The BEGINNING which is not itself necessarily after anything else, and which has naturally something else after i t . . . , u The history of emergency medicine is not yet written. But less important than who were the first physicians to restrict their practice to emergency medicine are the reasons for the appearance of the specialty. It is hard to comprehend why it took so long for attention to be paid to the demands of the specialty. Certainly, since man took his first steps, there have been accidents and ailments that struck him down unawares. Doubtless, it takes a certain technology and willingness to intervene in natural disasters by an emergency response. Nevertheless, it is still an unaccountably late development in modern medicine. The beginning cannot, therefore, be the onset of those medical conditions that would mandate a professional emergency response. In fact, when one analyzes emergency medicine in terms of its case load, one is quickly struck by the fact that true emergencies, ie, the life or limb threat, are .not what has produced the beginning of the field. Even the urgent cases (nonlife or limb threat but requiring a response to prevent deterioration into true emergency) probably would not have produced the field. In fact, I believe that two events coincided to produce the beginning: first was increasing numbers of nonemergency patients in the emergency department; second, the initial financial support for these cases in the emergency department. The cause of the increased workloads is multifactorial: the disappearance of primary physicians; the demise of the housecall, the growth of urban populations, the increased expectations of the public (If you can put a man on the moon, why can't you cure my cold?); the initial willingness of third party carriers to pay for emergency department visits but not office calls, and last, but not least, the captive presence of a physician in a predictable geographic area
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