[sidebar]From Left: Kåre Løvstakken, MD, project leader at AHUS; Gayle Galletta, MD, FACEP; and Lars Petter Bjørnsen, MD, FACEP, founder of Norwegian Society of Emergency Medicine, at the Society’s fourth national symposium on emergency medicine, November 2014, Trondheim, Norway. [/sidebar]
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.
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.
EM Gains Steam in Europe
Emergency medicine was in various phases of development throughout Europe at this time. While the United Kingdom had recognized the specialty for almost half a century, most other European countries were in their infancy with regard to emergency medicine. In 2013, the European Society for Emergency Medicine administered its first written board exam in emergency medicine. I was among the first 100 physicians who sat for this exam. It was administered in five locations throughout Europe. I flew to London for my exam, knowing that I was helping to create history. The 36 of us who passed this exam were invited to take the oral exam in Italy the following May. It was similar to an objective structured clinical examination. While it was not in a hotel room with an examiner behind a binder, I felt like my residency training and American Board of Emergency Medicine certification and recertification had prepared me well for the European exam. At the 2014 European Society for Emergency Medicine (EUSEM) conference in Amsterdam, I was recognized as one of the first 12 physicians to have passed the first written and oral emergency medicine exam in Europe.
Back at AHUS, patient care was improving. Since starting our pilot project, there had been no unexpected deaths in the emergency room. I can think of several of my patients who certainly would have died without the attending-level emergency medicine supervision I was able to provide. I remember a type A dissection that I diagnosed with bedside ultrasound, an unrecognized acetaminophen overdose, a patient sent in for presumed urosepsis that I correctly identified as Fournier’s gangrene, and a patient with pericardial tamponade (also diagnosed with bedside ultrasound), just to name a few.
At the same time, patient complaints to the ombudsman drastically decreased from 92 in the two-year, eight-month period before emergency medicine staffing to just two in the six-month period after staffing the emergency department with attending physicians around the clock. Lifesaving treatments such as cardioversion for unstable atrial fibrillation were now being performed immediately in the emergency room rather than after the delays around admitting these patients to hallway beds on the cardiology floor for management. We also discharged patients faster from our observation unit. The nurses and EMS felt safer having a small, dedicated group of attending physicians in the emergency room rather than relying on inexperienced interns rotating from the various services.
Many Challenges, Many Successes
Despite the obvious improvement in patient care we provided, the specialists felt threatened, particularly the cardiologists. They did not understand our scope of practice. How could a physician who was not a cardiologist manage ventricular tachycardia or cardiovert atrial fibrillation patients? We were not even allowed to intubate, as that was the anesthesiologists’ job. Despite having diagnosed tamponade, dissection, and several aortic aneurysms by bedside ultrasound, I was accused of not being trained as a radiologist. Our CEO stepped down after a staffing conflict with the nurses’ union, so we lost our support at the top. After almost one year, all success aside, our pilot program was shut down.
But it was too late to stop the momentum that had started. In 2015, the Norwegian Society for Emergency Medicine (NORSEM), which had been formed in 2010 by a Norwegian emergency physician who had trained in the United States (and of which I am a board member), was asked by the Ministry of Health to help develop an education framework and curriculum for a primary specialty in emergency medicine that would comply with EUSEM’s curriculum and international guidelines. In 2017, the Minister of Health approved emergency medicine as Norway’s newest specialty. One year later, NORSEM joined the International Federation for Emergency Medicine as a full voting member. In March 2019, the Ministry of Health began accepting applications from those physicians wishing to be grandfathered in as Norway’s first emergency medicine physicians. On Oct. 17, 2019, I received confirmation that I was to be one of them. The process of approving training facilities is currently under way.
More than two decades ago, during residency, I took my first trip to Norway and had a tour of an akuttmottak in Oslo. I knew at that time that someday I would like to work as an emergency physician in Norway. I knew I would first have to learn the language. I didn’t know that I would have to help create the entire specialty. It was a pipe dream, but with hard work, good timing, and a little luck, that pipe dream came true.
I’m back in the States now with no immediate plans to move back to Norway. But if and when I do, I can proudly work as an emergency physician.
Dr. Galletta is associate professor of emergency medicine at the University of Massachusetts in Worcester.