An exterior shot of the UVM Medical Center Emergency Department entrance. (Photo courtesy of UVM Medical Center)
The scenario is familiar, yet alarming: a siren wailing, lights flashing, a gurney sliding out of the back of an ambulance. Defined as an unexpected or sudden urgent situation, an emergency often requires immediate medical care delivered by skilled practitioners. Yet before the 1970’s, formal medical training for delivering emergency care did not exist.
The field of Emergency Medicine is relatively new; it began to take shape in the mid- to late-1960s, when the American Medical Association established an emergency medicine committee and the American College of Emergency Physicians was founded. However, it wasn’t until 1979 that the American Board of Medical Specialties finally recognized the field as a unique specialty. Soon thereafter, in 1981, the University of Vermont’s College of Medicine established a Division of Emergency Medicine within the Department of Surgery, with Professor of Surgery Emerita Ruth Uphold, M.D. – the first board-certified emergency medicine physician in Vermont – serving as its inaugural chief.
Over the decades since its founding, the Division of Emergency Medicine saw many milestones, ushered in by Uphold and the chiefs that followed. Filling the role after Uphold were Stephen Leffler, M.D., UVM medical alumnus and current president and COO of UVM Medical Center, Ray Keller, M.D., associate professor emeritus, Peter Weimersheimer, M.D., professor emeritus, and finally, Ramsey Herrington, M.D., associate professor of emergency medicine. Their and their UVM colleagues’ unrelenting passion, dedication and patience built the program into an department within the Larner College of Medicine, which became official on July 1, 2022, along with Herrington’s appointment as the inaugural chair.
Decades of Milestones
The medical center’s verification as a Level One Trauma Center – the highest category for trauma services – by the American College of Surgeons in 1994 marked a major milestone for the entire institution. In addition to requiring a full-service Emergency Department (ED), this designation denotes the institution’s ability to provide care for every stage of injury – preventative through rehabilitative. UVM continues to be the only Level One Trauma Center in Vermont and one of about 100 in the U.S. The medical center is also a Level II Pediatric Trauma Center.
Long before the COVID-19 pandemic, emergency medicine faculty and staff, as well as colleagues in other clinical departments, began utilizing telemedicine. The two-way videoconferencing technology allowed for UVM emergency medicine (EM) and specialty care consultations in emergent and non-emergent cases for patients in rural communities. Pediatric critical care medicine became a particular focus, as many rural emergency departments lacked trained pediatric trauma specialists. “Telehealth has been a part of the practice of emergency medicine for many years,” says Matthew Siket, M.D., M.S., associate professor and associate residency program director in emergency medicine. He is leading a Health Resources and Services Administration-funded program focused on providing peer-based decision support to emergency departments across the UVM Health Network, as well as to regional ambulance services.
The ED’s adoption of electronic documentation in 2004 marked another technology-related achievement. According to Keller, the division “used a gift from a grateful patient to install the electronic ‘T-system,’” which established the division as a leader in electronic health innovation. After the implementation, Keller, who was chief at the time, was enlisted to assist with the medical center’s Epic electronic health record software installation in 2009. The ED was second to launch the system, after the pharmacy. Currently, Alison Sullivan, M.D., assistant professor of emergency medicine, serves as director of medical informatics and leads most of the department’s work – and collaborates with other departments and hospitals – to improve Epic utilization and best practices.
In 2005, emergency medicine (EM) began to play an increasingly important role in training the next generation of physicians at UVM. In parallel with national trends, this contributed to the field’s popularity with graduating UVM medical students. In fact, says Siket, EM has been one of the top three specialties chosen by each graduating class for the past six years.
“EM has been involved in medical education since the implementation of the Vermont Integrated Curriculum,” says Christa Zehle, M.D., senior associate dean for medical education. “They have established a comprehensive EM curriculum within the UVM and Nuvance health networks and the EM course has been required for all students at our Vermont and Connecticut campuses since 2017.”
Research has played an equally pivotal role. In 2007, Kalev Freeman, M.D., Ph.D., associate professor of emergency medicine and pharmacology, joined UVM’s faculty and helped establish the Research in Emergency Medicine program. His appointment was a first – a faculty position with 75 percent of its time protected for research. Over the past 15 years, Freeman’s Trauma Physiology Lab has developed an international reputation and received continuous National Institutes of Health (NIH) funding to support trauma-related blood vessel and clotting research.
The most recent milestone, to which Herrington attributes the division’s biggest growth spike, was the approval of the EM residency program, and its 2019 launch. Weimersheimer developed a plan with input from several national experts and the support of UVM Health Network (UVMHN) Executive Director Bradley Krompf, M.B.A., Chair of Surgery Mitchell Norotsky, M.D., and Leffler. John Brumsted, M.D., UVMHN president and CEO, and Claude Deschamps, M.D., then president and CEO of the UVMHN Medical Group, supported the proposal and both the business plan and proposal received UVM Medical Center Graduate Medical Education approval in 2016. Associate Professor Richard Bounds, M.D., was recruited to serve as the first EM residency program director.
“With help from Mark Bisanzo, M.D., associate professor and associate chief quality officer for UVM Medical Center, and Melissa Davidson, M.D., in her role as Designated Institutional Official for the medical center, we successfully achieved ACGME [Accreditation Council for Graduate Medical Education] accreditation and recruited the first class of residents for the 2019 academic year,” says Bounds.
The Broadening of Emergency Department Care
In recent years, the American public’s utilization of emergency medicine services has changed and grown. Prior to the pandemic, emergency department visits had reached an all-time high, according to a 2016 Centers for Disease Control and Prevention report, with the majority of care being sought outside business hours, when regular doctors’ offices are closed. A 2019 cross-sectional study in JAMA Network Open examined emergency department visit rates using data from the National Hospital Ambulatory Medical Care Survey and found that visit rates increased by more than 50 percent from January 2005 to December 2016.
“As emergency medicine physicians, we are at the frontlines of the impact that inequity and social determinants of health play in the health of our most marginalized and vulnerable patient populations,” says Katie Wells, M.D., M.P.H., assistant professor and director for international emergency medicine and health equity in the department. EM specialists “are uniquely positioned to develop great relationships with our inpatient and outpatient colleagues,” says Bounds, pointing to compelling examples of collaboration during the height of the pandemic and with hospital capacity issues, to ensure close follow up and improved care coordination for our patients.
Former EM chief Leffler says, “Over the 29 years I have been at UVM Medical Center, there has been tremendous growth of our Emergency Department. When I started in 1993, we saw about 30,000 patients a year and had six attendings [physicians]. Now more than 50 providers care for more than 60,000 patients a year. We have specialists in ultrasound, pediatric emergency medicine, EMS, critical care and global heath. This greatly improves the care and expertise the patients in our region receive through the UVMMC ED.” In addition to the areas mentioned by Leffler, today's ED also provides specialist care in toxicology, geriatrics, wilderness medicine, and sports medicine, as well as medical education and simulation instruction.
Like Vermont, UVM’s emergency medicine faculty share a reputation for being unique and innovative.
With its distinctive blend of academic emergency medicine training and rural/resource-limited emergency medicine training, the UVM EM residency program is gaining national recognition. Features include UVM Health Network community hospital rotations, as well as training in what Bounds describes as “austere and prehospital environments” – six different EMS (Emergency Medical Services) agencies, two wilderness backcountry rescue teams, the Army Warfare School in Jericho, Vt., the medical clinic at Sugarbush Resort, and for some, even training on the ice fields of Juneau, Alaska. In addition, says Bounds, “our residents develop cultural competency and a dedication to the underserved through their work with our local marginalized populations, electives with the Indian Health Service, and our various opportunities providing international emergency medicine across the world.”
The innovative and longstanding Emergency Medicine Research Associate Program (EMRAP), launched in 2009 by Freeman, provides UVM undergraduate students with an opportunity to both participate in research courses taught by EM faculty and enroll patients in Emergency Department clinical studies. In 2017, Roz King, MSN, RN, CNL, current EM research program manager, assumed leadership for EMRAP, which now consists of four courses for undergraduate and graduate students and staffs the ED 21 hours per day, seven days per week. Bounds notes that EMRAP “has served as a key driver for the tremendous growth of research and grant awards in Emergency Medicine.” He adds that in the last five years, King has assisted EM faculty with producing more than 150 peer-reviewed publications, and she and her team of research associates currently support 50 IRB-approved studies.
Another area where UVM EM shines is in the field of emergency ultrasound, also known as point-of-care ultrasound (POCUS) or bedside ultrasound. The technology, now a routine part of emergency medicine practice, can make a critical difference in clinical decision-making in resource-poor areas and across specialties. Siket says POCUS “decreases time to diagnosis, time to management decisions and resource utilization, and facilitates a more robust provider-patient relationship,” because it allows the physician to review relevant findings in real time with the patient.
UVM EM’s reputation as a leader and innovator in this field is largely due to the pioneering efforts of Weimersheimer, who established UVM’s ultrasound program in 2012 and served as its first director. Currently, there are eight faculty members, including Lindsay Reardon, M.D., ultrasound director and director of the Emergency Ultrasound Fellowship, who lead a four-year integrated ultrasound curriculum for Larner medical students, and train EM residents, fellows, and faculty at UVM Medical Center and across the UVM Health Network. “EM residents perform enough ultrasound examinations in their first year of training to be fully credentialed emergency ultrasonographers, an achievement most EM programs aim for in three to four years,” Bounds notes.
Working to Ensure Health Equity for Patients – Locally and Globally
“Equity is a central tenet of our Department of Emergency Medicine,” says Herrington. Because the department delivers care to the community’s most marginalized and vulnerable patient populations, creating systems to address healthcare inequity is a priority. According to Wells, the department is working with more than 50 community collaborators to build healthcare quality and access initiatives to address gaps identified by community members from across the state. Two recent Vermont Department of Health grants focus on addressing migrant farmworker health and safety, and a new Frymoyer Scholars grant, spearheaded by EM resident Ashley McCormick, M.D., aims to develop a multidisciplinary Gender Affirming Care curriculum. Working with Larner medical students, EM faculty have developed a Health Equity Curriculum for residents and faculty that incorporates anti-racism, LGBTQAI+ health, New American, Indigenous, and migrant health, homelessness and poverty, and gender equity principles. Assistant Professor and EM Clerkship Director Katie Dolbec, M.D., and Wells led the implementation of the Social Determinants of Health curriculum in the required fourth-year medical student Emergency Medicine rotation.
When international travel was restricted earlier in the pandemic, Wells and colleagues developed connections with Vermont's New American, Indigenous and migrant populations. The team connected with the UVM Extension Bridges to Health program, joining the Department of Family Medicine to conduct on-site medical exams and vaccine clinics for migrant farmworkers. Additionally, Wells and several EM colleagues worked alongside the Association of Africans Living in Vermont and UVM’s Department of Pediatrics to hold the first large-scale COVID-19 vaccine clinic in Vermont’s Chittenden county.
Wells says she believes that whether launching initiatives locally or abroad, “by working collectively to dismantle oppressive systems – led by the voices of those with lived experience – we can create true equity in our world, and in medicine.”
Currently, a multidisciplinary group of staff, faculty, residents, providers, medical students and leaders from across the UVM Medical Center and health network, in partnership with over 15 community organizations, are working to build the New American Indigenous Migrant Health (NAIMH) Initiative, which focuses on care coordination, provider education, and improved health literacy for Vermont's NAIM communities. In addition, says Bounds, EM team members, led by King, Mariah McNamara, M.D., associate professor and medical director of the ED, and ED social workers, has created a 72-hour callback program to ensure patients with limited English proficiency have an accurate understanding of the care they received in the ED and next steps for follow-up care.
The department’s global health work parallels and informs the health equity work performed by EM faculty members. McNamara, who is also associate director of the Larner/Nuvance Global Health Program, and Bisanzo built the EM Global Health program, which officially launched when Wells was recruited as the first director of international emergency medicine just prior to the initiation of the residency program. According to Wells, global health is a core component of the EM residency program, which includes education and clinical training on emergency care system development in resource-limited settings. Residents have the opportunity to participate in a four-week global health elective in Cape Town, South Africa, participate in Transcontinental Grand Rounds with the Emergency Care Society of Uganda, among other experiences, and all of the global health activities contribute important knowledge to the department’s rural and critical access care delivery and work with New American populations.
Impacting the Community through Research
In addition to EMRAP, another thirteen EM faculty members are engaged in funded clinical research projects, which, says Bounds, help to add value to the healthcare system, address disparities, and improve care delivery to community members. In total, the department has more than $9.3 million dollars in research funding, $4.6 million of which is NIH funding.
Daniel Wolfson, M.D., associate professor and state EMS director, leads the STAR (Start Treatment and Recovery) study, which facilitates both medication-assisted treatment and follow-up for recovery for patients with opiate use disorder receiving care in the ED. (Watch at WCAX-TV news story about the program.)
The COPE project (Community Outreach for Patient Engagement), another project led by King, brings healthcare directly to marginalized populations and addresses such needs as housing, food insecurity, and access to primary care.
Herrington’s recognition with the Larner College of Medicine’s Gender Equity Champion award at the inaugural Celebration of Gender Equity event in 2020 honored his work to ensure greater equity in UVM’s EM division. A member of the Larner Gender Equity Steering Committee, Herrington ably fits the award criteria as an individual who demonstrates “sustained commitment to equity and inclusion efforts to support the advancement of women and those with underrepresented gender identities.”
His faculty have embraced this mission. An internal education research grant supports Tabitha Ford, M.D., assistant professor and director of didactic education, who is working with Bounds to study implicit biases in the evaluation of Larner medical students on clerkships. Her goal is to foster gender equity in these evaluations by addressing implicit bias and training faculty to use practical tools to mitigate gender-related bias. At the national level, Sarah Schlein, M.D., associate professor and Wilderness Medicine Fellowship director, leads gender equity efforts for the Wilderness Medicine Society. In addition, faculty from UVM’s Department of Emergency Medicine serve on the Society of Academic Emergency Medicine’s Equity and Inclusion Committee and are members of the Academy for Diversity and Inclusion in Emergency Medicine.
The Draw of Emergency Medicine
Siket refers to EM as “the front door of the healthcare system” and describes it as “a collaborative field that is always focused on readiness, improvement, efficiency and evidence-based practice." He says he feels fortunate to have the opportunity to diagnose, treat, counsel and comfort patients when they are in need of acute care.
For Bounds, the teamwork aspect of EM is what drew him to the specialty – the work brings together not only physicians and nurses, but pharmacy staff, EMS, social workers and others, as well, to take care of patients.
“Everyone truly cares about the patients that present with urgent and emergent needs, and the high levels of compassion, collaboration, and professionalism make the ED such a great place to work,” he says.
In June, the department welcomed the fourth class of six EM residents since the launch of the UVM EM residency program. Bounds believes that these residents, who hail from around the country, “were drawn to this program’s unique ability to balance cutting-edge academic medicine with rural community-based care.”
To date, graduates of the residency program have been successful, matching into their top choices for faculty or fellowship positions. Some of them have stayed on at UVM, including one recent graduate who became the inaugural Wilderness Medicine fellow. Other EM fellowships include the Global Emergency Medicine and Rural Health fellowship, Medical Education fellowship, and Point-of-Care Ultrasound fellowship.
The role of the emergency department is to serve as the safety net of the healthcare system, says Herrington.
“We are the ones who are there 24/7, 365 days a year, to help anyone that comes in the door,” he explains, adding, “While it’s incredibly hard work, and sometimes heart-wrenching, it’s also incredibly satisfying.”