Emergency medicine was approved as the 23rd medical specialty in 1979, shortly after a young Elsburgh Clarke, MD, discovered the burgeoning specialty.¹ Just one year prior, Dr. Clarke had begun an emergency medicine residency at what was then known as LA County–USC Hospital, Los Angeles.

“I was about two months into a family practice internship when I went to visit my uncle whose neighbor happened to be an ED resident,” Dr. Clarke said. “I spoke with him and said to myself, ‘This may be something that I want to do.’”

The specialty, he said, spoke to his interest in surgery and EMS in a way that family medicine did not. A phone call to LA County–USC revealed that the emergency medicine program had one spot left for the following year.

So, about one year after graduating medical school, Dr. Clarke was set to begin a decades-long career in emergency medicine … and he brought along his camera.

Firsthand Account

An ambulance bay at the LA County-USC Hospital in 1978. (Click to enlarge.)

The photos that Dr. Clarke took from 1978–1980 provide a glimpse into working in an emergency department in the years the specialty was being established. At first glance, one might notice the clothes—nurses in white dresses and doctors in wide ties or bellbottom jeans—or the hair—afros, sideburns, and mustaches aplenty. A closer look, though, also shows the technology of the day—a bulky, two-way radio for communicating with EMS, metal gurneys, glass saline bottles, and portable ECG monitors the size of a small shopping cart.

Less obvious to the eye is the experience of the people working in the photos.

“Emergency medicine was fairly new then, and most attendings were not emergency physicians,” Dr. Clarke said. “In fact, the director of emergency medicine at the time was head of OB–GYN, and the assistant director was a psychiatrist.”

Dr. Clarke is a part of a generation of physicians who shaped the specialty. They learned by doing, he said, by falling down and getting back up.

ED attendings Dr. Gerald Whelan and Dr. Shumary Chow supervising a full arrest in “C” booth—the main trauma room—with an ED tech administering CPR. (Click to enlarge.)

“We learned a lot by ourselves,” Dr. Clarke said. “Some of the residents who graduated in those first classes came back to be our mentors, but as far as attendings go … there weren’t any at that time.”

Varied Career

From LA County, Dr. Clarke’s career has carried him through a variety of positions all throughout the country. After residency, he stayed in Orange County, Calif., for a few years working as an emergency physician. Dr. Clarke was then hired as assistant director in the emergency department (ED) at Pomona Valley Hospital, Pomona, Calif. A cross-country move brought him to Delaware, where he served as the director of a hospital ED in Milford, Del. After several more years, he was again recruited away to be director of an ED in Peoria, Ill.

Medical anti-shock trousers (MAST) being applied for a trauma patient and a Datascope cardiac monitor in use during traumatic full arrest. From 1978 to 1980 MAST suits were used in most trauma patients. (Click to enlarge.)

“I thought I was going to retire, but it didn’t suit me, so I joined an ED group as a ‘traveling physician,’ where I was also their photographer,” Dr. Clarke said. “After about eight or nine years of traveling to various EDs for the group, I decided to come home from being a ‘traveling physician’ and I took a position at Hopedale Medical Complex, where I have been for the last six years.”

Throughout his experience and across these many locations, Dr. Clarke said that much about emergency medicine has changed, but a lot has stayed the same. A typical shift when he was starting out would include patients falling into what was coded as “1350” major medical/trauma, “1060” minor medical/trauma, or “1050” medical walk-in.

“At that time, the senior residents were always in 1350, versus the second-year residents who would be in 1060 or 1050,” Dr. Clarke said. “Many of the cases we saw then—car accidents, gunshot wounds, stabbing, D and Cs—are the same as we see today, but the way the cases are handled is different.”

Today, a patient comes in and the emergency physician may do the airway, but a trauma surgeon does the surgery. In comparison, early in his training, Dr. Clarke said each physician did it all.

ED resident Dr. Steve Hui doing a pericardiocentesis on a trauma patient. Notice the use of the medical anti-shock trousers and the ECG machine. (Click to enlarge.)

Evolution

Many technological and economic changes have also come to the ED.

“When I started, if a patient came in with right lower quadrant pain, we would talk to them and think ‘appendicitis,’ without having any way to confirm it except by history, labs, and physical exam,” Dr. Clarke said. “Now, we have ultrasound or CT scans to confirm.”

The advancement of radiology was the first thing that came to mind for Dr. Clarke when discussing how technology has advanced emergency medicine. Today, physicians can utilize MRIs, CT, and ultrasound, with the latter often available at the point of care. Expedited lab work has also improved care, Dr. Clarke said.

“We can order a CBC or a [comprehensive metabolic panel] and make a faster diagnosis,” Dr. Clarke said.

From an economic viewpoint, emergency physicians today are faced with an increasing number of patients who use the ED as a source of primary care, Dr. Clarke said, although perceived issues around the “misuse” of the ED date back to the 1970s.²

Parked Los Angeles Fire Department rescue ambulance in 1978. (Click to enlarge.)

“Even in my smaller hospital, we see a lot of patients who come in if they’d had a cold for several days, and when we ask them why they haven’t gone to a doctor or urgent care, they tell us that they don’t want to have to pay up front,” Dr. Clarke said. He is also familiar with the delayed care and crowding, including boarding issues, that occur.

The economics of emergency medicine has also evolved. Dr. Clarke recalled issues with payment and salary in his earlier years, especially those related to contract management groups like the ones detailed in the 1992 book The Rape of Emergency Medicine.

“The groups would hire physicians and pay them a certain salary and then have a contract with a hospital where the group would be making a lot more money,” Dr. Clarke said. “It was almost like a pyramid scheme. That has changed, even within the group I work for, because ER physicians are learning more about businesses and contracts.”

Same Beating Heart

Throughout all these changes over the decades, Dr. Clarke is still in love with the specialty.

“I am not one to sit down and look at an ECG or sodium potassium in the ICU,” Dr. Clarke said. “I like the excitement.”

Emergency medicine allows physicians to be wanderers, Dr. Clarke said. They can be ship doctors, go on mountain treks, work in forensics, or be a part of a S.W.A.T. team.

“You can do so many things, and I think a lot of the physicians in emergency medicine still do it because they like the excitement,” Dr. Clarke said.

It is because of this excitement—and the fact that his salary helps support the expense of his love for photography—that Dr. Clarke continues to practice, but really, when it comes down to it, it is because “I love emergency medicine.”

Ms. Lawrence is a freelance health writer and editor based in Delaware.

References

1. Huecker MR, Shreffler J, Platt M, et al. Emergency medicine history and expansion into the future: a narrative review. West J Emerg Med. 2022;23(3):418-423.
2. Nelson DAF, Nelson MA, Shank JC, et al. Emergency room misuse by medical assistance patients in a family practice residency. J Fam Pract. 1979;8(2):341-345.