My career in Emergency Medicine spans 30 incredible years. I would like to trace my intellectual, social and political evolution by reviewing my personal, and our collective experiences during the growth and development of our specialty. I have found my own strength in studying literature and philosophy. The authors, playwrights and poets who have analyzed our diverse societal problems have allowed me to maintain an essential skepticism of the precepts I was exposed to in life in general, and in medicine specifically. I have found literature and philosophy to be an effective antidote for societal and medical rigidity.
There is no more certain way to halt party conversation than by saying, “I work in the Bellevue Emergency Department (ED).” Visions of our work are shared by so many people. More than 100,000,000 come to EDs every year and millions more watch TV shows about our work. Caleb Carr’s description of late 19th century Bellevue in The Alienist is much like my first visit there, or a patient’s first visit to an ED.
The square, solemn, red brick buildings of Bellevue appeared on the horizon, and in just a few more minutes we crossed First Avenue and pulled up behind a large black ambulance on the Twenty-sixth Street side of the hospital grounds, near the entrance to the Insane Pavilion. I paid my cabbie off and headed in.
The Pavilion was a simple building, long and rectangular. A small, uninviting vestibule greeted visitors and internees, and beyond this, through the first of many iron doors, was a wide corridor running down the center of the building. Twenty-four “rooms”—really cells—opened off of the corridor, and separating these cells into two wards, female and male, were two more sliding doors at the corridor’s midway point. The Pavilion was used for observation and evaluation, primarily of persons who had committed violent acts. Once their sanity (or lack of it) had been determined and official reports were received, the internees were shipped out to other, even less inviting institutions. [(1), page 27, reprinted with permission]
When asked, “What did you do today?” or “What is emergency medicine like?,” my response is often based on my energy level and my fear of disrupting the party. Do these people really want to know about a patient stabbing, domestic violence, victims of torture, acute MIs, a new toxin or even a sore throat? Our work is a new geography lesson where we encounter patients from across the world, a crash Berlitz course where we hear numerous languages, a wild roller coaster ride sometimes as thrilling as winning the Lotto and sometimes as tragic as losing a new friend.
I would like to portray my journey and its links to progress in Emergency Medicine faithfully, but my optimistic nature may alter history and offer a revisionist’s version. Many of the events that I will describe, such as establishing an Emergency Medicine residency and building a new Emergency Department, were like running up Everest or swimming the English Channel, Sisyphean by any measure. We’ve all gained strength to do our jobs through parents, peers and family. In addition, literature played a fundamental role in shaping my character. Camus’ vision of personal responsibility helped form my persona and enabled me to create my vision of Emergency Medicine in New York City.
Nonetheless, he knew that the tale he had to tell could not be one of a final victory. It could be only the record of what had had to be done again in the never ending fight against terror and its relentless onslaughts, despite their personal afflictions, by all who, while unable to be saints but refusing to bow down to pestilences, strive their utmost to be healers. (2)
My love of botany and understanding of plants probably originates in my early years in the 1940s spent in rural New York working in the garden and orchard. There were more cows on our adjacent roads than houses and people combined; there were wild strawberries, blackberries and ancient apple trees; and the woods were filled with wild lilies, orchids and untouched beauty.
Watching my mother at her typewriter working and reworking manuscripts for children’s books, science books for young adults, news articles and several books about Picasso and Brancusi set an example for personal industry. Listening to my father explain the diverse utilities of a natural gum guar (Cyamopsis psorabides) first as a river floculant, then as an adjuvant for enhanced extraction in the oil fields, a smoothing additive to ice cream and so many other interesting applications, was a remarkable lesson in creativity and serendipity. This blend of industry and creative thinking at home was my foundation.
I have always found peace while thinking about complex problems and relaxation while spending time splitting wood, planting or digging on the land—a pleasure I have shared with my wife, Susan, and our four children. Thoreau was a mentor both from a politician’s and naturalist’s perspective. He wrote:
The bullfrogs trump to usher in the night and the note of the whip-poor-will is borne on the rippling wind from over the water. Sympathy with the fluttering Alder and poplar leaves almost takes away my breath; yet, like the lake, my serenity is rippled but not ruffled. (3)
Early first-hand experiences of immense conflict created the mold for my personality and resolve. My first encounter with politics occurred in 1953 when my mother was investigated by the House Committee on Un-American Activities. The travails of my parents and our family in seeking work and a safe place to live led me to a fuller appreciation of their anti-Fascist efforts in the Spanish Civil War and Nazi Germany. My community civic lesson came early as so-called friends abandoned my parents and sisters in droves while rare individuals and true friends demonstrated integrity and support at substantial personal risk. Around and among my family, I did not have far to look to see models of real commitment. These Blacklist survivors, people truly dedicated to American democracy, were vital to my intellectual growth and development. I remember walking out of a theater at age 17 and experiencing the immense power emanating from Arthur Miller’s description of the Salem witch trials as a metaphor for McCarthyism:
Danforth: Proctor, you mistake me. I am not empowered to trade your life for a lie. You have most certainly seen some person with the devil (Proctor is silent). Mr. Proctor a score of people have already testified they saw this woman with the devil.
Proctor: Then it is proved. Why must I say it?
Danforth: Why “must” you say it! Why you should rejoice to say it, if your soul is truly purged of any love for hell! (4)
Freshman year high school biology was taught without support for evolution; the remainder of the coursework wasn’t much better. Fortunately, my home was filled with books. I read Charles Darwin’s Voyage of the Beagle; and I saw Jerome Lawrence and Robert Lee’s play Inherit the Wind about the 1925 Dayton, Tennessee, Scopes “Monkey” Trial, describing the seismic American debate between Clarence Darrow and William Jennings Bryan.
Drummond: I don’t suppose you’ve memorized many passages from The Origin of the Species.
Brady: I am not in the least interested in the pagan hypotheses of that book.
Drummond: Never read it?
Brady: And I never will!
Drummond: Then, how in perdition, do you have the gall to whoop up this holy war against something you don’t know anything about? (5)
My understanding of public health and medicine’s interrelationship was enriched by The Jungle, Upton Sinclair’s expository novel describing Chicago’s meat packing industry which led to the pure Food and Drug Act of 1906. His images of the exploitation of immigrants, poverty, occupational risk and the lack of any semblance of food hygiene standards remain with me today. The muckraker role was certainly my perception of my ideal position in society. Sinclair’s vision is much like our vision from the Emergency Department.
…for the worker bore the evidence…on his own person—generally he had only to hold out his hand.
There were the men in the pickle-rooms, for instance, where old Antanas had gotten his death; scarce a one of these that had not some spot of horror on his person. Let a man so much as scrape his finger pushing a truck in the pickle-rooms, and he might have a sore that would put him out of the world; all the joints in his fingers might be eaten by the acid, one by one. Of the butchers and floorsmen, the beef-boners and trimmers, and all those who used knives, you could scarcely find a person who had the use of his thumb; time and time again the base of it had been slashed, till it was a mere lump of flesh. [(6), pages 97–8, reprinted with permission]
Arrowsmith, Sinclair Lewis’ 1925 assault on the quality and beliefs of American physicians, published shortly after the release of the Flexner Report, demonstrated a standard for becoming a physician. The experiences of Lewis’ hero, Arrowsmith, are based on the medical adventures of Paul de Kruif. de Kruif, a microbiologist and author, wrote Microbe Hunters, Hunger fighters and the Fight for Life, which set standards for scientific and medical idealism. Lewis expressed concern about the future of the American medical profession, physician integrity, education and avarice.
Doctor don’t be buffaloed by the unenterprising. No reason why you should lack the equipment which impresses patients, makes practice easy and brings honor and riches. All the high class supplies which distinguish the Leaders of the Profession from the Dubs are within YOUR reach right NOW. (7)
In addition to our extensive home library, The New York Times became part of my daily routine. The formation of my personal literary style developed in part from my mother’s reading suggestions each month when Berton Roueché’s “Annals of Medicine” appeared in the New Yorker magazine. Little did I appreciate, then, the importance of the fact that in the late 1950s and 1960s Roueché sat every week with the New York City Poison Center staff to collect cases for his columns. I still recall his powerful description of our predecessor Dr. Harold Jacobziner, Assistant Commissioner for Maternal and Child Health of the New York City Health Department and chief of the department’s newly established Poison Control Center, as he cared for a critically ill child poisoned by aspirin.
In 1958 I won a scholarship to a summer science program linked to the Worcester Foundation for Experimental Biology. There, a small number of high school students were given the opportunity to communicate with great scientists as they learned laboratory skills. The efforts of two men I met that summer shaped my concept of the global scientist. Gregory Pincus, who was evolving his bench and animal work on the oral contraceptive from the bench to the patient, spent days in discourse with us about his work’s significance in terms of world population, pregnancy, women’s rights, abortion (then illegal) and contraception for women (then negligible). Perhaps Max Planck stated best what I learned from Dr. Pincus. Max Planck, during his Nobel Prize in Physics acceptance speech said:
The pursuit of a goal, the brightness of which is undermined by initial failure, is an indispensable condition, though by no means a guarantee of final success. (8)
My second intellectual role model was N. W. Pirie, a renowned British biochemist driven to feed the world’s starving populations by developing the resource of leaf protein, and by hybridizing plants to design the “ultimate” plants with all the essential amino acids for Ghana, Indonesia and Jamaica, the countries where his projects were advancing. These relationships inspired me to return to Massachusetts, to Clark University and the Worcester Foundation for my university education. The concept that molecules, science, politics and societal hostility to change were intimately linked provided a foundation for my beliefs and life choices. Marie Curie, several years after her acceptance of the Nobel Prize for Chemistry in 1911, wrote:
And this is the proof that scientific work must not be considered from the point of view of the direct usefulness of it. It must be done for itself, for the beauty of science and then there is always the chance that a scientific discovery may become like radium, a benefit for all humanity. (9)
College proved remarkable: a community rich with diverse people, complex scientific studies, an activist role as President of the student body—rent strikes and civil rights demonstrations. As a student of the works of Thoreau, Ghandi and King, I found clarity for my analysis and practice of civil disobedience and my status as a conscientious objector. These philosophers would later shape my position in opposition to the war in Vietnam and crystallize the expression of my beliefs as a conscientious objector. Mahatma Ghandi’s principles were defined in his book Non Violent Resistance, in which he stated that civil disobedience was a civil breach of unmoral statutory enactments. He attributed the concept of civil disobedience to Thoreau, who utilized this approach in his resistance to the laws of a slave state.
Rachel Carson’s Silent Spring demonstrated the inextricable link between my youth in the garden and woods and my new college experiences in the chemistry laboratory.
There was once a town in the heart of America where all life seemed to live in harmony with its surroundings. The town lay in the midst of a checkerboard of prosperous farms, with fields of grain and hillsides of orchards.
Then a strange blight crept over the area and everything began to change. Some evil spell had settled on the community: mysterious maladies swept the flocks of chickens; the cattle and the sheep sickened and died. Everywhere was a shadow of death. (10)
Searching for the next step in my career and life, Johns Hopkins University became the obvious choice for me to develop my civil rights beliefs, medical education and research, so I traveled to Baltimore for my medical education. The medical community was divided over the concept of socialized medicine, which many physicians believed Kennedy and Johnson were developing in the form of Medicaid and Medicare. The South was still violently struggling with institutionalized racism, segregation and poverty. The stark truths about our society troubled me, so much that it became difficult to perform effectively as a young medical student.
On my first visit to the colored side of the Johns Hopkins Emergency Room, an upper-class tour guide showed us an “Old Black Drunk” whom I could sew up—even after I explained my lack of knowledge of nerves, veins and arteries! This image will stay with me forever. The Johns Hopkins restrictive admission policy towards blacks (the first African-American man was admitted to my class in 1963) and women (an agreement permitted a maximum of 10% of each class to be women), and the sexist approach to nursing students and staff amazed me. I was provoked to become involved in student-driven efforts at reform. The institution’s approach was intolerable to diversity, high quality education and medical humanism. I questioned whether I could become a responsible and excellent physician under these circumstances. David Feldshuh described the racial and research problems of the era in Miss Evers’ Boys.
Willie: You try to understand me. That Penicillin would have made it so I could walk without pain and may be even Jackspring. And they didn’t give that to me…so I could be part of Miss Evers’ Boys and Burial Society. So you could all do your watching while I wake up past midnight not feeling my legs or else feeling pain. (11)
Termination of my student career at Johns Hopkins led me to the Free University of Brussels, and to a distinctly different experience in a country with socialized medicine, and a widely integrated student body with many African students, often from newly independent states, and an equal number of men and women. In this time, during which my wife and I and our two children had begun to thrive in Brussels, I came to understand the complexities of universal healthcare, public health and their importance in the poverty-stricken existence of the newest European immigrants who depended on the Emergency Department for healthcare access.
In the early 1970s, I began a Pediatrics/Internal Medicine internship in Hartford, Connecticut, attempting to find a specialty that could meet my intellectual and political demands. Life was too calm in Hartford. The next year I transferred to Montefiore Hospital in the Bronx. As a resident in Internal Medicine, I began to spend most of my time in the South Bronx at the City Hospital affiliate, Morrisania. In the shadow of Yankee Stadium was a 100,000-visit emergency area: no attendings, no organization, no triage and no structured outpatient department existed—exactly the chaos I was seeking! Lewis Carroll described our work environment perfectly:
“Now here you see it takes all the running you can do to keep in the same place. If you want to get somewhere else, you must run at least twice as fast as that!” said the Queen. (12)
With the assistance of the hospital leadership and the future leader of Ambulatory Care, I wrote a proposal creating the position of Director of Emergency Medicine, which I subsequently assumed in July 1973. We began to institute systems, to triage patients using volunteers and nurses, establishing critical care and trauma rooms and a separate place for children. When we required that all patients’ vital signs be taken, we found severe hypertension in large numbers of people. We saw 10 people a day who seemed asymptomatic yet had diastolic blood pressures > 130 mm Hg, 15–20 patients a day with critical asthma, 5–10 patients with heroin overdoses, multiple patients with gun shot wounds and stabbings, child abuse and neglect, and a gonorrhea and syphilis epidemic.
All of these patients had problems that led us to innovative solutions. This was a unique era in medicine. Montefiore Hospital was an institution led by Martin Cherkasky, who believed that our task was to first dream of solutions and then to find the dollars to enhance fundamental human values and improve healthcare. The approach was based upon the precept that if it needed to be done, it should be done. We established an Ambulatory Care Department with teams of attendings and nurse practitioners. Within 3 years we were able to show dramatic decreases in hospitalization rates for diabetes, heart failure, asthma and hypertension. We rapidly established a trauma team with full-time surgeons in hospital to meet the overwhelming trauma needs.
We began to study naloxone—a new antidote for the ever-present opioid overdoses—which rapidly replaced nalorphine and levallorphan as the drug of choice due to its pure opioid antagonist properties. We in Emergency Medicine were the first and often the only physicians to see the devastating effects of new drugs, toxins and injury. It had become obvious that we could define a medical problem, investigate, develop a solution and confront great political issues. Illegal drugs, antidotes, treatment, rehabilitation and the police demands were all intertwined.
We were observing and making history. Everything that happened in New York City’s physical and political environment altered patient needs and disorders: the weather, the closing of hospitals and psychiatric facilities, new reimbursement strategies. We knew first which societal experiments were succeeding or failing. We were the 6 o’clock news and tomorrow’s headlines in the Daily News. I translated medicine for the media and assisted reporters on their projects—I had long ago learned of their importance—and assumed that ultimately I would need their support.
When I began to ride the train to work every morning, I revisited and was renewed by my college experiences. When I was in college I began to listen to folk music—Joan Baez, Woody Guthrie, the Weavers and Pete Seeger expressed themselves eloquently and I listened and learned to whistle. I found solace and inspiration in the lyrics as well as the melodies. I found a great sense of pride and community whenever, over the past 20 years, I have seen on my daily train commute to New York City, Pete Seeger, the man who saved the Hudson River with his Clearwater sloop singers. Woodrow Wilson Guthrie spoke for these great folk singers:
I am out to sing songs that will prove to you that this is your world, and that if it has hit you pretty hard and knocked you for a dozen loops, no matter how hard it’s run down and rolled over you, no matter what color, what size you are, how you are built, I am out to sing the songs that make you take pride in yourself and your work. And the songs I sing are made up for the most part by all sorts of folks just about like you. (13)
In this preparamedic era with limited EMS organization and training, patient arrival to our department was chaotic and typically no medical care was initiated in the field. The delay in receiving care for trauma victims was inordinate, the airway was not protected, cervical collars weren’t used, patients arrived with rigor mortis, and patients were dumped by families and by private hospitals at our public doors.
In the mid-1970s, paramedic education began to develop in New York City. This education created a gap between the newly organized prehospital care and the persistent chaos of most hospital EDs. Although we believed in hiring full-time attendings at the North Central Bronx and Montefiore hospitals, these attendings were surgeons, internists and pediatricians working with very junior house staff. The future of Emergency Medicine was ill defined and we had little faculty and administrative support from the hospital staff, who did not understand our goals and feared that potentially disruptive changes would ensue.
The critical developmental events of the 1970s for Emergency Medicine were the Emergency Medical Systems Act of 1973 and its extension in 1976, which mandated a systems approach and design to alter delivery modalities. There were seven major clinical categories to develop, including behavioral emergencies, burns, cardiac, high-risk infants, neurotrauma, general trauma and poisoning emergencies. We were led by the categorization and implementation czar, David Boyd, with national and local meetings to regionalize, rationalize and improve care. We began to effect changes that ultimately led to an EMS power structure that would be the future of New York State and New York City Emergency Medicine. Initially, national support for poison management, education and prevention was limited; however, our ability to show the links between all of the other types of emergencies and poisoning led to a significant increase in funding. These systemic changes, grant funding and national support dramatically improved clinical care, and our treatments for the poisoned patient were revolutionized.
I began to appreciate the breadth and depth of urban poverty in the mid-70s as I witnessed on a daily basis the human toll we observed in the ED. As I tried to understand my environment, I found no texts in Emergency Medicine and only a few texts with content focused on Medical Toxicology. None emphasized our greatest problems: alcohol and drug use, trauma, homelessness, hypothermia, heat stroke and cardiac arrests. Certainly none focused on what I saw in the South Bronx; and minimal scientific literature offered me an evidence-based approach to this field. The discussions I had with those developing Emergency Medicine elsewhere in the country (in Alexandria or Lansing) had little to do with my efforts. I was beginning to understand the urban elements that no one had yet formally studied, I was beginning to see the symptoms, the patterns of survival and the plight of the urban poor.
I realized my task was to care for people in need—the uninsured, the unemployed, the new immigrant populations and those just beginning to escape from pervasive racism. We were part of a large, relatively impoverished, socialized system: the New York City Health and Hospitals Corporation. The concept of a group practice for the insured, debated and practiced elsewhere, held little interest for me.
I recognized that Emergency Medicine could have an immense political influence in alleviating the burden of the poor and disenfranchised. We in Emergency Medicine were ideally suited to meet Rudolf Virchow’s belief that “the physician is the natural attorney of the poor.”
I was sure that the viewpoint of an emergency physician on the frontline was different and difficult to interpret clearly to those outside the specialty. I began to seek alternative means of self-expression through writing: from the mid-1970s through the 1980s, I wrote monthly columns, with various key collaborators, on medical toxicology for the journal Hospital Physician. We focused on history and anecdote, attentive to the curious mind, concerned with practical issues, controversial and evidence based, but conscientious that our delivery would allow our perspective as evolving emergency physicians and toxicologists to be heard and understood. During the 1990s, I had the privilege of writing editorials and commentaries as the President of SAEM and as a member of the editorial board of Emergency Medicine News. These opportunities provided me with a forum for intellectual expression and substantial freedom not offered by many peer review journals. I could incorporate history, philosophy and literature in an attempt to offer my analysis of our current problems, while trying to communicate with others facing similar concerns.
In 1979, when the position of the first full-time Director of Emergency Medicine at Bellevue Hospital became available, I jumped at the opportunity. I believed that if I moved to America’s oldest public hospital with ready access to television and the press, I could speak about social justice and more effectively change healthcare policy. I also took the voluntary title of Medical Director of the New York City Poison Center, located in the New York City Health Department across the street from the Bellevue ED.
My wife and I felt that life in an old Hudson River town, Ossining, would offer beauty, nature, history and a complex integrated environment where our children could appreciate many of the dilemmas of New York City. It also meant that I could easily ride the train with hundreds of thousands of others to Grand Central Station and walk daily to and from the hospital with our patients. Caleb Carr imagined my daily voyage 100 years earlier:
It’s less than an hour by train from the middle of Manhattan to the small town on the Hudson River named by an early Dutch trader for the Chinese city of Tsing-sing; but for visitors and prisoners alike, the trip to Sing Sing is usually divorced from real time, seeming at once the shortest and longest journey imaginable. Situated hard by the water and offering a commanding view of the Tappan Zee bluffs opposite, Sing Sing Prison (originally known as “Mt. Pleasant”) was opened in 1827 amid claims that it embodied the most advanced ideas in penology. [(1), page 230, reprinted with permission]
In the early 1980s, we saw many patients die of heat stroke, others freeze to death and many present with frostbite. These patients were invariably homeless, recently discharged from psychiatric facilities and under the influence of alcohol and drugs that affected their hypothalamic thalamic axis. These thermoregulatory emergencies and the cellulitis log book that had 5–10 entries for admissions each day in our ED were indicative of the collapse of public health in New York City. Florence Nightingale’s perception of the vital role of the public hospital helped guide our staff: The public hospitals of any country may be fairly taken as a standard of civilization.
We, as emergency physicians, were the first group of individuals to care for such large numbers of truly sick and disenfranchised people on a continuous basis. We saw clearly how the poor suffered in America. The societal demands created by the newly found access achieved by Medicare and Medicaid overwhelmed the fragile public health systems. It became obvious to many new emergency physicians in public hospitals, and to me, that our society was not assuring conditions in which all people could prosper and be healthy.
E.B. White in 1949 described what I appreciated in my daily tasks:
Walk the Bowery under the El at night and all you feel is a sort of cold guilt. Touched for a dime, you try to drop the coin and not touch the hand, because the hand is dirty; you try to avoid the glance, because the glance accuses. This is not so much personal menace as universal—the cold menace of unresolved human suffering and poverty and the advanced stages of the disease alcoholism. On a summer night the drunks sleep in the open. The sidewalk is a free bed, and there are no lice. Pedestrians step along and over and around the still forms as though walking on a battlefield among the dead. In the doorways, on the steps of the savings bank, the bums lie sleeping it off. Standing sentinel at each sleeper’s head is the empty bottle from which he drained his release. Wedged in the crook of his arm is the paper bag containing his things. The glib barker on the sight-seeing bus tells his passengers that this is the “street of lost souls,” but the Bowery does not think of itself as lost; it meets its peculiar problem in its own way—plenty of gin mills, plenty of flophouses, plenty of indifference, and always, at the end of the line, Bellevue. [(14), pages 38–9, reprinted with permission]
There were many other markers of public health failures. The most obvious toxicologic problems in the cities were lead poisoning, alcoholism and heroin use, while elsewhere, environmental issues—Love Canal (New York), Times Beach (Missouri), toxic waste in our rivers (Woburn, Massachusetts), air pollution, lack of food quality control, the residues of pesticides in our foods and water—and our inadequate occupational health system, were great concerns. Profit, integrity and the environment were in conflict everywhere as Jonathan Harr described in A Civil Action:
By the time Schlichtman had finished with Riley he revealed: Riley had lied about never removing anything from the fifteen acres, about never seeing debris on any part of the land, about destroying all tannery records before 1979, even about the machine that had used tetrachloroethylene. (15)
I understood that our success in Emergency Medicine would be measured by how effectively we met the needs of our patients. The wealthy were well protected by elite systems of health coverage. We were faced with meeting many of the needs of those who were of no interest to society or organized medicine. Our efforts were frequently opposed by America’s leading physicians. A common rejoinder to the development of an Emergency Department or a residency was: “over my dead body.”
Whereas many other hospitals in the city were simply dumping patients with costly diseases, immigrants, trauma patients, alcoholics and those with psychoses, with an intent to avoid social integration and complicated costly services, we began to serve the whole community: anyone who came to the door would be cared for in an order based upon severity of illness.
I saw our future as a communitarian battle to serve the neediest, least advantaged amidst abject poverty. I shared ideas with Sandra Opdycke, who described the differences between Bellevue and the prototypic private hospital, New York Hospital, in her doctoral thesis and ultimately analyzed the importance of Bellevue. Her answer to the following rhetorical question was a resounding “Yes.” Given the public hospitals’ many flaws and their unequal status with the city’s network of hospitals, was New York justified in maintaining them for 2 centuries? (16)
In the early 1980s, a single toxicologic emergency associated with non-seasonal heatstroke altered the level of support and importance of medical toxicologists and emergency physicians in the medical and legal communities. A young female patient was admitted and examined by an intern and a resident after being brought by family to an Emergency Department with agitation, fever, chills, myalgias and arthralgias. Her medical history included psychiatric treatment for stress and a recent tooth extraction and earache. She was taking phenelzine, oxycodone and erythromycin. On admission her temperature was elevated to 39.7°C and she had orthostatic pulse and blood pressure changes. The young woman’s private attending physician declined to come to the hospital. The resident made a diagnosis of “viral syndrome with hysterical symptoms,” obtained blood cultures, and prescribed acetaminophen for fever and meperidine for agitation and shivering. The intern was called when the patient became restless and disoriented, and, rather than evaluate the patient, the intern ordered, by telephone, physical restraints and haloperidol. When the patient became more agitated and febrile to 42°C, the intern was again paged; she ordered, by phone, a cooling blanket. Four and one half hours after admission, the patient experienced a respiratory arrest and died.
The cause of death was unclear, but infection and drug reaction or interaction, were implicated. Meperidine was known to react adversely with phenelzine, and traces of cocaine were found in the serum. Whatever the cause, respiratory and cardiovascular arrest resulted from inadequate treatment of hyperthermia. Her fate was similar to that of George Orwell. This is how he described his care in a Parisian Hospital:
During my first hour in the Hôpital X I had had a whole series of different and contradictory treatments, but this was misleading, for in general you got very little treatment at all, either good or bad, unless you were ill in some interesting and instructive way. (17)
I worked as an informal advisor on the Report of the Fourth Grand Jury of the New York Supreme Court for the April/May term of 1986, Concerning the Care and Treatment of a Patient and the Supervision of Interns and Junior Residents at a Hospital in New York County. I spent the better part of 2 years on the New York State Department of Health Ad Hoc Advisory Committee on Emergency Services, Supervision and Residents’ Working Conditions, acting as the emergency physician with my good friend Dr. Bertrand Bell. We listened to the testimony as leaders of America’s medical establishment disagreed with our ideas on house staff supervision, regulation of working hours and the role of Emergency Medicine.
We concluded that unsupervised house officers should not care for patients in Emergency Departments and the number of consecutive hours an emergency physician worked should be limited. It was also decided that computerized systems to identify drug interactions should be utilized. This experience and the fate of the young patient helped me develop my perspective on the special role of medical toxicologists in Emergency Medicine, and of emergency physicians in Medical Toxicology. This experience established my absolute commitment to the development of both specialties and to the employment of numerous individuals who have been trained in both specialties.
This grand jury and the New York State Health Department effort dramatically enhanced the power of the Emergency Department in our state. This case and subsequent efforts are detailed in The Girl Who Died Twice: The Libby Zion Case and the Hidden Hazards of Hospitals by Natalie Robins.
Key emergency physicians throughout the state recognized that although this case did not actually result from Emergency Medicine malfeasance, the quality of the care would have been altered had an emergency physician been involved. We felt that supervision throughout health care was essential, and attending emergency physicians were the only ones who could achieve quality care in our departments. It became our goal to implement the supervisory regulations in our state, thereby creating a necessary deficit of formally trained emergency physicians, which, in turn, would affirm the need for Emergency Medicine residencies.
In these battles the old regime stood as a stark silhouette to the premier institutions in our city who fought the development of academic Departments of Emergency Medicine and Emergency Medicine residencies. I was most fortunate to have so many prominent “antimentors” to lead me. Bertholdt Brecht’s poem Burning Books stayed on my desk for decades as a reminder of integrity in battle.
When the Regime commanded that books with harmful knowledge
Should be publicly burned and on all sides
Oxen were forced to drag cartloads of books
To the bonfires, a banished
Writer, one of the best, scanning the list of the
Burned, was shocked to find that his
Books had been passed over. He rushed to his desk
On wings of wrath, and wrote a letter to those in power
Burn me! He wrote with flying pen, burn me! Haven’t my books
Always reported the truth? And here you are
Treating me like a liar! I command you:
Burn me! (18)
From my first days at Bellevue in 1979, we were confronted with many rare and inexplicable conditions in young 30ish homosexual men and intravenous drug users. The diversity and frequency of exceptionally rare infectious diseases—cytomegalovirus, Pneumocystis carinii pneumonia, diverse sexually transmitted diseases and textbook classic Kaposi’s sarcoma in the wrong populations as well as what was called GRID (gay-related immunodeficiency disorder) were amazing. The CDC’s MMWR and the New York Times Science Times pages were filled with details about our patients.
We talked continuously about these unbelievable patients. As the Emergency Department and the hospital filled with sick young men, fear grew throughout the hospital and government. These young, gaunt men with unrelenting fevers were beginning to die everywhere. We tried to assure everyone, clerks, aides, nurses, doctors and students that although we didn’t know much about this disease we believed that “it was not contagious” to the healthcare worker.
Some admitting clerks, dietary aides and doctors hesitated to do what was necessary to render care. We were serving society, but were we a risk to our families? We were revisiting the mindset of the 14th century.
As we began to understand the infectious nature of this entity, gloves became routine garb; universal precautions were developed; blood banking was revolutionized; sexual activities and patient sexual preferences became a routine component of the patient history; hemophiliacs were dying; needlesticks (sharps’ injuries) became a grave risk; ED thoracotomies were questioned. Did the risks to our staff exceed any possible benefits to our patients? The debate about the civil rights of our patients and ourselves, and the rights of all to be protected from these poorly understood disorders, was continuous.
And progress began to occur—we acquired a diagnostic test, a drug (AZT), AIDS wards, AIDS clinics, experimental agents—protease inhibitors, more drugs, grants, HIV testing in the ED and post-exposure prophylaxis for needlesticks and sexual assaults. Now in 2002 we see so few prisoners and gay men with AIDS due to such effective primary care and follow-up and a system. We all changed so much and so did the world. As progress began to occur in HIV, a concomitant tuberculosis (TB) epidemic resurfaced. The federal, state and city governments reinvested in public health care for TB and AIDS because the safety of the hospitals, shelters, prisons and any place of societal congregation was threatened.
Our social workers—1–2 workers/24 h a day, 7 days a week at Bellevue since 1979—saw every homeless or alcoholic patient. In the 1980s every social worker converted his or her PPD during the first year of work despite the pervasive use of masks and UV lights. These data were tragic, yet their risks and ours gave us the evidence to tell the mayor and every news reporter that it was too risky for their Bellevue photo opportunity. We would only survive at Bellevue with a new Emergency Department with many negative pressure isolation rooms, no recirculated air, and space—lots of space.
The inquisitive mix of medical toxicologists and emergency physicians in our department led to an understanding of patient reactions and drug interactions to new clinical trials of diverse agents and exposure to the surging number of alternative therapies such as the Chinese cucumber (compound Q), St. John’s Wort, Peptide T and diverse charlatanical therapies.
The tensions in our community were enormous—patients questioning the medical establishment for delays in therapeutic interventions and for requiring placebo-controlled studies in the face of this lethal epidemic. The societal response, particularly gay men’s action groups, led to action by the FDA and NIH, helped us rethink the standards for drug trials and medical research.
Across the country many have described this era with eloquence: Have you read Randy Shilts, And the Band Played On: Politics, People and the AIDS Epidemic, a view from the west coast; Abraham Verghese, My Own Country: A Doctor’s Story of a Town and Its People in the Age of AIDS, a view from the rural south; and Abigail Zuger, Strong Shadows: Scenes From an Inner City AIDS Clinic, a view from New York City? These authors dealt with the physical and metaphysical suffering of many of our nation’s young and creative people. The values, character and empathy of many of my coworkers were remarkable in their efforts to aid a suffering humanity. Many of us reread Camus’ The Plague; we rethought our stereotypic analyses and we began to consider the unthinkable. Camus’ biographer Herbert Lottman emphasized Camus’ belief that the plague was everyone’s responsibility. In this discussion Camus responded: “It can be as dangerous not to be in the resistance as to participate.”
One additional legislative effort had a dramatic role in confronting what had become a common practice—the transfer and abandonment of complex, poor, or “uninteresting” emergency patients. These “uninteresting,” demanding and costly patients had common disorders such as alcoholism, trauma, substance use and psychosis. These callous acts led Congress in 1986 to pass the Comprehensive Omnibus Reconciliation Act (COBRA) that prohibited the transfer of unstable emergency patients for financial reasons by any hospital accepting Medicare payment. This act created a limited form of emergency access by mandating that any patient presenting to an Emergency Department must have a screening examination and was entitled, at a minimum, to stabilizing treatment in the face of an emergency. This law and numerous common law precedents established a guaranteed access to the Emergency Department, and ultimately to the hospital, regardless of a patient’s ability to pay. This concept of unconditional access was to be based solely on the patient’s belief that he or she had an emergency condition. Because COBRA and its legislative sequel, the Emergency Medical Treatment and Active Labor Act (EMTALA), assured access but guaranteed no funding, an unwritten mandate for the care of the uninsured was established. To me the great success of this legislation was that it counterbalanced the rapidly evolving medical climate that was grounded in business values and, it seemed to me, was inconsistent with the essential values of Emergency Medicine. The iconoclastic George Bernard Shaw, who was to win the Nobel Prize for literature in 1925, had foretold the conflict almost a hundred years ago:
Nobody supposes that doctors are less virtuous than judges; but a judge whose salary and reputation depended on whether the verdict was for plaintiff or defendant, prosecutor or prisoner, would be as little trusted as a general in the pay of the enemy. It is simply unscientific to allege or believe that doctors do not under existing circumstances perform unnecessary operations and manufacture and prolong lucrative illnesses. (19)
By the mid 1980s, I realized that the next level of success could only be achieved at Bellevue and New York University with the development of an Emergency Medicine residency. This unique environment was a ready classroom: a place with innumerable opportunities to help patients, while studying Emergency Medicine, Public Health and Medical Toxicology.
I lobbied everyone who would listen and many of those who wouldn’t! Various hospital leaders, all the chairs of academic departments, the head of the Health and Hospitals Corporation, the City and State’s Commissioners of Health, and the Mayor and his Deputies. I pleaded that patients could not get the care they were entitled to without Emergency Medicine residents, that I could not keep the best faculty and that students could not become great doctors without an academic Emergency Medicine experience.
I tried to demonstrate our academicity through our textbook, currently released as a seventh edition, showing that we were trying to understand a body of knowledge and link our passion for clinical medicine with the promise of science to solve a few of medicine’s complex problems.
I lost or was rebuffed at every level, numerous times; my opposition representing the viewpoint of organized Internal Medicine was intense and there were many, even in organized Emergency Medicine, who opposed the concept of education in public hospitals.
As Camus reevaluated the absurdity of post-Nazi European life, I found strength in his wisdom:
But Sisyphus teaches the higher fidelity that negates the gods and raises rocks. He too concludes that all is well. This universe henceforth without a master seems to him neither sterile not futile. Each atom of that stone, each mineral flake of that night filled mountain, in itself fills a world. The struggle itself toward the heights is enough to fill a man’s heart. One must imagine Sisyphus happy. (20)
During this era I worked with Edward Zeigler, who visited the Bellevue Emergency Department weekly for a year and then spent nights and weekends collaborating with me on Emergency Doctor. Through this vehicle I expressed our passion and my vision. We described the special characteristics of Emergency Medicine, Medical Toxicology and Public Health in New York City through the experiences of my coworkers and myself. It was my goal to explain Emergency Medicine to the public, describe our collective mission and use this document to mobilize the effort for an Emergency Medicine residency and an academic department.
Unfortunately, many of my committed staff left due to neglect, abuse and an often intolerable environment. When the community board came to my assistance, stating that New York University medical students would not be allowed into Bellevue if we could not develop a residency, a resolution was brokered by the President of the Health and Hospitals Corporation, the Mayor’s Deputies and our Dean. This battle, reported weekly in the New York Times by a critical metropolitan reporter, Howard French, strengthened the will of our staff, taught us the importance of Emergency Medicine to the people, and exposed the fear and hostility that organized medicine had towards Emergency Medicine.
Pangloss sometimes said to Candide:
All events are linked up in this best of all possible worlds; for if you had not been expelled from the noble castle, by hard kicks in your backside for love of mademoiselle Cunegonde, if you had not been clapped into the Inquisition, if you had not wandered about America on foot, if you had not stuck your sword in the Baron, if you had not lost all your sheep from the land of Eldorado, you would not be eating candied citrons and pistachios here. “Tis well said” replied Candide: but we must cultivate our gardens. (21)
Now with two decades of graduates of our Medical Toxicology fellowship, a decade of graduates of our Emergency Medicine residency, and a decade of stability for an exceptionally diverse and creative faculty, we are accepted as an essential part of a great and troubled hospital.
No one can analyze these complex problems alone. I have had many great and supportive coworkers at Bellevue and across the country and the world. My hidden resources at home have been plentiful as my wise and supportive wife used her rigorous study of psychology and humanism to redirect and develop my ideas. Our children Michelle, Andrew, Jennifer and Rebecca have left imprints on my efforts through their analysis of work as volunteers in the Emergency Department and as tableside voices of integrity, personal action and passion. Their voices and wisdom are found everywhere in my daily actions.
Bellevue has always served America’s new immigrants. The institution is Ellis Island in the form of a hospital. Our experience in serving people from 85 different nations speaking 35 different languages each month makes us a United Nations of healthcare. The education of our staff with regard to global and international health has led to an understanding of new infectious diseases such as AIDS, new complications of global chaos such as slavery and torture, new educational exchanges in Emergency Medicine and Medical Toxicology, research grants in global health and Emergency Medicine in diverse international sites. Many of our staff have become ambassadors for Emergency Medicine working in other countries and hosts for visitors in our department promoting international health, friendship and understanding. These staff members were among the hardest workers after the terrorist attacks on our city and the most committed to a rational response.
How we related to these daily new experiences has formed us. Remembering Lederer and Burdick’s The Ugly American and understanding new cultures through the eyes of Barbara Kingsolver in The Poisonwood Bible and Anne Fadiman in The Spirit Catches You and You Fall Down has allowed our staff to visit the four corners of the world and successfully contribute to improved international relationships. Anne Fadiman’s description of the Hmong in California in The Spirit Catches You and You Fall Down demonstrates the complexity of our tasks. Her description of how she thought the Hmong parents of Lia, an infant with refractory epilepsy, desired their child to be treated is essential to understand the complexity of our tasks as physicians.
What kind of treatment do you think the patient should receive?
What are the most important results you hope she receives from this treatment?
You should give Lia medicine to take for a week but no longer. After she is well, she should stop taking the medicine. You should not treat her by taking her blood or the fluid from her backbone. Lia should also be treated at home with our Hmong medicines and by sacrificing pigs and chickens. We hope Lia will be healthy, but we are not sure we want her to stop shaking forever because it makes her noble in our culture, and when she grows up she might become a shaman. [(22), page 260, reprinted with permission]
Our experience after the World Trade Center bombings; the numerous calls to police and the Poison Center with regard to “Anthrax;” our previous experiences with capsules, candy and drink contaminated with cyanide, thallium and strong bases, as well as West Nile Encephalitis, have led to our preparedness for biochemical terrorism.
We have had to think about the unthinkable, answer questions about the unknown, and work to develop strategies for risk reduction. We have tried not only to understand the terrorist mentality, but to study abandoned diseases like smallpox and anthrax, and the risks of chemicals thought to be left in Second World War stockpiles. Our roles with the New York City’s Office of Emergency Management became vital to society’s safety as we tried to use these real or perceived threats to enhance the public’s health for disorders that naturally occurred—the environmental spills and the dangerous disorders such as AIDS, multiply drug-resistant tuberculosis, Hantavirus and whatever else might come.
All the same, let us be clear that the toll of work for our Emergency Department and Poison Center during the first West Nile virus epidemic in 1999 and the Bacillus anthracis epidemic of 2001 overwhelmed the surveillance, educational, laboratory and information systems. As new resources are developed and infrastructure expanded, much as a result of these recent experiences, the importance of Emergency Medicine’s essential role in public health will be further appreciated.
New York City’s and America’s greatest current problems were foreseen by E. B. White in 1949:
The subtlest change in New York is something people don’t speak much about but that is in everyone’s mind. The city, for the first time in its long history, is destructible. A single flight of planes no bigger than a wedge of geese can quickly end this island fantasy, burn the towers, crumble the bridges, turn the underground passages into lethal chambers, cremate the millions. The intimation of mortality is part of New York now: in the sound of jets overhead, in the black headlines of the latest edition.
All dwellers in cities must live with the stubborn fact of annihilation; in New York the fact is somewhat more concentrated because of the concentration of the city itself, and because, of all targets, New York has a certain clear priority. In the mind of whatever perverted dreamer might loose the lightning, New York must hold a steady, irresistible charm.
It used to be that the Statue of Liberty was the signpost that proclaimed New York and translated it for all the world. Today Liberty shares the role with Death. Along the East River, from the razed slaughter houses of Turtle Bay, as though in a race with the spectral flight of planes, men are carving out the permanent headquarters of the United Nations—the greatest housing project of them all.
This race—this race between the destroying planes and the struggling Parliament of Man—it sticks in all our heads. The city at last perfectly illustrates both the universal dilemma and the general solution, this riddle in steel and stone is at once the perfect target and the perfect demonstration of nonviolence, of racial brotherhood, this lofty target scraping the skies and meeting the destroying planes halfway, home of all people and all nations, capital of everything, housing the deliberations by which the planes are to be stayed and their errand forestalled. [(23), pages 52–3, reprinted with permission]
We have many directions in which to go and many areas yet to investigate in Emergency Medicine. A great deal of our future lies within collaborative care and research relationships in out-of-hospital settings, hospitals and medical centers. These collaborative principles should form key relationships for ambulatory and hospital clinical care pathways and research design. Our creative approaches to patients with undifferentiated illnesses, our ability to solve problems and make decisions for the acutely ill and injured in the face of limited data and substantial uncertainty, and our participation in advances in resuscitation define the future of Emergency Medicine. In addition, this “first contact” form of medicine emphasizes the humanistic, social and intellectual aspects of medical education that will retain and inspire the most committed students to the highest forms of idealism. The opportunity to study in the Emergency Department will prepare some students for future training in Emergency Medicine. For most students the Emergency Department offers a first broad exposure to society. They will gain essential skills in the assessment and management of the patient with undifferentiated clinical problems infrequently seen elsewhere in medicine today. These factors and a creative approach to new and innovative treatment modalities will allow clinical Emergency Medicine to play a vital role in the education and service roles in healthcare. Students, residents, research fellows and faculty will continue to ask the critical questions, frame the essential hypotheses and offer vital answers for emergency healthcare.
In our clinical settings each patient represents part of a kaleidoscopic view of our communities. It is my belief that each patient, when cared for and understood, allows us a better chance to care for and understand the community and society at large. Many of our patients represent both a failure of our public health system and simultaneously an opportunity to consider how to correct a problem.
Effective patient-physician communication is fundamental to the effort of all physicians in achieving compassionate patient care. The potential obstacles to effective communication (language, culture), communication with the difficult patient (dementia, psychosis, intoxication), the challenging situations (victims of violence, sudden death), to discharge instructions and medicolegal issues—these present basic dilemmas for all emergency physicians. Learning to work in an environment with these complex problems allows the student to learn effective communication skills.
I have often thought about my lack of classic mentors in Emergency Medicine, but I have not been left wont for other heroes and heroines. The study of literature, philosophy, medicine and politics could be essential for you, too, as emergency physicians to direct the specialty in the 21st century. In Emergency Medicine we deal with uncertainty at every level and traditional philosophy will help us develop our arguments and logic, our skepticism, our antidotes to the rigid assertions of our professors, our politicians and their dogma. But, I believe that it is our study of literature that encourages the continual analysis of our complex world, the social intricacies of our patients, and the everchanging perspectives of our sciences. These readings provide essential alternative perspectives and an ethical foundation necessary to understand and solve the moral problems we must confront. Our learning and our teaching of students, residents and ourselves begin with the patient in his or her global community. Our strength is our commitment to the science of medicine and our continuing drive to enhance the rights of our patients and improve their access to care by altering our political environment.
FULL TEXT
