Emergency Medicine specialist, Lewis Goldfrank, M.D.

0:00 Hi, it's Doctor Robert Seikart. And today we have another Doctor Podcast interview with a prominent physician, Dr. Louis Goldfrank, who's sitting right here next to me. Doctor Goldfrank was the Chairman of the Department of Emergency Medicine at the NYU Langone Medical Center and the NYU Langone School of Medicine for 40 years, and also the director of the Emergency Medicine Department at Bellevue Hospital in New York City. Bellevue Hospital is an incredibly important hospital to New York City. It's the flagship hospital for the entire public health system in New York City.

0:42 So I'm really pleased to have this giant in medicine here today, not only because he's very tall, but also because of all the great contributions that he's made to emergency medicine over the last 40 years. And he still continues to teach residents and fellows in emergency medicine. Doctor Golf. Frank, thanks very much for coming today. We really appreciate your time and we look forward to speaking with you today. Pleasure to be here. Thank you. So tell us about Bellevue Hospital, some of the history of Bellevue with regard to emergency medicine, and New York City.

1:22 Sure. Bellevue is America's oldest hospital, started as a six bed unit of an alms house downtown way downtown before its trajectory ended up at what's called Bellevue which was in Kips Bay Hospital initially grew in the face of all sorts of the new diseases, yellow fever, unknown diseases downtown in the and moved to really become a creative force in the city. It had the first ambulance system when Dalton left, his work as the Lincoln's commander responsible for health services of the Potomac, when a unit was developed at Bellevue for children, for psychiatric patients, All of these firsts in America.

2:18 So we're going back about 200 years. 1736, the whole thing started and really the lots of action began to develop in the certainly at the later part of the 18th century and the 19th century, there was a revolution going on of of all sorts of ideas of firsts. And the hospital began to grow enormously. Once it started to make this area near Kips Bay and it became enormous and it became a training site for people from most of the big medical schools that developed. It was where Columbia first did its training.

2:53 It's where Cornell did training. It's where Bellevue Hospital Medical Center did its training and as was where New York University did. And the Columbia has done it for almost a couple of 100 years. NYU for more than 150 years. Bellevue's been there. And it's everybody seems to know some story about Bellevue and the stories probably are, you know, every child that said my mother said that if I didn't behave, I was going to be brought to Bellevue. So it had a big psychiatric service there and everybody was worried about that.

3:25 On the other hand, it's where those people who didn't know where to go and couldn't go anywhere didn't have the resources. They knew they had to get somewhere for help. It was a safe harbor. Even in those days where not many people were paying for their healthcare, it was known that you had to go to Bellevue to get the best answer. It was the first in all of these areas and real commitment to to the changing the way people could live, and that's the way it was when all of us got there, probably throughout the 20th century.

3:59 It was always the place where no one was ever turned away and everybody who was turned away came there to get care. So it gave you a special feeling as a doctor and everybody who works there for some time has a special passion for exactly what this hospital means to society and what the style of a public hospital is. You mentioned Kipps Bay, that's the Midtown east side in New York City, Manhattan. When when did Bellevue move there to that? Location in the early 1800s. It was a farm then at that point, and that was the Bellevue looking over the East River and this farm and they built up this enormous number of buildings.

4:38 There were many buildings. Some people said there were A-Z and there were A, AA and B and think host of different things for different reasons of different kinds of health function as they de differentiated this, the alms house concept. There were things being done that were revolutionary and improvement of care and development. So I didn't know that Bellevue served as the origins for many current medical centers. NYU, you mentioned Cornell, Columbia. They eventually split off and develop their own medical centers and other parts of Manhattan.

5:11 That's correct. What what happened was that it said was before my time, certainly, but up until even the 60s, there were rotations of admissions to the hospital and they would go with a Columbia was on one floor and the next floor was Cornell, the next floor was Bellevue's effort. And then there was NYU. And so this is a rotation of all of these people rotating through with different faculty supervising more or less sometimes. So it was an enormous passing for almost every young doctor in America who was in New York.

5:47 Boston City Hospital was like that too. Harvard, Tufts, Boston University all rotated through Boston City Hospital. So these city hospitals were where people could learn and understand the most complex of problems and do care for people who had no resources. That's interesting. One of the previous chairmans of ophthalmology at NYU and Bellevue was Doctor Brinan and he always used to refer to it as Mother Bellevue and I I see why he called it that because it it did lead to many other Medical Center that's that's very interesting.

6:23 Where where did you do your your training and what kind of training did you do? What kind of residency? So I was unsure what I wanted to do, and I I first, in an internship, I did six months of Pediatrics, six months of medicine. I couldn't decide. And then I went to Monafure Hospital in the Bronx, and I did two years of internal medicine there. But the excitement I had was, was really the experiences we had in our public hospital that we rotated from Montefiore in the north part of the Bronx 210th St. and Morrisania City Hospital 168th in the midst of the South Bronx.

7:06 So everybody, the faculty rotated, some of the nurses rotated between the two hospitals and all of the residents rotated and many of the students went. So I started to say in in my third year residency training, the second year, the second year resident, I was the chief resident and I said I really want to be in the South Bronx and and do my time there. I'd like to start to spend my time really working in the emergency department and see if I can help. There never been an attending physician. There were no staff, there were no attending physicians of any sort.

7:40 So they were just residents who were unsupervised. And that's that's the way it was across the country. Emergency emergency care was not supposed to be so important. People hadn't done all the things that we do today, but it was for me an exciting experience and I then stayed in the South Bronx to start becoming an emergency physician. There was no one training people to be as that, but they were big events happening in the country. The National Academy of Sciences had said that injury in America is the greatest killer and they talked about that.

8:15 They they did the work in this. There was a that was a 1965 study that really said you had to think about these things as errors that could be prevented and really that one had to stop using the term accident. And they that led in the early 70s to let's say the National Highway Traffic Safety Administration which became the job was to really look at how you prevent crashes at at the same time in the early 70s, nineteen 73, I think there was a National Highway Traffic Safety Act that led was then during the Nixon administration.

8:50 They what they decided to do was to recognize that there weren't enough ambulances and there weren't any paramedics and the ambulances look more like horses than real ambulances. So they're really looking at a host of critical issues there. In addition, there was no they they looked at the issues that were developing across the world. In some places, there were no intensive care units, there were no coronary care units. There were no trauma services. There were no services for emergency needs of burns.

9:23 There really weren't staffing of an emergency department in any place with people who were going to be there and understand what had to be done. So that all of those parts came out of this act. And that act led to a place like Bellevue being the central force in the city of New York for meetings that were held by three leaders from each hospital in the city of New York, a nurse, a physician and administrator. And they were called the 911 committee by the city of New York. And what we were supposed to do was to establish standards for all of those things, for children, for burns, for trauma, for neuro trauma, for emergency care itself and how ambulances run.

10:07 And so we began to work together. And ultimately it began a revolution about what really should be done. It wasn't going to be a passing way. It was going to be a real entity that was consequential. And this began to really change the whole city, because you had these leaders. Many, many of us had very little experience at that time, but we had these leaders working together. And so, so that those events took place in the Rose Room on the 12th floor of Bellevue Hospital twice a month. And people got together of the subcommittee's or the committee and the plan and the audits and the efforts we would make for the city.

10:45 The city was being responsible. There was some money going to this. And really the plan was to say is this place can be good enough, good enough to receive ambulances. There were 60 hospitals that were sending these three people, but many of them were clearly not able to do the job. So it was going to be a revolution about who should receive ambulances and who how you take care of them, the patients who were brought. So how did you wind up at Bellevue from the South Bronx? From Morrisania. Hospital in the 1976, they closed the Old Lincoln Hospital and the Old Morrisania Hospital both in the South Bronx, and they created a new hospital for Lincoln, and the staff from the old went to the new Lincoln.

11:27 That old Lincoln had had been hospital from the Civil War for freed slaves. Then the North Central Bronx was right next to Mon. If you and I went there for several years and I then got involved with these meetings at Bellevue and it was pretty exciting. I was getting to meet a lot of people, and what happened in 1978 was the Joint Commission on Accreditation of Hospitals. They interviewed went to Bellevue and took a look. They said we're not going to approve you as a hospital to receive ambulances any longer because there's no full time attending in the emergency department.

12:01 There's no supervision there. Residents who who work unsupervised moonlighters that no one knows is not a system. They weren't the only people who seem to have a system with the nursing people. So they told, they told the City of New York and Bellevue Hospital that you're not going to pass your next survey unless you have an attending physician to run the emergency department. So having gone there, I knew the woman who was the head nurse at that point at Bellevue. I'd met her. We she was on some of the committees with me.

12:32 I met Joe Ranzohoff who was a very famous neurosurgeon, pretty wild. A very friendly guide to me in the beginning on those things. And they said, you know, Bellevue has to have a a leader and there's a search committee he's going to start the new head of the head of the hospital woman named Madeline Bowman. And the Dean at that point was a guy named Ivan Bennett. So he was a prestigious guy, I think who later went on he he was there for a short time, but he, he was a Dean. And so I had meetings with various people and they said, well, you're great, you can come.

13:11 And I talked to Ivan Bennett, I met him and I talked with him a lot. He's a he had worked at Grady and he would love Grady the way he said he loved Bellevue while he was the Dean at NYU. And he said we really need somebody and I'd be very, he said he'd be very supportive. We talked about methanol poisoning. He had, he had run an effort to care for the largest methanol epidemic in in and I think in the United States of Grady where they had 400 some patients I think who and he. So he and I talked about patients that I had seen and we had a good time and he said you know we'll have to get you to meet the other people, but I really want to get you hired.

13:49 This was in the spring and so I was hired. I was going to start October 1st and I don't think I got to meet any of the other people at that point. I got to meet the administration at Bellevue and the affiliation administration. They never hired anybody to work at Bellevue as a doctor and the collaboration with the with Bellevue in this affiliation seemed to be pretty good. I got an office in the middle of the Bellevue emergency department. It was, you know, it was probably it wasn't the old I room, but it was somebody's little room there.

14:18 It was a very small emergency department at that time and it it seemed very promising. And then, by the time I arrived on October 1st, Ivan Bennett had had moved rapidly to become acting president of NYU downtown, the whole university, and Doctor Saul Farber became the Dean. And so when I came, I I was really beginning to work at Bellevue, but I was accepted as a faculty member at NYU and I was a it was called the 10 year professor of Emergency medicine tenure, Professor of internal medicine at at Albert Einstein before I left.

15:03 And I was an associate professor. So that was actually many thought that was a good protective thing to have been to have a position that should be respected and maybe not get fired immediately. So then I met. I went to talk to the Dean, and I told him my big vision for what emergency care would be. We'd improve the ambulances, get better ambulances. The system was saying. We'd make sure that we had paramedics who could do resuscitations in the field. We'd train them here. The Bellevue Hospital agreed to all of that.

15:37 We would move towards the development of a residency of people who were really committed to emergency medicine. We wouldn't use all the residents that come from all the services here that just rotated through, didn't have any interest or experience. And they they were wonderfully committed people, but they weren't trained in what to do when someone came in who was bleeding or someone came in who has a corneal abrasion or they needed help, they could work on it, but they needed help. And we, we didn't have any trained emergency medicine residents in America but we had some people interested yet they were the first residencies were developed.

16:06 I said I wanted to work towards that and I then went to meet said you just meet the faculty and see what they think. So I met all the chairs. He said he was totally opposed to that doing those things. He didn't believe in emergency medicine at that day. They didn't have special people doing critical care, intensive care units or coronary care units. The the regular doctors did it and he believed that his residents could do this quite well. I said that's not I I certainly didn't believe that. And that was we're going to work on that.

16:35 And I I went to see all the chairs and all the chairs of each department had a they they were well prepared for my visit. They said you're seem like a nice young guy, but we're not going to do that here. And so I did. Then I wasn't incorporated in the academic life at the university. I went to the medical board of Bellevue. But there were many battles, and some people try to be very helpful, but they were tremendous efforts. I needed to get faculty. I need to convince people they they were, they were getting interim appointments of some sort.

17:12 The people I could find, people who had finished internal medicine or surgery but wanted to do this, or some people who hadn't fully finished. So how do you hire people like that in a system that had never had people who were other than experts at some level? So that became a battle, and it took time to find who could be friends. But I thought I had to start somewhere. So I went to the Community Board and I started to talk to people. I said, what do you think about? What are the problems? What would you like solved in the emergency department?

17:43 What do you think's consequential who, who would be help me understand what the community thinks I need to do to help out? I had to talk to somebody to find about something, and certainly the people who are getting care, I wanted to meet and understand them. And so I went once a month and I told them what my plans were to develop. So we'd have residents, we would train students so they'd be good at CPR. They weren't taught CPR yet. They weren't taught a host of things that had to do with the basics of resuscitation.

18:11 Some people were starting, actually, Neil Lewin was working in the emergency department on a part time basis and he was trying to teach people, but it wasn't part of the process we needed. We needed to do a host of training to get all the people who participated trained up and those battles became such a level that that I was not making any progress. I lost whatever goodwill I had in relationship with many of the chairs of the Dean were were deterioration. And so I thought I talked a lot with the people at the Health and Hospitals Corporation who ran these 11 big public hospitals about some help and they tried to help and said they would be be fully be fully supportive of residency and emergency medicine.

18:58 Well, the Deans or at NYU said it will, will, will not happen. So I would, I would go back and tell, look at my staff that we're in a battle. We need to make some progress on this. I'm working as hard as I can to accomplish this task, but there there's a limited amount of support. So I went back to the Health and Hospital Corporation. Stanley Brezhnev was a leader at that point, and Josephine Buford, who was the head of the of the present Health and hospitals One point. She and I were residents together at Montefiore.

19:29 She understood the battle. She was very supportive of it because my belief was really that we wanted to cooperate, but we need to improve the care. We need the people who are really going to develop long term relationships with the nurses and the social workers and the understand the patient needs coming in. So you start out as a troublemaker. I said so. And eventually you became the father of emergency medicine. It was, it was not really a residency. I didn't realize that the people staffing emergency rooms at that time, we're not trained in that.

20:05 It was just random doctors who rotated through the emergency. So they might send that there was in the old diet style, they were probably maybe an ophthalmologist was down there to share part of the time and intern maybe a dermatologist, a host of people and there wasn't much of a system. And in the battle, I had to go back to Community Board and tell them that I wasn't making progress. And so they they were more agitated than I was. I was measured, but I needed their help. So they ended up sending a letter to the Dean to say that we think for the welfare of our community we need to have people who are trained in emergency medicine, the emergency department.

20:49 And if there isn't cooperation, we don't think NYU medical students should be allowed to train at Bellevue until they had a residency in emergency medicine. So that blew the roof off the relationship. That's not a battle, that's a. War That's right. Right. So that the ultimately that led to an intervention probably because of all the things we were doing for the development of emergency medicine. We were well recognized that everybody in the city knew each other and everybody was really supportive and helped us bridge the gap.

21:25 The ultimately the head of the health and hospitals tried to work and get us someone to cooperate. Frank Spencer helped to some extent. He was going to be responsible, potentially for the residents. He was a chairman of surgery at the time. And then they said, well, none of your faculty are acceptable. None of them have appointments. Well, I said they don't because no one ever gave them an appointment. They were refused. So they'd said we would spend the next year to look carefully at them to see who could get an appointment.

21:52 So everybody got an appointment. We waited. The residency review committee for the country came to look and they said the environment is too hostile to bring residents into the situation at this time. We need more support and we need the demonstrable support by the medical school and the hospital. The hospital was very supportive. Ultimately, we got going. That was 1991. We'd started to work on this in 1980, but we accomplished it and then had. Persisted. Persisted. Yes. There's no other option.

22:28 I still may. Basically I didn't know anything when I started and was a resident working. The residents in this great institution didn't know any more than I did. It wasn't fair to people. We had to have this develop and we needed supervision and you know, people would say we have supervision. You can call down the fellow in months in surgery or the resident, the senior resident or the second year resident, they're going to help you. Well, that's not real help. I'm going to be trained in this field.

22:58 I'm going to need faculty who also I can talk with about tough problems so that I don't can't debate all these problems just with a resident, it's not fair. And our residents are going to know more about the general care of someone who comes in off the street and is very weak and has a tough problem. Then someone else who doesn't want to see that person because that person maybe doesn't smell well or is not not a cooperative patient at that time. So it's a different kind of medicine that we had to be able to do and we tried to push the enhance that understanding that the social determinants of life where we were going to see it, maybe we can.

23:34 You know, a lot of people just need a prescription for please give this person food or please give this person a home or please find a way to deal with my substance dependency or whatever that's going on. So we need to change the way people thought in an emergency department. That's fascinating history that I wasn't aware of, but it's it's quite interesting. So it took you about 10 years to to really get going. So since that time, once you establish this emergency medicine department, which served as a role model for other hospitals around the country in the world, how many, how many residents and and fellows have you trained over the years in emergency medicine?

24:14 We started in 1990 with let's say 12 residents and now we're now we're at 18. So I would say it's been a four year program. So it's in in 30 years we've probably trained 300 or so residents and and then you know they've been come there, the most creative and interesting people, just as probably when the people you were working with an ophthalmology people wanted to come to Bellevue. These people came from everywhere. They were interested in seeing how a kind of care could be given to the poorest people in the country, the the newest immigrants, the most needy, the most people with the grave of psychosis, the people, all these problems, how one could handle that and gain strength.

25:00 And many people came specially to Bellevue because it was going to be a great challenge and got we. We got tremendous people who've gone on to say, you know, I came to Bellevue because I wanted to learn how to solve the problem of homelessness or I don't want people to die in ambulances who would just like to be able to die. I I if someone's needs to be resuscitated, they should. But I don't want everybody to have to be resuscitated. I want to make sure we do better thing at the end of life. And so people who had specific problems came to a place such as Bellevue and they really said I I want to do things to make the world a little better.

25:36 I want to solve problems that others have neglected. So it was an exciting group of people and they became the really mature leaders in many parts of the country at this time. The world. Many people went back to other countries or went on projects that elsewhere and and became leaders in education. So it it had tremendous opportunities for people to grow and develop. Right. So as you know, New York City over the years and decades has had many disasters, things like floods and buildings and streets exploding and hurricanes and fires and other types of disasters.

26:16 How does the emergency department deal with that when you have a major disaster and you could have dozens or or possibly hundreds of people severely injured simultaneously? How? How do you handle that? You know that that's an image that we don't really have any more because what we did with that 911 committee and with the great ambulance services is that the development of the training of paramedics and the emergency medical technicians manning ambulances, womaning ambulances, people of all types being the leaders.

26:54 That what happened is that strategy had to be given at the scene with great triage to sorting of people to decide. A large number of these people are very concerned about what they have, but they're not so sick. Those people we take in the ambulances to distal distal hospitals for, they go much further away. They don't. The people who have the most serious injuries are going to be brought to a certain number of core hospitals that are trauma centers or that are burn centers or they're going to move people.

27:24 And some of us, some of the closer hospitals will get many more because people will walk there. But the redistribution has been very effective in in the number of people can be hundreds but they may go to 15 different hospitals. And in the past there was chaos and they went mainly Bellevue was supposed to take most everything. Bellevue was supposed to be the biggest and best, but no one can do a good job under those circumstances. So it doesn't. There are great events, but the distribution and the quality of care done in the field and the distribution of the people to different hospitals has has revolutionized the way we respond to a disaster.

28:00 So it was rapid triage, figuring out who needs emergency emergency care and and then sending other people elsewhere. And we we could take, we could really take a lot of people and we never turned anybody away. But we also tried to do it in a fashion with the system for a whole city to use the other people so that people didn't the the the same time that we're having that catastrophe, we're still having many others of the 300 some patients who come in every day, right? It doesn't. It doesn't inhibit people to most instances.

28:34 Right. And those people are coming in from different parts of the world. I know when I worked at the Bellevue Eye Clinic, we we saw patients from all over the world, lots of poor people who didn't have insurance, didn't have income. We saw patients from Africa, South America, Europe. How do you deal with patients who can't communicate with you because they they don't speak English? So that's attracts a lot of people to Bellevue because the city is filled with immigrants, you know, first generation or second generation who speak many languages so that a lot of people come if I want to.

29:17 Someone says to the child, you know you're not going to maintain your Cantonese unless you go to work at Bellevue. You're not going to maintain your Mandarin unless you do something like that, your Bengali, you're going to get it. You'd be a good doctor there. That makes a big difference. You can communicate and you can help. And we all learn different languages. Actually, some of us were required to take a Spanish course and a Chinese course and host of things to be able to function. We had those small course that didn't help that much, but we have.

29:43 When I first came, there was a long list on the wall of all the restaurants from different parts of the world, so you could talk to the waiter there who spoke Hindi to know exactly what to do. Then we said that's probably not the best idea. It was very clever. That's the start. Yes. And certainly, you know, there were probably we had to be able to speak 200 different languages or dialects to do our job. So the language line systems were developed. We have in person translators available for the communist languages in different parts of our hospital as well as in others.

30:20 And then you have these language lines that have very, very large numbers of people to communicate. So we work on it, but and and lots of staff come with special skills. They take the the test and they pass a test that they're qualified to do the medicine in their particular language. But it's one of the most exciting things. You know, when there's a revolution in, you know, in West Africa, then the people are going to come to the hospital. They're going to be in distress. Their families are in trouble.

30:49 They're coming. They're worried they may not be so terribly sick, but they're anxious and they're worried they may be documented or undocumented. Everybody gets care. Everybody's got a problem that we have to find a way to solve it. That's that's interesting about how you deal with people of different countries. Another thing about Bellevue, I always hear on the news that whenever a police officer or a firefighter or a first responder gets injured, they always mentioned on the news they went to Bellevue for treatment.

31:20 Bellevue seems to be the place where you get the best care and and especially first first responders. How did you deal with? Sometimes there are incidents where several police officers or firefighters are severely injured and come to Bellevue simultaneously. Well the the strategy has been the probably they don't need to come to Bellevue and they've over the years they've learned that it was historically the place to come because it was the best developed in many domains and there are many of us were police surgeons so that one could help and on site and they set that up in many of the hospital so people could go to many hospitals as opposed to just Bellevue.

32:04 And I think that's really changed over the years. The responsibility the the police officers are bringing lots of patients of Bellevue. Remember Bellevue was as a large prison ward. It's getting a much larger prison ward now it's being rebuilt so that care can stay there. There was we know what to do with prisoners that prisoners come the officers who brought the prisoner in or brought the person who's arrested and also was injured in the process. So someone helping them. It's a it's an easy step to become the service for all of those people and we do when we learn a lot that you work very closely with police officers.

32:44 You learn very closely with the fire department with the ambulance score. They're all part of the same team. We're all involved with lots of things together so that it it's a it's not so large numbers of people would get distributed the same way that ambulance triage is doing it and the fire department treaty and people often are driven by ambulance or by the in the police car someplace. So the it's not as busy as it used to be because I think the systems are more logical. I think they have more confidence in many of the other hospitals and when when the codification of hospitals occurred that they were considered trauma centers so they could handle and then there are good places to go to with regard to trauma.

33:24 Historically, everybody could take any patient. But then the standards we established in the 1970s led to codification that you had to maintain your standards. You could you be adult trauma and paediatric trauma. Could you handle whatever you can do was determined by a committee of peers. So you basically created the standards that then other hospitals copied or tried to copy so that they could become efficient and proper Centers for all sorts of care. I think we all were cooperating, the city and there were many places that didn't want to have ambulances because it's disruptive.

34:03 And when you get an ambulance, you're getting a person who you don't know what this person can pay or what he can't pay, never bothered. The public hospitals, the private hospitals had to make those decisions to care for people so that it it became a big issue. And that that that led in probably in the early 80s something called AMTALA, which is the Emergency Medical Treatment and Active Labor Act. And that was law that made anybody who came to your emergency department you had to take responsibility for unless you could not do what had to be done and then you had to effectively transfer, transfer that patient to another hospital under supervision if it were a serious patient.

34:47 But that really meant that you can't ask someone can you pay before you get your care? You have to take all people to come through the door and you can't and ask to be an appropriate examination that meets the standards that anyone would expect for that person in the condition that he or she arrived. So that not limited what many people have tried to do of to say maybe we should see whether the visit is really an emergency. But we don't really believe that before you examine someone and care for someone you can say it's it's not an emergency.

35:22 So it forced us and the society to accept that you had to give person the right to get in and get an exam to decide whether it's an emergency. You know someone's pain, you get a a compromise person. I remember very sad story of a woman who came in with a severe pain and she was crying and talked a little bit with her, finally did some translation and could find out that she it sounded as though she'd had a catheterization, some other hospital for heart disease. But when you really talked with her, you could see that her problem, she just said on Tuesday, she she talks to her mother in Guatemala and she's an undocumented immigrant and her her mother in Guatemala has never spoken to the grandchild.

36:09 She has never met the grandchild who's in New York. So that that's a that was enough to cause her chest pain and to get evaluated elsewhere. But that she needed social support. She needed a mechanism to solve some of those problems, which we actually, this was a decade ago got some special permission for a visit and a visa. So you can do things, but it's that all things might look alike, but the things we do are going to be very different. And that's the uncertainty and the excitement of emergency medicine.

36:39 Right. Sounds like there are a lot of little battles along the way, right? That's I think that's the challenge of emergency medicine. Right now, in addition to being the director of the emergency medicine department at at Bellevue and NYU for many decades, you were also the head of the New York City Health Department Poison Center. Can you tell us about that? How you got involved in that and what that entailed and how did you manage to run all the emergency departments and run that simultaneously?

37:12 Well, the easiest answer to the last one is that we really have remarkable people who wanted to share this job. And so there are lots of people helping in many different avenues. And you know, my feeling was the great people do well if they're given a lot more liberty at times and work together. And that, you know, I worked hard every day and they worked hard and we did things and many of those work together. But the poison center interest started when when I first went to work in the South Bronx and there were so many poisonings and this, this committee from the the that set up these 911 efforts, one of the objectives like trauma and children's care and emergencies and amateurs was poison control.

37:55 So at that point I became actively involved in the poison centers in 1976 or so and we set up a meeting. We didn't have anybody to help us. The poison center at that point had been there for many years since the 1950s and it was run by wonderful people who were called sanitarians and they were really responsible for knowing that the water was clean and the food was not infected or compromised for people. And the the head of the poison of the health department that year when we started these discussions was a guy named David Sensor, who had been the head of the CDC and he then became the head of New York City's poison center, New York City's health department.

38:46 And he I was working on under these projects and he said well I'll give you a job, it'll be a non paying job of a dollar a year that you don't ever expect to get paid on. So we worked on that and I began to set up meetings and I had, as I mentioned these two two young people who were clinical pharmacist from St. John's University who came by gift to be at Bellevue Hospital with me and wanted to work in poison services. That's why they were there. And we decided we'd start having a conference the first Thursday of every month in 1976.

39:24 And we would have representatives from hospitals present their most interesting poison case and we would talk about it and study up and we would begin to use that as the, the arm and term to develop a fellowship in medical toxicology and training for our residents. And so it became just another part of emergency medicine that we integrated and developed. And now we have nurses and pharmacists who answer the telephone calls to the poison center. They're probably 60,000 tough calls that need to come in.

39:52 Anybody in the world has the right to call a poison center. It's free. It's 212 poisons. There's a good number for our unit. You can. Anybody can call and we help that. It's. Emergency departments, intensive care units, pediatric cases or family members, anybody can call and say what happened. Johnny ate a red Berry or this this pesticide I brought back from Guatemala when I was visiting. I think it works very well on my house and my child ate it. You know we everything imaginable and and we have the ability to go anywhere to look at what's being done by the patient and other hospitals they ask for help.

40:31 We we talk with the various people and ultimately we've trained enormous number of toxicologists and toxicology fellows at the poison center who are remarkable leaders in health departments, poison centers, academic institutions, CEC, Environmental Protection Agency, because it's such a stimulating job. It's, I think the way we often tell people. It's a little bit what it was when Lewis Carroll wrote about the Red Queen saying to Alice, you got to believe several unbelievable things before breakfast every day.

41:05 That's like going to work in Bellevue or the Poison Center in New York. You mentioned there are a lot of poisonings in in the Bronx and and then in the rest of New York Say what are the most common poisons that that? People the mentioned this this case I had that talked about with Ivan Bennett about methanol poisoning. We have ethylene glycol, you know antifreeze. We have they talk about today the opioid epidemic. But the opioid epidemic existed in in the 1960s and 70s and we had the the good fortune to work at Einstein just when developing naloxone and becoming utilized Narcan and we began to use it in the South Bronx.

41:50 The guy at Vincent Dole was working at Rockefeller and was working extensively in Rikers Island, working using methadone to treat people who were opioid dependent and really began to show that it prevented people when they left prison to not go out on the street and use the same opioid again and die. So we were learning about methadone, about Narcan, we're learning about strategies and it became a very great part of our work in in poisoning. You had alcohol is a tremendous poison, you know, cocaine.

42:27 We had an era with overwhelmingly agitated patients, critical injuries to the heart and the brain. So all of those things, everything might be a poison, you know, could be poppers. It could be something that else that that people try, people do a lot of experimenting and so they all the calls would come to the poison center. The fellows would work on that, the residents would work on that. We talked to the people in the other hospitals and so it it really makes the kind of communication. New York used to have 60 poison centers, 25 poison centers probably then there were there were little in the back office of some emergency there was 25 and then with in the Mario Cuomo ever era it was decreased to an upstate and a downstate.

43:12 Syracuse and New York are the two poison centers. And so all the calls are divided in that fashion between the two areas. And you have an organization that really feeds back to the hospitals and the doctors and the nurses who were doing these things. So it's it's very collaborative and altruistic, particularly that everyone has the right to call and everybody's going to get help and there you can get it. You can call in on any language. We also use the language line to do that. So, and it's 212 poisons.

43:40 That's what it is. With an S at, then poisons, That's the number and and. There's several other numbers, but that's that's. The main one. So that, I think led to your incredible book, which is Gold Frank's Toxicological Emergencies, which is the Bible of toxicological medicine. Can you tell us about how that started and how you got involved in that while running all the emergency departments and the poison center? By the way, I I have an older edition here, which is edition eight. It's also great for lifting weights.

44:18 It's about 20 lbs. We're up. You're doing.

44:23 Yeah, that's that's incredible. Can you tell us about that, how that got started and how it's evolved? Sure. I when I started an emergency medicine in the South Bronx, I didn't really have any knowledge of emergency medicine. And I was my assignment was to give a lecture to the residents in the South Bronx who I was starting to train each month about some topic and emergencies. So I decided that all those poisonings that I didn't know anything about and they couldn't find a good clinical text to do it, I would write a talk about it.

44:57 And then I did that and I started to accumulate those talks. And then someone came in and said, you know, everybody says they're great talks. Would you submit them to my journal? So this was the hospital physician, which was the house staff journal available at that time. And so I worked with a number of the collaborators to submit an article every month for about 5 years. And those were about cases we had of poisoning. And by the time we got near the 5th year, someone from a publishing house had seen them and asked if I wanted to publish a book.

45:38 So what happened is we took 170 pages worth of the first articles, redid them and worked on them, and they were published as a small book of about a of 170 pages. It's and we've now continued that developing much more detail, developing the science, a broader view of the basic component of education and the social needs and the psychiatric issues and everything imaginable. And it's now as a 2000 page book with 200 different people who were trained in toxicology, writing chapters and collaborating on the field.

46:15 That's now of great international importance as well as national importance. And many of those authors of sections of the book are people that you trained, right? Almost every the fellow who trained with us in a two year program has written a chapter and collaborate on a chapter so that it's it retains the novelty and the integrity of the young people changing and teaching us the things that we might not have known so well or need to learn better. Going back to Bellevue Firmone, you mentioned a couple of times about the psychiatric patients and in the past Bellevue was known as the mental hospital where where people go.

46:59 How did you deal with having an influx of emergency patients who possibly severely injured or poisoned or an accident and simultaneously having psychiatric patients who come in this emergency who may be disruptive or aggressive or or possibly overdosed on various medications or alcohol? How do you deal with that? It's a great problem and we work very hard on it. I mean the the Bellevue emergency department when I got there was about 20,000 square feet. It's now well over 100,000 square feet. And and you do certain level of triage, they may say that there's a agitated person and so that that person who comes to triage has moved immediately into a space where you can treat people who were agitated.

47:50 The the agitation may be the person may be in may have encephalitis may have 115 temperature maybe has taken too much cocaine maybe has delirium tremens. So maybe is anxious. So you bring the patient to do a safe space. If the police have brought the person in, sometimes the person's restrained and they're they're tied down and we they may be have handcuffs on them. And we have good teams of people who are behavioral health assistants now who moved to that site as soon as they call a psych behavioral health emergency.

48:29 And the attending a senior person, couple of residents approach the person, some good nurses and you start to talk with the person and you decide whether it's a life threatening problem. That's extreme hyperthermia because they were using drugs on a on a roof and hot tin roof and had a seizure or something like that. That person might get one type of intervention and that person may be immediately sedated with something to that. We have that works very rapidly. An intramuscular drug, for example.

48:59 Sometimes it's too dangerous to take the handcuffs off until you're sure what you should do, and you may switch to restraints that are safer for the person and carry on with the care. Someone may, if the patient's got 115 temperature, that person may be put in an ice bath immediately to bring the temperature down and save the life. The life of the person's body is being destroyed by the extreme hyperthermia, the liver or the heart of the brain. Other people, you start to talk with them and they say they're hallucinating and they you start to talk with them.

49:26 They feel better, calm down, you may take the cuffs off, you may talk to them, and they may then have a good discussion that you see. It's really purely A psychiatric problem. And then we would get them liaison. Psychiatrist might come or the patient may go to the psychiatric part of the emergency department. Safer. There are host of nuances between life and death, someone desperately ill and someone who's got some significant psychiatric problems. Then there are a lot of people in between who, you know, some things you like to say that when someone's got an altered consciousness change and thought, but you've truly got to think about these unbelievable things.

50:06 You know, we have receptor antibodies and MDA receptor antibodies, you know, from people who might have an ovarian cancer that caused them to have terrible confusion and act. It's totally strange. Someone had been normal a few days before. And so that we've only learned in the last, I don't know, 5 or 10 years. But that's that's the kind of thing that makes you think that who knows what's happened to people, what is actually going on. There's so much knowledge that we learn, there's so many rare different things that call encephalitis, encephalitis, infection of the inflammation of the brain.

50:42 It could be an immune response, It could be a bacteria, a virus, so that we don't know enough and we always work together with the psychiatrist. We never turn someone over to the psychiatrist unless we both agree that the person has a psychological problem that they can work on and other people may need a Spinal Tap. We need to know what's happening to them. They may have a bleed hemorrhage into the brain. So we're really trying to to make sure in this extreme collaboration between the people who call themselves psychiatric emergency physicians and emergency physicians to to really be able to to do the best possible care for people under those circumstances.

51:18 Right. So you first have to figure out if it's a medical problem causing a psychiatric condition to be displayed by the patient, as opposed to purely a psychological problem. That's right. And and I think we, we always want to be sure we're thinking about the thing that might be medical that we have to work on and we don't want to, we want to only turn over to the psychiatrist a problem that they can handle with collaboration of let's say someone who does internal medicine in the hospital. And and until we can be sure about that that that's not a primarily a a medical problem that we take care of that person as emergency physicians not as emergency psychiatrist.

51:58 Right. You mentioned that there's a huge amount of knowledge and we're learning things all the time that we didn't know before. So you update the the book how often? Every four years. So when we finish the book that we're already we we're already starting on the next edition because things are changing. We we. You'd think you could do it electronically, but in a book like this, where there's so many chapters deal with many nuances of the same problem, the principles, the interactions that are occurring in different types of diseases that we found it was too difficult to do just online.

52:36 And so we the corrections are coming in because the last year we're just correcting what we've got past the sage when you can make changes, the publishers working on it and was making changes at that point. And then we go over each chapter in immense detail by all the editors, the authors and the editors to rewrite it and to make it consistent. So the same discussion about a similar problem because associated with one disease and another disease and one drug and another drug are handled appropriately in the same fashion.

53:07 Right, the I understand the book is fairly expensive, but where do profits from this book go? We we have always said that the money is to be used for the care of people who were poisoned and to improve that care and for the money goes to the New York City poison center to allocate to the people who need it most. And that's often for residents to learn on something special, someone to go to work on a project that might help us in that fashion. And we've done that. Money's been given continuously for the use of the poison center.

53:44 So all the authors and editors can contribute their time. Yes, everybody's in agreement. They can feel proud that they've created a book and that you know the people who need the help or getting it and the that means the rest of us are getting there. We want to be able to have anybody in the world call us about a problem and let us try to help and lots of us do international work that where we collaborate with poison centers across the world to do that. So when you it's the only way to learn what the plants do in other country what the what are what are the things people use for pesticides.

54:19 Is it too Jane dangerous to live, leave in the hands of someone who might be depressed host of things that are essential for better public health and better health policy in our world all. Right. In the last five or ten years, I've seen, I'm sure you've seen as well, there's a lot of urgent care centers that have opened up there. They're private emergencies. The thought was initially that people wouldn't go to the emergency rooms and hospitals or emergency departments and and wouldn't clog those systems up as much because they'll be going to these urgent care facilities.

54:55 How has the urgent care facility evolution affected Bellevue and other major emergency departments in the hospitals? Well, as you said it there, the the urgent care centers take people who can pay. So those are not necessarily the patients who would have necessarily gone to Bellevue. On the other hand, to private hospitals, it may decrease the number of people who go to that private hospital because some people get quick fixes in the urgent care. You know, we only see in the emergency department people who've been to the urgent care who are very sick and are brought to us.

55:34 And sometimes people go in with appendicitis, they go and they have a fracture, they need to get help so that that there's a reasonable relationship in transferring the patients. I think after COVID many people were developing virtual urgent care so they could they could call a a number and get a quick consultation over the phone telephone you know when the video assistant. So it's it's a little bit like what we do at the poison center. The poison center calls though we're absolutely free everybody can call the poison center.

56:08 There's no cost in the least. It's we want people to call. It's the public health gesture, the virtual urgent care centers maybe a contract to pay some instance. I don't know precisely but that's so I don't think it's it's not been. Some are some places are pretty good others it's hard to judge. You don't really see many of the patients in Bellevue. For right. My my impression is the urgent care centers take care of minor issues and problems and if if they find the patient who's severely I'll or has a major problem they'll send them to Bellevue or other hospital emergency departments.

56:46 So it's a it's a triage tool that's correct in in many ways you mentioned about COVID. How did Bellevue deal with with COVID when it first started and there were just a huge number of severely I'll patients? Every I think everybody in the city was overwhelmed. Everybody in the world was overwhelmed. And I think the Bellevue hospital dramatic increase in beds utilized for the care of people. The large number of intensive care beds across the hospital, just most beds became high quality intensive care increase.

57:25 The intensivity and large numbers of these patients were transferred from other hospitals in the city. Some places were far more overwhelmed, such as places in Queens with tremendous fatality rate in the beginning and tremendous change in how everybody functioned was a remarkable time for, you know, growth and development. I mean the tragedies of being able to talk with people and try to help people understand why it's valuable to get vaccinated, what what masks really were, what N 95 masks would mean.

57:58 So I think for you know young doctors and nurses it was a phenomenal experience. You know having seen more people die in in a month or in a week then they might see an entire day of their career. And with everybody transformed to acting on behalf of so many patients and doing and not being able to share the the relationships with family at the end so much isolation. So I'm just so many tragedies and helping people understand what we're we're trying to do is people were working very hard. I mean clearly a lot of people had to.

58:35 It was terribly debilitating, the numbers of people in the severity of their illnesses so. Right as as head of the emergency department and the poison center and and things you just mentioned. I I would think it would be very stressful for you because everything is an emergency urgent. You have a lot of sleepless nights over over the past few decades because of all the emergencies and I think issues you need to deal with. You know I I think that doctors like to work and I like to do things that are necessary.

59:12 I mean I think it's a the beginning of my career we fought continuously to develop the right to have people doing this work. I think we've shown over the years that you know emergency medicine and medical toxicology remarkably important areas, not more remarkable than any other place but the the idea of how you develop new specialties. And I think, I think people place like Bellevue, people come to work with the sense that if I didn't get to work today something might not get done. I think that they're they're always more people than you can do the best job possible and because we set no limits on how many people we take and I think it's you grow up as a different way I think you can when you can train people to believe that way that they're they're a vital part of the healthcare system and trying to help people educate people and serve people then you feel pretty good about it.

1:00:05 I mean I get much better sleep these days and probably I did when there were no other faculty and there were few faculty and the residents were new. I have a feeling that their everyday. In the emergency department there are lots of people trying very, very hard to do a good job. But. You still actively teach, right? I do, but I'm I'm not a essential participant in the running the department anymore, so I can take with pride at how the other people do it and how it gets done. That's good. Now in the news now you hear every day about AI or artificial intelligence.

1:00:40 And I recently saw an article about AI and and emergency medicine and the authors concluded that it's it's not as good as we think it is or or we think it should be. What What do you think the role of AI is in medicine in general and emergency medicine? Someone sent me an advertisement a few weeks ago about doing triage with artificial intelligence. So triage is the is the first time that any human being meets the patient at the door of the emergency department. The kind of case I talked to you about is, you know, someone can say I have exactly the kind of pain that I've the heart people get with a heart attack, and it may be a heart attack most of the time or some of the time.

1:01:23 And then some people have that pain because they're terribly anxious and that's the way they're expressing themselves. And I think we try to teach people that you find out immediately, in a matter of a minute or two, whether the person needs to to go to the operating room or go get, has, needs cardiac resuscitation done or needs talking. And then once you get to the stage of talking, you're going to find out this, that slow medicine is vital for people. It's almost vital for every you've got to know what the person is thinking and you have to understand how to speak to that person.

1:01:59 I I'm always use the phrase, Mandela said. If you want to talk to somebody and get to that person's heart, you speak in his language and their language. If you want to not make progress, you talk in your language to his head. And so it's it. It's the kind of thing we it's hard for us. We have to learn what people need and we have to be able to listen and talk to people and hold their hands and get there. And I don't know that artificial intelligence is going to do that. It's got that it There are too many uncertainties.

1:02:34 There could be 100 things that cause 'cause you to have chest pain, right? And it takes time. It takes to be an ophthalmologist to look at why the eye hurts. You know, with everybody, everybody's got to do something carefully and it's it needs a lot of information before you going to be able to make a decision. So I'm I don't think that the artificial intelligence as I understand it's going to take over the job that most doctors have to do to really know people and feel for them and speak with them in a in a fashion, it's going to be very productive.

1:03:07 Yeah, that's a critical point. When I speak to a patient, I I get certain vibes and certain information just from listening to how the patient is explaining what their issues or problems are. And that's my brain working. And from experience figuring that out. I think it's going to be a while before computers can figure that out, if ever. I'm not sure. I think that's the advantage we have in being in a place where there's such a heterogeneity of of young doctors and nurses. Older doctors and nurses come from every nation in the world and they can it's it's a lot easier for that person who happens to speak the same language or maybe look the same color or have a lot of the same values.

1:03:57 These, all of these are are issues that alter the quality of the communication and until we have a, you know, a staff that represents the lots of the people and types of people in the world working with the others, you don't get as good care. You see big differences. I remember as a young doctor in the South Bronx, I was starting to work in the South Bronx just at the time that Tuskegee report about discrimination and very poor handling of people who had neurosyphilis in Tuskegee, AL. And that was recent.

1:04:31 And then most of my patients were black or Hispanic. And they said I don't want to be seen by a white doctor anymore. I'm worried. I'm worried about how you behave, machines not going to handle that. I mean, there's a big jump that the the human is pretty important and the humans got to be a kind of decent person, able to be humbled and get to meet people and feel good about people to solve these problems. And I don't know that the machine's going to solve it just yet. Yeah, maybe in the future.

1:05:00 We'll see. So we, we touched upon it several times here. The the healthcare system has many problems and issues and some people say it's totally broken, Needs to be revamped. You've been through this for decades now. What what do you think our main issues or problems are? What what are your suggestions for how to fix? I don't I don't see how how we can it's it's. I think it's morally and ethically irresponsible not to the universal healthcare system. I think everybody needs to be able to get care that's of a high quality.

1:05:35 I consider you know that the only way. It's it's unconscionable that we make so many people with such limited capacity, sometimes would to be uninsured or poorly insured and the hoops you have to go through to be able to get the care delivered that other people would do routinely. It just doesn't make any sense. It's not it doesn't lead to a healthier life for that family, that person, that individual. It's very expensive What we do. We're the we're one of the richest countries in the world and we're one of the last of those very rich countries to have universal healthcare.

1:06:09 We are asking people in some states maybe as a vestige of discrimination that that the care is not going to be good. They're not going to get even the Affordable Care Act. They're not going to get the same kind of care. We have so many things we know that are just discrimination against people of color. It's it's not reasonable not to have universal care. It's it's unconscionable and it's probably a waste of money. I mean the lives of people, so many people die, so many people suffer unnecessarily because we don't have a reasonable healthcare system.

1:06:42 So why isn't the government doing that? What's blogging? Is it politics? Money. Combination. I don't think it's I think I certainly it it's it's in pretence is about money but I think you you're wasting human lives so it's not very valuable to cut back on the money make to make someone choose whether I'm going to get a co-pay if I don't have the money and and not get the the medication this week for diabetes and split the pills in half isn't the solution they're going to end up with kidney failure or something terrible I. Have a.

1:07:16 Bigger problem. So I don't, I think that it's a the philosophy that we believe that not I but as a society would believe that you know people should pull themselves up and get them, get themselves taken care of, earn more money to pay for these things or whatever. It's not it doesn't make any sense. Every other country that's got the wealth that we have as a universal healthcare system, you don't have to give people the world. If you gave a lot of the basic things that thought about preventive healthcare, that thought about making sure you get your immunizations, make sure you get your appropriate studies done there, those are routine.

1:07:53 Preventive health would be an immense solution for everybody. And then the fancier things you might debate. But then our country, there are lots of people who have nothing and there are lots of people who are uninsured and when they have a job or they get a new disease or they switch, they can't get it because they had a pre-existing condition. It's just not, it's not reasonable. I think that it's to see the the people that we see who suffer because of want of money is just it's just not a reasonable way to run a healthcare system.

1:08:27 You mentioned preventive healthcare, that's a big issue. I think that we're just totally ignoring many of my patients who some of them are very educated and also in some cases very wealthy, for example, have diabetes and and they know nothing about it, don't don't have any idea of how to monitor it or or what to do about it. And they're walking around with elevated blood sugars or with high blood pressure, high cholesterol. Part of this is just poor education. I I think we need a better education system about preventive healthcare.

1:09:03 Definitely. That's that's the crux I I think one of the debates I had when I first started at Bellevue was that I wanted everybody who came to the emergency department who didn't have a primary doctor to go on to the optician department and I wanted follow up to be done. And we have 500,000 or 450,000 people who go to the outpatient department. But it's never enough to deal with all the people. And in many ways that was following year after I was hired because they needed someone to run an emergency department.

1:09:33 They for the first time hired someone to be the head of the outpatient department. And you know it's it's a matter of we try to get people when they finish in the emergency department to go to the outpatient department or maybe one near their home like Gouvenir, which isn't a little bit further. The South in Manhattan or all the other hospitals in the city that that run outpatient departments for the very poor and the neighborhood family care centers are remarkably good and they're the access is tremendous but the demand is phenomenal and I think that's where our action should be.

1:10:03 That's you. You know what the let's people lose their teeth or lose their function before they get to the the full. Realize the full potential for living IS is a disgrace. Yeah, lots of work to be done. Yes. I'd like to thank you very much for coming today for this Doctor podcast interview. It's been very interesting and lightning educational and I think the audience will really enjoy watching this. Thank you very much for coming today, Doctor. My pleasure. Thank you. All right.