Life and Death Docs : New UCI Medical School Program Set Up to Train Physicians for Emergency Room
Dr. Laurel Hodgson was working feverishly on an ashen-faced 17-year-old who was rushed to the UCI Medical Center after he fell from a moving truck.
Minutes earlier, the new physician had been leisurely questioning a woman who had come to the emergency room with an earache.
But now in the trauma center, as doctors, nurses and technicians swarmed around the youth--bumping into each other as they sliced away his black pants, drew a blood sample, inserted IV tubes--Hodgson probed for internal injuries.
“Does this hurt? Does this hurt?” she asked, palpating his abdomen, then stopping a moment as, eyes closed, the youth groaned “Ow! Ow!”
At 44, Hodgson, a mother of four and former phone company manager with curly brown hair and a ready smile, is training to be a specialist in one of her profession’s hottest fields--emergency medicine.
And for Hodgson, this was a typical 12-hour day in the emergency room--treating a minor ear infection one minute, a life-threatening injury the next. But, she and her colleagues said, they like the unpredictability of this work, the constant test of medical skills.
Also, Hodgson said, she loves the excitement. “I’m an adrenaline-junkie,” she admitted during a lull between patients. “A good day is a lot of interesting cases. And they required intervention. And you went in. And you fixed them.”
Hodgson and 11 other recent medical school graduates are among the first residents at the UC Irvine School of Medicine’s new, three-year program in emergency medicine.
Approved in February, 1989, it is the first new medical-training program at UCI in a decade and one of 12 emergency-medicine residencies in California. (Others include those run by USC, UCLA, UC San Diego and Loma Linda University Medical Center. Also Stanford University last February won approval for a training program that will start in July, 1991.)
Around the nation, 83 residencies have been approved since 1979 when the American Board of Medical Specialists formally recognized emergency medicine as one of 23 distinct medical fields.
But 11 years later, there is still a shortage of credentialed emergency physicians. Of 23,000 emergency room doctors, only 9,000 are board-certified, according to the American College of Emergency Physicians. And, with just 650 new specialists graduating each year, the residency programs can’t meet the demand.
Emergency physicians attribute the shortfall in part to their specialty’s relative newness. And, around the country, faculty members in the field are young. At UCI for instance, Dr. Kym Salness, director of emergency services and founder of the program, is the oldest professor--at 40.
Also, the demand for these specialists has escalated as hospital after hospital has sought board-certified emergency physicians for their emergency rooms. Partly, they have done so out of malpractice concerns, doctors and hospital administrators said, but there’s been a general move to raise quality.
“It used to be a dermatologist could be an emergency room physician. Any doctor could practice in the emergency room. That’s not true anymore,” said David Langness, a vice president with the Hospital Council of Southern California.
Twenty years ago, the doctors who staffed emergency rooms were surgeons or internists, including some whose private practice was failing or “they hadn’t decided what to do,” Salness said.
But as time went on and patients clamored for more sophisticated emergency care, emergency room doctors became more sophisticated, too.
“You can be shot in the heart or crunched in a traffic accident and the community expects there will be somebody to take care of you who is flawless,” Salness said, adding: “They’re willing to sue your butt off if you can’t deliver a baby or handle a baby” whose heart stops. “And where do you take the person with a drug overdose? Where do you take a woman who’s been raped?The emergency room does it all.”
Initially, national medical leaders were skeptical that the art of evaluating, stabilizing and resuscitating critically ill patients was a specialty of its own, according to Jane Howell, a spokeswoman for the American College of Emergency Room Physicians. “The old boy network” of physicians thought surgeons or internists could do the job, she said.
But after 11 years of lobbying, the American Board of Medical Specialists finally gave approval to the new field. At first, emergency medicine had “modified” status, requiring it to include other specialists like psychiatrists or pediatricians on its credentialing panel. But last year, it gained full approval, with the power to issue emergency medical credentials in sub-specialties such as toxicology.
Although some doctors have raised eyebrows about emergency medicine, they sometimes have come to appreciate it the hard way, said Dr. John C. Johnson, a Valparaiso, Ind., physician who is president of the American College of Emergency Room Physicians.
Three years ago, when a man came into his emergency room with chest pain, a family practice physician took over. “So I went around the corner to get a cup of coffee,” Johnson recounted. But moments later, Johnson was paged to return immediately to the emergency room.
“And as I turned the corner, that same physician ran by me, yelling, ‘I don’t do codes!’ ” (In medical parlance, a patient whose heart has stopped has “coded.”)
Johnson revived the patient but, he said, that physician and many doctors like him are finally willing to admit that “they really don’t feel comfortable in an emergency department” where a doctor often has to play “super sleuth. . . . You have to look at what few tests are available and in 30 minutes, 50 minutes--you gotta do something. Or it’s going to be a dead body in the morgue.”
At UCI, Salness helped create the medical center’s top-level trauma center in 1981 and began recruiting certified emergency medicine physicians (10 so far) to help run it. Then, in 1987 he began aggressively lobbying for the new residency.
The battle was uphill at first, largely because the money to train 18 residents--three classes a year, each with six students--came from other specialists’ budgets. Still, Salness said, eventually “I was able to convince them that the medical students were getting gypped because there was no training for emergency medicine.”
Walter Henry, UCI vice chancellor of health sciences, is one of the program’s boosters. “I fully expect this to be one of those programs at Irvine that will be nationally competitive,” he said.
Hodgson was among the first six students who joined the program when it began in June, 1989.
Older than her fellow students--not to mention all her emergency medicine professors--Hodgson quit her job as a telephone company manager, where her husband still works, and in 1985 began studying to be a doctor. Her two children and two stepchildren helped her study at home, she said, grilling her on medical terms and typing her papers.
After four years of medical school, Hodgson said she came close to “settling for a residency in internal medicine” at about the time that UCI announced its new emergency-medicine residency.
Like her colleagues, she draws a salary that is a fraction of what she will make as full-fledged emergency room doctor--$27,700 as a first-year resident, $30,800 in the second year and $33,600 by the third year.
Not only must Hodgson and other residents work long hours in Orange County’s busiest emergency room, they work in other departments such as pediatrics and anesthesia and they must publish at least one research paper in a national medical journal.
Hodgson says emergency medicine offers the variety of practice she wants--”where you walk into the emergency room and pick up a chart and it could be something like opening up an abscess or a pediatric emergency . . . and you have to make an instant decision. And that decision better be right.”
She also likes the hours. Though she regularly draws graveyard or weekend duty--always in 12-hour shifts--”it’s scheduled. I’m going to work 12 hours. And then I’m done. And now (the emergencies)are someone else’s problem.”
While a resident, Hodgson is supervised every minute of her day. Before prescribing, she must describe her diagnosis and review recommendations for treatment with a senior physician. Still, she said, it is very satisfying to make the right diagnosis, to save someone’s life.
Consider the day a woman with breast cancer came in.
Her face was puffy, her lips were blue, and Hodgson quickly diagnosed “superior vena cava syndrome,” in which a large cancer compresses the vein that feeds the heart.
“I thought: Get a chest X-ray. And they did. And there was nothing there,” Hodgson recalled. So as the woman continued to gasp, Hodgson thought again.
The patient had a “porta-cath,” a plastic catheter, implanted in her chest for chemotherapy treatments. Wondering if the catheter were clogged, Hodgson ordered an angiogram.
Meanwhile, the woman was growing more and more short of breath. “She had this feeling she was going to die,” Hodgson said. “She was grabbing my hand, saying, ‘Let me die in peace. Let me die in peace.’ ”
The angiogram showed that her catheter was indeed clogged, but Hodgson had to convince the woman that she wasn’t dying. ‘No! I’ve got medicine,” she announced firmly, saying she could clear the clogged porta-cath.
As Hodgson administered the medicine, the woman’s breathing eased and her color gradually returned to normal.
“It was fairly dramatic,” Hodgson said. “This was a nice lady. Her breast cancer was under control. She had a number of years left in her life. And clearly if we hadn’t done something, she would have died in a few hours.”
But, Hodgson said, that’s emergency medicine: “I want to see it when it’s really looking bad”--and then fix it.
