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Hospital-Based Emergency Care: At the Breaking Point
es in the treatment of acute coronary syndrome (ACS). In Belfast, Ireland, Dr. Frank Pantridge was demonstrating that a mobile coronary care unit could substantially reduce mortality among heart attack victims (Pantridge and Geddes, 1967). Following his lead, several medical centers in the United States began programs to deliver rapid emergency care to cardiac patients. William Grace, for example, established a mobile coronary care unit at St. Vincent’s Hospital in New York City—the first of its kind in America—that transported physicians to the scene of patients experiencing ACS (Key et al., 2005). Other programs were started independently in Los Angeles, Seattle, Columbus, and Miami.
The recognition that injured or acutely ill people could be saved if they received treatment within a short span of time led to the development of prehospital EMS systems designed to get patients to the hospital quickly. This in turn stimulated the development of hospital-based emergency care and the specialty of emergency medicine. The introduction of new technologies that facilitated the rapid diagnosis and treatment of injuries and acute illnesses, such as the computed tomography (CT) scan and cardiac monitoring, contributed to this growth.
Public interest in the importance of emergency services was sparked by the 1966 landmark National Academy of Sciences/National Research Council (NAS/NRC) report Accidental Death and Disability: The NeglectedDisease of Modern Society (NAS and NRC, 1966). The report described the epidemic of automobile and other injuries—due in part to the expansion of the interstate highway system—and the deplorable system for treating these injuries nationwide. At the time, most emergency rooms appeared to offer only advanced first aid; only a few facilities had the staff and equipment to provide complete care for seriously ill or injured patients. Patients who appeared at the hospital were often turned away if they did not have funds to pay for their care, and transfers to the city or county indigent care facility were conducted without concern for patients’ well-being (Rosen, 1995). To many in the field, the 1966 NAS/NRC report marked the beginning of the modern emergency care system. Coupled with advances in military medicine and civilian cardiac care, this report led to the Highway Safety Act of 1966 (P.L. 89-564), which created the National Highway Traffic Safety Administration (NHTSA) within the Department of Transportation and required states to develop regional emergency care systems.
The growing demand for emergency care and the difficulty of finding physicians to provide it led hospitals to require that active medical staff take turns covering the ED at night and to hire additional ED staff, regardless of their skills or experience. Eventually, some physicians gave up their regular practices to work in the ED full time. One of the first to do so was James Mills, M.D., who started the Alexandria Plan in 1961, a group made up of physicians who worked only in the ED. Similar plans in Pontiac and Flint,