Royal Free Hospital, Gray’s Inn Road. Accident ward.. Credit: Wellcome Collection. Attribution 4.0 International (CC BY 4.0)
The emergency department is seen as the ‘coal-face’ of any hospital, providing 24-hour-access medical assessment to members of the public.
Having just started my first job in emergency medicine, after working in general practice and in other hospital specialties, I have been struck by how distinct the challenges are facing staff in this environment. And for a specialty that is so publicly ubiquitous, it is hard to imagine that it is also one of the newest; in the UK only forming The College of Emergency Medicine as we know it, in 2005.
A brief look at the history of the accident and emergency department paints a picture of a speciality that has always adapted to the populations it serves.
Dominique Jean Larrey, a French surgeon in Napoloeon’s army, is seen as an early pioneer of many of the concepts of emergency medicine having developed a system of battlefield triage and emergency treatment. During the battles of the French Revolution in 1793 he commandeered the French flying artillery and made them into ‘ambulance volantes’ – literally meaning ‘flying ambulances’ – to transport the wounded from the battlefield rapidly.
He also improved the organisation of field hospitals and developed the technique of ‘triaging’ the wounded based on the seriousness of their injuries, rather than rank or nationality. Wounded soldier of enemy armies were also treated in his hospitals, demonstrating one of the central tenets of emergency medicine of care being open to all.
While Larrey may have been one of the first to define and formalise some of the concepts of modern-day emergency medicine, the offering to civilians began in the form of accident services set up by the citizens themselves in some cities. A 1905 article in The Lancet, describes attempts by the city of Berlin to set up municipal accident and emergency services.
Residents of a particular quarter within the city set up a ‘Sanitätswache’ – ‘first-aid station’ – by hiring out a building and setting it up with the instruments and dressing needed, and appointing surgeons to ‘staff’ them. These Sanitätswache were privately-run by committees and were subscription-fee only – a far-cry from open-access to all. Moreover, they had few visitors as they only operated at night, when accidents were less likely to happen due to the closure of factories and reduced foot-fall.
This concept was built upon by a new organisation of ‘Unfallstationen’ – ‘accident stations’ – to serve workers who wished to insure themselves against work-place accidents. Unlike the Sanitätswache, these were open during the daytime and proved to be popular among the general population, not just the workers at which they were aimed. They were still private enterprises with fees recuperated through cooperatives, or directly from individuals.
However they had their own issues, including criticisms that those with more serious injuries would be better off being conveyed straight to hospitals, many of whom had set up their services to see accidents, and had their own in-house surgeon.
Instead, a new society known as the ‘Berlin Rettungsgesellschaft’, the ‘Berlin First-Aid Society’, was created backed by the medical establishment to unite the Sanitätswache and Unfallstationen. The Rettungsgesellschaft introduced a central office with a special telephone communication service between local hospitals and the ambulance service, so that if more than one person was injured at a scene, enough surgeons and ambulances could be alerted to attend the scene.
Unfortunately, all three of the services relied on private subscriptions, and later a fight broke out over funding (sound familiar?), over whether they should be fully-funded by the municipalities which they served. The Lancet article ends with the future of civilian emergency services in Berlin hanging in the balance.
It was in the late 1800s and early 1900s that Anglo-American hospitals established ‘accident’ departments, although their official modern equivalents only becoming established in the 1960s. Prior to this, although hospitals would provide some level of accidental or urgent care this service was staffed by surgeons and general medical physicians who rotated in from other specialties. In the 60s and 70s, it became more common for surgeons and physicians to leave their respected specialties to focus primarily on emergency medicine.
In the US, emergency medicine was formally recognised as a specialty in 1979. In the UK, it was not until 2005, when The British Association for Emergency Medicine (BAEM), formerly the UK’s Casualty Surgeons Association, combined forces with the Faculty of Accident and Emergency Medicine (FAEM), a daughter organisation of six medical colleges, to form the College of Emergency Medicine, which became the Royal College of Emergency Medicine.
In spite of its relative youth as a recognised specialty, the importance of emergency treatment has been recognised in some capacity for hundreds of years, particularly in the field of battlefield medicine. And while we recognise it faces many modern pressures, Emergency Medicine’s long history of flexibility in the face of changing demands, is uniquely one of its strengths.
Words by Dr Flora Malein
Sources used:.
The College of Emergency Medicine [archived page].
Howard, MR. “In Larrey’s shadow: transport of British sick and wounded in the Napoleonic wars”. Scott Med J. 1994 Feb;39(1):27-9. doi: 10.1177/003693309403900109.
The Lancet, Volume 2, Part 2 (p. 1808-1809).
Suter RE. “Emergency medicine in the United States: a systemic review.” World J Emerg Med. 2012; 3(1): 5–10. doi:10.5847/wjem.j.issn.1920-8642.2012.01.001.