/790053-overview
 Zink, Brian....
“Both the presence and absence of health insurance drive people to
emergency departments. We are privileged to see both”
The history of emergency medicine
The history of emergency medicine
The history of emergency medicine
The history of emergency medicine
The history of emergency medicine
The history of emergency medicine
The history of emergency medicine
The history of emergency medicine
The history of emergency medicine
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  • “ No unique body of knowledge”“No Research basis”“Too many specialties already”“They will steal our patients”
  • The history of emergency medicine

    1. 1. “In the 1950s, both the presence and absence of health insurance drove people to emergency departments” – Brian Zink MD
    2. 2. The History of Emergency Medicine Why we do what we do today Steven Elsbecker D.O. July 24th 2013
    3. 3. “Keep your sock game tight” 12/14/85 – 6/3013
    4. 4. Imagine……
    5. 5. Imagine…...
    6. 6. 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
    7. 7. Inception Style
    8. 8. The Pride Slide  “Emergency physicians are the jack of all trades and the master of none”
    9. 9. The Pride Slide  Well Trained Emergency Physicians are the masters of 4 areas ….and the jack of all trades
    10. 10. 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
    11. 11. The History of Emergency Medicine Part 1 The Timeline
    12. 12. 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.
    13. 13. Military Contributions to EM
    14. 14. Transition From GPs to EDs  Between 1940 and 1960, ED visits/year tripled  Increased availability of health insurance  24 hour coverage  DEMAND SKYROCKETED!
    15. 15. Staffing EDs in the 1950s and 60s
    16. 16. But those were the good „ol days…
    17. 17. 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
    18. 18. 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
    19. 19. America Got Hungry
    20. 20. 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….
    21. 21. The Founding of ACEP  1968 Vision: “Emergency Medicine should be practiced by qualified and certified emergency physicians”
    22. 22. TRIVIA !!!  In 1970, the first residency program got its roots. Where was this program founded?
    23. 23. The First Residency Program  1970
    24. 24. The First Department of Emergency Medicine  1971
    25. 25. Challenges Obtaining Specialty Status  During the early 1970s, other specialties attacked EM saying
    26. 26. It Becomes Official 1979  The ABMS approves Emergency Medicine as a specialty
    27. 27. The History of Emergency Medicine Part 2 Events That Defined Us
    28. 28. The Alexandria Plan JL Dewitt James Mill
    29. 29. The Alexandria Plan  Gave up on images of James Mills Nathan J Cleveland Cleveland State Basketball Player J‟Nathan Bullock
    30. 30. The Alexandria Plan
    31. 31. In 1961, the Alexandria Plan laid the foundation for us to become what we are today
    32. 32. Evolution occurred in reverse order
    33. 33. TRIVIA !!!  Name the country in which Emergency Medicine was first recognized as a distinct medical specialty
    34. 34. TRIVIA !!!  United States – 1979  Canada – 1980  Australia – 1981  Hong Kong – 1983  Singapore – 1984  UK - 1986
    35. 35. 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
    36. 36. 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
    37. 37. 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
    38. 38. 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
    39. 39. TRIVIA !!!  For a beer….  What does EMTALA stand for?  Emergency Medical Treatment and Active Labor Act
    40. 40. 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
    41. 41. 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.
    42. 42. 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?
    43. 43. 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?
    44. 44. The Bad  EMTALA mandates labor  EMTALA does not guarantee payment  EMTALA exposes physicians to an increased volume of high-risk patients  Limited risk however
    45. 45. … 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
    46. 46. If all else fails….
    47. 47. Famous Emergency Physicians
    48. 48. Famous Emergency Physicians
    49. 49. Emergency Medicine‟s Rise to Fame
    50. 50. TRIVIA !!!!  What does MASH stand for?  Mobile Army Surgical Hospital
    51. 51. EMTALA Discussion Questions Could the legislators responsible for the creation of EMTALA have anticipated the complications we face today ?
    52. 52. 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?
    53. 53. 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?
    54. 54. THIS NEXT ONE IS CONTROVERSIAL
    55. 55. EMTALA Discussion Questions EMTALA has been described, by some, as one of the only forms of slavery left in the US. Thoughts?
    56. 56. 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
    57. 57. “Both the presence and absence of health insurance drive people to emergency departments. We are privileged to see both”

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