New specialties are customarily, even necessarily, derived from old ones, gaining recognition when they have evolved sufficiently in a different direction, meeting different needs, to warrant standing on their own. The new specialty is tasked with defining the skills, patient population, focus of care and science that necessitate its discrete existence, and continually refining that definition as it matures. In the case of emergency medicine, that process began long before its acceptance as a full-fledged academic department by the University of Michigan Medical School in 1999.
Several societal forces converged after World War II to lay the foundation for emergency medicine in the United States. Among them were the decline in the number of general practitioners who made house calls, a growth in urban poverty, the experience gained by battlefield surgeons in both that conflict and the Korean War, and the enactment of Medicare and Medicaid, which enabled people who previously could not afford treatment to seek both scheduled care and emergency care.
In the 1960s, most ambulance services were part-time businesses that simply picked up injured or ill people and took them to the hospital; their passengers received little or no treatment en route.
Medically equipped ambulances, operated by medical centers, arose after a 1966 report by the National Academy of Sciences/National Research Council that described traumatic injuries as “the neglected disease of modern society”. This report led to the development of emergency medical services (EMS) and a push to provide better emergency room care and staffing and more extensive services.
The first full-time emergency practice in the U.S. was incorporated in Virginia in 1961, and the first organization in the field, the American College of Emergency Physicians, was formed in Michigan in 1968. But most emergency departments continued to be staffed by residents, interns and physicians who were either unable or unwilling to secure hospital appointments or establish their own practices. Few of the latter had envisioned emergency medicine as a calling, and none had any specialized training in it. It wasn’t until 1970 that Dr. Bruce Janiak became the first emergency medicine resident, at the University of Cincinnati.
Dr. William G. Barsan, the first chair of U-M Medical School’s Department of Emergency Medicine, described emergency medicine providers pre 1980 as “upstarts,” a mix of idealists eager to serve the underserved without regard to financial benefit, entrepreneurs forming group practices to retail emergency services, doctors who enjoyed the relatively regular hours or the thrill of the unexpected or both, and those whose past performance made it difficult for them to find employment otherwise.
As their orientation departed from the medical norm, they were stigmatized. They had no relationship with their patients over time. The field’s early leaders were clinicians, not academicians, and its earliest advances often involved the creation of delivery systems as well as advances in emergency medical care. With a preponderance of the poor and indigent among its patients, emergency medicine was often perceived as a money sink, and its practitioners derisively defined by the space where they worked (e.g. “an emergency physician is whoever practices in an emergency room.”) The most prestigious academic medical centers often saw nothing in it for them, and the nascent specialty was shaped in its infancy by hospital administrators, government policy makers and “second tier” universities.
In many ways, it was the entrepreneurs who foreshadowed the breadth that today’s specialty encompasses. They were concerned with every aspect of service delivery, from ambulance deployment to the effect of their operations on a care facility’s bottom line. When the perception of emergency operations changed from seeing them as a financial drain to appreciating their potential as a revenue stream, they began to gain in both popularity and credibility.
The arc of the discipline’s rise was consistent with that of other patient-based, rather than organ- or disease-based, specialties that attained official recognition in the same era, such as family medicine, geriatrics and pediatrics. Some in the field prefer to think of it as event-based, or centered around a phase of care or of illness or injury, or technique-based. They note that emergency physicians can be more successful at caring for a patient with a severe asthma attack than a pulmonary specialist would be, and that, unlike emergency physicians, most cardiologists never see cardiac arrest. They also need a high level of diagnostic expertise and the ability to deploy it quickly.
Emergency Medicine at the U-M to 1992
Like many other prestigious academic institutions, U-M was slow in granting departmental status to emergency medicine. Beyond its clinical value, the specialty had to demonstrate the quality of its research and teaching before it got space and money.
When Dr. William Barsan was hired in 1992 as the Section Chief of Emergency Medicine within the Department of Surgery, replacing Dr. Richard E. Burney, a surgeon who had been instrumental in the field’s progress at U-M. Dr. Burney later prepared a chronology to record and celebrate its evolution to date. It began by noting that Minnie Rice, a licensed practical nurse, started work in a unit called Emergency Services in September 1966, one of the few solid pieces of information extant about the early days of emergency care at U-M.
According to some sources, Dr. Charles Frey, a member of the U-M surgery faculty from 1964-76, was in charge of the Emergency Department in the 1960s, but he said in a 2015 interview that he could not recall that he, or anyone else, had held such a position. Dr. Frey noted that the younger surgical faculty instructors and assistant professors at the U-M Medical Center were responsible on a rotational basis for surgical coverage of the Emergency Department. Interns and residents from internal medicine and surgery provided most of the initial care, with the faculty being contacted only when an operation or some major decision was required.
This was common practice at the time at most university medical centers in the U.S. Most of the surgical faculty considered covering the emergency department to be an imposition. Since there was as yet no academic track for a trauma surgeon or emergency department physician, time spent on improving emergency department function or operating on trauma patients was a distraction from an academic career. According to Dr. Frey, “The administration of the Emergency Department was largely left to the Nursing Service and hospital administrators, with very little physician input.”
Although he himself eventually pursued a more traditional career, eventually serving on the University of California at Davis faculty for 18 years and as Chief of Surgery for the U.S. Air Force, Dr. Frey was a passionate advocate for improved emergency services in the 1960s and ’70s. He helped found and was the first chairman of the Michigan Emergency Services Health Council, an organization dedicated to improving statewide emergency medical services, and was the founder and first president of the University Association for Emergency Medical Services, which sought to establish an academic orientation in the field.
In a memoir prepared for the Bentley Historical Library, Dr. Frey noted that “The state of pre-hospital care in the 1960s of the acutely ill and injured was dreadful or absent in most areas of the country. Most victims of motor vehicle accidents in the 1960s at the University of Michigan were delivered to our hospital in hearses by personnel who had no training aside from a 12-hour Red Cross first aid course.” There was neither equipment nor competent personnel on board these vehicles for airway maintenance or administering IVs, and they showed up without warning, generally going to the nearest hospital rather than one capable of emergency care.
In 1967, Dr. Frey conceived and implemented a course called “Motor Vehicle Accidents and Their Sequelae,” designed to address the causation and prevention of vehicular accidents, the pattern of driver and passenger injuries, the initial care of the acutely ill and injured, and the need for injured patients to be transported to designated hospitals for definitive care. It was the first Medical School course of its kind in the U.S. and continued for six years before being integrated into other aspects of the curriculum.
The hospital continued to view its emergency department as a non-academic entity and ran it accordingly. Dr. Sidney N. Smock, an anesthesiologist and U-M Medical School alumnus, was hired in January 1974 as, apparently, the first official director of emergency services. Later that year, a task force under Dr. William Olsen, a professor of surgery with a special interest in trauma, recommended the establishment of a Section of Emergency Services, assigned to the Department of Surgery, to manage the Emergency Department. During the ensuing debate between the departments of surgery and internal medicine over where the ED would be sited, Dr. Smock returned to anesthesiology and Dr. Jeoffrey K. Stross, an assistant professor of internal medicine, served as interim director.
Also in 1974, Dr. Jeremiah G. Turcotte became chair of the department of surgery, the year before Dr. William N. Kelley was named chair of the department of internal medicine. Dr. Kelley believed that his department was the appropriate home for the emergency department, and worked tirelessly to prove his point. Among other tactics, he established a competing operation called the Medicine Walk-In Clinic across the hall from Emergency Services. In Dr. Kelley’s view, all emergency patients should be seen first by internists and admitted to internal medicine unless they determined otherwise. Even though Dr. Stross had staffed the Emergency Department primarily with internists during his brief tenure, Dr. Kelley would not allow internal medicine faculty to work in the Emergency Department.
Dr. Kelley’s demurrals notwithstanding, Emergency Services was now officially a section of the Department of Surgery, and Dr. Turcotte needed someone to oversee it on a part-time basis until a full-time section head could be appointed. Dr. Burney seemed especially well suited. As a general surgery resident at Yale, he had been part of the newly created Yale Trauma Program, devoted to developing pre-hospital care, and studied how emergency departments functioned. Dr. Burney’s qualifications as an academic surgeon may have been modest by traditional standards, but his familiarity with, and understanding of, emergency operations set him apart. As he later said, “They had not planned that I would be an academic star.”
Dr. Burney began work at U-M in September 1976 with a half-time appointment as an assistant professor of surgery and a half-time appointment as head of the section of emergency services. It took more than two years to hire a full-time head.
What Dr. Burney found when he arrived as its administrator was a clinical service that comprised five rooms on the fourth floor of the hospital’s Outpatient Building, adjacent to the Department of Surgery faculty offices, that was linked to the ground floor by a “frustratingly slow elevator.” Its location was convenient for doctors who were called to provide care – there was no full-time medical staff – because the orthopedic clinic was on the fourth floor and that’s where the casts were. Coupled with a notoriously slow elevator, the location was rather less convenient for patients.
Discussions began in February 1977 with hospital planners about the emergency department in the proposed replacement hospital, which led to a debate about whether to renovate the existing facility or wait for the new hospital to open. The decision was to go ahead with the renovation, and planning for that began in July 1978. The Board of Regents approved the replacement hospital plans in the following September. The renovation began in October 1980 and was completed in January 1982, doubling the size of the department. It doubled again with the move to the replacement hospital in 1986. The Medicine Walk-in Clinic moved to the Internal Medicine Clinic on the third floor of the Outpatient Building in January 1981.
Dr. James Mackenzie, a general surgeon who specialized in trauma and had spent four months in Vietnam in 1968 as a volunteer in civilian hospitals, became the first full-time head of the Section of Emergency Services in February 1979, the same year emergency medicine was recognized as the 23rd specialty by the American Medical Association and the American Board of Medical Specialties. Dr. Burney became Associate Chief.
A descendant of Alexander Mackenzie, the first Liberal Prime Minister of Canada, Dr. Mackenzie was hired from McMaster University in Hamilton, Ontario. He first interviewed for the position in April 1977, was offered it in August 1977, and visited again in April 1978 as part of ongoing negotiations over who would “own” the emergency department. Dr. Kelley, the chair of internal medicine, objected to the new director having authority over medical as well as surgical patients. Dr. Mackenzie accepted the position in June 1978, to start work October 15, but couldn’t get a visa that allowed him to be employed in the U.S. until the following February, 1979.
During Dr. Mackenzie’s tenure at U-M, which ended in 1985, emergency clinical services grew dramatically and emergency medicine itself began to establish itself academically. In his first month in office, the Medical School approved $13,000 for equipment to teach Emergency Care to first-year medical students. In February 1980, at a time when only five U.S. medical schools had academic Departments of Emergency Medicine, the Emergency Medicine post-graduate course at U-M had 265 participants. Now that a full-time section head was on board, empowered to recruit faculty, the hiring of physicians with an interest in academic emergency medicine began in earnest. The emergency department began to be staffed 24/7 with physician faculty, both surgeons and internists, in July 1981. Dr. Mackenzie even took it upon himself to help Dr. Burney burnish the lackluster research credentials that threatened his continued employment in an academic institution, and they began presenting their findings at emergency medicine meetings.
Dr. Mackenzie’s single greatest accomplishment may have been conceptualizing and leading the creation of Survival Flight, the first medical flight service in Michigan and one of U-M’s most visible connections to the community. Hospital administrators gave the green light to Dr. Mackenzie’s proposal in March 1982, and the flight nurse training program for the service began the same month. Dr. Burney, the program’s medical director; flight nurse Melanie Strozeski, and pilot Ed Gabryszewski made the first flight on May 15, 1982. The service initially consisted of a single helicopter on call 24/7 with a medical crew comprised of a nurse and a doctor. After Dr. Burney studied the difference between a nurse/attending physician team and a nurse/nurse team, measuring data such as morbidity and mortality (the kind of systems research that got him into the field in the first place), and found no difference in outcomes, the medical crew composition changed to the two-nurse team it is today, freeing the physician to remain on the ground to care for patients. Fewer than 10 percent of air medical programs today use the nurse/nurse model that’s in place at U-M, relying on a nurse/paramedic team instead. All Survival Flight nurses are also licensed paramedics.
Peter Forster served as the Survival Flight program manager from its inauguration until 2014. Denise Landis started as a flight nurse with the program in 1984, becoming chief flight nurse within a year. “Survival Flight was the brainchild of some very, very smart people,” Landis said in a 2014 interview, “and they set the program up right, with the right philosophy to do the right things. It’s always been based on patient care, not how many transports you need to complete each month to be considered viable.”
Dr. Mackenzie announced in January 1985 that he would step down as Section Head, effective June 1. Dr. Burney was named Interim Head and took over permanently when Dr. Mackenzie’s tenure ended, naming Dr. Lenore Kaplan Associate Chief.
Emergency Services’ offices and staff moved to the replacement hospital in February 1986. The Emergency Department in the new facility was divided into three areas: the main emergency department, managed by the Department of Surgery, Section of Emergency Services; the medical walk-in clinic, managed by the Department of Internal Medicine, and the pediatric walk-in clinic, managed by the Department of Pediatrics and Communicable Diseases.
The conflict over control of the discipline of Emergency Medicine between the departments of surgery and internal medicine continued to simmer. Negotiations between the two over the medical walk-in clinic begin in January 1987. Dr. Burney and company argued that all patients arriving at an emergency department are by definition emergency patients (which recalled the early definition of an emergency physician as a physician who works in an emergency room), that emergency medicine is what is practiced in Emergency Services, and that all clinical revenues must accrue to Emergency Services. But the concept of an emergency patient was as new as the concept of an emergency physician. Internal medicine argued that no one who was not an internist was qualified to diagnose and treat a “medicine” patient, which in their view was anyone who was not injured, and that revenues from emergency patients who were seen by internists should go to internal medicine rather than Emergency Services. The controversy continued until Dr. William Kelley, the chair of the Department of Internal Medicine, left U-M to become CEO of the Health System and dean of the School of Medicine at the University of Pennsylvania in 1989; ironically, one of his first acts was to establish a Department of Emergency Medicine there.
The football team is often called U-M’s “front door,” but that metaphor is equally apt for what Dr. Burney had in mind with his vision for emergency services: a place where the University is directly helping members of the community, without regard to who they are or whether they can pay. If anything, emergency services had once been seen as the “back door” to the hospital, but now the operation was becoming a primary entrance, increasingly integrated into its overall operation.
In 1987, the first full year of the new facility’s operation, 40,000 patients used the main emergency department; 6,000 used the adult walk-in clinic, and 12,000 children were brought into the pediatric walk-in clinic. The total of 58,000 was nearly 15% of the medical center’s 400,000 outpatient visits. From 1986 to 1988, emergency visits rose 20%, due at least in part to the fact that the service was now much easier to find.
It was becoming clear in the 1980s that without an emergency medicine residency, U-M would never be able to successfully recruit good emergency medicine faculty, and that no one trained in emergency medicine would work in a department run by a surgeon. For U-M to have a strong academic emergency medicine presence, it would eventually be necessary to have both a residency program and a department run by an emergency medicine trained and board certified specialist. Moreover, the American Board of Emergency Medicine board would only approve residencies with 24/7 supervision by attending physicians, the first specialty with that requirement.
Dr. Kimball I. Maull, a nationally known trauma surgeon, was commissioned as a consultant on the advisability of launching an emergency medicine residency program, and his report in March 1989 endorsed the need for it. It also endorsed having associate Emergency Services directors for internal medicine and pediatrics.
Soon after Dr. Lazar Greenfield succeeded Dr. Jeremiah Turcotte as Chair of the Department of Surgery in 1989, he began to create the framework for an emergency medicine-based emergency department. One of the first steps was to recruit an emergency medicine specialist to the faculty to establish a residency program and, eventually a full-fledged department at Michigan. Dr. Burney recommended Dr. William G. Barsan from the Department of Emergency Medicine at the University of Cincinnati College of Medicine.
Cincinnati had been the cradle of academic emergency medicine in the U.S. since admitting the country’s first emergency medicine resident in 1970. After earning his medical degree from the Ohio State University College of Medicine and Public Health, Dr. Barsan was a resident in surgery and radiology at the University of Virginia before realizing that emergency medicine was right for him. Although his mentors at Virginia tried to talk him out of it, he moved on to begin his emergency medicine residency in Cincinnati in 1977 and joined the faculty there in 1979.
Not only did Dr. Barsan have administrative and teaching experience in one of the few well regarded academic emergency medicine departments in the country, but his research dovetailed with the U-M’s strengths. U-M cardiologists had pioneered the use of thrombolytic therapy, dissolving clots in the coronary artery, to treat heart attacks. Dr. Barsan was working on thrombolytic therapy for strokes, which seemed like the logical next step but would also be a much trickier undertaking. Dr. Barsan had been an NIH funded researcher at the University of Cincinnati and was a tenured professor with a respectable academic background. The fit was good, and the time and place were right.
Barsan Years (1992- July 2012)
When Dr. Barsan was invited for an interview, the U-M had a “terrible reputation” in emergency medicine, he later recalled. Perhaps this was a lingering effect of the internal medicine department’s prolonged antipathy toward the field. Dr. Lazar Greenfield, the surgery chair, made it clear that the institution was committed to establishing a quality emergency medicine residency and an academic unit comparable to others at UM. Dr. Barsan to interview for the job, and he was selected as Head of the Section of Emergency Medicine in the Department of Surgery in 1992.
Dr. Barsan found himself in charge of a clinical service that still functioned much the way emergency rooms had in the 1960s. When patients arrived, nurses had to determine if their problem was medical or surgical, and thus whether they would be seen by an internist or a surgeon. Pediatric surgical patients were sent to the main emergency room, and children with medical problems to the pediatric walk-in clinic (which closed at midnight, after which all children went to the adult emergency room). All the faculty members in the Section were assistant professors except Dr. Barsan, who was the only tenured professor and the only professor who was board-certified in emergency medicine. Research in the department-to-be was scattered and uncoordinated, with minimal outside funding.
As Dr. Barsan later put it, “We probably weren’t worse than anyone else was around 1980.” But by 1992, U-M was well behind the curve. “I think they realized they were really behind the times,” he said later. “I told them a whole ton of stuff needs to change; if you’re not ready to change it, you don’t want me here. They said, ‘We do want to change it, but we don’t know what to do. You do, that’s why we’re hiring you.’ The biggest surprise was just how welcoming the U-M was to a new specialty because that wasn’t always the case in other institutions. We really had it relatively easy. Their attitude was ‘we’re not interested in just having you provide a clinical service; we want you to look like any other department at Michigan and we will give you the resources to do it. They were one of the few places that did that.”
But the clinical service’s operational processes clearly needed to be totally revamped to improve function, patient satisfaction, quality and outcomes. Moreover, statistical information to guide the improvements was sparse. According to Dr. Barsan, “It was not an area that people focused on very much, in terms of metrics: how fast people were seen, how many walked out before being seen, quality processes, the triage system. It wasn’t that we didn’t do some of that, but we didn’t do it very well and nobody was following it to see how well we were doing it. We had to set up all those procedures, including quality metrics.”
There were 11 faculty members in emergency services when Dr. Barsan arrived, including Dr. Ronald F. Maio and Dr. Marie M. Lozon. Both of them would play significant roles in the department’s evolution: Dr. Maio, recruited from Michigan State in 1989, as an innovative researcher and the second tenured professor in the department after Dr. Barsan, and Dr. Lozon, who joined the faculty shortly before Dr. Barsan’s arrival, as a champion of pediatric emergency medicine.
But it was still difficult to find a talent pool in 1992. Academically qualified faculty were not easy to find in the specialty at that time. Dr. Barsan’s chair at Cincinnati, Dr. Richard Levy, became head of the department only three years out from his residency. Dr. Barsan brought 4 faculty with him from the University of Cincinnati, including Dr. Steven C. Dronen, who became the first director of U-M’s emergency medicine residency program, a key element in achieving departmental status. By the time Dr. Barsan stepped down as chair in 2012, emergency medicine faculty numbered about 80.
U-M’s interest in an emergency medicine residency pre-dated Dr. Barsan’s arrival and may have been a factor in its timing. In 1991, a strong emergency medicine group at neighboring St. Joseph Mercy Hospital applied for an emergency medicine residency and inquired about residents doing some off-service rotations at the U-M Hospital. U-M officials felt that if an emergency medicine residency were to be established in Ann Arbor, it should be based at the U-M.
The solution was to operate a residency jointly with St. Joseph, one of the first major accomplishments of Dr. Barsan’s tenure. It proved to be an arrangement that not only benefited both institutions but also the residents themselves, who were exposed to a greater diversity of patients and clinical settings. “Residents historically have greatly valued the diversity of the training environment offered by the residency’s design,” according to the Department of Emergency Medicine’s Internal Review in 2010. “The chief limitation of this approach is the perpetual tension between the philosophies of the two groups towards patient care, academics, the role of residents, and the duties of faculty,” the Internal Review adds. “Although the relationship has been complex and has at times required significant effort to maintain, it is the longest standing, and currently the only, active training partnership between any clinical department in the medical school with an outside institution.” Even though the residency became a four-year program in 2000, a year longer than 75% of U.S. emergency medicine residencies, the U-M continued to be nationally competitive for residents.
The nursing staff for all three areas of the Emergency Department was centralized in 1995, and the Section Head of Emergency Medicine, Dr. Barsan, became responsible for managing all areas of the Emergency Department. The Section of Emergency Medicine also began staffing the emergency departments at Hurley Medical Center in Flint and Foote Memorial Hospital in Jackson (the Foote Hospital contract was terminated in 2009) and Hurley became a third rotation site for residents.
Founded in 1908 as a “safety net hospital” whose mission was to care for all who needed it, regardless of their ability to pay, Hurley’s inner-city location and patient population provided a learning environment far different from that of Ann Arbor. Creating a teaching site at a distance from the main campus was a new challenge for U-M but, like the partnership with St. Joseph, the relationship has endured. Emergency physicians at Hurley are members of the U-M Emergency Medicine Department faculty and most of them work full-time there, some with additional clinical or research duties in Ann Arbor. U-M faculty members working at Hurley were instrumental in the design and rollout of the hospital’s new emergency department in March 2012, which doubled its size and capacity and included a new, separate pediatric emergency department. Hurley has also provided fertile ground for urban-based research on such issues as access to care, service disparities, substance abuse and teen violence. The community has benefited as well from the level of care provided by first-class emergency physicians.
Pediatric Emergency Medicine
After Dr. Barsan assumed his duties as section head of the Section of Emergency Services at U-M, he and Dr. Lozon quickly began a productive and congenial working relationship. In 1994, pediatric emergency medicine faculty became members of, and a Division of, the Section of Emergency Medicine, having previously been part of the Department of Pediatrics and Communicable Diseases. It had become clear to Dr. Barsan that the skills, work flow, and approach to patient care in emergency pediatrics would be a better fit in his unit, and he negotiated the transfer of Pediatric Emergency Services from the Department of Pediatrics and Communicable Diseases. Pediatric emergency became a 24/7 service at around the same time. University of Michigan pediatric emergency faculty continue to have appointments in Pediatrics, but their primary appointments are all in Emergency Medicine, which is also the source of their funding.Dr. Marie Lozon joined the faculty in the autumn of 1991, she was one of only two physicians at U-M who specialized in pediatric emergency medicine. The institution was interested in the emerging field because, as a Level I Trauma Center, it cared for some children with complex problems. Many large academic hospitals still do not have pediatric emergency specialists.
Children’s Emergency Services became a free-standing service in C.S. Mott Children’s Hospital when it opened in 2011. By 2015, it was caring for more than 20,000 children a year. Although injuries from trauma are the leading cause of death and disability in children, 82% of children’s emergency hospital visits are to non-specialized emergency departments, and pediatrics runs about three-quarters of the pediatric emergency facilities in major academic hospitals in the U.S.
As the pediatric component of clinical emergency medicine at U-M grew, Dr. Lozon was asked to work with colleagues at St. Joseph Mercy Hospital to help create a pediatric component of the residency program. The first fellowship program offered by Emergency Medicine after it became a Medical School department was in pediatric emergency medicine, starting in 2007 Dr. Rachel Stanley directed the Pediatric Emergency Medicine Fellowship for its first year. She was succeeded by Dr. Michele Nypaver, who held the job until Dr. Michele Carney took over in 2014. By then, about half of the pediatric emergency faculty members were former fellows in the program.
Emergency Medicine became a Medical School Department on July 1, 1999, and Dr. Barsan was appointed its first chair. Dr. Lozon was named director of Children’s Emergency Services in 2000.
The strength of the emergency medicine research program was important in attaning departmental status and has become a national leader by any measure. It is regularly among the top three, and often the leader, in funding from the National Institutes of Health for emergency medicine research.
Drawing on the teamwork inherent in emergency medicine, which leverages the strengths of so many other specialties to provide care, and the U-M’s history of interdisciplinary strength (U-M medical researchers had worked with colleagues in transportation, engineering, public health, and business administration), it became an anchor for national research networks. U-M is the clinical coordinating center for the 22 centers for the Neurological Emergencies Treatment Trials Network (NETT), which was the largest NIH-funded emergency medicine project in history when it was launched in 2006. It has been the lead institution since 2001 for the Great Lakes Emergency Medical Services for Children Research Network (GLEMSCRN), of the Pediatric Emergency Care Applied Research Network (PECARN), a federally funded network of 18 health systems for research in pediatric emergency medicine. And its Injury Research Center, founded and originally directed by Dr. Ronald Maio, received funding from the Centers for Disease Control and Prevention in 2012 as one of 11 national Injury Control Research Centers. Dr. Rebecca Cunningham is the Director of the Injury Research Center.
NETT was one of Dr. Barsan’s visions, an outgrowth of his longstanding interest in stroke research, and he worked on it for three years prior to its official launch. Initially funded by a $7.7 million, five-year grant from the NIH’s National Institute for Neurological Diseases and Stroke in 2007, it became a backbone for a broad variety of studies conducted in ambulances and emergency departments nationwide. The grant was renewed for another five years in 2011. By involving many sites where brain and spine emergencies are treated, NETT overcame one of the biggest roadblocks to finding better emergency treatments: having enough eligible patients with the same condition at any single hospital. After his tenure as chair ended, Dr. Barsan continued to serve as the principal investigator of NETT’s clinical coordinating center.
In addition to advances in patient care, NETT demonstrated the value of emergency medicine as a research interface. “Typically, in the past, an acute stroke study would be led by a neurologist, who would get some emergency medicine people to help,” said Dr. Barsan. “A traumatic brain surgery study would be led by a neurosurgeon or a trauma surgeon, who would enlist emergency medicine help. What they all have in common is they can present as an emergency, so it makes more sense to have it focused around emergency medicine. You have to know the territory, which is pre-hospital and emergency care, and we know that better than anybody.” NETT’s leadership includes specialists in neurology, neurosurgery and trauma surgery, in addition to emergency medicine.
The U-M Injury Research Center is a multidisciplinary program devoted to reducing and preventing injury caused by motor vehicle crash, violence, prescription drug misuse, concussion, and other intentional and unintentional injuries. It was founded in 1997 by Dr. Ronald Maio as the Department of Emergency Medicine Injury Research Center and was housed in the Section of Emergency Medicine and later the Department of Emergency Medicine. When Dr. Rebecca Cunningham, the EM department’s first female full professor, succeeded her mentor Dr. Maio as the center’s director in 2005, she broadened the scope of its investigations and it became an institution-wide entity that is funded and run by the Medical School, School of Public Health and U-M Transportation Research Institute. The Injury Research Center received a five-year, $4.2 million grant in 2012 from the Centers for Disease Control and Prevention as one of its Injury Control Research Centers.
Dr. Maio, who was also the founding Principal Investigator of the Great Lakes Node of PECARN, drew on what he called “a global picture about issues” in launching the Injury Research Center, not only by collaborating with other U-M units, including psychiatry and the Transportation Research Institute, but also by looking at the entire continuum of trauma care, including how to keep people out of the emergency room in the first place. While injury prevention became a staple of emergency medicine research, the concept was innovative at the time. Using the emergency department as a location to do public health interventions was comparably innovative.
“I don’t see myself as doing emergency medicine research,” he said later. “I saw myself as doing research in trauma care, injury prevention, and pre-hospital care, and I happened to be an emergency physician. If you have surgical oncologists working on a vaccine to prevent cancer without using surgery, are they doing surgical research? They’re doing cancer research. There can indeed be emergency medicine research that might focus on very specific, operational issues, but even with that there’s a lot of crossover.”
The Injury Research Center’s CDC grant in 2012 helped U-M researchers expand their work on preventing death and disability, as well as treating injuries from automobile crashes, prescription drug overdoses, violence and other leading causes of injury in the region. “Becoming a CDC injury center will help us take our work to the next level, to help us understand why injuries occur, and what works best to mitigate physical and emotional harm,” says Dr. Cunningham.
Dr Cunningham came to U-M for her residency and research fellowship after earning her M.D. at Jefferson Medical College and was one of the emergency physicians whose principal work site was Hurley Medical Center. “If you’re going to work with underserved populations and problems around injury and violence, Flint is a good place to help the community by the research you’re doing,” she said later. Dr. Cunningham became the department’s associate chair for research in 2014. Soon after taking that position, she described emergency medicine research as “inherently collaborative and communal, and inherently as varied as the types of patients we see. Research in emergency medicine covers everything from vaginal bleeding to stroke to trauma to substance abuse.”
Dr. Cunningham also noted shifts in the kinds of issues studied in emergency medicine research. “Ultimately, the emergency room is the gatekeeper for what happens in the rest of the hospital and a huge user of health care resources,” she said, “so researchers are looking at several aspects of health service utilization.”
PECARN’s work focuses on research and education for physicians and emergency responders on a broad range of children’s emergency medical issues, including pre-hospital care, injuries, violence, acute infectious diseases, access to emergency care and medical training. The network approach to research is especially useful in pediatrics because “compared with adults, medical emergencies in kids are rare, so much more cooperation is needed to gather data and prove the effectiveness of treatment,” said Dr. Rachel Stanley, a U-M assistant professor of emergency medicine who became the Great Lakes Node’s Principal Investigator in 2008.
In 2010, as Dr. Barsan neared the end of his term as chair, department leaders prepared an internal review to assess the state of emergency medicine at U-M and provide candid analyses that would both guide its future development and furnish Dr. Barsan’s potential successor with relevant information. It listed the strengths of the department’s research program as sustained federal funding to support research in each of a broad base of interests related to the care of patients in emergency circumstances, including stroke and other neurological emergencies; injury; substance abuse; shock, sepsis and infectious disease, and a variety of pediatric disorders; campus-wide collaboration including the Medical School, the College of Engineering, the College of Literature, Science and the Arts, the School of Public Health, the Ross School of Business, and the U-M Transportation Research Institute; the expansion of the faculty to include PhD researchers, and the active participation of emergency medicine faculty on dissertation committees within the School of Public Health and College of Engineering.
The review also perceived weaknesses in a few areas, some of them resulting from the department’s relatively small size and youth: limited alignment between the research mission and the department’s clinical and educational missions; research program success that had predominantly taken place independently of other departmental functions; a research program that was geographically over-distributed (arguably the down side of its often generally interdisciplinary nature) insofar as some emergency medicine researchers did not view the department as their research home but tended to associate primarily with their extra-departmental collaborative teams; research programs that did not readily provide spinoff projects that might contribute to promotional opportunities for clinical-track faculty, and a departmental research portfolio that had grown organically, rather than by long-term planning and focused hiring.
The role of emergency medicine’s educational mission in the U-M Medical School grew during Dr. Barsan’s tenure. It became part of the residency training programs of internal medicine, pediatrics, family medicine, otolaryngology, anesthesiology, and hospital dentistry. In 2006, it also became a required rotation for fourth-year U-M medical students. Its principal pedagogical value lay in diagnostics, especially for acute illness, injury, and decompensated chronic illness. When students work on a floor in the hospital or in a clinic, the patients they see already have a diagnosis and a treatment plan. When they see patients in the emergency department, they’re challenged to diagnose and initiate treatment for undifferentiated presentations like chest pain or headache. The department has also taken a leading role in the use of the human patient simulator for medical student education in both the fourth-year rotation and in other training and testing experiences.
The U-M Graduate Medical Education (GME) office’s Health Administration Scholars Program grew out of a series of seminars for emergency medicine residents, inaugurated in 2006 by associate professors Dr. Jeff Desmond and Dr. Marie Lozon. Based on the concept that emergency physicians, practicing at the crossroads of all other specialties, would benefit from a broad knowledge how the health system worked, it introduced them to topics relevant to hospital administration such as health laws, finance, nursing management and education, malpractice management, regulatory issues like privacy and compliance, advocacy, and physician compensation. The value of the track was recognized by other residency programs, including surgery, radiology, obstetrics, psychiatry, internal medicine, pediatrics and rehabilitation. Dr. Lozon and Dr. Desmond, along with colleague Dr. Susan Stern, were awarded a two-year GME Innovations Grant in 2008, and the emergency department seminar series became a structured 20-month course available to all resident trainees and research fellows within the U-M Health System. When the grant expired, the departments whose residents participated in the course assumed responsibility for funding it.
A $20 million renovation of the Emergency Department was completed in 2002. A $17.7 million renovation and expansion of the Emergency Department opened in December 2011, increasing its size in square footage by almost 17 percent and adding 27 new patient care rooms. The project also expanded and improved the triage area as well as the arrival and waiting areas. Adjacent facilities for psychiatric emergency care, a 24/7 service run by the Department of Psychiatry, were also renovated. Since at least the early 1990s, patients who came to the emergency room with mental health and behavior issues could be managed by mental health professionals, which was not the case in most emergency departments. Nursing and triage functions between the psychiatric component and the rest of the department were integrated as much as possible. By 2015, psychiatric emergency was seeing nearly 6,000 patients a year.
Ghana Emergency Medicine Collaborative
The Department of Emergency Medicine began its leading role in the Ghana Emergency Medicine Collaborative in 2008 at the request of the Rector of the Ghana College of Physicians and Surgeons. The project’s mission is to improve the provision of emergency medical care in Ghana through a formal residency program at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana – where a new Accident and Emergency Center was completed around the time the collaborative was launched – as well as through training programs for medical students and and nurses. In addition, the U.S.-based members of the collaborative have access to an appropriate setting for resident and faculty research and teaching in global emergency medicine. By 2015, other partners in the collaborative were the Kwame Nkrumah University of Science and Technology, the Ghana Ministry of Health, and the U-M School of Nursing. The project received a 5 year award for the Medical Education Partnership Initiative (MEPI) from the Fogarty Center of the National Institutes of Health in 2010, with additional support from the Department of Emergency Medicine and the U-M Center for Global Health.
Survival Flight’s complement of leased aircraft grew during Dr. Barsan’s tenure to three helicopters, two of which are in service at any given time, and a jet for transporting patients outside the helicopters’ 250-mile range. It also contracted for ground ambulance service and became a rotation for emergency residents, all of whom fly at some point in their training. In mid-90s Survival Flight went to two aircraft 24/7, have three aircraft now that are licensed by stateand keep two in service at one time. Dr. Mark Lowell has served as the medical director of Survival Flight for over 15 years.
In one of the most searing events in U-M history, six Survival Flight crew members lost their lives on June 4, 2007, when their leased Cessna jet crashed into Lake Michigan while on an organ recovery mission: David Ashburn, a cardiothoracic fellow near the end of his training; Dr. Martin Spoor, a cardiac surgeon and U-M faculty member; Richard Chenault II and Rick LaPensee, transplant donation specialists, and pilots Bill Serra and Dennis Hoyes. The program resumed operations just four hours after the tragedy. Survival Flight memorialized the occasion by hosting its annual safety day seminar on June 4.
Saint Joseph Mercy Health System announced in June 2011 that it would transition its use of emergency medical helicopters to Survival Flight, which expanded its service to include patient transports between the seven hospitals of Saint Joseph Mercy Health System in southeast Michigan and other locations. Saint Joseph closed its Midwest Medflight program, which it began in 1986.
Several faculty members who were among Dr. Barsan’s earliest recruits were later tapped for leadership roles by other institutions. In 2000, Dr. Carl R. Chudnofsky became chair of the department of emergency medicine at the Einstein Healthcare Network in Philadelphia. Dr. Steven Dronen was named director of the emergency department at LeConte Medical Center in Sevierville, Tenn., in 2001. Brown University chose Dr. Brian Zink, a 1992 arrival, to chair its newly created department of emergency medicine, the first in the Ivy League, in 2006. Dr. Susan A. Stern, who also started at U-M in 1992, became head of the Division of Emergency Medicine at the University of Washington in 2009. Dr. Terry Kowalenko was appointed chair of emergency medicine for the Beaumont Health System in southeastern Michigan in 2013. Dr. Zink was one of several U-M faculty members who served as president of the Society for Academic Emergency Medicine, an experience that he said prompted him to spend three years (instead of the nine-month sabbatical project he originally envisioned) writing Anyone, Anything, Anytime: A History of Emergency Medicine, the definitive account of the discipline’s evolution.
When Dr. Barsan turned over the reins of the department to Dr. Robert Neumar on July 1, 2012, emergency medicine at U-M was a vastly different enterprise than the 1970s-style clinical service with a handful of faculty, mostly from other departments, that greeted him when he arrived 20 years earlier. Its residency program was one of the most highly regarded in the country, its impact on the Medical School curriculum was profound and pervasive, it was an interntationally recognized leader in emergency medicine research and regularly ranked in the top three in emergency medicine research funding from NIH, and its clinical facilities were state of the art. It would be Dr. Neumar’s task to not only preserve that foundation but build on it.
Neumar Years (7/1/2012-Present)
Dr. Neumar, a leading expert in research on cardiac arrest, came to U-M from the University of Pennsylvania Perelman School of Medicine, where he was an Associate Professor of emergency medicine and associate director of the Center for Resuscitation Science.
His appointment brought him back to the state where he received his PhD in physiology from Wayne State University. Dr. Neumar received his MD from the University of Pittsburgh School of Medicine, where he also did his internship and residency.
His interest in basic science laboratory research signaled an additional direction for the department. Shortly after his arrival, in the first issue of the department’s newsletter, he described his vision as making it “the leader in our specialty, and the place where the future of emergency medicine is created.”
Two large-scale ground-breaking projects that embodied that stance, one in research and one in treatment, and both exemplifying emergency medicine’s focus on the continuum of care, were landmarks of Dr. Neumar’s first years at the helm. The Michigan Center for Integrative Research in Critical Care (M-CIRCC), whose administrative home was in the Department of Emergency Medicine, began operations at the North Campus Research Complex in the spring of 2013, bringing together more than 100 U-M scientists and clinicians with early-stage entrepreneurs and industry partners to develop and deploy critical care solutions. The 7,800-square-foot Emergency Critical Care Center (EC3) opened in the hospital’s emergency department in February 2015. The $7 million project occupied the space that served children until the opening of the pediatric emergency department in the new C.S. Mott Children’s Hospital in 2011. With five resuscitation/trauma bays and nine patient rooms, the EC3 gave teams of doctors, nurses, respiratory therapists, pharmacists and others the necessary space and tools for patients’ initial diagnosis and stabilization, as well as an intensive care unit-level environment for initial care.
The EC3 provides a setting for young physicians who had finished their emergency medicine training to pursue fellowships in critical care, a new subspecialty that was emerging to meet a growing demand for doctors with expertise focused on the first hours after the onset of a major health emergency. Completing the two-year fellowship made emergency medicine-trained doctors eligible to be board certified in critical care by the American Board of Medical Specialties.
Even as these initiatives were implemented, one of the department’s most historic innovations was maintaining its state-of-the-art status. Survival Flight leased three new American Eurocopter 155 helicopters that arrived in August 2012, replacing three Bell 430 helicopters that had been in service since 1998. They were the first EC155s to be put into emergency medical service in the U.S. and were equipped with advanced equipment and safety features, including the ability to fly in low-visibility conditions. They had nearly 50 percent more cabin space for nurses and patients than their predecessors, and could fly 500 miles without refueling.
Especially in comparison to its modest, if not helter-skelter, beginnings, there were some who saw emergency medicine, both nationally and at U-M, entering a golden age. As the specialty became more sophisticated, its services became increasingly useful to the rest of the hospital, and its practices and processes were seen as models for providing value in the overall health system. Concomitantly, emergency medicine physicians, due to the breadth of their expertise and the collaborative nature of their work, were increasingly tapped for administrative roles in health care.
In the half century since emergency patients began to be seen in a five-room area on the fourth floor of the University Hospital outpatient building, the emergency medicine enterprise at U-M had grown to encompass a regional emergency trauma center with a trailblazing Critical Care complex, a training program in emergency medicine and related specialties that was second to none, and a research program whose fruits prolonged and improved patients’ lives and whose methods provided a template for the future.