For 21st century ED nurses, a visit to a 1950s hospital would be like landing in a scene out of the movie “Back to the Future.” In those days, EDs were known as “accident rooms,” and the care provided there would seem as vintage as poodle skirts and bobby socks. “It was a different time and a different era,” says Libby Liberatore, RN, MSN, the head nurse of the accident room of St. Joseph Hospital in Baltimore in 1957, which later moved to Towson, Md, and became St. Joseph Medical Center.
A necessary evil
Local facilities, such as St. Joseph, The Johns Hopkins Hospital, and the University of Maryland Medical Center (UMMC), have all played key roles in the evolution of accident rooms of yesteryear into ERs and then into today’s cutting-edge EDs and trauma centers.
From the 1950s to the late 1960s, providing emergency care was often viewed as a necessary evil by physicians and hospital administrators of the time. Emergency care was not considered a specialty, and accident rooms were not deemed hospital departments or even wards.
Accident rooms were often attended by the least experienced physicians. It was also not unusual for physicians such as dermatologists and psychiatrists to provide rotating coverage for the accident room. Medical rotations changed often, and often, physicians had to be called to the accident room from other duties to see patients.
On the other hand, nurses were a stable, driving force in accident rooms from the beginning. At St. Joseph Hospital, the accident room had a regular staff of experienced nurses who frequently had more knowledge of emergency care than the interns and “sometimes we didn’t agree with their decisions,” says Liberatore.
It was not an uncommon practice for nurses to advocate for patient safety by lending their expertise to interns and, if necessary, challenging them or “going over their heads” to get another opinion from a more experienced physician, according to Liberatore.
The accident room at St. Joseph Hospital was probably typical of a city accident room of the times. It was just big enough for four or five stretchers and was often staffed by only one nurse.
There was no formal triage procedure, although, “Nurses took what needed to be seen first,” says Liberatore. “Nurses always triaged.”
Emergency care was often not standardized or evidence based, and advanced diagnostic technology, such as CT and MRI, did not exist. Even the use of X-ray was allocated for only the most emergent cases.
“If someone had an injured ankle, the physician would often simply wrap it with an Ace bandage, put them on crutches, and tell them to come back for an X-ray if it wasn’t better in a few days,” says Liberatore.
Although a 12-lead EKG machine was available, cardiac monitoring, defibrillators, standardized advanced cardiac life support training, and even CPR hadn’t been invented yet.
“In those days, we cracked open chests and massaged hearts,” says Liberatore.
The level of prehospital care was also in its earliest stages of development. The trauma center system didn’t exist, and there was no such thing as emergency medical technicians. The “ambulance drivers” of the day were only trained in basic first aid and perhaps spinal immobilization.
“It was more of a transportation system, and they took everyone to the closest hospital,” says Liberatore.”
Accident room nurses generally had no special training beyond their nursing education and whatever experience they brought to the table. But they were quick to learn and adapted basic nursing principles and critical-thinking skills to the emergency setting, says Liberatore.
From accident room to ER and ED
In 1965, St. Joseph Hospital moved from Baltimore to Towson, Md. By this time, the facility was regularly referring to the accident room as the ER, as was the trend at the time. But the country’s ERs still had a long way to go.
“The quality of care in ERs was terrible, and they had a bad reputation,” says Angie DeVincentis, RN, APRN-BC, an NP in the current ED at St. Joseph Medical Center. But things changed drastically in 1968–St. Joseph’s ER was transformed into a department when her father, Michael DeVincentis, MD, a general surgeon, teamed with five other seasoned physicians to devote their practices to ER care. They would go on to become founding members of the American College of Emergency Physicians.
Big strides were also being taken in advancing first responder and pre-hospital care. In 1959, researchers at The Johns Hopkins Hospital, Baltimore, developed the first portable defibrillator, and in 1966 standardized recommendations for CPR were published in the Journal of the American Medical Association. The first paramedic system was initiated in 1967 in Miami, and the first advanced life support (ALS) mobile coronary care unit, or ALS ambulance service, began in New York City in 1968.
During the Vietnam War era, the healthcare community began to realize soldiers were less likely to die in the war than young men in the U.S., partially because soldiers had rapid access to specialized trauma care. At the same time, the concept of a civilian trauma center had been developed at UMMC in Baltimore, which opened the first clinical shock trauma unit in the nation, the R. Adams Crowley Shock Trauma Center. By 1979, emergency medicine had become a recognized specialty and by July 1980, a total of 902 emergency nurses across the country passed the first emergency nursing certification examination.
Catherine Spader, RN, is a contributing writer to Nursing Spectrum.
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