Critical N e e d for a National Institute of E m e r g e n c y M e d i c i n e A critical need now exists for a National Institute of Emergency Medicine (NIEM) to provide an impetus for basic research in Emergency Medicine; to serve as a center for toxicological research for acute toxic exposures in children and adults; to be a center for study of the resources available for providing emergency medical care in the United States; and to provide a center to study and coordinate prehospital emergency medical services (EMS} systems. At this time, responsibility for research in areas related directly to Emergency Medicine is fragmented among many federal agencies. Prehospital EMS systems have no federal agency responsible for their coordination on a national basis. Despite the fact that the Federal Emergency Management Agency (FEMA) has responsibility for management of disaster recovery, it has no direct relationship to local EMS systems, has no responsibility for research into medical conditions associated with disasters, and has no formal or informal liaison with Emergency Medicine. Furthermore, Emergency Medicine has no coordinated systematic input into emergency medical care on a local basis. In most places, Emergency Medicine does not control the allocation of resources for patients brought to the emergency department. The result is that inner-city EDs in many cities are required to provide critical care to patients for days in many cases and to provide this care without any additional resources or personnel. Hence, the conclusion is inescapable that emergency medical care in many localities is in critical, even desperate, condition. Critical need also exists for basic research in Emergency Medicine. Much research is needed to study those conditions that present with an abrupt, severe change in physiological function and require immediate intervention. The acute onset of severe physiological dysfunction, such as acute respiratory distress, shock, alteration of consciousness, or multiple trauma, represents a critical medical emergency requiring immediate resuscitation. Emergency Medicine must have the resources to investigate these problems. We cannot expect others to do this investigation for us. We must find a way to implement a program of basic research in Emergency Medicine, despite the few emergency physicians who have taken fellowships or graduate training in basic sciences, the limited opportunities available to emergency physicians for such training, and the meager opportunities available collectively to develop research programs in Emergency Medicine. During its development as a clinical specialty, Emergency Medicine has demonstrated its capacity and willingness to accept responsibility and its eagerness to respond to challenge. Emergency Medicine is capable of solving the current crisis in emergency medical care, but the resources that it needs are those that comprise an NIEM. When Emergency Medicine is given these resources, the fragmentation and scattering of research re19:11 November 1990
lated to Emergency Medicine will end, the current lack of resources for providing emergency medical care will be identified, and a new beginning will be experienced in academic Emergency Medicine, with the specialty firmly rooted in basic science. Areas of research that relate directly to Emergency Medicine are: resuscitation research, which includes the study of oxidative stress, calcium entry into cells, and energy production by cells in resuscitated tissues; toxicology research, including the effects of illicit drugs, with a focus on the mechanisms of acute toxic injury and treatment; environmental stress research, including the effects of heat and cold, altitude, hyperbaric pressure, electrical injuries, near-drowning, animal and insect bites, and radiation effects; research into acute, severe physiological dysfunction of organ systems, such as occurs in acute respiratory distress or acute e l e c t r o l y t e d e r a n g e m e n t ; the molecular biology of human cells in crisis, or the molecular biology of resuscitation, including the study of mechanisms of damage and repair to nucleic acids and proteins and the production and inhibition of production of individual intracellular proteins; trauma research; burn research; investigation into the causes and treatment of medical and surgical problems associated with disasters, eg, thc "crush syndrome" from earthquake, and establishment of triage criteria for evacuation of patients from the disaster site, for obtaining studies with limited resources (eg, computed tomography scans and Doppler studies), and for use of surgical resources during disaster; research into ways to minimize the risk of HIV infection and other critical infections for medical personnel and patients in the emergency setting; study, design, and coordination of EMS for urban and rural environments with the intent of promoting a national coordinated EMS network in the event of disasters; and continuing assessment of the resources available for providing emergency medical care, especially in the inner city, where illicit drug abuse and HIV infection are significant problems. Current basic research in areas of primary concern for Emergency Medicine, now scattered among government agencies, is not necessarily focused on the problems related to the clinical practice of Emergency Medicine. Let us survey areas of research critical to Emergency Medicine and apparent federal resources that can be identified as responsible for research in those areas. At present, most support for research in resuscitation research comes from the National Institute of Neurological Disorders and Stroke and the National Heart, Lung, and Blood Institute. The American Heart Association, although not a federal agency, also contributes to resuscitation research. Toxicology research, carried out in the National Institute of Environmental Health Sciences and through the National Toxicology Program, is focused on nonacute en-
Annals of Emergency Medicine
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EDITORIALS
vironmental or occupational toxic exposures. Drug and alcohol acute toxic ingestion are studied in the National Institute of Alcohol and Alcoholism. However, there is no center for the study of those acute toxic exposures that occur far too frequently among children and adults seen in EDs. Poison control centers are unable to promote basic research in toxicology. Research into the biological effects of environmental stress has been carried out primarily by the Department of Defense, in medical research institutes supported by one or more branches of the military. However, there is no federal agency responsible for the investigation of other environmental injuries, such as electrical injuries or animal and insect bites. It seems appropriate that ongoing research into the effects of environmental stress should also be performed in civilian medical research centers, especially because far more civilians are potentially at risk of environmental stress conditions than military personnel in peacetime or war. Research into acute, severe derangement of physiological function or organ systems is a legitimate research focus of Emergency Medicine, although overlap occurs with areas of research interests of other specialties related to critical care m e d i c i n e . E m e r g e n c y M e d i c i n e has scarcely contributed to this area of research, although this area should be a dominant concern for the specialty. Research in this area, when now performed, is scattered widely among various institutes and agencies. Molecular biology is supported by all institutes at the National Institutes of Health, although few scientists focus primarily on human cells in crisis, a topic directly related to Emergency Medicine. Trauma and burn research are areas of investigation with no representation at the national level. The Shriners Burn Institutes have provided much-needed opportunities for burn research and burn treatment. At present, no federal agency is responsible for investigation into the causes and treatment of medical problems related to disasters. Emergency Medicine should be on board for the planning and implementation of plans for medical care in disaster situations. This role is currently the exclusive responsibility of the FEMA. Although much research is now carried out in the study of AIDS and HIV infection, there is little coordinated effort to study the problems of infection in the emergency setting. Exposure is magnified in the ED due to unrecognized HIV infection and crisis conditions, ie, hemorrhage, multiple trauma, and CPR. Emergency Medicine must have the resources to investigate this topic to protect patients and ED personnel. Coordination of EMS systems should occur on a national level especially in the event of a disaster. There must be a center for continuing study and design of EMS systems with scrutiny of their interrelationships both locally and nationally. The economic crisis in emergency medical care can no longer be ignored unless we are willing to accept disaster for all of our health care delivery systems, especially in our largest cities. Emergency Medicine has a pivotal role 162/1341
in bringing an end to the critical lack of resources that now exists in providing emergency medical care in our cities. Who might understand these issues and underlying problems better than emergency physicians? The development of an NIEM would bring into focus the problems now confronting Emergency Medicine and provide a mechanism to solve them. Understanding and correcting the problems that exist in the provision of quality care in the prehospital EMS setting would improve morale among EMS personnel while providing better prehospital care. Similarly, the 2-year-old girl who has ingested a poisonous substance found in the garage might have a better chance for survival following research sponsored by an NIEM. The frontiers of resuscitation research might be pushed back so that changes occurring in cell death now thought to be irreversible tomorrow might be shown to be reversible. Furthermore, other federal agencies would profit from the development of an NIEM. A close liaison between the Department of Defense and an NIEM would assist in the development of optimal emergency medical care for both military and civilian populations as well as contribute significantly to combat readiness. Studies sponsored by an NIEM on medical problems associated with disasters would assist FEMA in ensuring that the best emergency medical care possible would be available following disasters. During the initial phases of an NIEM, training grants should be given high priority. Special fellowships should be established to enable qualified emergency physicians to train for a PhD for up to five years. In this way, the Institute could provide the faculty and basic scientists needed to develop the basic research programs necessary for Emergency Medicine. I n t r a m u r a l research programs should also be established at an NIEM in areas primarily related to the specialty. Funding of extramural research programs in Emergency Medicine should also grow in importance as special fellows attain their second doctorate and begin their own research careers. NIEM would serve the twofold mission of optimally conducting research in Emergency Medicine and training future research personnel for the specialty. Basic research in Emergency Medicine would benefit people of all ages and walks of life. Emergency Medicine has the primary responsibility for providing medical care following natural or man-made disasters. A cross section of our society comes to the ED during normal times and after trauma, toxic exposure, environmental injury, and other causes. Considering the very frequent occurrence of such medical emergencies, the economic impact of improving the outcome of individuals so afflicted should place basic research in Emergency Medicine among the highest priorities.
Hubert S Mickel, MD, FACEP Research Director Emergency Department Barnes Hospital St Louis, Missouri
Annals of Emergency Medicine
19:11 November 1990
lated to Emergency Medicine will end, the current lack of resources for providing emergency medical care will be identified, and a new beginning will be experienced in academic Emergency Medicine, with the specialty firmly rooted in basic science. Areas of research that relate directly to Emergency Medicine are: resuscitation research, which includes the study of oxidative stress, calcium entry into cells, and energy production by cells in resuscitated tissues; toxicology research, including the effects of illicit drugs, with a focus on the mechanisms of acute toxic injury and treatment; environmental stress research, including the effects of heat and cold, altitude, hyperbaric pressure, electrical injuries, near-drowning, animal and insect bites, and radiation effects; research into acute, severe physiological dysfunction of organ systems, such as occurs in acute respiratory distress or acute e l e c t r o l y t e d e r a n g e m e n t ; the molecular biology of human cells in crisis, or the molecular biology of resuscitation, including the study of mechanisms of damage and repair to nucleic acids and proteins and the production and inhibition of production of individual intracellular proteins; trauma research; burn research; investigation into the causes and treatment of medical and surgical problems associated with disasters, eg, thc "crush syndrome" from earthquake, and establishment of triage criteria for evacuation of patients from the disaster site, for obtaining studies with limited resources (eg, computed tomography scans and Doppler studies), and for use of surgical resources during disaster; research into ways to minimize the risk of HIV infection and other critical infections for medical personnel and patients in the emergency setting; study, design, and coordination of EMS for urban and rural environments with the intent of promoting a national coordinated EMS network in the event of disasters; and continuing assessment of the resources available for providing emergency medical care, especially in the inner city, where illicit drug abuse and HIV infection are significant problems. Current basic research in areas of primary concern for Emergency Medicine, now scattered among government agencies, is not necessarily focused on the problems related to the clinical practice of Emergency Medicine. Let us survey areas of research critical to Emergency Medicine and apparent federal resources that can be identified as responsible for research in those areas. At present, most support for research in resuscitation research comes from the National Institute of Neurological Disorders and Stroke and the National Heart, Lung, and Blood Institute. The American Heart Association, although not a federal agency, also contributes to resuscitation research. Toxicology research, carried out in the National Institute of Environmental Health Sciences and through the National Toxicology Program, is focused on nonacute en-
Annals of Emergency Medicine
1340/161
EDITORIALS
vironmental or occupational toxic exposures. Drug and alcohol acute toxic ingestion are studied in the National Institute of Alcohol and Alcoholism. However, there is no center for the study of those acute toxic exposures that occur far too frequently among children and adults seen in EDs. Poison control centers are unable to promote basic research in toxicology. Research into the biological effects of environmental stress has been carried out primarily by the Department of Defense, in medical research institutes supported by one or more branches of the military. However, there is no federal agency responsible for the investigation of other environmental injuries, such as electrical injuries or animal and insect bites. It seems appropriate that ongoing research into the effects of environmental stress should also be performed in civilian medical research centers, especially because far more civilians are potentially at risk of environmental stress conditions than military personnel in peacetime or war. Research into acute, severe derangement of physiological function or organ systems is a legitimate research focus of Emergency Medicine, although overlap occurs with areas of research interests of other specialties related to critical care m e d i c i n e . E m e r g e n c y M e d i c i n e has scarcely contributed to this area of research, although this area should be a dominant concern for the specialty. Research in this area, when now performed, is scattered widely among various institutes and agencies. Molecular biology is supported by all institutes at the National Institutes of Health, although few scientists focus primarily on human cells in crisis, a topic directly related to Emergency Medicine. Trauma and burn research are areas of investigation with no representation at the national level. The Shriners Burn Institutes have provided much-needed opportunities for burn research and burn treatment. At present, no federal agency is responsible for investigation into the causes and treatment of medical problems related to disasters. Emergency Medicine should be on board for the planning and implementation of plans for medical care in disaster situations. This role is currently the exclusive responsibility of the FEMA. Although much research is now carried out in the study of AIDS and HIV infection, there is little coordinated effort to study the problems of infection in the emergency setting. Exposure is magnified in the ED due to unrecognized HIV infection and crisis conditions, ie, hemorrhage, multiple trauma, and CPR. Emergency Medicine must have the resources to investigate this topic to protect patients and ED personnel. Coordination of EMS systems should occur on a national level especially in the event of a disaster. There must be a center for continuing study and design of EMS systems with scrutiny of their interrelationships both locally and nationally. The economic crisis in emergency medical care can no longer be ignored unless we are willing to accept disaster for all of our health care delivery systems, especially in our largest cities. Emergency Medicine has a pivotal role 162/1341
in bringing an end to the critical lack of resources that now exists in providing emergency medical care in our cities. Who might understand these issues and underlying problems better than emergency physicians? The development of an NIEM would bring into focus the problems now confronting Emergency Medicine and provide a mechanism to solve them. Understanding and correcting the problems that exist in the provision of quality care in the prehospital EMS setting would improve morale among EMS personnel while providing better prehospital care. Similarly, the 2-year-old girl who has ingested a poisonous substance found in the garage might have a better chance for survival following research sponsored by an NIEM. The frontiers of resuscitation research might be pushed back so that changes occurring in cell death now thought to be irreversible tomorrow might be shown to be reversible. Furthermore, other federal agencies would profit from the development of an NIEM. A close liaison between the Department of Defense and an NIEM would assist in the development of optimal emergency medical care for both military and civilian populations as well as contribute significantly to combat readiness. Studies sponsored by an NIEM on medical problems associated with disasters would assist FEMA in ensuring that the best emergency medical care possible would be available following disasters. During the initial phases of an NIEM, training grants should be given high priority. Special fellowships should be established to enable qualified emergency physicians to train for a PhD for up to five years. In this way, the Institute could provide the faculty and basic scientists needed to develop the basic research programs necessary for Emergency Medicine. I n t r a m u r a l research programs should also be established at an NIEM in areas primarily related to the specialty. Funding of extramural research programs in Emergency Medicine should also grow in importance as special fellows attain their second doctorate and begin their own research careers. NIEM would serve the twofold mission of optimally conducting research in Emergency Medicine and training future research personnel for the specialty. Basic research in Emergency Medicine would benefit people of all ages and walks of life. Emergency Medicine has the primary responsibility for providing medical care following natural or man-made disasters. A cross section of our society comes to the ED during normal times and after trauma, toxic exposure, environmental injury, and other causes. Considering the very frequent occurrence of such medical emergencies, the economic impact of improving the outcome of individuals so afflicted should place basic research in Emergency Medicine among the highest priorities.
Hubert S Mickel, MD, FACEP Research Director Emergency Department Barnes Hospital St Louis, Missouri
Annals of Emergency Medicine
19:11 November 1990
