Dr. Don Melady delivers the George Podgorny lecture at ICEM 2025, reflecting on his journey and outlining how emergency medicine can rise to the challenge of an aging world.

Emergency Departments on an Aging Planet:  What EM has to offer

Don Melady

International Conference of Emergency Medicine

Tuesday, May 26, 2025

I have been invited here to talk about my favourite topic for the past 30 years – the care of older adults in the world’s emergency departments and the development of the field of Geriatric Emergency Medicine.   In every country represented in this audience, there are more and more older people arriving in our emergency departments every day.  And I think that many of us in every country have the uneasy feeling that those older people do not always receive the highest quality care that we would want for them.  My goal in this talk is to describe how emergency medicine can respond to this challenge of our aging planet; why it’s essential that we make it one of the many challenges that we conquer every day.  I will describe some ways in which you can do that when you go back home.  But before I get to that I’ll spend a few moments talking about my journey into and through Emergency Medicine and why IFEM has been so important to me and the work I’ve been able to do. 

It often surprises people to learn that I started out as a farm boy, milking cows, the son of dairy farmers on a small farm in Southern Ontario.  I was in the first generation in the history of my immigrant family to attend university, the first generation to move out of comfortable but real poverty.  I came from a family that valued education, hard work, and a commitment to making the world a better place by improving the lot of disadvantaged or vulnerable people.   I think that everyone in this room realizes that those three things – learning, hard work, and social commitment – are the essential ingredients that we emergency doctors use every day.  They are the things that allow us to have an impact on each shift and over the course of a career, and, ultimately, to change our world.  My international experiences have allowed me to integrate my daily life as an emergency doctor in Canadian hospitals in a broader context of how life is lived and how medicine is practised around the world and across the life span. 

And do you know what?  It turns out that we are all pretty similar.  People everywhere wish to be treated with care, kindness, respect, and to the best of the ability of the physician in front of them.  And physicians everywhere want to produce the best result for every patient, in spite of the challenges that their system poses.  Unfortunately, access to high quality emergency care still varies a lot across countries and within countries.    And it varies a lot across the lifespan with the  ever-larger cohort of older people sometimes getting less than the excellent care that everyone deserves, and we want to deliver. 

So this is where my involvement with the International Federation of Emergency Medicine began.  I attended my first ICEM in Vancouver in 1998.  That was the first time that I knew about this organization that links emergency department workers around the world and is committed, as our mission statement says, to “creating a world where all people, in all countries, have access to high-quality emergency medical care.”  Interestingly, emergency medicine is one of the few specialties that actually has a truly international organization – a fact that reinforces that our mission is international, and our practice is similar no matter what country we are in. 

In the years since discovering IFEM, I have found a new home within it.  This took off at ICEM 2012 in Dublin, Ireland.  Probably the best-known thing coming out of the Dublin ICEM was the beginning of the FOAM-ED movement, “free open-access medical education” which has re-shaped EM practice everywhere.  But equally importantly --  it was the first time that a small group of international ED specialists, people focussed on the care of older adults started finding each other.  It was the beginning of an international focus on Geriatric Emergency Medicine, driven by IFEM.  Jay Banerjee from the UK; Ian Sammy from Trinidad; Judy Lowthian from Australia; and myself from Canada banded together.  Shortly thereafter, we added in people like Chris Carpenter and Kevin Biese from the US and Colin Ong from Singapore.  In Dublin, the then IFEM president, Peter Cameron, gave this same George Podgorny lecture on the topic “Re-orienting EM for an Aging Population.”  For the first time, Geri EM became “a thing.”  We started using the new term, coined by Ula Hwang, the Geriatric Emergency Department.  We started talking about  standards and guidelines, about identifying practice competencies for practitioners specific to older patients; about developing a research agenda; and about expanding our network to include all IFEM member countries. 

“2012?  But surely Geriatric Emergency Medicine didn’t just start 13 years ago.”  Well, to a very great extent, geriatric care is a relatively new addition to the practice of EM.  And older people are arguably among the last to be identified as deserving of the “high-quality emergency care” that is IFEM’s mission.   I’m particularly proud of the fact that ten years ago, the Board of Directors of IFEM declared that the ED care of older people was a priority for the organization and asked some of us to form the Geriatric Emergency Medicine Special Interest Group.  In these ten years, it has been an enthusiastically productive group within the organization led by me, then Dr. Carolyn Hullick from Australia, and now Dr. Rosa McNamara from Ireland; and the most congenial collegial group of colleagues from all continents.  You know who you are.  It is a great example of the ways in which IFEM is fulfilling its mandate to allow all people to access high-quality care. 

In almost every country of the world, older people are the fastest growing cohort of the population.  This is not limited to populations in the global north, North America, and Europe.  There, the increase is due to the famous Baby Boom after World War II.  But also there are more older people in Africa, Latin America, and Asia.  Globally, we are seeing the benefit of decades of improved public health measures such as access to vaccination; improved nutrition, income, and education.    And the very real impact of excellent medical care and the management of chronic diseases.  Today even in the lowest resource setting, it is now possible for a middle-aged person to hope or even expect to live well into older age.  It’s important to remember that all these older people aren’t coming to our EDs because we’re doing something wrong – but because we’re collectively doing a lot of things RIGHT!  And when they get to our doors, we need to ensure we continue doing things right. 

Emergency medicine has a long tradition of responding rapidly to changing social realities.  EM grew out of war medicine in the ‘60s and ‘70s where doctors realized that we could make a huge difference in trauma survival and outcomes by quickly developing new skills, new processes, and a new team-based approach.  Since the specialty has developed, we have added skills to address the AIDS epidemic, to identify how children need a different approach in the ED, to manage cardio-vascular emergencies, to develop systems to confront sepsis.  Just 5 years ago, we became infectious disease resuscitationists in the face of a novel virus. 

But the increasing number of older people at our doors poses a new challenge that probably needs another new approach.  Although it is impossible to generalize, older people are different from the other 70% of patients we see in a few ways.  Unlike younger patients, they are more likely

• to have multiple chronic problems;
• to take multiple medications;
• to have or be at risk of cognitive decline;
• to have some functional dependence; and
• to have syndromal presentations that we don’t immediately recognize; for example, confusion as a symptom of sepsis; weakness as a symptom of acute coronary syndrome; a wrist fracture as a symptom of arrythmia.

Sometimes this level of complexity can be daunting or off-putting; especially for systems and practitioners that prioritize what I might call “easy” problems (like a polytrauma or a sepsis resuscitation.) Those are amenable to quick decisions, established algorithms, clear pathways, and rapid resolution.  But if we emergency physicians are to contribute on this aging planet, we need to change ourselves and our approach to the increasing number of people who are not like the “easy” patients.  We need to learn a few new things and to change some of the things about our department function.

In the last part of this talk, I would like to suggest what many of us see as some basic changes that any emergency department can implement and give you a practical framework for those changes. 

Three years ago, I co-wrote a book called Creating a Geriatric Emergency Department:  A Practical Guide with my friend John Schumacher, an American gerontologist.  First of all, we clarified that when we use the term, “Geri ED,” we do NOT mean some separate and different space which focusses on superficial physical changes.  We do NOT mean staff who are somehow different from “real” ED types -- like geriatricians who have disguised themselves in scrubs and accidentally wandered to the ground floor.  No, when we use the term “Geriatric ED,” we mean some changes for every emergency department – including all the noisy chaotic ones where you all work.  A Geriatric ED can be every emergency department in the world where you can do things differently to ensure the complex needs of older people are met. 

We proposed an approach structured around the 3 Ps – People, Processes, and Place.   I’ll talk about each of them in turn. 

As always in an emergency department, the most important factor is the People.  To create a geriatric ED, you need to have ED staff – both doctors and nurses – who have an expanded set of skills knowledge and attitudes from what we typically get in our “basic training.”  As we know or quickly learn through practice,  emergency medicine is NOT a steady stream of single-system problems, resuscitations, traumas, ultrasound-guided procedures, and cool machines (though it is those things too.)  And yet our training typically focusses only on those parts of our craft.  Our training typically excludes the reality that at least a fifth of our patients – older adults – have presentations to EDs that are complex.  They have presentations that require us

• to recognise MORE than one acute problem AND multiple chronic problems;
• to confidently manage the necessary polypharmacy of older adults;
• to recognise the presence or potential for cognitive impairment;
• to assess medical problems in the presence of the altered physiology and anatomy of aging.

In the People department, we need to enhance our own skills and knowledge.  I hope you took the opportunity to do just that at some of the excellent Geri EM tracks at this conference, coordinated by the IFEM Geriatric EM Special Interest Group. 

We, the People of EM, may also need to address our attitudes and acknowledge that many of us live in intrinsically ageist cultures where youth is valourized and age is stigmatized.  Like all implicit biases, each of us may carry unquestioned prejudices about that next older patient that we’re seeing.  Remember that just like you, most older people value autonomy and independence over safety and dependence.  Engage your older patient in decision-making that prioritizes their wishes and wants.  I’d urge you all to “re-frame” your attitudes to aging as something that we celebrate, something that we aspire to, something that we all have in common.  I’d urge you to re-see that next older person as another version of yourself, imagining what your experience would be – will be --  in that same situation.  I’d like you to think of aging not as a disease state that happens to “those other people.” I’d like you think of aging as a shared experience that happens to us all -- if we’re lucky. 

But there is another important part of the People change -- not at the personal level but at the system level.  Because of the complexity of many presentations by older patients, it is probably helpful to expand your ED team to include interdisciplinary assessment and thus expand your assessment.  Even 15 years ago, this seemed like just a fantasy.  But now in 2025, many EDs internationally have implemented advanced assessment teams that include a geriatric nurse, plus some of the following: a social worker, a physical therapist, an occupational therapist, a pharmacist, a community care coordinator.  In the absence of an expanded interdisciplinary assessment of an older patient, the only ED response to managing an older person with  complex needs is admission to increasingly overloaded hospital beds where they spend a lot of time and often don’t get the care they need.  Adding interdisciplinary staff in the ED takes a burden off the medical team, provides a better outcome for the patient, and pays for itself by avoiding unnecessary, unhelpful, unwanted admissions. 

The second P is for different or additional Processes.  Every experienced emergency clinician knows that the presentations and needs of older people are different from those of the “average” patient – and yet our approach is often of a “one size fits all” nature. There are many different changes in your ED processes you can make.  I’ll mention four to get you started.  Pick one to add when you return home! 

• Add standardized screening or assessment of cognitive impairment to identify those people who have chronic brain failure, dementia, or acute brain failure, delirium. There are simple quick ED-validated tools for this screening;
• Establish a way to identify and measure a person’s fitness or frailty. Knowing whether your patient is a fit and active 85-year-old involved in the family business or a polymorbid 65-year-old with limited mobility is going to have a big impact on every moment of their stay in your ED.  So knowing early is helpful;
• Establish links with community resources or providers that can be easily connected to the ED, for example the rapidly expanding cohort of community paramedicine or links to acute rehabilitation beds. Perhaps that person with pneumonia doesn’t need admission – just a definite assured re-assessment in a day;
• Many hospitals already have volunteer programme. Why not train a small cohort to support the needs of older people “trapped” in your ED for hours or days particularly if ED boarding is a problem?

 Supposedly Einstein said that the definition of “insanity is doing the same thing over and over and expecting different results.”   We know that older ED patients need different things.  It’s our job to make sure we are using different processes to address those needs.  We can improve care for our patients, to get better results for our system, to make our work better and more satisfying. 

The final P is for Place, making changes in your physical environment.  If you have unlimited budget and good planning, you can completely transform your space into some Las Vegas dream of an ED.  However that is not going to happen in most places.  Instead, concentrate on simple changes with an immediate impact on the care older patients gets – a few hearing assist devices, a supply of mobility aids like walkers, easy access to food and drink, eye masks and ear plugs for those prolonged stays.  As I have seen in EDs all over the world, great care can happen in even very constrained physical settings with limited resources.  What really counts is well-trained caring people working in a system that supports them. 

I wonder how many of you are sitting there, thinking, “why is this guy talking to us about looking after older people?  Shouldn’t that be someone else’s job?  Why does it always have to be the ED that does everything?”  Well, the easy answer is that because that’s what you signed up for when you became an emergency physician.  It is our job and our privilege to be able to accept everyone and do our best to help them.  The ED is where people, ALL people, come when they need help.  We don’t have the option of doing an excellent job for some and not-quite-so-good job for others.  We are the Anyone Anything Anytime specialty that provides care to the critically injured trauma patient and the cardio-vascular resuscitation patient AND the complex frail confused older person. 

But an even better answer than “it’s our job” references an often-told story about the famous anthropologist, Margaret Mead.   She was asked what she thought was the earliest sign of civilization among human beings.  Her surprising answer was this: 

• archeologic evidence of a healed human femur fracture.

It doesn’t take much to understand what she meant.  A cave man with a fractured femur needed a lot:  a conscious effort by an organized system to help him to return to his function and his ability to contribute to his community.  Mead’s definition of “civilization” was a society that could organize itself to do that even for members who were no longer able to contribute as they had previously done.  Even 15,000 years ago, an adult with a fractured femur needed support, special attention, a different approach, additional resources, an empathic understanding that they have a problem, a willingness from the community to get them through a difficult time.  Our early ancestors – the first civilized ones -- were able to provide all those things so that the person’s femur could heal, and he could continue his life and his contribution to society.  Mead’s conclusion -- and mine – is that our ability to provide care for and support the most vulnerable and frail is what defines us as human beings.  It’s what makes us “civilized.”  And furthermore, it’s what turns a good emergency doctor into a great one. 

In conclusion, emergency medicine continues to respond to the ever-changing societies in which IFEM members work.  I hope I have made you think about the society that you serve – and how it is changing, for the better, by including more older people than ever before.  Emergency departments have yet another opportunity to rise to the challenge presented by our aging planet.  Emergency departments have successfully adapted to wars, pandemics, social disruptions.  I have suggested a few relatively easy changes you can make in our ourselves and in our systems.  If you do, you will be able to provide excellent care to that increasing part of the world’s population that needs us the most – and you’ll make me know that the past 20 years of my career in Emergency Medicine and in IFEM have had an impact.