Fifty years ago, trailblazing physicians in Fresno established an Emergency Medicine Residency Program – one of the first in the country – to train doctors to respond to medical emergencies swiftly and skillfully.
“They had the vision to start an Emergency Medicine program here, and it has made all the difference in the world for the community,” said James Comes, MD, an Emergency Medicine physician at UCSF Fresno who served as chief of the UCSF Fresno Department of Emergency Medicine (2017-2022).
The UCSF Fresno Emergency Medicine (EM) Residency Program is now one of the highest-regarded and sought-after in the country. Medical school graduates apply for 10-12 spots in the four-year residency program and train at Community Regional Medical Center (CRMC), one of California’s busiest hospital emergency departments and trauma and burn centers.
“We’re used to seeing 350 patients a day – and we’re good at that,” said Danielle Campagne, MD, an Emergency Medicine physician who completed EM residency in 2008 at UCSF Fresno and is now chief of the UCSF Fresno Department of Emergency Medicine.
About half of the UCSF faculty in the Department of Emergency Medicine at UCSF Fresno, a regional campus of the UCSF School of Medicine, received training in Fresno at some point, Dr. Campagne said.
That may be why the EM program has pioneered advancing Emergency Medicine in the San Joaquin Valley – and nationally.
Some of the innovations and accomplishments of the program:
- Leading Emergency Medicine Services (EMS) for Fresno County
- Offering a Parkmedic Program where residents can become EMS directors for nearby national parks
- Starting the fourth Wilderness Medicine Fellowship in the nation
- Conducting research that has led to new protocols adopted by EM physicians nationwide.
“Fresno has a rich heritage,” Dr. Comes said.
The EM Residency program has always been one of the busiest in California. In 1974, more than 70,000 patients a year were seen at Valley Medical Center (VMC), the old Fresno County hospital. A need for physicians propelled then-VMC Medical Director Jerry Harris and Bob Peters, MD, VMC chief of gastroenterology, to develop the residency program. They recruited Bob Dailey, MD, from the new EM Residency at USC, to start the Fresno program.
Creating an EM residency program was a radical idea in 1974. The American Medical Association had only recognized EM as a specialty in 1972. EM would not become an officially recognized specialty by the American Board of Medical Specialties until 1979.
Before EM residency programs, any doctor on call – from a gynecologist to an ophthalmologist – would respond to emergencies, including heart attack, head trauma, or open wounds. Only after a “White Paper” published in the mid-1970s showed soldiers in Vietnam received better care than car accident victims in the United States did EM gain traction as a specialty.
In a 2018 interview, the late Gene Kallsen, MD, chief of the Department of Emergency Medicine at UCSF Fresno (1990-2012), recalled his hesitation in 1977 to apply to the EM Residency Program in Fresno. “It was kind of dangerous to commit your life to training in something that is not even a specialty yet and might never become one.”
Understandably, early residents in EM programs had reservations. In the early days, before 1984, faculty physicians were in the emergency department from 8 a.m. to midnight, leaving residents without an attending physician during the night shifts. “That’s just the way it was all over the United States of America. “Faculty was home,” said Herbert Bivins, MD, a Fresno EM resident from 1979-1981 who stayed to join the faculty and became residency program director in 1993. Dr. Bivins continues as a part-time faculty member at UCSF Fresno and works triage in the Emergency Department at CRMC.
The UCSF Fresno EM Residency Program today is fully staffed – and there are faculty with subspecialty expertise, such as ultrasound, research, critical care and toxicology, pediatric EM, an MD/JD, Wilderness Medicine, and Medical Education, said Dr. Campagne. “Faculty are present seven days a week, 24 hours a day. The residents are never alone, so it is a great place to train for them.”
The EM Residency Program took little time to grow and become firmly established in the community.
Within two years of its start, the Fresno EM Residency Program lengthened training from two years after a one-year rotating internship to a post-graduate PGY 2-3-year format in 1976, and in 1985, it became a PGY 2-4 program. In the 1990s, it became a PGY 1-4 program, and the rotating transitional internship closed.
“There was no doubt in our minds when we went to a four-year program that the residents were competent and confident – and ready to go anywhere,” Dr. Bivins said.
Over the years, the program has added services and fellowships, broadening its scope in the community.
For example, in 1977, the program started a Parkmedic Program that provides EM residents the unique opportunity to become EMS directors (under faculty supervision) for the EMS providers at Sequoia and Kings Canyon National Parks and, most recently, Yosemite National Park.
The UCSF Fresno Parkmedic Program has developed EMS protocols adopted nationally. Every other year, the Parkmedic Program invites park rangers from national parks throughout the United States to participate in an intense certification course (the only one in the country) to augment their skills and knowledge to function as Advanced Life Support Paramedics.
Early in the EM residency program, in 1981, Dr. Kallsen became Fresno County EMS Medical Director. Chairing the first statewide EMS organization, he helped develop EMS policies that are in use today. Fondly called the grandfather of EMS in Fresno County, he fought to reform ambulance services, resulting in faster response times. The endowed chair for the Chief of Emergency Medicine was named in Dr. Kallsen’s honor. He passed away in 2023.
The leadership of EMS in Fresno County continues in Dr. Kallsen’s tradition. Miranda Lewis, MD, who did her Emergency Medicine residency at UCSF Fresno, returned after fellowships to be faculty and now is the EMS Medical director for the Central California EMS Agency. This four-county region includes Fresno, Madera, Kings and Tulare counties.
“It’s wonderful to see UCSF faculty leading the future – and leading the past of EMS development,” said Dr. Campagne, the medical director for American Ambulance, which serves Fresno and Kings counties.
Another expansion and change in the Residency Program occurred in 2007. Growing to 10 residents per year, the UCSF faculty and residents in Fresno began covering shifts at the Emergency Department at CRMC, which opened following the closure of University Medical Center (the old VMC).
The CRMC Emergency Department and the Trauma Center care for all injured and sick patients. And this was no more evident than during the COVID-19 pandemic when physicians in the emergency department were on the frontlines. CRMC saw more COVID-19 patients than all the hospitals in San Francisco.
Dr. Comes was chief of the UCSF Fresno Department of Emergency Medicine during the brunt of the pandemic, and he said: “I am really proud of the team who I had around me for the work that we did. And I’m very proud to have been an emergency physician during a once-in-a-century pandemic.”
For Dr. Comes, there’s also a sense of pride in the breadth of emergency care provided by faculty and residents at CRMC. “This is where the poor people go; this is where you go when you are really sick and bad things are happening – you’re having a stroke or heart attack or you’ve been in a motor vehicle accident. And if you have just got a chest cold, you can walk in. This has cemented my commitment to UCSF Fresno and Community Medical Centers.”
Dr. Bivins also lauds the access to care afforded to anyone. “You walk in here, and you are going to be seen. Whoever you are – we’re going to take care of you.”
Dr. Campagne summed it up: “If you train here, you can go to work anywhere in the country because you have been exposed to so much.”
Cassandra DeWitt, MD, a Class of 2025 EM resident, grew up in Clovis and wants to work locally after completion of training. She has had family members cared for at CRMC. “Our team here has taken care of my family on more than one occasion, and I would trust them with my life and my family’s.”
When looking for EM residency programs, Dr. DeWitt said the UCSF Fresno program’s reputation stood out, and she wanted to work with the “incredibly skilled faculty.” At UCSF Fresno, she said, “You get the full breadth of training here, and that leads to really strong clinicians when you graduate.”
Over the EM Residency Program’s 50 years, several trailblazing moments stand out. Among them is the 2008 start of the Wilderness Medicine Fellowship, making it the fourth fellowship program in the United States.
The late Lori Weichenthal, MD, a resident of the UCSF Fresno EM Program from 1994-98, had the vision to start the Wilderness Fellowship. While developing the curriculum, Dr. Weichenthal was the fellowship program director in its first years. Shortly before her passing in 2023, she worked with other fellowships nationwide to create a standardized curriculum.
Her legacy continues today: The Wilderness Medicine Fellowship has had 17 graduates as of this year. Since 2010, Fresno County Sheriff’s Search and Rescue has had Wilderness faculty and fellows as sworn team members.
Dr. Weichenthal, a resident in the UCSF Fresno EM program (1994-1998), stayed on at UCSF Fresno to become faculty, and in 2016, Professor Weichenthal served as Assistant Dean of Graduate Medical Education (GME). In 2021, she was named Associate Dean of GME and Clinical Affairs. She also held the title of Designated Institutional Official.
The UCSF-Fresno Department of Emergency Medicine also has been active in research since its inception.
“We participated in multicenter trials that established the NEXUS clinical decision rules for C-spine radiography and abdominal CT usage, defined the safety of managing patients using bedside ultrasound for ureteral stones, and demonstrated the safety of a new black widow antivenom, said Brian Chinnock, MD, a UCSF Fresno EM physician and the EM Program research director. “And, in 10 COVID studies, we examined vaccine efficacy in U.S. health care workers, ED detection of barriers to vaccination, and many more.”
Dr. Chinnock said UCSF-Fresno faculty-initiated studies developed the "Captain Morgan" shoulder reduction technique, demonstrated that physician gestalt (historical facts and physician exam findings) was not sufficient to rule out spontaneous bacterial peritonitis (infection of abdominal fluid), and affirmed phenobarbital as a treatment for alcohol withdrawal. Faculty also did one of the earlier studies showing the efficacy of video laryngoscopy, showed irrigation was not a necessary component of abscess treatment, first tested haloperidol (an antipsychotic) as a treatment for gastroparesis (delayed gastric emptying), and showed self-swabs to be non-inferior to provider-collected swabs in gonorrhea/chlamydia detection.
Dr. Campagne said that UCSF Fresno’s EM Residency Program is the place to become a skilled clinician, develop research skills, and serve a diverse population with complex medical, social and environmental needs.
Over the years, many residents have realized it’s a wonderful place to develop as a physician, develop roots, and stay. “That’s part of our strategy to grow physicians in the Valley. If you can retain them, it just shows they got great training here and want to continue the momentum,” she said.
“So, I really thank our forefathers for creating this program because now we are continuing their greatness.”
