THE FIRST REVOLUTION

It was an idea that sprang up like wildfire in places all over the United States during the decade of the sixties. The thought was simple. Care in "emergency rooms" should no longer be in the hands of interns and untried foreign medical graduates but sh ould be provided at a much higher level and by Attendings. This idea shocked the medical community which, in general, knew very little of what went on in their emergency room and cared less. But, suddenly people did! In the mid-west the "Pontiac Plan" was born. Under this configuration, attending physicians covered their emergency room on a part-time basis using a voluntary call list. They were sometimes formed into a partnership or corporate structure but on many occasions became hospital employees.

In nearby Virginia the "Alexandria Plan" developed. Under this scenario a group of family practitioners in private practice changed careers, closed their offices, and formed themselves into a full-time emergency group. As the idea of real doctors in the emergency room spread throughout the country the pros and cons of each of these two plans were hotly debated. When the dust settled it was the Alexandria Plan that was the clear, logical, and inevitable choice.

In the mid-sixties this idea hit New Castle County, Delaware. The Wilmington Medical Center began to wrestle with the question. After a long debate the Medical-Dental Staff opted for the Pontiac Plan. As a result, a group of physicians met in the libra ry of the old Memorial Hospital to discuss whether or not such a revolutionary idea was in fact possible. The resulting discussions and decisions led to the formation of an organization named Doctors for Emergency Service or as it is commonly known, DFES . A more disparate group could not be imagined. Surgeons, anesthesiologists, family practitioners, and even a psychiatrist.

Without having a fully-formed idea of the shape of the consistency of the future, this group made an offer to the Medical-Dental Staff to try to carry out its decision. This was accepted and so DFES approached the Wilmington Medical Center’s administraton. The Medical Center was somewhat further along in its planning and had prepared an offer to the group which would make them part-time hospital employees with a contract guaranteeing them $31.50 an hour.

To the administration’s surprise the group insisted that they wished to form themselves into a private partnership, treat the emergency room as they would their office, hire billing and management people, and conduct it on an entirely private basis. The Medical Center appointed Jim Tyler and Bob Barnett to negotiate with DFES which was represented by Ahmed Madani and Ronald Corballis. After a period of what we considered to be very tough negotiations, it was agreed that the DFES plan would be accepted. The Medical Center further agreed that DFES would try out the proposition for at least a year at the Wilmington General Division to see if it was feasible. WMC agreed to close the Emergency Room at the Memorial Division, to remove the cashiers from the emergency room, and to make a one time gift of $12,000 to the group to enable it to do the various necessary legal things.

DFES was officially formed as a partnership. Medical Ancillary Services of Troy, Michigan was hired to do the management and billing, and over a period of time March 3, 1969, was selected as the starting date. At a meeting in January of 1969, the first Board of Directors was elected consisting of:

The Board of DFES established the hourly wage at $15.00 with the clear and full understanding that the physicians would receive pay only when patient receipts became a reality and that it would take several months for them to achieve parity.

To everyone’s astonishment the program was so successful, so obviously the thing to do plans were immediately made to not only continue working at the General Division but to move to the Delaware Division as well on July 1, 1969. Again to everyone’s amazement the additional physicians necessary to staff both facilities were rather easily recruited. On July 1, 1969 fee-for-service emergency care became the watchword at the Wilmington Medical Center. As an inducement for recruitment, the new physicians were promised that their salaries would begin immediately and the original 18 agreed to postpone their reimbursement until such time as money was freely available.

It was, in fact, not until November of 1969 that each of these 18 pioneers was paid in full for all of the work done from the founding of the organization.

The Department of Surgery agreed to create a Section of Emergency Medicine in its table of organization and to take responsibility for this newly formed organization.

In 1970, Doctors Hunt and Corbalis attended a meeting in Las Vegas, Nevada of a new and little-known organization called the American College of Emergency Physicians. They found to their astonishment that there were real doctors all over the United States engaging in the practice of something called "emergency medicine" and that there appeared to be a limitless future for what everyone at the meeting thought of as a new specialty.

Upon returning to Delaware they transmitted this enthusiasm to their associates and very shortly were able to organize a Chapter of the American College of Emergency Physicians in Delaware. As you will see from the following chart, Delaware was the third state to have such a Chapter.

ACEP CHAPTERS

Changes began to come fast and furious after that. In 1971, Doctor Corbalis became the first full-time emergency physician in the State of Delaware. Shortly thereafter he was joined by Rene Bondoc and Virginia Vergara. Dr. William Wright was the next full-time emergency physician and he became Assistant Director of the Section.

In late 1970, a new Delaware law established the existence of professional corporations. We immediately instructed our attorneys to convert our partnership to a corporate identity and, we are told, DFES became the first professional corporation of physicians established under this new law.

In 1973, the Section applied to the Medical-Dental Staff for full department status. This, as might be expected, caused a rather significant uproar! When emergency medicine becomes a department it takes turf from virtually every other department and turf is not given up easily. But, after a year of debate, the Department of Emergency Medicine was established in 1974 by Staff Council. This action was subsequently confirmed by the Administration and the Board of Trustees. The Department chose to have an elected Chairman and at its next meeting Doctor Corbalis was elected as Chairman of the Department of Emergency Medicine.

As part of the establishment of the Department, the hospital changed the mandate and in a newly-negotiated contract required that the Department be staffed by full-time physicians. Time was allowed for this change to take place so that appropriate people could be recruited.

This change gradually took place until within a few short years the bulk of the work in the emergency department was being done by full-time physicians.

Plans were under way at that time to consolidate all emergency care for the Wilmington Medical Center at the Delaware Division, and construction began on a new emergency department at that site.

In 1976, with great fanfare, the new emergency service building was opened. The Emergency Department at the Wilmington General Division was closed and a new era began. Also, in 1976, Ronald Charles Corbalis, M.D. became Ben Charles Corballis, M.D.

In 1977, the Liaison Residency Evaluation Committee of the American College of Emergency Physicians approved the establishment of a Residency in Emergency Medicine at the Wilmington Medical Center. Discussions were entered into with the Center’s adminisration which very wisely chose not to establish a residency in an unrecognized specialty. The details of funding, etc., would have been insurmountable. But they invited us to reapply if and when the specialty was recognized.

It wasn’t long after the recognition of the need for appropriate care in our emergency departments that surgeons throughout the United States began to realize that patients were dying unnecessarily from trauma. The parade was led by Dr. R. Adam Crowley w ho founded the Shock/Trauma Unit in Baltimore and developed the idea of "the golden hour of trauma". The out-growth of all of this was a training program to familiarize surgeons and others with the principle and practice of trauma care. This developed into what was known as the Advanced Trauma Life Support Course.

In early 1980, Doctors Mansoory, Morovati and Corballis went to Philadelphia to take the ATLS Course and become the Affiliate Faculty in Trauma for the State of Delaware. Upon their return, Dr. Mansoory took the lead in developing what became one of the outstanding ATLS Courses in the United States. Soon people were coming from all over the country to take the course at the Medical Center. This led naturally to the development of a Trauma Service at the Medical Center. It was not very long before this service had organized itself to the point that it sought recognition from the American College of Surgeons Committee on Trauma.

The Medical Center applied for a College survey hoping to have the Medical Center appointed a Level II Trauma Center. As a result of the College’s survey, based in no small part on the strength of the emergency department, the survey team recommended that the Medical Center be a Level I Trauma Center. Application was then made to Charlie Nabb, the State EMS Director, who legally established the Medical Center as a Level I Trauma Center. The Trauma Service has since grown, in coordination with the growth of the State EMS System, to the point where we now have an outstanding Trauma Service.

In 1976, the Wilmington Medical Center, New Castle County, Delaware Heart Association and DFES each had made a financial contribution to the development of a training program for "Paramedics".

This led to the development of a school for Paramedic training at the Medical Center and in time to the development of what we believe is one of the finest Advanced Life Support systems in the United States. Dr. Howard Lovett was appointed as the first head of the school and in time became well recognized as the "guru" of Paramedic services in Delaware. With Dr. Jim Bouzoukis as Chairman of the State Advisory Commission (DEMSAC), a long and bitter battle was waged and won to have a statewide Paramedic program. Delaware is rapidly approaching the full deployment of its Paramedic System which will make it the first in the nation to have such a complete system. Dr. Bob O’Connor is State Medical Director of the system and Dr. Ross Megargel is the Medical Director of the New Castle County system.

As part of the development of this system there came into being what is known as the "Trooper Medic" program. Under this program members of the State Police Aviation Unit are trained into full Paramedic level. When you hear the "whop-whop" of a state police helicopter overhead, you can look up with confidence to know that there are two police officers aboard the craft; one is a pilot and the other is a Paramedic. The citizens receive the wonderful benefits of police work and MedEvac work. Above all, one of the greatest benefits is that this service is free to the citizens of Delaware. Dr. John Madden is currently the Director of the Trooper Medic Program.

On September 28, 1989, The American College of Emergency Physicians achieved its crowning glory - emergency medicine was named as the 23rd specialty! All of our hopes and dreams had finally been crowned with success.

As the excitement died down, the Department of Emergency Medicine approached the administration of the Medical Center once again with the proposition of starting a Residency in Emergency Medicine. This time the Medical Center was receptive. A Search Committee was established to recommend the appointment of a Director of Medical Education for the Department of Emergency Medicine. After months of interviews and adjudication, it was recommended that Dr. James Bouzoukis be appointed to the job. Events have subsequently shown that this appointment was to prove to be one of genius!

With enormous support from the Director of Medical Education of the Medical Center, Dr. Wayne Martz, and his trusty secretary Lois Dickson, who typed out our first application for the Residency Program, we began the difficult task of obtaining approval once again from ACEP.

This approval was not immediately forthcoming and it required a fair amount of political arm-twisting before we were approved to begin a program. The program began on July 1, 1981, with two residents who came in at the second year level, Dr. Lillian Avner and Dr. Steven Zebert, and Dr. Dave Gingrich at the first year level.

The second year we added five residents at the second year level and appointed six residents to the first year level, thus fulfilling the six per year for which we were approved. The beginning of the Residency Program once again changed DFES. It no longer was an Emergency Room but rather an Emergency Department. Recruitment began on the Attending level for "faculty members". No longer was it enough to be an excellent emergency physician but now the requirements were for people who were interested and talented insofar as teaching was concerned and who would become Board Certified in Emergency Medicine.

It is impossible to overestimate the impact Dr. Jim Bouzoukis has had on the Residency Program. He has shown enormous growth in his own medical knowledge and activity. He stays current with all the literature and does a wonderful job running the conferences and Journal Club with the residents. He also acts as father confessor, mother, confidant, and all-around friend to the residents.

We are very proud that the residents know that at all times, if they need help, Dr. B’s door is always open.

Research is now a very important part of the everyday life of DFES. Attendings have specially designated "academic weeks" to pursue learned activities. Most of our faculty have appointments at our affiliated medical school, Thomas Jefferson University in Philadelphia. We are beginning to turn out papers and articles published in the most prestigious journals. Great credit goes to Dr. Bob O’Connor for these developments. In his role of Research Director for our department, he has pushed, prodded and led our faculty and our residents into ever-increasing activity in this important area.

As a result of all these activities ACEP honored the Delaware Chapter in 1991 for having the highest percentage of Board Certified Emergency Physicians in the United States.

In our department all practitioners are Board Certified Emergency Physicians. In addition one of our faculty is triple Boarded and four physicians are double Boarded.

In 1985, the Medical Center opened the Christiana Hospital and closed both the Memorial and General Divisions. There was a change of administration at the highest levels and the Wilmington Medical Center became the Medical Center of Delaware.

This is a story which will be told more appropriately in other volumes but I believe it is fair to say that it resulted in ever-increasing support for the Department of Emergency Medicine which has culminated in 1993 as work began to build the new and expanded Emergency Department at the Christiana site.

This new building brings us to the forefront of emergency care in the United States and provides the kind of facility in which we can deliver the care which we believe our patients require.

As a further innovation to give better service to our patients and to help control the cost of medical care, DFES established, in 1990, a program of hiring Physician’s Assistants to work both in Fast Track and in the Core. We began with two PA’s and noware very fortunate to have many full-time PA’s and part-time PA’s.

They have become an integral part of our program and do yeoman work in serving our patients in Fast Track. This is one program which we expect, with confidence, to continue and expand as years go by.

In addition, we have PA’s in training rotate through our emergency department as part of their clinical rotations.