In February 2013, I was contacted by a Norwegian anesthesiologist who had heard through the grapevine that there was an American emergency physician living on a potato farm in rural Norway, teaching swim lessons. That April, I was informed, they were to start a pilot project at Akershus University Hospital (AHUS), which has Norway’s largest emergency room—not a department. This is the story of how my midlife crisis morphed into helping found the specialty of emergency medicine in a country that I was still just getting to know.
Explore This IssueACEP Now: Vol 39 – No 02 – February 2020
The year before, after being an attending emergency medicine physician at the University of Massachusetts for 12 years, I had taken a one-year leave of absence. I moved to Norway with my Norwegian husband and our three elementary school–aged children. I knew that I would not be able to work as a physician there, as there is no reciprocity between the United States and Europe. Nonetheless, I submitted my paperwork to start the process of obtaining a Norwegian medical license (which typically takes at least six years) just in case I decided to return there one day in retirement. We enrolled our children in the public school where my husband had matriculated, and I enrolled myself in a language class for immigrants. I worked hard to learn the language and tried to make as many connections with physicians as I could.
That unexpected message was the first indication that my efforts were paying off.
Emergency Care in Norway
Norway has a population of 5.4 million and a gross domestic product of approximately $400 billion (or $75,000 per capita), making it the fourth wealthiest country in the world today. It has one of the world’s best health care systems, with universal health insurance and a well-organized primary care system that functions as a gatekeeper to specialty care. However, when I moved there, Norway did not have a specialty in emergency medicine nor a system that we would find familiar. Moreover, AHUS had faced many challenges. It had a poor reputation—patients had died in the waiting room, primarily due to the lack of resident supervision.
Here’s how it “worked.” Patients who required inpatient treatment were referred to the hospital’s emergency room (actually “akuttmottak,” which means “acute receiving area”). Patients would be processed for admission by an intern. If a patient was too sick to be treated as an outpatient, the primary care doctor (or “legevakt,” which means “doctor on call”) was required to refer them to a specialty service, such as medicine, surgery, orthopedics, neurology, gynecology, psychiatry, or pediatrics. However, approximately 30 percent of patients arrived by ambulance. Problems would arise when patients were referred to the wrong specialty (such as a patient with back pain being referred to orthopedics when the real diagnosis was an abdominal aortic aneurysm) or when patients had problems that spanned different specialties (such as a patient with chronic obstructive pulmonary disease and amyotrophic lateral sclerosis with respiratory distress referred to surgery for a bowel obstruction). Placing undifferentiated patients was a problem, as akuttmottaks were primarily staffed by nurses and resident physicians with an average of six months’ experience. Something had to be done.
By the time I got involved in 2013, the CEO of the hospital happened to be from Iceland, a country that has recognized emergency medicine since 1992. In an attempt to improve the quality of care, she started a pilot project at AHUS modeled after the United States/United Kingdom/Australian model of staffing the medical receiving area 24 hours a day with supervising physicians. To help roll this out, I was fast-tracked to receive a Norwegian medical license. I was asked to lead a group of eight and a half full-time attending physicians from various specialties, including three American-trained emergency physicians, three Norwegian internists, a pediatrician, an anesthesiologist, and a surgeon. My one-year study abroad trip had morphed into a two-year adventure.
During the same time frame, several other hospitals also began developing permanent attending emergency medicine positions in their hospitals. Simultaneous with the development of these programs, there was increased focus on emergency care in the media, and pressure on the government was mounting. At AHUS, we invited politicians and the Minister of Health to see what we were doing. I was selected by AHUS to be featured on a television documentary series, “På Liv od Død” (“Of Life and Death”), that showcased a day in the life of the Norwegian health care system. Our pilot project on emergency medicine was now in the spotlight.