The onus upon any rookie or newcomer is to prove his worth. He must fight through hazing and expectations and demonstrate he not only belongs but can thrive and prosper.

The inception of emergency medicine as an academic discipline at Hopkins is a good case in point for such humble and trying beginnings, according to Gabe Kelen, professor and director of the Department of Emergency Medicine in the School of Medicine.

In 1974, as a result of the Emergency Medical Services Act of 1973, The Johns Hopkins Hospital officially began a residency training program to expose students and physicians to the tumult of daily medical emergencies. The fledgling department had one full-time faculty member, an annual operating budget of $1.3 million and eight residents who rotated into the program from other subspecialties.

Unfortunately, Kelen said, in those days the discipline was not taken completely seriously. He cites an all-too-common opinion of the emergency department at the time as "a sandlot for interns to play in."

"The early years were very brutal," said Kelen, now in his 18th year of emergency medicine and director of the department since 1992. "We were like a new immigrant group on the block, constantly being tested and challenged. It was new, and there was this perception that emergency medicine was a piece of cake, that it was easy work that anyone could do."

This "false sense of security," Kelen said, was detrimental to both the residents and patients.

Today, however, as the department celebrates its 25th birthday, Kelen said there is a far different, and significantly more positive, attitude toward emergency medicine.

Evidence of this attitude change is the exponential growth of the department, which was honored this weekend with a seminar and a black-tie gala whose guest list included Mayor Martin O'Malley, Sen. Barbara Mikulski and Rep. Elijah Cummings.

Emergency care at Hopkins has grown since 1889 from a two-bed accident room, to which patients were transported by police wagon, into a multidisciplinary department that evaluates and treats more than 50,000 patients a year, has 34 full-time faculty members, five postgraduate fellowships, a residency program training 36 students a year and an annual operating budget of nearly $13 million.

The department has expanded to include a cardiac evaluation center, an interhospital transport service, a telemedicine partnership with a cruise ship line and the Center for International Emergency Medicine Studies. Future expansion plans include establishing the nation's first fellowship in acute care medicine and a 14-bed acute care unit for emergency patients who need monitoring for up to 72 hours before admission, an entirely new concept that is pushing the envelope as to what emergency medicine is, according to Kelen.

"One of the things that is particularly unique about us is how we practice outside the traditional hospital-based department," Kelen said. "At one time, all we were was a little clinical area down on the corner of Monument and Broadway. Now we are doing urgent and acute care, we are a regional trauma center, and we have gone well beyond the very basic area of clinical care to introduce innovative programs."

Kelen said these innovations are largely the result of the specialty's academic status at Hopkins, as historically most emergency departments are strictly hospital-based without research or teaching niches in schools of medicine. And it is the faculty, Kelen said, that is driving the growth of the department.

"We have probably the most accomplished research faculty in the country, and we receive the most total dollars in grants for our clinical research programs," Kelen said.

The demands and expectation on the faculty and residents also have changed over the years, Kelen said. Emergency treatment that used to resemble an assembly line, with patients going from one specialist to the next, has evolved into a more broad-based and holistic approach to patient care.

"We teach our students to consider the whole patient so they can perhaps find the root cause behind the ailment the patient was initially brought in for," Kelen said.

Most of the emergencies they handle occur right here in Baltimore, but EM faculty are often called upon to respond to disasters and crisis situations in areas as "wild and remote" as Zaire, Somalia, Boznia and Kosovo.

Mike VanRooyen, director of the Center for International Emergency Medicine Studies, said Hopkins views its international role not just as a caregiver but as an entity that can provide quality assurance, training and development.

"We try to design a program that can help transition and help change the country's health system in a more sustainable fashion" so that local physicians are better suited to deal with these disasters and emergencies when they occur again, VanRooyen said.

Kelen said the experience gained from these international public health efforts is part of the department's aim to produce leaders in teaching, research and administration. He said many EM graduates have gone on to become directors or chairs of emergency and other departments, and even politicians.

As to what type of students, residents and faculty are attracted to a life in emergency medicine, Kelen said they are, indeed, a unique breed. Being able to deal with the onslaught of trauma cases and chaos of the emergency department, he said, is certainly not for everyone. Unlike physicians in other specialties, on any given day these people never know quite what to expect.

"It certainly requires a different mentality, a sense of poise," Kelen said. "I guess you would say a lot of us like the adrenaline rush and enjoy trying to master the chaos that goes on around us."