A personal perspective on the history of Emergency Medicine in Australia written by life member – Dr Edward Brentnal titled ‘A Short History of Emergency Medicine in Australia’ provides additional insight and understanding regarding those formative times
A Short History of Emergency Medicine in Australia
Author: Dr Edward Brentnal, MBE, CStJohn, MBBS, DObstRCOG,FRACGP,FACEM
Before about 1969, no Emergency Department in Victoria had a Director or any senior doctor in charge. Bernard Alderson was appointed at Geelong in that year, and others followed slowly. The rationale for these appointments was given by the medico-legal problems caused in junior doctors working without any supervision or teaching. I moved from General Practice to Box Hill Hospital in July 1975: Fools rush in where angels fear to tread! The organisation that was to become VEDA (the Victorian Emergency Department Association) had already been started, and became a vital tool for communication, mutual encouragement, and education. Even more importantly, it became an effective political unit. As it represented both doctors and nurses, the politicians listened to it. Gradually we pestered hospital hierarchy and Government Departments to allow improvements in staffing levels. Our numbers increased and the EDs changed. We became more ambitious and tried to expand our organisation to include the other states. Initially we had success with a Western Australian Society for Emergency Medicine formed in 1978 and an Australian Casualty Association in 1979-the latter holding the first national meeting in Sydney. By 1980, amid discussions to establish a doctor only organisation, the Australasian Society for Emergency Medicine was formed and held its inaugural Scientific Meeting in Sydney 1981. Victoria felt that the numbers and the political advantages of a combined doctors and nurses front group were more important that forming a purely medical society. However, when it became apparent that NSW and WA would refuse to join any organisation that included nurses there was no choice but to propose the formation of a College for Emergency Medicine. Rather Bad temperedly, that is what I did!!
The ACEM was formed in 1983, and rapidly created a training programme, an examination and a qualification – FACEM. There was strong opposition initially from the established colleges, especially the College of Surgeons. They wanted us to become affiliated with them, as the Anaesthetists were then. We were offered enticing inducements, including a joint FRACP (Emergency Medicine), but we wanted to be independent, and went our own way. The next ten years was a time of work and consolidation. Excellent doctors worked in the ED and developed the quality of care to a point when the next stage became possible. VEDA continued for some years, but eventually died. The ASEM and the College worked together, as it was clear that there would always be a need for an organisation to serve the needs of those who were not yet fellows or who for various reasons did not wish to sit the very tough examination. Some of us were lucky enough to be founding members of the College, and thereby gaining a fellowship.
We were not recognised as Specialists just because we had formed a College. We had to convince the Canberra Committee that we deserved to be so recognised, and that did not happen until 1993. Many of our medical and surgical colleagues did not believe that we were, and out application was not with any favour. Indeed, many regarded the whole business as nonsense. “Any fool can manage Cas” was the attitude. In some quarters, it still is. However, we found that we were winning when in-patient staff asked for an opinion on some aspect of toxicology or environmental emergency management. When the intensive care unit selected trainees in Emergency Medicine in preference to anaesthetic trainees (because of their general medical experience) we knew that we were winning. With the development of the specialist recognition came the trainees. At last it was apparent that there was a genuine career possibility, and excellent junior doctors applied for registrar positions. This was the point at which the quality of care in the ED moved into the excellent category, and this started to become recognised by patients, colleagues and the hospital. We have come a long way in thirty years. Our younger graduates will not recognise how far until they think of the primitive conditions that we had to deal with. For Example: Staffing. Most departments were staffed almost entirely on interns. At Box Hill (a medium sized hospital serving a population of approximately 750,000) we had 5 or 6 interns and 2 second year residents. One of these was the “Cas Senior” and the other the Admitting Officer. One of the interns started his year on night duty in the ED at midnight, and everyone else went to bed. He could call the Senior ( who was rostered on duty for 24hours), but was generally reluctant to admit his inadequacies. However, he or she was usually scared stiff for the first few nights, imagining all the catastrophes waiting to arrive. It took a little while for him/her to realise that most of the patients had problems that he could managed, and that help was available for those that were too difficult. The nurses were wonderful, advising on occasion that “Dr So and So usually orders this for such a problem”. Registrars were scarce, with only one on call for medicine or surgery, and they also were “on” for 24 hours at a time. Senior Medical staff were mostly non-existent in the ED except when one of the in-patient specialists came down to see a patient for admission. They were usually magnificent when there was a real emergency, but not always! Nursing staff were the backbone of many Departments. The senior nurses often had years of experience, know how to recognise really sick patients and what was needed. They also knew how to guide the junior doctors tactfully and sometime firmly.
Ambulance Officers (often then referred to as “Driver”) were not highly trained, although the new Mobile Intensive Care Ambulances (MICA) were staffed by well trained and resourceful officers. Communication between the ambulance cars and the hospital was minimal, usually via the control desk, and rarely useful.
Seat belts had been mandatory for a few years but we still saw injuries in patients who had not worn them. Despite the more recent legislation on drink driving, alcohol was a huge contributor to the road trauma that we saw. The compulsory blood alcohol samples from every patient over the age of 15 – including all passengers – gave us a huge amount of work, and often an appearance in court as well. At Box Hill in our peak year we too 1800 samples.
There was no Triage system. Patients were seen in the order of their arrival, unless they seemed to need to be put ahead because of their condition. In many hospitals this was decided by the clerical staff. Patients who were vomiting, bleeding all over the floor or unduly noisy were thus seen ahead of the quiet patient with severe chest pain or “indigestion”. The introduction of the first Triage system at Box Hill Hospital made a huge difference, and was rapidly copied all over Australia. One result was the drop in patient numbers as the non-urgent patients went elsewhere. At Box Hill out numbers dropped from about 50,000 per annum to about 36,000. We were too busy to worry about whether this was a good thing, or politically correct. At night there was often X-ray facility. The Duty Radiographer had to be called in if there was a need, and sometimes there was a dispute as to whether his call was truly needed. Likewise there was no Pathology service at night after about 10pm. It was theoretically possible for the intern to go up to the lab to use a microscope, but the pressure of work and the lack of proper training made this unlikely. The Director had to be all things; administrator; teacher; expert in resuscitation; politician; – whatever was necessary. Until Deputy Directors arrived to help with the work load, the Director was the “back stop”. Whenever the workload exploded, he was on call as a reserve. When there was a medico-legal problem, he was the first to be asked. When the duty surgeon was short tempered and unreasonable, the Director had to come to sort out the problems. When the fracture clinic was moved to the ED over Christmas, he had to deal with it. When the fractured nose clinic had no ENT surgeon, he had to come to reduce the noses. Problems with relatives, police, the media, – all of these came his way.
Our Equipment was mostly very basic. The ECG machine was a single channel model, and tracings took a long time. With a nervous patient in a strange environment – possibly in severe pain as well – tracings were not marvellous. The physicians were always trying to persuade us to let the Ward ECG nurse show our nurses how to take the ECGs without so much “interference”. The new PageWriters solved the problems instantly! We had only rudimentary monitors and defibrillators, usually “hand me downs” from the ICU. Our procedure room was regularly used by the surgical registrar for his “lumps and bumps” clinic, and even when he was late in arriving, he took precedence over the needs of the ED. In short, we were “the pits” and we were regularly reminded of that fact. We have made huge progress in thirty years, and our patients, as well as ourselves, have benefited accordingly.
THREE CHEERS EDWARD BRENTNAL!!!
The Society includes medical practitioners and others interested in or who have an involvement in emergency medicine, and aims to promote an humanitarian approach to patients, and to promote fellowship and communication in the emergency medicine community.
With ACEM, the Society is co-publisher of the journal Emergency Medicine Australasia. ASEM also supports education and trainees through seminars and the awarding of prizes to best trainee papers at the Annual Scientific Meeting of the Australasian College for Emergency Medicine and the Spring and Winter Seminars. The Society has particular interests in trainees, non specialist emergency medicine doctors, rural and remote emergency medicine and staff working in private emergency departments.
The affairs of the Society are governed by a Council comprising the president, two elected representatives from NSW, QLD, and Victoria, one elected representative from each of the other states and NZ as well as it’s various standing subcommittee chair persons. The executive comprises the President, Vice-President, Honorary Secretary and Honorary Treasurer.
Full membership is open to all registered medical practitioners in Australasia with a direct involvement in emergency medicine. Associate and institutional memberships are available to other doctors, health professionals or institutions with an interest in Emergency medicine. Memberships may include subscription to the journal Emergency Medicine Australasia. Emergency Medicine Australasia is the only peer reviewed journal in the specialty of emergency medicine in Australasia and is published five times a year. (Fellows and Trainees of the AEM Receive the journal as part of their College subscriptions). However members who subscribe through ASEM for Emergency Medicine Australasia receive a substantial discount to the standard rack rate for the journal.