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Memorable Moments

Emergency medicine calls for a cool head, but also a deft touch with people: With a dying child's parents. With a patient who thinks he's Jesus. With someone who's slit his own throat but is still alive. Here are some compelling stories from caregivers in perhaps the most harrowing specialty.

By Laura Stephenson Carter

Fifty years ago, hospitals didn't have emergency departments. If they had emergency rooms, they were staffed by a resident or two, or a nurse-supervisor who'd call in a physician when necessary. And ambulance services were operated by funeral homes—with hearses often doing double duty as ambulances, and the drivers and attendants usually having basic first-aid training but little more.

As the field of emergency medicine began to evolve, some hospitals advertised "physician on duty 24 hours." But that didn't mean a physician was on the premises—only that a doctor could be summoned by phone if necessary. Many physicians didn't particularly welcome this on-call duty. And no one was specially trained or certified in emergency medicine.

"It was a very loosely organized endeavor," says Dr. Norman Yanofsky, medical director of DHMC's Emergency Department. "Then some farseeing people realized there ought to be a way to produce competent physicians" trained to practice in emergency situations.

In 1968, the American College of Emergency Physicians (ACEP) was founded by eight physicians from Michigan. The first residency program began at the University of Cincinnati in 1970 with one resident. By the time Yanofsky graduated from Tufts Medical School in 1977, there were 10 emergency medicine residency programs in the U.S.; he got his training at Northwestern. In 1979, emergency medicine was officially recognized as a specialty. In February 1980, more than 600 emergency physicians sat for the first certification exam. Yanofsky took the exam soon after that and, in 1982, became board certified in emergency medicine. Today, there are more than 32,000 emergency physicians in clinical practice and about 180 emergency medicine residency programs.

When Yanofksy was hired by Dartmouth-Hitchcock in 1982 as the head of its new emergency department—and the department's sole staff physician—he oversaw three residents and several nurses. Gradually, the fledgling department grew. It went from seeing some 13,000 patients a year—only about 9,000 of them sick enough to be seen in an emergency room by today's standards—to more than 30,000 a year today.

As emergency medicine has evolved, DHMC has kept pace. In 1994, the Medical Center established an air ambulance service known as DHART

(pronounced "dart"), for Dartmouth-Hitchcock Air Response Team. In 1996, DHMC was designated a Level I Trauma Center. In 2000, DHART acquired a ground-based mobile ICU and changed the name behind the acronym to Dartmouth-Hitchcock Advanced Response Team. In 2006, a much bigger emergency department opened as part of DHMC's Project for Progress expansion. And the department is now developing its own residency program, which, if all goes well, may start up in 2009.

It takes a special kind of person to work within emergency medicine. "I think most

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Laura Carter is the associate editor of Dartmouth Medicine.

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