Chapter 10: Emergency Medicine

INTRODUCTION

Emergency medicine liability for oncology had been minimal in past decades, but this is changing. The intersection of oncology and emergency medicine liability has widened in recent years. In order to understand this, it is necessary to explore the history of emergency medicine and recent changes in American health care delivery.

Ancient roots

The history of emergency medicine is both long and short. Emergency medicine has its deepest roots in ancient Greece. Around 400 BC, Hippocrates realized the importance of rapid removal of projectiles from soldiers during battle. As such, the origins of emergency medicine lie in the military.

Military origins of emergency medicine

In more modern times, emergency medicine found its early progress in the 19th-century French army, specifically during the Napoleonic wars. One of Napoleon’s chief military surgeons, Dominique Jean Larrey (1766–1842), can be considered the grandfather of emergency medicine. Larrey analyzed Napoleon’s military tactics and the resultant changes in military combat injuries. Compared to the 17th and 18th centuries, tactical changes resulted in more widely scattered battlefield casualties.

The biggest military tactical change in the 19th century was the use of wheeled, quickly moving artillery as opposed to prior lines of slower-moving infantry, thus resulting in the scattered wounded. Larrey developed a system of carriage evacuation for battlefield casualties, labeled “flying ambulances,” to ensure more rapid treatment of the wounded. Further building on that efficiency, Larrey also developed a system to categorize battlefield injuries based on the level of need for care. In essence, Larrey introduced the first emergency medicine triage system, which replaced the prior loose system based on military rank (or nationality in the case of multinational forces).¹

In the United States, emergency evacuation and treatment were introduced during the Civil War by Dr. Jonathan Letterman in 1862. Letterman instituted forward first aid stations, which served to reduce mortality. He was instrumental in establishing the US Army Medical Corps. Previously, military medical care was delivered by a division of the Army Quartermasters.² In 1864, the US Congress established forward line treatment, evacuation, and triage for the entire US Army, the earliest codification of what evolved into modern American emergency medicine.² Emergency medicine principles primarily remained within the military until the mid-20th century, including the introduction of early physician extenders, the military medics.

Civilian emergency medicine

Prior to the 1960s and 1970s, no emergency medicine specialty existed in the United States. Civilian emergency medical care was delivered by general practice physicians and surgeons. The first emergency medicine “group” was started in 1961 at Alexandria Hospital in Alexandria, Virginia, by five doctors: James DeWitt Mills, Chalmers A. Loughbridge, William Weaver, John McDade, and Steven Bender. The group provided 24-hour medical coverage, and this model became known as the “Alexandria Plan,” thus ushering in a template ...