A Discipline for the 90s:
Emergency Medicine Comes of Age and Gains New Visibility in the Medical School

by Jeffrey Mortimer

In 1967, when he was a high school senior in Akron, Ohio, the personal became professional for William Barsan, M.D. although he didn’t know it at the time. It’s a recurring theme among emergency physicians — the personal becoming professional — and the chair of the newest department in the University of Michigan Medical School is in this respect cut from the same cloth as many of his colleagues. For him, it happened when his best friend, like him still a teenager, died in the hours following a car crash.

“It happened on the median strip of a highway,” Barsan says. “He was thrown out of this van he was driving, was probably not breathing very well at all, had a brain injury. There were no paramedics back then, so somebody threw him in the back of what was probably a hearse and took him to the nearest hospital, a small hospital which didn’t have the capabilities of flying him out. Very likely, had he crashed today out on US 23, he would probably not be dead for a lot of different reasons.”

The burgeoning field of emergency medicine can take at least some of the credit for those reasons. In fact, Barsan’s friend’s case, which it still pains him to remember, is a dramatic reminder of what has been learned since then. Thanks in large part to the work of emergency medicine researchers and clinicians, not only are vehicles themselves safer and the use of seat belts more widespread, but the health care system’s ability to respond to the consequences when a crash does occur has been vastly enhanced, from the reaching and transporting of victims to their stabilization and treatment.

If you apply those concepts—more effective prevention, faster response and stabilization, and greater understanding of the body’s behavior in such situations—to everything from sore throats to gunshot wounds, season with the urgency of the decision-making, complicate with a patient population that is increasing in both size and acuity, and deduct what one emergency physician called “the need to do a wallet biopsy,” you begin to get a picture of the specialty.

The arc of emergency medicine’s ascent mirrors, in many ways, Barsan’s own career. He graduated from Ohio State University Medical School in 1975, only five years after the start of the first emergency medicine residency in the country and the year before the University of Michigan Medical Center (now called the Health System) first gave anyone official responsibility for operating its emergency room.

“Prior to that time, it had sort of been run by committee,” says Richard Burney, M.D., who took on the responsibility for overseeing the emergency room as part of his duties as a member of the faculty in the Department of Surgery, which became its departmental home. “It was a stepchild of the hospital,” he adds. “It had no clinical base and nobody paid much attention to it. Because it wasn’t part of a department it was mostly invisible.”

It was certainly invisible to Barsan. “At the time I graduated, I didn’t even know you could do anything in emergency medicine,” he says. “I was in a surgery residency for a couple of years at the University of Virginia, and then decided I didn’t like surgery. I had discovered that I liked more the acute medical aspects.”

So he went to the University of Cincinnati, home of the first emergency medicine residency. The year he completed his training, 1979, was also the year emergency medicine was approved as a specialty by the American Board of Medical Specialties. By then, there were more than 40 graduates of the Cincinnati program.

Cincinnati, as it turned out, was the canary in the coal mine of a national trend. “In the early 1970s, patient volumes in the emergency department rose to over 100,000 a year from 20-30,000 ten years earlier,” says Barsan. “Nationwide, you had a real switch in demographics in medical care from people being cared for by their primary physicians to a much more mobile population, and more episodic care. A lot of hospitals were finding themselves totally inundated with emergency patients. At Cincinnati they realized that there weren’t any individuals who could really care for all these patients who were often being piecemealed out very inefficiently, so they thought they should train people to do this.”

Because of the way emergency departments were organized (or not), those patients were often treated in a rather ad hoc fashion. “You would have medicine doctors seeing medicine patients, pediatricians seeing pediatric patients, surgeons seeing surgery patients,” says Barsan. “That was okay as long as the patients coming in knew what they needed, but a lot of time they didn’t know. This led to an inefficient use of resources because there wasn’t really anybody who could take care of assigning patients appropriately. There was also a lot of interest among graduating medical students in pursuing that. That’s what got people interested in it. It was a societal need and a medical need.”

There was also a need to recognize the unusual demands of many emergency cases that helped make emergency medicine a distinct branch of health care: the need for fast-moving triage and stabilization and airway management, a need to understand toxicology, head and brain injury, hemorrhage. In many locations, including Michigan, once emergency medicine was recognized as a discrete entity, it was put under the aegis of the surgery department. Historically, after all, surgeons had seemed to be the busiest group in the emergency room.

But it could also be, as it was at Cincinnati before gaining departmental status in 1984, a kind of freestanding division that reported to the dean, “analogous to a blood bank,” says Barsan. “People didn’t have a clue as to what to do with emergency medicine, so it was dealt with on a local basis.”

While U-M was not among the first to get a clue, it has arguably been among the shrewdest. “It took a long time for the University to come around to the fact that emergency medicine would be a valuable addition to the academic medical center,” says Brian Zink, M.D., “but once it made its commitment, it did it the right way.”

Zink is an associate professor in the department and the Medical School’s assistant dean for medical student career development. He is also the incoming president of the Society for Academic Emergency Medicine, where presentations by Michigan researchers have dominated the proceedings in recent years.

Michigan succeeded, he says, because “it provided resources, guidance for young faculty, start-up money for research, research laboratories, adequate administrative support, adequate office space—all the ingredients that were needed to make a successful program, and they did a good job of recruiting probably the best person at the time in the country who could come in and make it work for them. This program is looked at nationally as a model of how a program can become successful academically in emergency medicine in a relatively short period of time.”

The push began in 1992, when Barsan was hired. “My job was to get a training program started,” he says, “and I think they realized they needed someone in emergency medicine to be in charge of that. It was a specialty the U-M didn’t offer, and every year many of their really good medical students were choosing to go into emergency medicine somewhere else.”

Besides, as was happening at other institutions, “people began to realize that the way things were being run in the emergency department wasn’t the best way to run them,” he says. “It was not a real efficient triage system. People got taken care of, but sometimes not as expeditiously as possible.”

The first priority was a training program. “The expectation was that if we were good at recruiting residents nationally, and if we were able to run in the black as a business, and able to get our research productivity up to a level that was considered acceptable, they would consider making us a department,” Barsan says. “The Health System obviously feels we did that.”

It was the defining moment at Michigan in a field that has gone from stepchild to poster child in less than a generation, a progression in no way hindered by the glamour associated with emergency medicine thanks to a number of television shows. Going all the way back to M*A*S*H, they have helped make the often dramatic work of emergency medicine seem seductively appealing, intense, consuming, and full of professional victory. Many emergency physicians say they like the variety and excitement portrayed in these shows as much as the viewers do; they readily admit it’s part of the specialty’s attraction.

If I go to a dinner party and start telling war stories about my experiences in the Emergency Department, people say I should write a book,” says Barsan. “You see so much bizarre, weird stuff that most people don’t see and half the time don’t believe really happened.

“I like those high-pressure situations,” he says. “I like having to think on your feet. It’s intellectually challenging, having to know a lot about a lot of things. You realize that your capacity to intervene in a meaningful way is very high.”

He cites his previous night’s shift (and the fact that it is, indeed, shift work, is a purely practical part of its appeal): “I went from seeing someone with an eyelid laceration from playing basketball to a patient with pneumonia to a patient with chest pain to a patient with a miscarriage to a patient with multiple trauma to a patient having a heart attack.”

Then there are the anonymous patients. “There are a lot of John Does, people found unconscious at the side of the road,” he says. “It’s a behind-the-scenes detective game sometimes, trying to find out who people are. And I tell students they really have to have good interpersonal skills. You have to figure these are patients who would much rather be doing something else. That’s a challenge for lots of people in the field—finding ways to create some instant rapport when you meet people, so that they trust you. You never know what’s going to come through the door.”

But whoever it is and whatever is wrong, they’re entitled to the finest care possible. “We see everybody and we take care of them, regardless of their ability to pay, regardless of where they come from, and I really like that,” says Barsan. “I like taking care of all comers. I might see professors at the University or corporate CEOs, and I also see the homeless guys who sleep under the bridge. I had a patient last night who was psychotic. He kept insulting me in the same vulgar, unprintable language, repeated over and over again. He didn’t care if I was the chairman of the department or not. It keeps you humble.”

Such stories illustrate, however crudely, that the emergency department increasingly functions as a community triage center, a gateway to the health system, and, in this and other academic medical centers, an interface between town and gown.

Says Burney, the head of emergency services at U-M from 1986 to 1992: “The University of Michigan Hospital was not perceived as the community’s hospital, so we tried to change that. In order to do that, you have to change attitudes, increase resources, teach staff to reach out, and you have to make it clear to people that they’re going to be well taken care of. The fact that we now have a very busy ground-level emergency room that accepts large numbers of people locally, and that people feel comfortable coming here, is the result of having worked in that direction from the beginning.”

“Emergency departments are often really the interface between society and medicine,” says Barsan. “You see a lot of people on the fringe. You feel like you have the opportunity to do something; it’s a way of doing a social triage as well as a medical triage. Sometimes the most important things I do have nothing to do with medical care—getting someone in a rehab program, or getting them to a social worker.”

The emergency departments at Hurley Medical Center in Flint and at Foote Community Hospital in Jackson, staffed under contract with U-M and headed, respectively, by Carl R. Chudnofsky, M.D. and John C. Maino II, M.D., also serve to expand the service and teaching missions inherent in emergency medicine at Michigan, as well as to increase clinical research opportunities.

There’s a profound and historic connection between emergency physicians and social concerns, given that the former have to cope so often with the consequences of the latter. It’s the kind of field where there is support for research focused on better ways to connect emergency departments with social services. As Barsan says, a patient’s medical situation just might be affected by “living in a house with no heat, or not having enough food to eat.”

Many of these people will never feel any gratitude to the emergency room staff who save their lives. “Typically, they come in unconscious, confused, in shock. We may save their lives but they have absolutely no memory of us,” Barsan says. “The people they relate to are the ones they saw later in the hospital; they don’t have any clue what happened at the front end.”

For reasons that are subject to debate, the percentage of patients admitted to the hospital from the emergency room has climbed dramatically. “When I first got in, if an emergency department admitted 15% of its patients, that was pretty high. Now it’s between 25% and 30%,” Barsan says, “We see sicker patients than we used to, and I don’t think anybody knows why.” Balancing this development is the fact that “a lot of patients are able go home now that we didn’t use to send home,” says Barsan, “and we have better outpatient follow-up.

“My theory is that medicine has developed to such a state that we have patients out there who never would have been out there in the past, because they would have been dead,” he says. “It’s a byproduct of becoming so successful at keeping people alive and functioning even though they have pretty bad conditions. My dad had his first heart attack when he was 51, and now he’s 84. It used to be if you had your first heart attack at 50, only very good luck would keep you going to 65.”

That kind of progress has as much to do with prevention as it does with remediation, and the former, broadly defined, is a leading concern of emergency medicine research and thinking. “Prevention is the way to go,” says Marie Lozon, M.D., medical director of the emergency department’s pediatric section. “I would like to be put out of business. If we could get people to use their seat belts or appropriately restrain children, my job would be considerably easier and the amount of morbidity from head injury would be greatly reduced. The horse is out of the barn by the time I get to them.”

Ron Maio, M.D., is director of the U-M Injury Research Center and currently involved in two major injury prevention studies. “Even though I want to find out how we can treat people better who are injured,” he says, “I’m even more interested in what we can do to prevent people from being injured. I’ve become more and more concerned with trying to do something for people other than putting a bandaid on them.”

In June, work began on what might be called the externalization of emergency medicine’s new status, an expanded and reconfigured space at University Hospital. “When this hospital was built, there were no emergency physicians here,” says Barsan. “The departments of pediatrics, medicine and surgery each ran their own sides, so when they built the emergency department, they built it as three separate areas. Now all of it is run under emergency medicine, but we still have three separate geographic areas, which has been very problematic for us. It’s not a very good system, the way we have it right now.”

Soon, it will be better—more efficiently designed, better integrated and, yes, bigger. The cowboys of health care (James MacKenzie, M.D., a Canadian surgeon who worked closely with Burney in the formative days at U-M and was Emergency Services chief from 1979-1986, actually was a rodeo rider before turning to medicine) will have more room and improved tools. “The ambulance entrance leads right into the resuscitation areas,” says Barsan, ticking off improvements, “which can be used for any sick patient: pediatric, adult, medical or surgical. They all go into the same area, which is more economical than having separate resuscitation areas.”

No longer will patients taken from ambulances or helicopters be wheeled through public areas in the department, a chronic source of distress for all concerned. “We’re building a new landing pad, with a tunnel right to a one-floor elevator for the exclusive use of the helipad,” says Barsan. “CAT scan and regular radiology are right there; they can all get done right within the department. Emergency laboratories will be right next to the vestibule, and an on-site lab will make a huge difference. Psychiatry—and this is the only 24-hour emergency psychiatry facility in Washtenaw and Livingston counties—has 2,200 square feet instead of 700.”

Another part of the expansion will be a “clinical decision area” for observing patients, such as those with chest pain, who may require more time for diagnosis. “If you had come to the emergency department with chest pain five years ago, and we did an electrocardiogram and you weren’t actually having a heart attack, the only way to know if you were really coming to a heart attack would be to admit you to the hospital, observe you for two or three days, do a stress test, and probably schedule at least one or two return visits.”

Now the whole process can be expedited. “After we evaluated you in the emergency department to make sure you were not having a heart attack right now, you would go into the clinical decision area,” Barsan says. “You would be seen by a cardiologist, have a stress test, and we would get you out in 12 to 16 hours. We’re taking what used to be a two- to three-day work-up and compressing it into less than a day. You get a quicker answer, you’re not spending days in the hospital when you don’t need to, and you’re having the same outcome you would have had if you had been admitted to the hospital.”

Asthma attacks are another example. “Someone having a bad attack that doesn’t clear up in several would typically get admitted and be in the hospital several days,” he says. “With this new area, if they’re not better in six hours but better in 16, we’re able to get them out much quicker.”

Needless to add, reducing admissions and shortening stays are popular procedures with the moguls of managed care, but better care remains paramount with Barsan and his colleagues, who feel great pride in being the first new department in the Medical School in 15 years. “Emergency medicine has matured into an independent discipline here at Michigan as it has at our peer institutions around the country,” notes Dean Allen Lichter, who was the first chair of the Department of Radiation Oncology when it was established in 1984. “Under Bill Barsan’s direction, the department is in an excellent position to experience the academic growth it deserves and to attract more of the best faculty and trainees from around the country.”

Also:

25 Years of Progress
in Emergency Medicine.

Emergency Medicine Research:
The Goal is Always Fewer Emergencies

The Emergency Medicine Delivered by Hawkeye and Hot Lips Was Always the Best—and Walter Dishell Was There on the TV Battlefield to Make Sure of It

When Little Ones Get Hurt