FORUM

The Biology of
Emergency Medicine
Peter Rosen, MD
Denver, Colorado

Rosen P: The biology of emergency medicine. JACEP 8:280-283, July, 1979.

emergency medicine, specialty

INTRODUCTION
Aristotle has often been misquoted as stating that all things must have a
beginning, middle, and end. What he actually said 1 was, "A whole is that which
has a beginning, middle, and end." I think it might be instructive to analyze
emergency medicine as a whole to present my vision of the specialness of
emergency medicine.
THE WHOLE
The BEGINNING - - "that which is not itself necessarily after anything
else, and which has naturally something else after i t . . . , u
The history of emergency medicine is not yet written. But less important
than who were the first physicians to restrict their practice to emergency
medicine are the reasons for the appearance of the specialty.
It is hard to comprehend why it took so long for attention to be paid to the
demands of the specialty. Certainly, since man took his first steps, there have
been accidents and ailments that struck him down unawares. Doubtless, it takes
a certain technology and willingness to intervene in natural disasters by an
emergency response. Nevertheless, it is still an unaccountably late development
in modern medicine.
The beginning cannot, therefore, be the onset of those medical conditions
that would mandate a professional emergency response. In fact, when one
analyzes emergency medicine in terms of its case load, one is quickly struck b y
the fact that true emergencies, ie, the life or limb threat, are .not what has
produced the beginning of the field.
Even the urgent cases (nonlife or limb threat but requiring a response to
prevent deterioration into true emergency) probably would not have produced
the field. In fact, I believe that two events coincided to produce the beginning:
first was increasing numbers of nonemergency patients in the emergency de-
partment; second, the initial financial support for these cases in the emergency
department. The cause of the increased workloads is multifactorial: the disap-
pearance of primary physicians; the demise of the housecall, the growth of urban
populations, the increased expectations of the public ("If you can put a man on
the moon, why can't you cure my cold?"); the initial willingness of third party
carriers to pay for emergency department visits but not office calls, and last, but
not least, the captive presence of a physician in a predictable geographic area

From Emergency Medical Services, Denver General:Hospital, Denver, Colorado.

Presented at the Fifth Annual Rocky Mountain Regional Conference on Emergency Medicine in
Keystone, Colorado, January 1979.
Address for reprints: Peter Rosen, MD, Director, Emergency Medical Services, Denver General
Hospital, West Eighth Avenue and Cherokee Street, Denver, Colorado 80204.

ss/2S0 JACEP 8:7 (July) 1979

 ~hen t h e p a t i e n t w a n t e d to be seen: the interface w i t h
the medical d e l i v e r y system. I,m sure t h a t m a n y o t h e r
factors can be offered to e x p l a i n this onset, b u t what-
ever the conglomeration of sociologic, technologic and
sedical events, in the late 1960s the crisis became
~biquitous, a n d t h e r e s p o n s e p r o d u c e d e m e r g e n c y
~edicine.
The MIDDLE - - " t h a t which is b y n a t u r e after
one thing, a n d has also a n o t h e r after it. ''1
I It is h a r d l y a r g u a b l e t h a t e m e r g e n c y m e d i c i n e
evolved along the only possible p a t h or even t h a t w h a t
we recognize as emergency medicine t o d a y is the form
that it will a s s u m e over the n e x t s e v e r a l decades. B u t
as we a l l s t r u g g l e to define o u r roles a n d respon-
sibilities, it is worthwhile to pause and ask: Is t h e r e
anything u n i q u e a b o u t e m e r g e n c y medicine t h a t we
can see in our struggle to define it as a special entity?
That this was not done before the specialty h a d its be-
ginning is not unique. While one can clearly distin-
guish b e t w e e n the allergist a n d t h e v a s c u l a r surgeon,
and r e a d i l y u n d e r s t a n d the i n t e l l e c t u a l a n d t e c h n i c a l
concerns t h a t s e p a r a t e them, the epistomological wa-
ters b e c o m e v e r y m u r k y w h e n t r y i n g to d e c i d e to
whom to refer the facial fracture - - oral, plastic sur-
geon, or otolaryngologist.
DEFINING THE SPECIALTY
Webster's Dictionary d e f i n e s a s p e c i a l t y as: " A
branch of knowledge, science, a r t or business to which
one devotes o n e s e l f w h e t h e r as a n avocation or a pro-
fession, and u s u a l l y to the p a r t i a l or t o t a l exclusion of
related matters~. ''
W h a t is there to e m e r g e n c y medicine to j u s t i f y
this definition?
First, t h e r e is the workload in and of itself. Not
only did it produce the economic incentive for people
to "exclude t o t a l l y or p a r t i a l l y r e l a t e d m a t t e r s , " b u t
its l o g i s t i c s b e g a n to s h a p e t h e s p e c i a l n e s s o f
emergency medicine.
One of the specialty's responsibilities is not only
to s e p a r a t e t h e sicker from the less sick b u t to j u g g l e
several patients simultaneously. The emergency
physician does not have the l u x u r y of devoting all of
his energy to a single case at a time.
To r e t u r n to the s e p a r a t i o n of emergency, u r g e n t ,
a n d n o n e m e r g e n c y , c l e a r l y m a n y of us c h o o s e
emergency medicine because of t h e life or limb t h r e a t .
The "cowboy case" m a k e s our a d r e n a l i n flow a n d com-
batting d e a t h is t h e i n t e l l e c t u a l and e m o t i o n a l chal-
lenge we sought in becoming physicians. But, in fact,
as we e x a m i n e our response to t h e emergency, o u r re-
s p o n s i b i l i t i e s a r e d e f i n e d less b y t h e d e f i n i t i o n of
the disease s t a t e t h a n by the level of life threat. As an
analogy, the role of e m e r g e n c y medicine is to catch the
climber who is falling from a precipice and r e t u r n h i m
to as much safety, as can be r e a d i l y achieved, b u t not
necessarily to get h i m all t h e w a y b a c k down to the
valley. Nor does it m a t t e r how he fell. The life t h r e a t
of the fall m u s t be overcome before d e t e r m i n i n g t h a t
his rope broke or t h a t he Was p u s h e d by a j i l t e d lover.
A t times, t h a t i n t e r v e n t i o n can be lifesaving; a t
times, m e r e l y stabilizing as in volume r e p l a c e m e n t in
the h e m o r r h a g i n g patient.
A n d as we define o u r r e s p o n s i b i l i t i e s , we g e t
c a u g h t up i n t h e u n i q u e n e s s of o u r s p e c i a l t y . T h e
dying o r g a n i s m b e h a v e s differently. W h e r e we inter-
8:7 (July) !979
vene in t h a t d e a t h t h r e a t , in fact, sets the limits of our
field.
L e t us e x a m i n e t h e d y i n g p a t i e n t . Despite t h e
etiology, t h e r e a r e o n l y a s m a l l , finite n u m b e r of
p a t h w a y s to death: f a i l u r e of r e s p i r a t i o n , f a i l u r e of
circulation - - e i t h e r v i a t h e p u m p or via the volume of
t h e s y s t e m , f a i l u r e o f t h e b r a i n , or f a i l u r e of
metabolism. A l t h o u g h specific i n t e r v e n t i o n s m u s t be
made for specific causes - - t h e response to the care
coronary is different t h a n to the r e s p i r a t o r y failure
from drug overdose -- our specialty establishes
a d e q u a t e oxygenation, a n d does not teach b e t t e r t a b l e
m a n n e r s to t h e former or p e r s o n a l i t y control to the
l a t t e r . F u r t h e r m o r e , t h e p r o c e s s of d y i n g c a n be
looked at grossly or microscopically. Not every p a t i e n t
with low blood p r e s s u r e and r a p i d pulse has inade-
quate tissue perfusion. Correct a s s e s s m e n t h a s to be
the most i m p o r t a n t r e s p o n s i b i l i t y of our specialty.
Nor is our s p e c i a l t y confined to medical p a r a m e -
ters alone. E m e r g e n c y medicine h a s extended the a r m
of t h e p h y s i c i a n to the field. In m a n y a r e a s we have
been r e m i s s in a s s u m i n g t h e obligations of p r e h o s p i t a l
care. But as one reviews t h e l i t e r a t u r e , it is s t r i k i n g
how i n a d e q u a t e a n d i n a p p r o p r i a t e is the field medical
control of the i n t e r n or of the coronary care unit. The
education, function a n d q u a l i t y control of p r e h o s p i t a l
c a r e m u s t , a n d w i l l , b e a s s u m e d by e m e r g e n c y
medicine.
In addition, t h e r e a r e the sociologic aspects of t h e
acutely d y i n g to be d e a l t with. Much of the w o r k on
d e a t h and d y i n g h a s b e e n in the context of chronic
disease. All preconceived lessons m u s t be u n l e a r n e d
w h e n calling out-of-state p a r e n t s to inform t h e m of
t h e i r child's sudden death.
To m y m i n d , t h e h a r d e s t t a s k in e m e r g e n c y
medicine is the decision to send home a p o t e n t i a l l y
life-threatened p a t i e n t . The p a t i e n t who is d i a p h o r e t i c
w i t h clenched fist a n d an e l e c t r o c a r d i o g r a m (ECG)
w i t h ST elevations p r e s e n t s no p r o b l e m in m a k i n g a
decision. Not so the p a t i e n t who has had some chest
pain, which is now gone, a n d no other clues to assist in
the decision. Our awesome responsibility is deciding
w h e t h e r to i n t e r v e n e in this p a t i e n t ' s life t h r e a t or to
send h i m home. I w i s h I could say I have a l w a y s e r r e d
on t h e side of safety for the p a t i e n t .
EMERGENCY MEDICINE'S UNIQUE BIOLOGY
To r e t u r n to the classic acute m y o c a r d i a l infarc-
tion, the biology of e m e r g e n c y medicine does not de-
m a n d proof of t h i s d i a g n o s i s in the e m e r g e n c y de-
p a r t m e n t ; it does d e m a n d stabilization. U n t i l this les-
son is learned, lives will be lost while ECGs a r e being
r u n prior to p l a c e m e n t of IV lines and a d m i n i s t r a t i o n
of prophylactic lidocaine.
For a n u m b e r of years, I have been s a y i n g t h a t
the e m e r g e n c y p h y s i c i a n m u s t be as good as the car-
diologist in r u n n i n g a n a r r e s t . After s e v e r a l r e c e n t
experiences w a t c h i n g cardiologists in charge of a n ar-
rest, I say they m u s t become as good as the e m e r g e n c y
physician.
It is t i m e t h a t we accept o u r role in m e d i c i n e
without apology a n d w i t h the confidence t h a t we can
do the job well w i t h o u t c a l l i n g for help u n t i l t h e n e x t
phase of care by the a p p r o p r i a t e specialty. The d a y s
w h e n the e m e r g e n c y p h y s i c i a n functioned as a refer-
r i n g s e c r e t a r y a n d a s k e d p e r m i s s i o n before i n t e r v e n -
JACEP 281/59
 ing in a p a t i e n t ' s life t h r e a t , must, should, a n d shall
come to an end.
P a t i e n t s do not '~belong" to p h y s i c i a n s or services.
P a t i e n t s have p r o b l e m s t h a t r e q u i r e c a r e on m a n y
levels. The quality, appropriateness and t i m e l i n e s s of
the i n i t i a l care is the biology and r e s p o n s i b i l i t y of our
specialty. No one who h a s n ' t t r a i n e d for it, or prac-
ticed it o t h e r t h a n full-time, is capable of r e n d e r i n g it.
Merely because someone passed through an
emergency medicine service as a student, intern, or
medical r e s i d e n t does not give t h e m the expertise of
our specialty. It t a k e s y e a r s of diligence, experience,
and c o m m i t m e n t to gain t h a t expertise.
The limit of our specialty is, therefore, set by its
u n i q u e biology, and t h a t t i m e c o n t i n u u m w h e n other
i n t e r v e n t i o n s b e c o m e a p p r o p r i a t e . These will v a r y
w i t h the degree of life t h r e a t , the need for future care,
or the need for i n p a t i e n t or follow-up care. But to a
degree, to r e t u r n to our analogy, the type of interven-
tion r e l a t e s to the distance to the valley. C e r t a i n life
t h r e a t s c a n be s t a b i l i z e d d e f i n i t i v e l y w i t h i n t h e
e m e r g e n c y d e p a r t m e n t . Others require special inter-
ventions, frequently dictated by how critical is time.
F o r example, an extensive facial l a c e r a t i o n m u s t at
t i m e s be referred to a surgeon because t h e r e are 20
o t h e r p a t i e n t s a w a i t i n g care.
EMERGENCY MEDICINE IN THE FUTURE
But is it enough to be involved in only one phase
of life threat? The a n s w e r to t h a t question is the shape
of emergency medicine in the future. The degree of
satisfaction or dissatisfaction in a n y field is the price
t a g or r e w a r d upon w h i c h c o n t i n u e d p a r t i c i p a t i o n
hangs. I t h i n k e m e r g e n c y medicine "burn out" is more
dependent on t h e psychic tension and stress of d e a l i n g
w i t h d e a t h as a s t e a d y diet t h a n a lack of being able to
"play in the valley."
A second component o f our specialty is the u r g e n t
patient. Here, too, is a special pathophysiology t h a t
r e q u i r e s knowledge, technique and c o m m i t m e n t s - -
the pathophysiology in acute exacerbation of a chronic
disease or l i m i t e d n o n l i f e - t h r e a t e n i n g disease. E v e n if
t h e p a t i e n t is n o t s e r i o u s l y d e c o m p e n s a t i n g , t h a t
t h r e a t m u s t be r u l e d out. The h a r d e s t m e n t a l change
to create in new r e s i d e n t s is to ~'assume the worst e v e n
if s t a t i s t i c a l l y i m p r o b a b l e . " N o w h e r e in i n p a t i e n t
medicine does one l e a r n t h a t in early disease states,
the t h r e a t to life, or well-being, hides itself. The re-
sponsibility is to describe or to deny t h a t life t h r e a t
r a t h e r t h a n to place a specific label on a patient.
M a n y p a t i e n t s c a n be t o t a l l y c a r e d for w i t h i n
e m e r g e n c y medicine; m a n y will require some follow-
up. Again, the degree of service will depend on f u t u r e
definitions and m a y h a v e much less to do w i t h s t a t e d
t u r f t h a n how care is p a i d t0r. For example, at the city
h o s p i t a l or u n d e r n a t i o n a l h e a l t h i n s u r a n c e m a n y
cases are, or will be, seen in the e m e r g e n c y depart-
m e n t which had been m a n d a t o r y referrals to private
offices.
F i n a l l y , t h e r e is t h e price t a g of our specialty: the
n o n e m e r g e n c y p a t i e n t . He, of course, t r i e s o u r pa-
tience, s t u l t i f i e s o u r d r e a m s of professional impor-
tance, produces voluminous letters of complaint, a n d
of course, p a y s our e x t r a v a g a n t salaries. But t h e r e is
still s o m e t h i n g unique about the p a t i e n t who d e m a n d s
a blood p r e s s u r e check a t 3 am.
But w h a t is unique t o the field in all t h r e e classes
ff
60/282
of p a t i e n t s is not j u s t w h a t is h a p p e n i n g on the cellu.
lar level b u t the interface b e t w e e n h e a l t h and disease,
between p a t i e n t and system, and between emergency
system and the i n p a t i e n t service.
No e m e r g e n c y patient, w h a t e v e r the m a g n i t u d e of
his problem, is free from fear. '~An emergency is a~
acute problem I have which I fear will t u r n into some.
t h i n g worse," said a s t u d e n t to m e once. The sore
t h r o a t t h a t seemed a mild a n n o y a n c e d u r i n g the day,
becomes d i p h t h e r i t i c choking (to the patient) in the
middle of the night. The blood p r e s s u r e check at 3 a~
is fear of i m p e n d i n g stroke.
Moreover, the fear of the r e l a t i v e s m u s t be part of
the interface. Who can forget the panic of a carihg
person facing the awesome r e a l i t y of an acutely in.
j u r e d and life t h r e a t e n e d relative? We all live on the
b r i n k of d i s a s t e r and helping people on the wrong side L
of t h a t b r i n k is one of e m e r g e n c y medicine's biologies.
Even w h e n d e a l i n g with a nonemergency, it is
s t i l l i n c u m b e n t u p o n t h e e m e r g e n c y p h y s i c i a n to
e l i m i n a t e all possible life t h r e a t s a n d to t r y to discover
w h a t m o t i v a t e d t h i s visit. Often, it is Something other
t h a n the s t a t e d complaint. S o m e t i m e s the motive is
never clear and the e m e r g e n c y d e p a r t m e n t has to ad.
j u s t to p a t i e n t s who will not seek medical attention
a n y w h e r e else. We h a v e f r e q u e n t l y s e e n t h e phe.
nomenon of p a t i e n t s who relate to an institution, and
specifically the e m e r g e n c y d e p a r t m e n t , r a t h e r than,
and in preference to, a n i n d i v i d u a l physician. This is
becoming true not j u s t for i n d i g e n t s who have been
n u r t u r e d in a s y s t e m of r o t a t i n g h o u s e s t a f f but also in
a d e q u a t e l y funded p a t i e n t s who s i m p l y possess what
we call the s u p e r m a r k e t m e n t a l i t y of medical care.
As one reviews the t o t a l c o m m i t m e n t of the field,
a new responsibility emerges t h a t indeed requires spe-
cial skills a n d knowledge - - the a b i l i t y to prioritize
and a p p r o p r i a t e l y t r e a t each of t h e s e t h r e e categories.
We are poorly t a u g h t in medical school and resi-
dencies to d i s t i n g u i s h sick from well. There are two
g r e a t shocks for every e m e r g e n c y medicine resident:
one, not every p a t i e n t is sick, and two, m a n y patients
are much sicker t h a n t h e y first appear.
Not only m u s t we l e a r n the specialized skill of
sorting and t r e a t i n g these categories b u t we m u s t re-
search the q u a l i t y and q u a n t i t y of care appropriate to
each.
RESEARCH
E m e r g e n c y medicine h a s y e t to define to anyone's
satisfaction its r e s e a r c h goals. T h a t is h a r d l y unique
to emergency medicine in its p r e s e n t infancy. IS there
a biochemical definition of d e a t h a n d dying? We still
live w i t h the legacy of t h e 1950s which insisted all
medicine fit into the Kreb's cycle. It will b e v e r y hard
to produce t h i s k i n d of research, not only because we
l a c k the t a l e n t (at p r e s e n t at any rate), b u t also be-
cause the big a n d e a s y basic r e s e a r c h dollar is now
much h a r d e r to come by. Nevertheless, I do believe
t h e r e is much basic l a b o r a t o r y r e s e a r c h p e r t i n e n t to
our field, and given t i m e and support, we will have a
m u c h e a s i e r t i m e d e m o n s t r a t i n g o u r own unique biol-
ogy. For example, let someone discover a solution that
will c a r r y and r e l e a s e oxygen a n d carbon dioxide and
a t r i p to Stockholm awaits.
U n q u e s t i o n a b l y , t h e r e is g r e a t room for viable
clinical r e s e a r c h and inroads have been made. t per-
sonally believe t h a t m a n y of our most respectable clin-
JACEP 8.7 IJo,i1979
 ical notions, doctrines and fads will be overturned in
the next t e n years as appropriate emergency medical
clinical t r e a t m e n t schedules are devised.
S y s t e m s r e s e a r c h is p r e s e n t l y f a s h i o n a b l e in
~Vashington b u t hopefully will produce something of a
little higher q u a l i t y t h a n anecdotes about MAST suits
or time schedules of patients a p p e a r i n g in emergency
departments.
i While we are t a l k i n g about our middle, we m u s t
discuss education. Our concept of w h a t constitutes a
valid residency experience in emergency medicine is
beginning to crystallize. There are three ingredients
t h a t appear critical: first, adequate p a t i e n t pathology
in the emergency department; second, an adequate at-
tending f a c u l t y in the emergency department, a n d
I third , a n adequate n u m b e r of residents in the emer-
i gency department. If you don't control your own serv-
ice, you cannot develop into a proper specialist.
The one t h i n g t h a t has r e f i n e d my v i s i o n of
emergency medicine more t h a n any other single factor
is watching the evolution of self confidence, specialty
awareness and poise of the emergency medicine resi-
dent who has acquired his t r a i n i n g i n the kind of resi-
dency described above. There is no substitute for on-
line experience. You cannot learn emergency medicine
on someone else's service.
We don't do a good job of educating the under-
graduate in emergency medicine. That, too, is some-
thing t h a t will require some time as well a s commit-
ment from the medical schools, nor is it u n i q u e to
emergency medicine. At present, our best effort is in
the senior elective b u t even this m u s t be improved.
Education for the practicing physician is also in
its infancy. Despite our efforts to s t i m u l a t e c o n t i n u i n g
medical education programs, there doesn't exist yet
the slightest shred of evidence t h a t CME effectively
alters b e h a v i o r , except i n m a k i n g c u r v e d p a r a l l e l
turns on the ski slope. Again, I believe in addition to
didactics, laboratories and workshops, we m u s t de-
8:7 (July) 1979
velop some in situ emergency d e p a r t m e n t teaching for
the practicing physician.
I cannot leave the middle w i t h o u t c o m m e n t on
emergency medicine a d m i n i s t r a t i o n and service. J u s t
as I b e l i e v e t h a t e d u c a t i o n b e s t occurs i n t h e
emergency d e p a r t m e n t , I believe t h a t the field has
suffered from too much a d m i n i s t r a t i o n divorced from
the d e p a r t m e n t - - either because the director simply
has not or does not now practice emergency medicine,
or because he is assigned to the d e p a r t m e n t with no
c o m m i t m e n t to the specialty. I cannot divorce service
from a d m i n i s t r a t i o n , nor do I t h i n k anyone will ever
comprehend the true responsibilities of the specialty
unless they have a m a l g a m a t e d both areas.
AND F I N A L L Y . . .
The END - - " t h a t which is n a t u r a l l y after some-
t h i n g itself, e i t h e r as its n e c e s s a r y or u s u a l con-
sequent, and with n o t h i n g else after it;...,,1
W h e n involved i n the middle, it is always difficult
to foresee an end. Perhaps there is no situation t h a t
will negate emergency medicine's ever being a whole,
short of a n u c l e a r holocaust destroying all m a n k i n d .
But even should unforeseen technologies, sociologies,
or economics produce an end to our specialty, we shall
have had an u n p a r a l l e l e d opportunity for intellectual
and emotional career growth and development.
I shall close by quoting Oliver Wendell Holmes
(Bartletts): "I find the great t h i n g in this world is not
so much where we stand, as in w h a t direction we are
moving: to reach the port of heaven, we m u s t sail
sometimes with the wind and sometimes against it - -
b u t we m u s t sail, and not drift, or lie at anchor."
REFERENCES
1. P o e t i c s B o o k 2 - A r i s t o t l e . Britannica Great Books, Ency-
clopaedia Britannica, 1952.
JACEP 283/61