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NORTH COUNTRY AT WORK: Dr. Paul Seward on the ER, emergency medicine

August 31, 2018
By AMY FEIEREISEL - NCPR correspondent , Lake Placid News

MIDDLEBURY, VT - Earlier this summer, Dr. Paul Seward, a long-time emergency physician who retired last year, published a memoir called "Patient Care: Death and Life in the Emergency Room."

Seward spent his childhood at North Country School, a boarding school in Lake Placid, and returned to work in the Adirondacks from 2000 to 2017, including time spent at the Adirondack Medical Center in Saranac Lake.

His book draws from his experiences working as an emergency room physician all over the country. When he entered the field, it was still young, having been pioneered by a few hospitals in the 1960s.

Article Photos

Dr. Paul Seward
(Photo provided — Cari Burkard)


Dr. Seward

Paul Seward trained and practiced as a pediatrician before entering emergency medicine. After medical school and residency, he worked in a group practice before establishing his own pediatric office. He got involved in the ER in the late 1970s, as the on-call pediatric doctor. But he found that he really liked the work, and one day while doing some yard work with his wife, it just hit him:

"You know, I should just quit and become a full-time ER doc. Ding! Slam. It was over. It just suddenly became obvious that that's what I was going to do. So I quit my practice, sold my building, and became the director of the local ER. Because of course a pediatrician who knows nothing about adults should be the director of an ER!"

Seward jokes that at that time, anyone with a pulse and an MD degree would have been a solid candidate. Emergency medicine - the medical specialty of taking care of unscheduled patients in crisis was a relatively new field. Up until the mid-1960s, hospitals had emergency rooms staffed by a nurse, who would contact the on-call doctor when a case came in. That doctor might have been "a dermatologist, an ophthalmologist, or an orthopedic surgeon, or a who-knows-what ..." and they would decide who to call next. For instance, if there was a knife in someone's chest:

"... the general surgeon would come in, and that's how we took care of emergencies."

This system wasn't liked by doctors or patients, especially those coming back from military service, where they had "field hospitals and MASH units and medics and paramedics, and they knew what good emergency care was like, and they asked: why can't we have this at home?"

Enter a more structured and staffed ER, including full-time physicians. When Seward entered the scene in the late 1970s, emergency medicine was making real strides, and by 1980, he says the field had a professional organization, academic recognition, training programs, etc. He became a certified emergency room physician in 1983, and never looked back. He was excited to work with adults and the elderly in addition to children, and to treat the trauma and emergencies he didn't see in a pediatric practice.


An ER doctor

While emergency medicine was certainly establishing itself, Seward said there were still assumptions made about ER physicians, and when he became one it wasn't exactly a typical career choice.

"To be an ER doc, it was sort of like 'Well, I wonder why is he doing that? Maybe he's got too many divorces and has to pay alimony, maybe he's an alcoholic and got booted off ..."

When asked about the fundamental differences between operating a medical practice and working as an ER physician, Seward said the most obvious one is a lack of stuff. A medical practice requires a building, furniture, equipment, employees ... but "if you're an emergency physician you need a stethoscope." And when you work for a hospital, they cover your insurance, and you work a shift, at the end of which you get to go home.

People also lose the predictability of appointments and schedules and gain a constantly changing environment. Doctors see most of their patients once (perhaps twice), and general know-how wins out over specialization. But Seward said it was part of the draw. He was excited to work with adults and the elderly in addition to children, and to treat the trauma and emergencies he didn't see in a pediatric practice.

On the personality type required, he said: "A lot of them [emergency room physicians] would have been fighter pilots if they didn't have another job (laughs). I think it's people who want to figure out if they really do have the right stuff. That's part of the attraction. But everyone is healthcare is by definition: neurotically guilty, has terrible self image, was always picked last at the basketball games, and has spent their life trying to overcompensate by jumping into the fire! But the real attraction. ... I get back to the fact that it's one heck of an opportunity to have an impact on people's lives one after the other."

And they're "doing something that makes someone get better. There's no feeling like it."


Team sport, emotional work

While television and the movies paint one scene - the heroic doctors, the frantic environment - Seward said to forget George Clooney's ER.

"An emergency room is the only place in the world where you're not supposed to have emergencies - because emergencies are what we do."

This is what the physicians, physician assistants, nurse practitioners, nurses' aides, respiratory therapy techs, patient representatives, pharmacist, et cetera, are trained to do. They deal with emergencies - as quickly and efficiently as they can. Seward considers them all to be crucial elements of a finely tuned machine, but especially the nurses.

"They know where everything is ... they are the ones that create the ER in which the physicians get to work."

And while there are always surprises, the machine knows what to do.

"This is what we do, and I've seen this, and if I fell apart every time I saw that ... I couldn't do the work. That being said, you have to have some places to put that."

Seward said a good marriage helps. So do friends, and if you don't have either: "I hope you have a nice spiritual community of some kind that will take care of you. You need to have a place to go to confess - in every sense of the word ... and then you have to go on and go back to work."

Not all the emotional weight comes in an operating room, or even with a patient. Seward has spent a lot of time communicating with the loved ones of his patients. Often he's delivering news no one wants to hear. He said it's one of the most important things he did as a doctor. He's seen relationships and families fall apart because of death - and the blame that goes along with it.

"Anybody who's ever been through a death in the family knows there's a lot of self-accusation. And you're in the position of 'this is your child or your wife, and you were taking care of them. It was your job to take care of them. And now they're dead. Or it was his job to take care of them, and now they're dead."

He said the people he treats are his patients, but so are the people around them. He hopes he can make a difference to them by telling them that it's not their fault. He says he'd have it tattooed across his forehead if he could.


What's in an ER?

Seward said there are three reasons people come into the ER. The first is real, life-or-death injury or illness. That's about 15 to 20 percent of cases.

The second - around 50 percent of cases - involve people with a significant symptom that they don't understand, and want fixed. Seward puts "nursemaid's elbow" - his favorite thing to treat - in that category. It's when an adult picks up a toddler by the arm, and ends up yanking a little bone in the elbow out of place, and when it goes back into place there's a piece of tissue pinched in there. Suddenly the child's arm is limply hanging and you have a crying child. The beauty of "nursemaid's elbow" is that it's easy to spot and fix.

"There's a little maneuver you do, it takes two seconds, and you get a nice little pop and the kid screams and suddenly it's all better. Anytime you get the chance to do something that makes you look really cool - ooh, what fun!"

Seward said it makes him feel like a real-life superhero. It's also one of the only things that comes into an emergency room that can be so easily taken care of - unlike in the movies, cardiac arrests usually end fatally. "We're not gods, but sometimes doctors have to clean up life's messes."

And even when family, friends, and community are not there, an emergency room has to be. And that's the third reason Paul says people come to the ER - often with problems not meant for an ER - because it's the only place they can afford.

"They have nowhere else to go. And you know I don't say to those people 'oh, this is nothing!' I know why they're in the ER. They're in the ER because they have to be."

Seward said he hates the term GOMER, an acronym for Get Out Of My Emergency Room.

"There are no GOMERs. No one should be told they don't belong in an emergency room."

It all comes back to what Paul writes in the preface of his book - that the ER is a place in which he learned the lesson of caring. One of his personal spiritual beliefs is that the problem of caring for other people - and for strangers in particular - is one of the fundamental problems of humanity.

Paul Seward retired last year, and moved from Keene to Middlebury. "Patient Care" is his first book, and was released in July of this year.


(This story comes to you from North Country Public Radio's North Country at Work project, which explores the working lives and history of our region. To see all the stories, check out



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