The ED: Then and now
“This was a time before ACEM existed to teach doctors how to work in emergency medicine, and before emergency medicine was established as a vital and legitimate specialty.”
It’s hard to imagine what the emergency department in an Australian hospital looked like in 1975. Before the establishment of many of the things we now take for granted – before triage, before supervision – junior doctors worked alone at midnight without easily accessible X-ray, without the internet or even many medical books for reference.
This was a time before ACEM existed to teach doctors how to work in emergency medicine, and before emergency medicine was established as a vital and legitimate specialty.
Nonagenarian FACEM Dr Edward Brentnall remembers it as a time when doctors avoided the ED and says many regarded it as similar to the “traditional ‘dunny’ at the bottom of the garden”.
“Necessary, but only to be visited when unavoidable.”
After qualifying in medicine (MBBS) in 1952, and after two residencies and a stint as a doctor in the Royal Army Medical Corps in Singapore, Dr Brentnall migrated from the UK to Australia. Once here, a chance conversation with a friend he was in St Johns with – Dr Alan Davis, the Medical Director of Box Hill hospital at the time – led to Dr Brentnall’s illustrious career in emergency medicine.
““I had no training or preparation for the job – there wasn’t any.””
Dr Davis mentioned a job as the Director of Accident and Emergency at the hospital was coming up. After his successful application for the role, Dr Brentnall became Director of the Accident and Emergency Department, known as ‘Casualty’ – or ‘Cas’ – at Box Hill Hospital in July 1975.
It was then a medium-sized hospital, serving a population of 750,000 people.
Dr Brentnall says he spent the first official day on duty simply wandering around the ED, “meeting all the staff members, finding out what they did, and wondering what on earth I was supposed to do”.
“I had no training or preparation for the job – there wasn’t any,” he says.
In 1975, the Box Hill Hospital ED was made up of a central waiting area, nine cubicles and just one room with privacy. There was also one resuscitation room with one table, one procedure room, plus a small observation ward, and a tiny “distressed relatives’ room”.
There was also, Dr Brentnall remembers, “a tiny office with no windows, next door to the patients’ toilets, that had a filing cabinet and a desk – and me”.
Back then, the director had to do and be “everything”. Dr Brentnall says the director dealt with police, media and patient relatives, and also solved medico-legal problems and staff problems – such as “when the duty surgeon was short-tempered and unreasonable”.
At that time, Dr Brentnall says “many of our patients were using the department as a substitute for the family doctor” to avoid the fee typically charged at doctors’ rooms across the country in the days before Medicare.
While most doctors were careful not to charge people who couldn’t afford much, Dr Brentnall says “the people who didn’t or couldn’t pay went to the hospital”.
There was no triage system and patients were seen in the order of their arrival, unless it was obvious they needed urgent attention. In many hospitals, the clerical staff decided this.
Retired FACEM Dr Edward Brentnall has many memories to share about the history of ACEM and his time at Box Hill Hospital.
Little information was available for the ED staff. With no computers and no internet to search for information, access to the hospital library was also limited from 9am to 5pm.
“There was a 1955 edition of Hamilton Bailey’s Emergency Surgery and a 1938 edition of Nelson’s
Medicine,” he says.
While the senior could, theoretically, be rung, interns were reluctant to call them unless it was “absolutely necessary”.
Luckily, there were the nurses – staff Dr Brentnall describes as “the backbone” of the hospital.
“The nurses were wonderful. They would say, ‘Dr So-and-So usually orders this for such a problem’.”
At night, there was no X-ray facility – unless the radiologist could be convinced to get out of bed – and there was no pathology service after 10pm. The ED never got new equipment. They only had rudimentary monitors and defibrillators – “usually ‘hand-downs’ from the ICU” – and the ECG machine was a single-channel model.
Another difficulty in the early years was that ambulance officers, called ‘drivers’, were not highly trained. However, a new initiative – Mobile Intensive Care Ambulances (MICA), which was piloted in 1971 at the Royal Melbourne – was staffed by well-trained and resourceful officers.
The attitude from hospital staff towards ‘Cas’ was poor.
“Most of the specialists were concerned with their elective patients,” Dr Brentnall says, and emergencies interrupted the elective surgeries they would have preferred to be doing.
But other changes at Box Hill ‘Cas’ were to change the face of emergency medicine. At this time, despite Dr Brentnall saying “the army has been doing basic triage ever since the Battle of Waterloo”, there was no triage system in Australia.
““There was no choice but to propose the formation of a College for Emergency Medicine.””
In 1976, the Sister-in-Charge, Mrs Noel Pink, devised a way to manage things more effectively.
It started with three colour-based categories: 1) the urgent (yellow) 2) the run-of-the-mill (blue), and 3) the non-urgent (white). Using corresponding coloured sticker dots on patient records supported faster reading.
“We also found the dots very useful for amusing small children,” Dr Brentnall says.
The introduction of the triage system was a success and was copied throughout Australia, with the College Triage Scale – based on the Box Hill system – now copied internationally.
Numbers dropped rapidly as the non-urgent patients went elsewhere.
“At Box Hill, our numbers dropped from about 50,000 per annum to about 36,000,” Dr Brentnall says.
As emergency medicine continued to evolve, the need for a cohesive organisation to advocate for the collected interests of practitioners arose. The organisation that was to become VEDA (the Victorian Emergency Department Association) had started in 1974, and it became a vital tool for communication, mutual encouragement and education.
“We used to invite all sorts of people to give us talks – for doctors and nurses,” Dr Brentnall says.
“Even more importantly, it became an effective political unit – as it represented both doctors and nurses, the politicians listened. We got to the stage where we were having regular meetings with the Minister of Health.”
By 1980, amid discussions to establish a doctor-only organisation, the Australasian Society for Emergency Medicine (ASEM) was formed.
Next, they wanted to expand VEDA and make it a national organisation. Dr Brentnall and other Victorian members wanted a group made up of nurses and doctors, believing it would have better numbers and, hence, better political advantage. But WA and NSW refused to join any organisation that included nurses.
“There was no choice but to propose the formation of a College for Emergency Medicine,” Dr Brentnall says. “Rather bad-temperedly, that is what I did.”
This idea was fiercely opposed by some of the established medical colleges, particularly the surgeons, who Dr Brentnall says tried hard to persuade them to join the College of Surgeons – as the anaesthetists and ophthalmologists had – instead.
“When they suggested that we were seeing mainly surgical patients, we asked them about babies with feeding problems or gastroenteritis, toxicology and overdoses, psychiatry, placement problems. At that point, they threw up their hands and agreed that we should go it alone.”
The Australasian College for Emergency Medicine (ACEM) was formed in 1983. It created a training program, an examination and a qualification – FACEM.
Founding members of the College, including Dr Brentnall, were automatically granted Fellowship.
“If you are going to set up a qualification, who are you going to have as examiners but the people who are already doing the job?”
VEDA continued for some years, but eventually faltered and disappeared. The ASEM and the College worked together, as it was clear that there would always be a need for an organisation to serve the needs of those who were not yet Fellows or did not wish to sit the “very tough” examination.
But ACEM still had to convince the Canberra Committee that they were a medical specialty, as, despite the formation of the College, their EM specialty was still not recognised by medical and surgical colleagues, who saw the application to be specialists as “nonsense”.
““It’s hard work. But it’s always exciting, it’s always interesting. You see things you’ve never seen before. I wouldn’t have missed emergency medicine for anything.’”
However, they persisted, and in 1993, emergency medicine was officially deemed a specialty. Once it was officially recognised as a specialty and a career, Dr Brentnall says “resident doctors seized the opportunity”.
“We were able to appoint Registrars, and many of the Box Hill residents have had distinguished careers in emergency medicine,” he says. “This was the point at which the quality of care in the ED moved into the excellent category, and this started to become recognised by patients, colleagues and the hospital.”
After 19 busy years, Dr Brentnall retired as the Director of Box Hill in 1994. Today, in full retirement, almost 50 years since he began his career in EM, he is thrilled with the growth and change in emergency medicine.
“There’s no comparison,” he says. “It is now a place that is safer for patients. But it’s also
much safer for the young doctors.
“Now interns love the emergency department because it’s the only place in the system where they can see patients first – the first presentation.”
Importantly, Dr Brentnall says, they also have back-up.
“They have senior doctors, a registrar to consult with, and to look over their shoulder so they’re safe, and they feel so much better about it.”
While it’s clear a lot has changed in emergency medicine in the last 40 years, Dr Brentnall believes one thing remains: the emergency physicians remain dedicated and professional.
“It’s not for some people,” he says. “It’s hard work. But it’s always exciting, it’s always interesting. You see things you’ve never seen before. I wouldn’t have missed emergency medicine for anything.”
