Medical Humanities Section Newsletter - January 2014
|Letter from the Chair - Medical Humanities Section Newsletter, January 2014|
|From The Editor: Apologies and a Promise - Medical Humanities Section Newsletter, January 2014|
|A reminder - Medical Humanities Section Newsletter, January 2014|
|A Letter from our Board Liaison - Medical Humanities Section Newsletter, January 2014|
|Emergency Medicine in the 19th Century: The Early Evolution of an Institution - Medical Humanities Section Newsletter, January 2014|
|Visual Arts Award Winner 2013 - Medical Humanities Section Newsletter, January 2014|
|Writing Award Winner 2013 - Medical Humanities Section Newsletter, January 2014|
|Novel Club - Medical Humanities Section Newsletter, January 2014|
|Dusting Off A Time-Honored Medical Tool: Words - Medical Humanities Section Newsletter, January 2014|
|Internets Links to Members Works - Medical Humanities Section Newsletter, January 2014|
|Open Mic Night - Medical Humanities Section Newsletter, January 2014|
|2013 Annual Section Meeting Minutes - Medical Humanities Section Newsletter, January 2014|
Letter from the Chair - Medical Humanities Section Newsletter, January 2014
Jay Baruch, MD, FACEP
I'm thrilled to be given the reigns for the medical humanities section chair. I bow to the previous chairs, who have established a creative vision and a standard for excellence. During my tenure, I'll strive to honor their legacy, while at the same time seek opportunities to strike new ground, taking full advantage of the range of talents and interests of section members.
Allow me to tell you a bit about myself. I’m an Associate Professor of Emergency Medicine at the Alpert Medical School at Brown University, where I also serve as the founder and director of the Program in Clinical Arts and Humanities and co-director of the medical humanities and bioethics scholarly concentration. I am also responsible for the medical humanities program in the department of emergency medicine.
My grounding in this field was established by curriculum development and creative work. My collection of short fiction, Fourteen Stories: Doctors, Patients, and Other Strangers (Kent State University Press, 2007) was Honorable Mention in the short story category in ForeWord Magazine’s 2007 Book of the Year Awards. My second short fiction collection, What's Left Out, is scheduled for publication in 2015. My short fiction and essays have appeared in numerous print and online literary, medical and humanities journals. I’ve also contributed book chapters to many humanities texts.
My teaching and curriculum projects at Alpert Medical School are rooted in interdisciplinary and inter-institutional collaborations, including Brown University, the Rhode Island School of Design (RISD), and the RISD Museum. I am a former Faculty Fellow at the Cogut Center for the Humanities at Brown, where I taught an undergraduate seminar bearing the unfortunate title, "Pragmatic Medical Humanities." I also direct the Creative Medicine Series at Brown, a lectureship cosponsored by the Creative Arts Council, the Cogut Center for the Humanities, and the Department of Emergency Medicine at Alpert Medical School. (Our own incredible Dr. Liz Mitchell was an early speaker/performer in this series.)
Though I have created and taught courses at Brown that fit under the banner of medical humanities, and I'm taking over a section with medical humanities in the title, I must confess a certain anxiety about the term medical humanities.
The question, “What is medical humanities?” has flummoxed the very experts who ardently argue for its importance to medical education and the professional and personal growth of health care providers. Rafael Campo, esteemed poet and physician, wrote in a JAMA essay that “no concept of the ‘medical humanities’ compels, caught somewhere between manifesto, mushiness, and marketing lingo.”
Individual persons harbor different meanings for the term, invest it with different values and goals. I believe the humanities are elemental to the act of caring for patients. To fully respond to the sick and injured, one must not only attend to disease and physical damage, but appreciate the impact and meanings of illness and impairment. Through stories we tell ourselves and share with others, knowledge is constructed, experience is interpreted and we work towards shaping what we consider “right” and “good.”
Such an approach is particularly important today, at a moment when our communities face increasingly complex health challenges compounded by greater social, financial and psychological burdens. New methods must be developed to meet the expanding needs of our patients while vigilantly regarding the growing demands placed upon emergency physicians to improve quality, reduce mistakes, and discipline the miscreant health care dollar. Our patients rarely present neatly packaged as a single problem with a well-defined answer; if anything, my patients increasingly present with what feels like ungraspable and complex needs. My creative writing skills, and my knowledge of the structure and anatomy of stories, has proven to be indispensable clinical skills in the emergency department.
Science and technology provide us with the means to diagnose and treat the very sick and badly injured, but they don't address the big, human questions that arise when patients face suffering and death, or prepare us to examine our own values, frailties, and capacity for compassion and tolerance. The medical humanities, regardless of its definition, provides tools for fostering critical thinking skills, encourages respect for different and differing opinions, nurtures passion and curiosity, and fosters cross disciplinary discourse.
The interdisciplinary nature of medical humanities, engaging in conversations with persons who possess different expertise, different knowledge and different approaches to knowing--core native talents to emergency physicians--provides a lens through which one’s moral imagination is given the necessary breadth and focus to wrestle with complex and messy issues, and ultimately, come to a thoughtful response. For me, it's what makes this work creative, stimulating and fun.
Let me share with you a few of my personal areas of focus--in addition to creative writing--as a way of starting a conversation with the section, hoping that we, as a group, can develop some projects that align with common interests:
- Importance of creativity as a medical instrument
- How creative writing skills and a firm understanding of principles of story structure are essential beside tools to improve clinical care, foster communication, and reduce risk and improve patient safety
- The use of the arts to improve critical thinking and metacognition skills in medical training. (Based on my work with RISD Museum educators)
- Role of the humanities as a means for community engagement on healthcare issues.
- Curriculum development
I encourage you to share your interests and ideas. Emergency physicians, and ACEP members, are innovators and leaders in fields that include, but aren't limited to, policy, politics, public health, research, education and medical ethics. Why not add medical humanities to this list? I hope to cultivate a space where individuals can develop their own personal relationship to this strange term "medical humanities." Along the way, I trust we can grow the membership at large. (Please encourage colleagues in ACEP to join us in the section.) For those who want to become more involved, please contact me. I'd welcome the assistance of a core group to help shape the future direction of the Section of Medical Humanities. I'd also like to foster an active community and a platform for communication between the ACEP national meetings. I'd welcome feedback from section members regarding interest in such an informal initiative, and ideas regarding what platform it might take, maybe Twitter?
Keep the ideas coming. Writing, for me, demands extreme humility. Emergency medicine does too. I step into my new role as section chair with similar respect and awe.
You can reach me by email or Twitter (I'm new to this world) @JBaruchMD.
From The Editor: Apologies and a Promise - Medical Humanities Section Newsletter, January 2014
Peter Paganussi, MD, FACEP
Greetings from the ACEP Section of Medical Humanities!
Here at the dawn of 2014 many, many apologies are in order from your editor. In 2013 I managed to get together only one MUSE newsletter. This is an all-time low. I am responsible, and most humbly apologize to the Section and our readers. My promise (and resolution) for the New Year is to get two more issues out before the end of 2014.
Some brainstorming with our Chair, Jay Baruch, has led to new ideas and new energy, which can only enhance this humble publication. I am thrilled at the prospects, but I will need your help. We need writers, artists, musicians, et al to step up and contribute.
The plan is to return to our old ways and set a theme for the next two issues. The first is planned for April/May and the theme is “Passion.” This is to be interpreted variously. It can be passion about art, poetry, food, work, listening to music, etc. Passion about travel can lead to an essay covering the topic. Passion about food may reveal a “history” of a regional or favorite food. Passion about anything you have passion for. Get ready, more to come.
The second issue should come out just prior to the Scientific Assembly/ACEP14 and the theme is loosely “Career Path/Trajectory.” We will discuss the perspectives from emergency physicians at various stages of their career. From residency to retirement, what have you learned lately, what drives you now, what keeps you sane? These are the things we need to hear from our members and others in the specialty. With older physicians (ahem, like yours truly), what has changed for you? Poetry, music, sculpture, photography, prose can all be used to capture these feelings. Once again, more details to come.
As for this issue, we have some truly wonderful works.
We begin with a letter from our new Chair, Dr. Jay Baruch, which you just read, as our introduction. Jay brings a cornucopia of experience and talent to the position. We are truly fortunate to have him.
Next we hear from Dr. Jay Kaplan. Jay is our Liaison to the ACEP Board of Directors and one of the true stalwarts of our Section. His poetry is thoughtful, his photography splendid, and he is another leader in the Section whom we are fortunate to have. Thank you, Jay.
Following the two Jays’ section we have a brilliant piece by Dr. Laurence Conley. I have always wanted to receive a historical work by a member and this one has exceeded my expectations. The work is entitled “Emergency Medicine in the 19th Century: The Early Evolution of an Institution” and is an absolute must read. It is very well written and clearly was well researched, Dr. Conley takes us through the “primordial ooze” from whence our specialty sprang. I am delighted to be able to present such a wonderful, and special, contribution. Bravo, Larry!
The two works following Dr. Conley’s are the Winner of the Medical Humanities Section Visual Arts Award 2013 and Creative Writing Award 2013, respectively. Dr. Kay Moody’s visually intoxicating photo work “Post Call: Early Morning Self Portrait” and the moving, heart-felt “Colombian Orchids” by Dr. Kate Aberger make it easy to see why they garnered the top prizes in this year’s competition.
Dr. Cindy Bitter sent me a very well-done book review last year and I never was able to use it, but I present it here. She reviews Ann Patchetts’ 2011 novel “State of Wonder.. It is such a nicely written piece and she raises some excellent questions in her review. Thanks, Cindy.
The last essay is from another stalwart of the Section, Dr. Seth Hawkins. Seth wrote this piece in 2013 and it appeared prominently in the Emergency Medicine News. It is not just well written, but it also expresses thoughts that I have long held dear myself. That is, words really do matter and the “power” of a physician lies in the ability to communicate and connect with our patients and the population in which we serve. We are indebted to Dr. Hawkins for reminding us that words can often be our best clinical tool. Thank you, Seth.
After Dr. Hawkins we have a couple of items from members online. The most exciting by far is Dr. Liz Mitchell who sang the National Anthem at Fenway Park for the opening game of the Major League Baseball ACLS, October 21, 2013. She did such a beautifully moving rendition that it did indeed bring tears to my eyes. What an honor and what a voice! The Red Sox went on to win the World Series and while David Ortiz had a big hand in this, I feel they owe Liz some kudos as well. Brava, Liz!
Dr. Maribel Gray is a very talented artist and has studied at the prestigious Corcoran College of Art and Design in Washington, DC. She has a Web site with postings of her many works in a multitude of media. This is most assuredly worth taking a few minutes out of your day to take a peek at. Beautiful stuff, Maribel!
Finally, we have a link to an essay I had published in the Washington Magazine Online. A little piece about my name, the problems it can cause and a place where it is actually ok. I hope you enjoy it.
Finally, we end with a photo of the crew from Open Mic Night. I am sorry I could not be there; it looks like another great time at this delightful event. Put me down for 2014!
As always we end with the business of the Section, the minutes from the annual meeting at the SA/ACEP13 in Seattle.
Cheers and thanks for your patience! This site is no longer “Under Construction.”
A reminder - Medical Humanities Section Newsletter, January 2014
Jay Kaplan, MD, FACEP
35 years old
you look at me
terror pouring out of your blue eyes
as red life-blood pours out elsewhere
your bold question
Am I going to die?
though I hear it
I say without words
Now is not your time
I watch you wonder
Who will be the mother to my child?
Who will be the lover to my husband?
Am I replaceable?
Can you help me?
I do what is immediately needed
and say only what is essential
as I am suddenly called elsewhere to respond to similar questions of others
Does my child have a broken neck?
Can you fix my lip so I will look as handsome as I have before?
Am I having a heart attack?
Did I break a bone? Can you ease my pain?
Is the child within me going to have the hope of life?
I reduce their anxiety and lessen their pain
as best I can
and then circle back to you
who truthfully needed me the entire time
I meet your eyes
and listen to your heart
and hold your hands
and assure you that you are not alone
We will work with you
We will find the way
We have journeyed here before
I tell you now with words
Now is not your time
a wake-up call
for you and for me
This time is short
The distance between this existence and the next is but a thin veil
This life is not a dress rehearsal
There are no guarantees
Feel life while you have it
Be astonished by its challenges
and its colors
Breathe in its expansiveness
Be nourished by its moments
Honor your friends
Love your family
and every experience
For all are gifts and blessings
You smile at me
more alive than before
more aware than before
more connected than before
to your life
I smile back
because I am too
Sun Cloud Over Wyoming – Jay Kaplan, MD, FACEP
A Letter from our Board Liaison - Medical Humanities Section Newsletter, January 2014
Jay Kaplan, MD, FACEP
Allow me to introduce myself. My name is Jay Kaplan and I am the ACEP Board of Directors liaison to the Medical Humanities Section this year. I have been a member of the Medical Humanities section for many years. I am grateful to feel blessed in my work and at home. I continue to love the clinical practice of emergency medicine and at home I have 3 beautiful daughters (ages 21, 23 and 26) and a wonderful wife-partner-companion of 35 years. I know that many of you are already be aware of ACEP leadership; for those who do not know, I thought I might provide some background for what we do as a Board to promote and safeguard your practice.
The Board of Directors provides day-to-day management and direction to ACEP and serves as its policymaking body. Board members are elected by the ACEP Council and serve three-year terms, with a limit of two consecutive terms, representing a wide variety of backgrounds and work experiences in emergency medicine. All of the current twelve members of the Board continue to work clinically in the emergency department setting. Currently we have two members of the Board who are women and we are actively seeking those interested in being nominated to run for the ACEP Board of Directors this next year. Every section in ACEP is assigned a section liaison who serves as a resource for the section.
In the past year we as ACEP can look at the following accomplishments:
- Had the largest educational meeting ever – what was formerly called the Scientific Assembly and is now being called “ACEP 13” (and next year will be ACEP 14) – we had 6264 4-day registrations, for the first time surpassing the 6000 attendee mark.
- Continued the tradition of the Open Mic Night with amazing performances by many ACEP members.
- Surpassed the 32,000 member mark – this is a great testimony to the value emergency physicians see in belonging to ACEP.
- Joined the Choosing Wisely campaign – and announced our list of five tests and procedures that may not be cost effective in some situations and should prompt discussion with patients in order to both educate them and gain their agreement regarding avoidance of such tests and procedures, when appropriate.
- Planned a significant revamp of ACEP News with the designation of a new medical editor, Kevin Klauer, MD. As of January 1, it will be called ACEP Now.
- Have in process the 3rd edition of the ACEP National Report Card on Emergency Care in the U.S., to be released in January and published in Annals of Emergency Medicine in the February edition.
- Worked with the Emergency Medicine Foundation to create an endowment for EMF, which will grow our capacity to fund practical research to help you in your practice and with the health policy challenges we face, as well as provide funding for young researchers.
At the same time that we as a board and organization are representing your interests nationally, I want to make certain that you feel supported in your local clinical and educational pursuits. If there are issues which you feel that we as a Board need to explore and act upon, please let me know.
If there is anything that I can do to assist you, please email me.
Orange Sunset Over a Sea of Clouds - Jay Kaplan, MD, FACEP
Emergency Medicine in the 19th Century: The Early Evolution of an Institution - Medical Humanities Section Newsletter, January 2014
Laurence Conley, MD, FACEP
Today, the specialty and the practice of emergency medicine is an essential link in the care of the acutely ill or injured patients. Most Americans have associated the specialty with care and treatment of those medical and surgical conditions that require timely and efficient intervention in order to prevent death or further morbidity; that is, they have a working definition of a medical emergency. And though the focus is on medical emergencies, the specialty is not limited to the acutely ill.* In addition, both the layperson and physician recognize this, essentially hospital-based, practice as a standardized medical safety net for their community. As a result most people with a perceived emergency wouldn’t hesitate to enter any given hospital emergency department knowing that there is a level of care and resources dictated by a nationally recognized standard. The emergency medicine specialty is therefore a formal institution with standards of practice and training. It emerged from the social, political, and medical environment of post World War II America that provided the milieu to satisfy all the prerequisites of a medical specialty1. However, these conditions didn’t just happen after the war; they had evolved over the course of a century or more. This explains why the practice of emergency medicine, the avocation, was recognized long before the label of emergency medicine specialist was acknowledged. In fact, by the end of the 19th Century many large American cities had a system of care that is easily recognized as emergency medicine. Just how the evolution of the informal institution of emergency medicine took place in the 19th century is the focus of this review.
In this analysis the working definition of emergency medical condition remains the same. However, the institution of emergency medicine is defined as a system of care that possesses four components, that is; a form of practice accepted by the lay-public as a medical resource specifically for medical emergencies; a practice and system of care in which the medical profession possess special knowledge regarding medical emergencies and actively participates in the care of medical emergencies; a hospital-based system with resources specifically designed to care for a perceived medical emergency; and finally, a system of care which is egalitarian and recognized by society as a community asset for the treatment of medical emergencies.
At the turn of the 19th century there is very little that could be recognized as an institution of emergency medicine. At this time medical care, both acute and chronic, from birth to death was predominantly home centered or domestic2. There was no established system of emergency care nor was there a biomedical definition of a medical emergency. Instead, the concept of the medical emergency was intuitive in its nature but vague, ambiguous, and dynamic in its application in everyday life. Most people understood that there were medical conditions that required immediate treatment to prevent disease from worsening or even to prevent death. But what exactly constituted a medical emergency was not well defined and could change because of perspective and experience. More importantly, most Americans recognized and were familiar with conditions considered benign and those considered mortal or in God’s hands for the time. The public understood basic approaches to medical treatment and often used contemporary domestic medicine references widely available. Occasionally, the family might request the advice of a non-traditional medical resource such as a bonesetter, herbalist, or midwife3. More importantly, it is unlikely a physician was called to the bedside at the first sign of illness or injury especially if a condition was considered benign or terminal. Essentially physicians were not major players in the general medical care of the common citizen at this time.
For the American physician in the early 19th century a medical emergency was not a specific entity or biomedical classification but a malady that had upset the natural balance within the patient that required a holistic approach to treatment and cure. The idea that there were medical conditions and injuries that needed timely intervention to prevent further morbidity or death, though intuitive, had not been clearly defined in medical terms4. Concepts like shock, hemorrhage, respiratory failure, or sepsis were framed within traditional medical theory without a clear understanding of the importance of rapid intervention. This is not to infer that they knew little or nothing about controlling hemorrhage, stabilizing long bone fractures or treating heat stroke but the importance of time in the equation was not clear. The outcome could just as easily be the result of the individual’s constitution as opposed to the speed and efficiency of intervention. In fact, in the early 19th century the term ’emergency’ was not really in the lexicon of the medical profession. A more common term used was “accident.” It denoted any unforeseen event and neither term incorporated a sense of urgency5. For the practicing physician, despite his training and experience, the medical emergency was almost as ambiguous and vague as that of the lay-public. The problem was again the nature of medical theory at this time as well as the limited repertoire of therapies available to the practitioner.
Interestingly, despite dogma, practical skills in the treatment and evaluation of medical emergencies no doubt emerged and were refined based on experience and likely repeated between patients. Doctors probably created within their own practices specific evaluation and treatment algorithms that were more diseased based than they were willing to admit6. Despite this, domestic medicine or at least home-based medicine was still the rule; that is if a patient had family, friends or associates that were willing to care for them. For those without, the hospital was the only medical resource available.
In the first quarter of the 19th century there were only a handful of hospitals in America’s major cities. Within these few structures there were no accident or casualty receiving areas nor any space designed to care for the medical emergency specifically7.
For these few hospitals there was no paradigm of emergency medicine. Built as nursing care facilities for the poor and disadvantaged, these institutions were essentially home and hearth for those acute and chronically ill city dwellers without family resources. Organized as both governmental and charity-sponsored institutions, the hospitals were lay controlled with a rudimentary nursing staff and limited medical staff. Though some medical training took place it was not an emphasis of the hospital function. Culturally, the hospital was not a preferred medical resource for the public and no one would elect to be admitted to the hospital if they could be cared for at home. Admission to the various hospitals was actually by-appointment-only though the government hospitals were less selective. For the charity institutions, also known as voluntary hospitals, the patient had to meet both medical and social criteria to be admitted and this could take days8. The exception to this practice for both the government and Voluntary hospitals was “in cases of sudden accidents”9.
Despite its nursing care emphasis the hospital elders recognized right from the hospital’s inception that the institution had a duty to evaluate and treat those whose disease or illness required immediate intervention or care. On the surface this suggests a rudimentary system for the care of the medical emergency. On a very basic level this is true but it was clearly not recognized as primary or even secondary function of the hospital and far from being a paradigm of care. The hospital provided no medical advantage to the patient who would have still preferred to be transported to their homes where family loved ones and the occasional doctor could care for them. The patient with a perceived medical emergency who had no family, home or whose condition prevented a choice would be transported to the hospital by any means possible where he or she would be taken to a bed on a ward. There, the physician in residence and the nursing staff would care for the patient initially. The attending physician would examine the patient later and create a treatment plan. The occasional emergency that the resident physician determines requires immediate surgical or medical evaluation by the attending staff would result in the porter being sent to notify and retrieve the respective physician. If the patient required immediate surgery he or she would be taken to the surgical theater if the hospital had one, otherwise, the surgery would take place at the bedside10.
Essentially, few patients and even fewer physicians had ever seen the inside of a hospital at this time and not just because of their scarcity and the domestic emphasis. There was a social stigma surrounding being a patient. To be admitted to a hospital was to acknowledge a need for charity and accept the loss of personal control of both daily life and the direction of medical care. Additionally, the reputations of hospitals in general were marginal and provided no advantage to the patient. For most physicians who were trained by an apprenticeship or a hybrid apprenticeship-medical school program the hospital was not available to them as a site of clinical training or clinical staffing. Only the connected elite could train or staff these few institutions11.
For society there was no model of emergency care; neither the profession nor the public recognized emergency medicine as a separate entity within the continuum of theory or therapeutics. Additionally, community governments and business leadership allocated few assets other than the occasional hospital for what might be occasional emergency care. Public health along with the police and firefighting organizations were rudimentary at best and had no role in the care of the acutely ill and injured in the community12.
Around midcentury hospitals became, to a limited extent, an accepted medical resource to many in the large cities. Immigration and the early stages of the industrial revolution had changed the face of medical care in that the influx of Irish and other Europeans were beginning to overwhelm public and charitable resources and industrial accidents were beginning to be more prevalent. Many immigrates were single with no family resources and those with families required most family members, including children, to work, in order to make ends meet. This meant that the family became less able to care for the ill and injured without impacting income and the ability to survive. No one really wanted to go to the hospital for care and though the outpatient dispensary was often an acceptable compromise, circumstances often left no alternative13.
Despite these changes, however, a model of emergency medicine had not evolved; home remained the acceptable and preferred treatment site for both the patient and physician, a biomedical definition of the medical emergency had not crystallized, physicians were still approaching each patient’s disease holistically. More importantly society and its institutions, like municipal governments, had not yet recognized the medical emergency as a public health issue requiring a system of intervention and resources for all its citizens. In 1861 this would change.
THE WAR OF THE REBELLION
The onset of the Civil War and its aftermath would not only change the sociopolitical environment of the country but also the medical profession and the public’s attitude toward the profession and its institutions, ie, hospitals. More importantly, it would be a catalyst if not the catalyst for the evolution of emergency medicine as a paradigm of care. When the war started the country, both north and south, was not militarily ready for a prolonged conflict. It was also not ready from a medical perspective. Neither side had an adequate hospital system nor an established system of patient transport for the number of casualties that the war would generate. More importantly the quality of physician and patient care was marginal14.
By war’s end much had changed. The American public was introduced to a system of medical care and hospital care, specifically, that was egalitarian and based on medical need without social stigma. Newspaper accounts and the extensive volunteerism of the civilian community educated people on the workings of these institutions that for the first time were commanded by physicians. Through the efforts of both the military medical department and civilian organizations like the United States Sanitation Commission the condition in various hospitals improved. Countless soldiers went through the hospital system after being evacuated from the battlefield medical resources and had a positive experience. Some of these soldiers were likely evacuated from the battlefield itself by an efficient and effective ambulance system that had evolved during the war15.
The war also forced the respective medical departments to police themselves. At the beginning of the war it became very evident that not all doctors were alike. Because there was no standard in training or credentialing the spectrum of skills and expertise was broad. Both sides created boards to review the credentials of the various practitioners and tested these clinicians to determine their fund of knowledge. Many practicing physicians were found wanting and therefore rejected as applicants16. For those accepted for a commission the review did not stop. For those physicians accepted into the military there was additional scrutiny. It was very evident after the first major battles that the various medical units were going to have to care for numbers of casualties and wounds that were beyond any clinician’s experience. It therefore became necessary for the battlefield hospitals to divide the labor among the physicians with the most experienced and skilled doctors performing major surgical emergencies and the less experienced doctors assigned as assistance or to care for the less emergent injuries17. Because of the nature of the war the learning curve was steep and short for most physicians. The war also introduced medical personnel and soldier to a system of triage and patient transport both within the battlefield and within the theater of operation. By the end of the war, most soldiers knew that if they were injured they would be transported to some form of medical care in a timely manner rather than stay on the battlefield for days and that the nature of the injury would dictate where or how he would get the receiving facility18.
For the military physician and the civilian associate the Civil War became a grand educational opportunity. This was clearly recognized early on by both the north and the south. And though the war took place before the advent of Germ theory and what would be scientific medicine, medical knowledge was advanced as a result of war. Specifically, medical specialties like general surgery, orthopedic, and neurology all advanced as a result of war experience. More importantly, physician began to accept specialization philosophically. Prior to the war there was clearly a generalist* bias though there were those who focused their interest in areas like ENT and ophthalmology. The war helped to change that attitude or at least set the stage for the change that would take place in the last quarter of the 19th century when medical specialization expanded exponentially in Europe and America19.
Even emergency medicine as a medical entity and specialty as we know it today was advanced or at least explored during the Civil War. Tucked within personal accounts and the voluminous “Medical and Surgical History of the War of the Rebellion” are glimpses of what present-day clinicians would clearly describe as emergency medical practices. Whether it was experimentation with open chest wound treatment or blood transfusion, the recognition of tourniquet complications, or the recognition and treatment of “shock” in general, tenets of emergency medicine were being explored and in truth, advanced. Time as a key dimension in the care of patients had been crystalized in both the mind of the soldier and the physician. Clearly no one recognized the style and principles of emergency medicine practiced as a distinct entity but its existence could hardly be denied.
EARLY POSTBELLUM PERIOD
One of the first recognizable legacies of the Civil War as it relates to emergency medicine in the civilian community is the development of a municipal ambulance system. The importance of timely evaluation and intervention had become clearer. In 1872 Superintendent Dalton, a veteran of the Army of the Potomac, designed and implemented an ambulance system for New York City which was initially associated with Bellevue and the other city hospitals in the municipality. It was fashioned after the same used by the Union forces. Within several years the system was expanded to include the voluntary hospitals of the city as well. Essentially the entire metropolitan area was divided into catchment zones with specific hospitals responsible for specific communities within the city. Most of the time the system was activated by the community police who were in communication with the office of the chief of police. This office would then determine which hospital should dispatch their ambulance and the specific hospital would be notified where to go via telegraph. Special ambulances were designed to take the ambulance surgeon and a driver to the patient where he or she would be evaluated and later either released or transported home or to the hospital. Timely evaluation and treatment had unquestionably become important both to the physician and the public20
In 1881, British surgeon, Benjamin Howardi, published an article in the British Medical Journal where he praises the New York Ambulance system and recommends its adaption to London and a future Ambulance Department21. Within this brief account is a rare first-person description not only of the ambulance system but also of emergency medical care within New York City. What is very clear after reading this article is that by the 1880’s there was within New York City a model of emergency medical care that looked remarkably like ours today. In the article it appears that both city hospitals and several voluntary hospitals accepted the regulatory role of the municipal authority and were connected by the recently invented telephone to the chief of police. He states that the police who notified the nearest police station of a need for an ambulance initiated this rudimentary Emergency Medical System (EMS). Each station was connected to the chief of police via telegraph so a location and the designated nearest hospital could be identified. The hospital was then notified and its ambulance dispatched to the patient.
In addition to a description of the ambulance system he provides a rare and fairly detailed review of a 19th Century emergency room, called the “reception or accident ward.”
The ambulance, on returning, comes in from an opposite direction, and stops under the large porte-cochere on the opposite side of the court, at the door of the reception or accident ward. This room is supplies with every surgical convenience: operating table, instruments, dressings, hot and cold water, and beds while opening into it are bathrooms and small bedrooms, all at a constantly agreeable temperature. According to expediency, the patient may remain a longer or shorter time comfortably where he is, be put into a private room adjoining, or be transferred on the lift direction the table to an ordinary ward above. If, on the other hand, the case be a trivial one, the ambulance takes him at once, or as soon as he may wish, to his own home22
He also describes the ambulance-surgeon who in this system functions as the triage officer.
The ambulance-surgeon, immediately on returning to the hospital, according as the case may be surgical or medical, notifies the house-surgeon or house-physician, who then takes entire charge of the case. Before attending to any other duty, however, the ambulance-surgeon enter in a book, kept for that purpose, time of call, start, arrival, departure, return and such details of history and diagnosis as a coroner’s jury might possibly require23.
Dr. Howards concluded that the New York system had three advantages: for the city, it offered a way of caring for the sick and injured without incurring the administrative, logistical, or medical cost, for the hospital, it provided excellent teaching cases, and finally for “the patient, it provide prompt help, and the most skillful attendance.”24
Another piece of insight that this article provides is in hospital design; that is, while the older hospitals modified established structures to accommodate the ambulance system, the newer hospitals designed the structure to accommodate the system. What he touched on was what Thompson and Golden refer to as “derived” as opposed to “designed” form in hospital architecture.25Up until the Civil War hospitals and their spaces were derived from plans that were not exclusively hospital in nature, that is, buildings were modified to function as a hospital; it was derived from some generic plan. Massachusetts General and Pennsylvania Hospital were derived institutions that could just as easily have functioned as country manors. It is this approach that allowed the modification of old police stations like the Chambers street branch of the New York Hospital system26. In contrast, the recently built New York Hospital that Howard references was specifically designed to accommodate both the ambulance and the needs of those treating the medical emergencies. Where the Chambers Street hospital received patients in a converted front basement of the old police station the casualties in the new hospital were on the first floor with specific spaces designed for the ambulance and emergency care. 27Other institutions like Pennsylvania Hospital and Johns Hopkins would follow suit later in the century with Massachusetts General Hospital following in the first decade of the 20th century. These changes in hospital design in which “… form ever follows function” suggest more than a philosophical change in the approach to the acutely ill and injured; they support the premise that there was a paradigm of emergency medicine.
THE 19 CENTURY COMES TO AN END
By the 1890s the ambulance service and its associated reception spaces within the various hospitals had become an established institution in New York City. The service had become an integral part of the urban landscape along with the police and fire department. And like the latter institutions there were public expectations and informal standards to be maintained. Like public health, it was also one area where the medical profession interfaced directly with government and the population. It was not uncommon for the press to criticize the ambulance service because of alleged inefficiency or physician poor judgment. In one instance where a New York grand jury was tasked with investigating the city’s ambulance program, Drs. Charles McBurney and Lewis Stimson authored a statement in defense of the ambulance service and like Howard’s article presented relevant insights into the emergency medical care at that time.28
In the article, McBurney and Stimson explain the organization of the citywide ambulance service. They explain how the ambulance surgeon is chosen among the junior house staff, his qualification, and his role in the system. They review his routine and how the police in the community activate the system. Within the short statement they also address two very interesting side issues; first, they allude to both the public and police abusing the system either by calling the ambulance for trivial complaints or by calling the ambulance in cases where the salaried precinct police physician could have and should have been alerted. Secondly, and more importantly, they address the complaint from the critics that the ambulance surgeon is young and inexperienced and therefore more senior experienced physicians should have the position. In their response they make it very clear that few experienced men could handle the rigors of the routine but more importantly that an experienced doctor who accepted the pay likely offered for the job would be a “self-confessed failure.” Basically, what they suggest is that no self-respecting attending physician would accept the position of ambulance surgeon. Despite the occasional attack by their critics the ambulance service continued to be a respected and integral part of the health care system, a system that was becoming more accepted by the average person.
By this time the public skepticism of medicine began to wane while confidence in its utility and safety improved. Advances in medicine were becoming well known not only in the medical literature but in the lay literature as well. As the medical profession transitioned from the eclectic and theoretical to the scientific and biomedical, the quality of care and patient expectations improved. No longer was domestic medicine the preferred approach. Hospitals became centers for treatment where the latest medical and surgical advances were demonstrated. New technologies such as laboratory resources and later radiologic were concentrated in the city hospitals. Men like Halsted and Welch brought home from their overseas training the latest in scientific approaches. No longer was the intellectual distance between the public’s understanding of medical theory and professions small; instead, the training and the science of medicine was becoming far too complex for the average layperson to master.29
For American society the hospital was becoming a broadly accepted community asset with emergency medical resources potentially an important component of the institution. Industrial and urban accidents were becoming commonplace. And with the changing demographics of major American cities the hospital, along with its associated outpatient and emergency services, became a community resource. Society and more specifically business leaders began to recognized that the health of the workforce was an important component of an industrialized country; that a system that can evaluate, treat and return a worker or citizen back to the community workforce rapidly was a social and economic asset. This same system was an asset for city government both from the public’s health perspective as well as for civil and criminal law, the latter aspect as medical resource to the coroner and the civil court.30
In the late 19th century, the hospital had also become an integral component of the physician’s medical education. The broad range of training in America had become unacceptable. More and more a uniformed standardized medical education program which included didactic, laboratory and clinical experience much like the German system was becoming the norm for the better medical schools in the country even before the Flexner report. Essential to this approach was the clinical experience on the hospital ward and in the operating room. As specialization became more acceptable and the knowledge within each specialized discipline expanded the hospital became even more essential for postgraduate medical education. Hospital outpatient departments with their specialty clinics became important resources for physician training. They were often located close to emergency medical spaces and were the site where minor emergencies would be treated.31
During this period medical knowledge from a biomedical perspective was expanding geometrically. Various specialty organizations were emerging both to define limits of the specialty, consolidate authority and to share knowledge. The idea that specialized training was a means of exposing the generalist to the various aspects of medicine had morphed into informal institutions with vested interest, both professionally and economic. Doctors were specializing not just to handle the expanding knowledge base within each discipline but also to actively expand it through research. Though the 20th century would witness the establishment of formal specialties, for all intents and purposes, medical specialties were alive and well at the turn of the 20th century.32 The public’s trust and the profession’s reputation was improving as a result of the both the medical and surgical advances at that time as well as the medical profession’s efforts to standardize training and promote state licensure. The turn of the 20th century saw the acceptance of the hospital as a medical and community resource and with it, biomedicine as the basis to medical practice. Medicine had finally acquired “…legitimate professional authority.”33
With the advancement of biomedicine, increase in urban population, and changing attitudes toward specialization within the profession and associated institutions, physicians were encouraged to limit their practice to specific medical specialties. Numerous specialty organizations were created to legitimize their avocation as well as control its growth. By the end of the 19th century many specialties had fulfilled the three criteria, which Rothstein acknowledges as necessary for medical specialization. He states that a specialty required: (1) a medically valid body of medical knowledge and techniques; (2) an urban population sufficiently large to support a specialist in the practice of his specialty; and (3) support and cooperation from both institutions and the medical profession which would make it financially rewarding for a physician to restrict his practice to a specialty.34
It is very easy to understand from the medical profession’s perspective why the 19th century American physician did not intentionally limit his practice to medical emergencies: first, there was no medically valid body of knowledge or techniques that were unique to the specialty with the except perhaps of the ambulance systems. Instead, those aspects of what we call emergency medicine evolved from the biomedical research within the various emerging specialties. For example, when George Crile published his “An experimental research into surgical shock” in 1897 or later studied cardiac arrest and the use of adrenaline in dogs it was as a surgeon in the world of surgery.35 Though the recognition and treatment of various medical and surgical emergencies were being researched, expanded and clarified, it was within the context of the specific specialty and not as a unified discipline. Second, though there was clearly a growing population who utilized the various hospital emergency services, there was little or no financial or professional incentive to limit a practice to medical emergencies (remember McBurney’s comment).
Emergency medicine had no physician advocates or cadre of enthusiasts to push their agenda at this time. Unlike other specialties where the pressure to define and limit a practice stems from the practitioners themselves, the informal institution of emergency medicine evolved from the sociopolitical and the medical needs of a growing urban and industrialized America and a rapidly expanding medical profession; that is, social and medical ecology determined the direction of emergency medical care. The closest medical professional to today’s emergency physician was not the general practitionerii but rather the physician- in- training, that is, the ambulance surgeon and the associated surgical and medical house officers. As an identifiable group these residents had the job of caring for any patients any time for any perceived emergency. They were tasked with rapidly evaluating and triaging the patient, initiating the appropriate care, requesting the appropriate consultants and finally determining the disposition of the patient 24 hours a day. They cared for a broad array of diseases and injuries and did not limit the scope of their practice. Though it is unlikely that these “young Turks” thought of themselves as specialists of any sort or would accept the sobriquet of “emergency physician,” especially in lieu of McBurney’s comments, they were the Homo erectus of the present day specialty nonetheless. Their compensation for their hours and workload was of course the experience, knowledge and confidence gained from their duties.
By the turn of the 20th century, all four criteria for the informal institution had been met yet, no formal mandate for the specialty evolved for close to 80 years. This is despite the fact that as the population increased and communities expanded so did the need and expectation of emergency medicine. The number of hospitals in America increased rapidly both in the urban and rural communities. With this expansion came the requisite and ubiquitous ambulance service and emergency care via various “emergency rooms.” In those community hospitals without training programs and associated house officers, general practitioners and their surgical colleagues participated in emergency coverage and were de facto emergency physicians. Basically, emergency medicine remained almost frozen as an avocation and informal institution without standards of practice, the ability to share and propagate knowledge and with no physician advocates until after World War II. It is at this time that forces both within and outside the practice catalyzed interest in emergency medicine as a recognized medical specialty. A few visionaries in the practice recognized the advantage and the importance of a formal specialty in the mid-1960s. They recognized that without true specialization the quality of practice and practitioner, as well as, the advancement of knowledge would remain haphazard and inconsistent. Unfortunately, as Brian Zink would so clearly chronicle in his book, Anyone, Anything, Anytime: a History of Emergency Medicine, the road to the formal institution from its inception to its establishment was rough, rocky and contained countless delays. In spite of this, in 1979 the specialty was formally recognized. However, as this review has attempted to establish, the story of emergency medicine began long before the post WWII era. It began instead in the changing medical, social and political environment of late 19th century America and catalyzed by the upheaval of the Civil War and its aftermath.
i Dr. Howard’s interest and connection with the New York ambulance system and America was more than a casual curiosity by a foreign clinician. In 1853 Dr. Howard had immigrated to America where he got o degree in medicine at New York’s College of Physicians and Surgeons in 1858. When the Civil War erupted he became Assistant Surgeon in the 19th New York Volunteers in the Army of the Potomac. It is here that he saw first hand the advantage of an efficient ambulance service. After the war he eventually returned to England and became a key figure in the establishment of London’s Ambulance service.
ii By this time the term referred to that physician who had a broad spectrum medicine practice during this era of medical specialization.
- Brian Zink, Anyone, Anything, Anytime- A History of Emergency Medicine (Philadelphia: Mosby, 2006).
- Paul Starr, The Social Transformation of American Medicine (USA: Basic Press, 1982), 32-37.
- Starr, 32-37, 47-51.
- Michael Nurok, “Elements of the Medical Emergency’s Epistemological Alignment: 18-20th –Century Perspectives,” Social Studies of Science 33/4(August 2003) 563-579.
- Nurok, 565-570; Samuel Johnson, A Dictionary of the English Language in which the words are deduced from their original 6th ed. (London: Strahan et al, 1778), 2004-2005.
- This was most applicable to surgery in general and trauma specifically.
- Rosenberg, The Care of Strangers, 24; an examination of early architectural plans of Massachusetts General Hospital, Pennsylvania Hospital and New York hospital demonstrates no space for receiving the sick and injured other than the ward.
- Thomas Morton and Frank Woodbury, The History of the Pennsylvania Hospital 1751-1895 Revised edition. (Philadelphia: Times Printing House, 1897) 549-559; Massachusetts General Hospital By-Laws, Rules and Regulations, Acts and Resolves (Boston: James Cotter &Co.,1874) 7-50; N. I. Bowditch, A History of the Massachusetts General Hospital (Boston: John Wilson and Son, 1851) 3-9; Starr,147-154; Harry Dowling, City Hospitals: the Undercare of the Underprivileged (Cambridge: Harvard University Press, 1982) 1-21; Rosenberg, 15-46; John Duffy, A History of Public Health in New York City 1625-1866 (New York: Russell Sage Foundation, 1968) 481-490.
- The New York Hospital Society, Charter of the Society of the New York Hospital Society and the Laws Regulating thereto with the By-Laws (New York: Daniel Fanshaw Printer, 1852) 103 (Reprint Bibliolife LLC).
- Charles Rosenberg,” The Hospital and the Patient in the 19th Century America,” Journal of Social History, 10, no. 4 (Summer 1977) 428-441; Massachusetts General Hospital, 7-50; New York Hospital Society, 23-74; Morton, Revised edition, 549-559; William Rothstein American Medical Schools and the Practice of Medicine (Oxford: Oxford University Press, 1987) 21-24;
- Morris Vogel, “Machine Politics and Medical Care: The City Hospital at the Turn of the Century,” in The Therapeutic Revolution: Essays in the Social History of American Medicine ed. Morris Vogel an Charles Rosenberg, (Philadelphia: University of Pennsylvania Press, 1979) 159-163; Rosenberg, The Care of Strangers, 70; Rothstein, 15-36; William Rothstein, American Physicians in the 19th Century: from Sects to Science (Baltimore: The Johns Hopkins University Press 1985) 85-93.
- George Lankevich, American Metropolis: a History of New York City (New York: New York University Press, 1998) 85; John Duffy, The Sanitarians: A History of American Public Health (Urbana: University of Illinois Press, 1992) 66-78.
- Duffy, A History of Public Health, 506-511; Rosenberg, The Care of Strangers,100-109; Walter Licht, Industrializing America: The Nineteenth Century (Baltimore: The Johns Hopkins University Press, 1995) 66, 70; Rothstein, American Medical Schools,42-49;Starr,72-77; Charles Rosenberg, “Social Class and Medical Care in 19th-Century America: The Rise and Fall of the Dispensary,” in Judith Leavitt and Ronald Numbers, Sickness & Health in America: Readings in the History of Medicine and Public Health (Madison: the University of Wisconsin Press, 1978) 157-171.
- Alfred Bollet, Civil War Medicine: Challenges and triumphs (Tucson: Galen Press, 2002) 7-36.
- Bollet, 1-6, 435-444; Dale C. Smith, “Military Medical History: the American Civil War,” Organization of American Historians 19, no. 5 (Sep., 2005) 17-19; Richard Shryock, “ A Medical Perspective on the Civil War”, American Quarterly 14, no. 2 (Summer, 1962) 161 173; Duffy, “A History of Public Health,” 490; Rosenberg, The Care of Strangers, 97-99.
- Bollet, 32-35.
- Bollet, 161-165;
- Mary Gillett The Army Medical Department (Washington, D.C.: U.S. Government Printing, 1987) 288-298; Bollett, 97-139, 442-444;
- Smith, 19; Bollett, 435-445; Gillett, 276-299; Shryock,” The Medical Perspective on the Civil War”, 168-169; Rothstein, American Physician in the 19th Century, 252; Dale C. Smith, “Surgery It’s not a Random therapy,” Caduceus 12, no. 3 (Winter 1996):24-26.
- Ryan Bell, The Ambulance: A History (Jefferson, North Carolina: McFarland & Co.: 2009) 30-79; Robert Carlisle, ed., An Account of Bellevue Hospital with a Catalogue of the Medical and Surgical Staff from 1736 to 1894 (New York: The Society of the Alumni of Bellevue Hospital, 1893) 65-73; Morton Galdston, “ Ambulance Notes of a Bellevue Hospital Intern: May 1938, Journal of Urban Health: Bulletin of the New York Academy of Medicine 76, no. 4 (December 1999) 509-512.
- Benjamin Howard, “ The New York Ambulance System,” The British Medical Journal 2, no. 1072 (Jul. 16, 1881) 72-73, http://www.jstor.org/stable/25257422 (accessed 10/08/2011); Howard was an English expatriate who served in the Union army during the Civil War and therefore had first-hand experience with the evolution of the ambulance service during the war.
- Howard, 72.
- Howard, 72.
- Howard, 73.
- Howard, 72; John Thompson and Grace Goldin, The Hospital: A Social and Architectural History (New Haven: Yale Press, 1975) 5.
- “The New Down-Town Hospital: an old Police Station put to Good Use- A Perfectly-Equipped Hospital,” from The New York Times (Sep. 27, 1875) 10 (accessed from ProQuest Historical Newspapers The New York Times (1851-2006).
- New York Hospital may be the first American hospital to incorporate specific emergency medical spaces into the architectural design at it inception.
- Charles McBurney and Lewis Stimson, “ City Ambulance Service: a Statement to which Public Attention is Called,” in The New York Times (March 28, 1892)
- Shryock, “Trends in American Medical Research,”61-62; Bert Hansen, “New Images of a New Medicine: Visual Evidence for the Widespread Popularity of Therapeutic Discoveries in America after 1885,” Bulletin of the History of Medicine 73, no. 4 (1999) 629-678, http://muse.jhu.edu.ezproxy.lib.ucf.edu, (accessed 11/12/2009); Rothstein, American Medical Schools, 67-88;
- Vogel, “Machine Politics and Medical Care,” 159-175; Rosenberg, The Care of Strangers,113-114; George Lankevich, American Metropolis: a History of New York City, (New York: New York University Press, 1998) 142-143;
- Rothstein, American Medical Schools, 89-116; Starr, 113-123, 145-147; Robert Hudson,” Abraham Flexner in Perspective: American Medical Education 1865-1910,” in Sickness & Health in America: Readings in the History of Medicine and Public Health (Madison: The University of Wisconsin Press, 1978) 105-115;
- Rothstein, American Physicians, 198-216;
- Starr, 12-13.
- Rothstein, American Physician, 207.
- Karina Soto-Ruiz and Joseph Varon, “ George W. Crile: A visionary mind in resuscitation,” in Resuscitation 80 (2009) 6-8 www.elsevier.com/located/resuscitation.
Visual Arts Award Winner 2013 - Medical Humanities Section Newsletter, January 2014
“Post Call: Early Morning Self Portrait”
K. Kay Moody, MD
Writing Award Winner 2013 - Medical Humanities Section Newsletter, January 2014
Colombian Orchids: Palliative Care in the Emergency Department
by Kate Aberger, MS, MD
From CHANGE OF SHIFT, Annals of Emergency Medicine
Copyright © 2013 by the American College of Emergency Physicians.
[Ann Emerg Med. 2013;61:488]
It was a usual day in the ED, and another possible stroke patient was placed into my bed. I started my assessment – determine onset, perform exam, call a stroke code, speak to neurologist, etc. However, this 65-year-old patient was not having a stroke, but a recurrence of his glioblastoma, only two weeks after the first resection. Now it was even bigger, with impending herniation and significant edema. His surgeon and all of his records were, of course, at a different hospital.
As my brain mapped out the ED course, stabilization, MRI and subsequent transfer, his sister came over to speak with me. The patient, a beloved local priest, had recently finished building his dream retirement home in Colombia, his native country. He had been planning it for years. His retirement was imminent when the glioblastoma was discovered a mere four weeks ago.
"What are the chances that another surgery will help?" his sister asked. She did not sound frantic, she sounded defeated. At this point my thinking stopped short. Why am I transferring him back to the facility where they might cut him open again? Why am I wasting his very short, very precious time that he has left? The truth is painfully clear: because it is how we are trained. Package and ship: dispo, dispo, dispo, it doesn't matter to where, just not here! This is the way most ED doc’s minds’ work. It is only recently that palliative care has been recognized as a subspecialty for Emergency physicians. I had made it a focus of study this year, but I was still finding it difficult to integrate into my ED practice.
I took a deep breath, shifted gears, and took the plunge. I told his sister surgery would not help. In fact, he might not even survive another operation. I asked if they had spoken about his wishes if curative treatment options were no longer viable, or if life-prolonging treatments were intolerable. She surprised me by saying that a close family friend had died of the same thing; both she and her brother both knew the rapidity and terminal nature of the disease. They had even arranged for a doctor friend from Colombia to come to the US and fly back with the patient, as soon as he was "stabilized". She also showed me pictures of the home, and its massive gardens - lush orchids were growing wild. “This is where my brother wants to die”, she said.
I assured them that although there were no further curative options, I could make him more functional and comfortable. I made a promise to try and get him home to Colombia. The transformation that occurred in the demeanor of the patient and his sister were remarkable and allayed any fear and doubt that I had. It was obvious that this beloved priest was the perfect patient for palliative care.
I peeked in on the patient, now "stabilized": he was lying on the stretcher with a blissful smile on his face. The sister was visibly more relaxed, her shoulders had come down from around her ears, and she had started breathing normally again. She kept asking incredulously, "no more doctors?” They had been trapped in our system; I had given them a humane exit.
After a few phone calls, I managed to get the on-call home hospice nurse to meet the patient and the family in the ED. I wrote prescriptions for steroids, seizure medications and painkillers. I assured the family the hospice social worker would help coordinate the arrangements to get back to Colombia.
In the meantime, my resident and I had together moved 30 other patients through our section of the ED. None I remember. I left work that evening flying high, a nice change from the usual numbness and exhaustion. I had alleviated suffering, and given hope. The power of the human connection made me feel like a Real Doctor. That night I dreamed of orchids and waterfalls, I imagined my patient did too.
Novel Club - Medical Humanities Section Newsletter, January 2014
Cindy Bitter, MD, MA, FACEP
STATE OF WONDER
Ann Patchett’s 2011 novel State of Wonder has spent 18 months on bestseller lists, and has been widely discussed among critics and lay book clubs. It was chosen as the summer reading book for the Duke class of 2017. The book also deserves a place on the reading lists of medical professionals.
The story centers on Dr. Marina Singh, who travels from her pharmaceutical research lab in Minnesota to the farthest reaches of the Amazon. She is sent by her company to check on the progress of a fertility drug being developed by a secretive researcher, and to learn the fate of her lab partner-- who reportedly perished during a similar mission. Along the way, she encounters difficulties ranging from lost luggage, Lariam-induced nightmares, carnivorous insects, tropical diseases, to a terror-inducing former mentor. She largely succeeds on her quest and manages to overcome some of her own demons along the way, but the answers she finds bring new questions.
Patchett raises questions of responsibility for therapeutic misadventures, motivations of medical missionaries, experimentation on vulnerable populations, research priorities for drug companies, and practical consequences of novel therapies. By avoiding easy answers, she invites the reader to contemplate the issues.
- The novel opens with Mr. Fox telling Marina of Anders’ death; the second scene is notification of Anders’ widow. How are the depictions accurate? Should Marina have been better prepared for her discussion with Karen, or do you think giving bad news never gets easier? How do these scenes make you think you could better handle death notifications in the ER?
- Marina was holding the scalpel during the C-section, but is Dr. Swenson ultimately responsible for the injury to the infant? Does the university share in the blame for allowing Dr. Swenson to shirk her duties (not responding to pages, failing to hold office hours?) How can attendings foster confidence and procedural skills in trainees without allowing harm to patients?
- After the therapeutic misadventure, Marina drops out of her OB-GYN residency. She suffers overwhelming guilt, marital discord, and social isolation. Sadly, these reactions are not unusual in physicians involved in malpractice suits. Should she have left her residency for a research position? Under what circumstances would you consider leaving clinical medicine? Does it seem that her program offered Marina support through the litigation? If you were involved in a malpractice action, what support would you expect from your peers and the hospital?
- On several occasions, Dr. Swenson describes providing medical care to the natives. What are the potential adverse consequences of providing Western-style care in the developing world on a temporary basis? How can global health providers work to improve conditions while respecting “the order that was in place”?
Dr. Swenson has worked among the Lakashi for many years but often seems to lack respect for their ways. Dr. Saturn bribes the tribe members to participate in the experiments. Do their attitudes reflect a necessary objectivity or a depersonalization that allows them to exploit the tribe? If they succeed in finding a vaccine for malaria, are the methods acceptable? What real-life examples of dilemmas in research ethics are echoed in this plot?
Dusting Off A Time-Honored Medical Tool: Words - Medical Humanities Section Newsletter, January 2014
Seth Collings Hawkins, MD
“Don’t tell me that words don’t matter. ‘I have a dream’ — just words? ’We hold these truths to be self evident, that all men are created equal’— just words? ‘We have nothing to fear but fear itself’ — just words?”
— Barack Obama, 2008
True story: A paramedic and his shift supervisor are kneeling next to a collapsed, unconscious child on a soccer field. One paramedic is evaluating the airway, which would be a difficult intubation because the child is overweight and vaguely gagging. “Oh, it sucks,” the supervisor says, looking down the throat and deciding he definitely does not want to RSI this child. Thirty seconds later, the paramedic brightly chirps, “Succ is in!”
We work in a field where words matter. Our success or failure is often determined by our ability to communicate. We go through four years of medical school and multiple years of residency only to learn that the medical skills we have assembled are merely the underpinning of our practice. The actual delivery of medical care is one part knowledge but also one part theater (that all-important “bedside manner”), one part writing (as charting develops more and more prominence in our work), one part rhetoric (convincing the cranky hospitalist to admit the same diabetic yet again who has, yet again, stopped taking his medications), and one part team sport (you are truly lost when you have lost the support of your partners or, God forbid, your nurses).
Words are a key factor — or maybe the key factor — and common denominator in every one of those elements. But we spend less time talking about our words than almost any other part of our medical practice. We should think as critically about the narratives we choose and the words we choose to fill them as we do about our choice of antibiotics. Our journals and trade publications are filled with coverage of the truly esoteric tools and debates of our profession while for the most part ignoring our most frequent tool: our words.
I am genetically forced into thinking a lot about words. My parents are humanities professors, and my sister has a doctorate in comparative literature. Like a stem cell that somehow missed the DNA memo, I am genetically purposed to be an English professor but somehow wandered instead into medicine. Like a surgeon reaching for a scalpel or a radiologist wanting a visual picture, I just can’t help myself. One of my favorite activities in medical school was founding IRIS: The UNC School of Medicine Art and Literary Journal with my good friend and fellow humanities renegade Joe Scattoloni, MD. We pushed the envelope on linking words, pictures, and medical care (and today’s editors still do the same; see FastLinks).
But even if you don’t have the same genetic handicaps and quirky predispositions that I do, words are still an intrinsic part of your work. I challenge you to think of a single therapeutic agent you use on every single patient as often as you do your words. Not only that, but this is your primary tool in every turf war, administrative issue, research publication, and interprofessional dialogue. Like the most potent medications, words are extraordinarily powerful and extraordinarily dangerous. The way we use, misuse, or confuse words is one of the most critical priorities for those working on safety improvements and the reduction of medical error.
I get twitchy every time I hear a physician say, “It’s just semantics,” “This is just wordsmithing,” or some other dismissive reference toward a thoughtful analysis of the words we use and how we use them. In fact, words are the most ubiquitous feature of emergency medicine — bar none — and one of the most critical tools to use correctly.
©Copyright 2013 by Emergency Medicine News/Lippincott Williams & Wilkins. Reprinted with permission: Emergency Medicine News 2013;35(9):7; http://bit.ly/1dOEOQN. All rights reserved.
Internets Links to Members Works - Medical Humanities Section Newsletter, January 2014
Maribel Gray, MD, FACEP – link to her multimedia art and design work.
Liz Mitchell MD, FACEP - National Anthem – Fenway Park, Boston, MA. Opening Game American League Championship Series, October 21, 2013.
Peter Paganussi, MD, FACEP – What’s In a Name?
Open Mic Night - Medical Humanities Section Newsletter, January 2014
Open Mic Night – Medical Humanities Section
Seattle, Washington 2013
2013 Annual Section Meeting Minutes - Medical Humanities Section Newsletter, January 2014
American College of Emergency Physicians
Section of Medical Humanities
October 15, 2013
Participating in all or part of the meeting were: Kate Aberger, MD, FACEP; David J. Adinaro, MD, FACEP; Cindy C. Bitter, MD, FACEP; Michael D. Burg, MD, FACEP; Judith Dattaro, MD, FACEP; Arthur Derse, MD, JD, FACEP; LE Gomez, MD, FACEP; David S. Howes, MD, FACEP; Jay. A. Kaplan, MD, FACEP; Marianna Karounos. DO; Walter Limehouse, MD, FACEP; Bonnie Marr, MD; James N. Pruden, MD, FACEP; Julie Sanicola-Johnson, MD; Jeffrey Sankoff, MD, FACEP; David P. Sklar, MD, FACEP; Katherine Vlasica, DO.
Others participating: Tracy Napper, ACEP staff liaison.
1. Call to Order
2. New Business
A. “Open mic” discussion
B. Web site development/newsletter expansion
C. Membership expansion/ideas for new projects
D. Writing Award for 2013
E. Visual Arts Award for 2013
Major Points Discussed
1. The meeting was called to order by Jeffrey Sankoff, MD, immediate past chair. Dr. Sklar said a few words of introduction and presented a certificate to Dr. Sankoff for his service to the section.
2. New Business
A. “Open Mic” – Ms. Napper is organizing the performers this year. We have again secured a sponsor, Hagan Barron Intermediaries. The $3500 sponsorship pays for the piano, a/v technology, food, and cash bar. Members were reminded to come to the event and to bring guests.
B. Dr. Sankoff discussed new ways to expand the membership and the section Web site. We have opened up the site to non-members, but it requires a log-in for the newsletters for the first 6 months after they are published, then making them free access, so as to preserve value for section members. Section members would like to add photos, music clips, videos, and other media to the site. A Facebook page was discussed; however, Ms. Napper noted that ACEP does not approve this. There may be a delay in uploading items to the section microsite due to staff shortages at ACEP.
C. A new project this year was the Visual Arts Award, where College members submitted a piece of visual art and section members voted for the winner. Dr. Kay Moody won this year’s award for her photo, “Post Call Early Morning Self Portrait.”
D. The Writing Award for 2013 was given to Dr. Kate Aberger for her piece, “Colombian Orchids.” Articles will be solicited for the eighth annual award in June 2014.
E. Dr. Jay Baruch, incoming chair, was unable to attend the meeting so Ms. Napper outlined some of his priorities for his term, including increasing the membership; creating a curriculum/education resource, including the use of humanities to improve critical thinking and clinical skills; continuing the work of Dr. Sankoff and others; seeking funding opportunities for projects; and using social media more effectively.
F. Dr. Sankoff solicited ideas for bringing more value to section members. He wants to collaborate with EMRA on a resident award and he may still work on this initiative with Dr. Baruch. He suggested applying for a section grant to create a book that collects the works of section members. Using social media for section purposes was also discussed; Dr. Aberger suggested using the Basecamp app. Ms. Napper suggested using The Central Line to post items from section members as well. Dr. Bitter noted that she participates in a medical book club and promised to share guidelines about the structure of the club. Dr. Kaplan said that ACEP News is becoming ACEP Now, and he suggested contacting the new editor, Dr. Kevin Klauer, about a new, “Piece of My Mind”-type column to which members could contribute. Ms. Napper will follow up on this. Dr. Kaplan also suggested that section members could sponsor a board member’s section membership for a year as a way to increase our membership numbers. Ms. Napper reminded members to sign up their residents for their one free section, if they haven’t already.
The meeting was adjourned.