}TEETINGOF I]NIVERSITY EMERGENCY DEPARTT"TEM DIRECTORS
MARCH 6, 7.970
UI{IVERSITY OF AI,ABA},IAIN BIRMINGITAI"I BIRMINGHAI\T,ALABAMA
NOTE: The presentations of thls meeting have been transcribed and dlstrlbuted with the assletance of the Divislon of EarergencyHealth Services, PubJ-ic Health Service, Departnrent of Health, Educatlon, and Welfare.
PROCEEDINGS
MarcLh 6. 1970
BIRMINGHAM,ALASAMA
6,itguf T$irmingfturn, $,luhunra OFFICEOF THE MAYOR
G E O R G EG . S E I B E L S ,J R .
March 5, L97O
MAYOR
TT's NTCtrTo HAVEYOU IN BIRMINGHAM We are indeed proud to have you with us for lt the new and growing Birmingham.
alLows us to show you
I know that your lnterest ls ln the fieLd of Emergency Servlce Departments. found anlnuhere. We are fortunate to have some of the flnest emergency factLities Blrnlnghan ls lndeed proud of, the people who have devoted themseLves to the perfectlon of these facilities. Wtrlle you are lrith us, please feel at horne and take tl.me to see the beauty and recreatlon spots of our city. I regret that I will not be abl-e to join you while you are wlth us. I have two conferences to attend ln Washington, D. C. EnJoy yourself of your conference.
and'plan
to return
to Birmlnghaur soon after
ncereLy,
George GGSJr:ss
Selbels,
the conpletlon
. r.i;i rt b.: q', f, .-' +, . ' r
. i{-
G
,t{i'4 119j, \.
/.tJl
-.
tle Untrsersityof-.{/abana tn Btrntnghamf
March 2, L970
TO:
?artici.pants Directors
FROM:
J. F. Volker
tn the Meeting of university
Emergency Department
r regret that a prior engagement prevents me from extending a personal welcome to you. es a untversity administrator and a concerned citizen, r have been very much aware ihat there are a number of very crittcaL areas r.n_our present system of heatth care delivery. This ie espectal.ly true of the emergency departments. l{e at the unrverstty of Alabama in Bi.rmingham feel honored that the problems associated wi.th this aspect of medical'care are the subJect of a meeting on our campus. Ifopefuil.y, the deriberatione wirr be profitable to aIL concerned and wilL- Lead lo " "onti.nuous communtca_ tion between aLl interested parties.
11
AGENDA Me e ti n go f u n i v er sity Em er gency Depar tm ent Dir ector s ' 1970 Fr i day, M ar ch6 , Room l l 2 ( G r o u n dF ' l o o r ) , L y o n s - H a r r i s oRne s e a r c B huilding u n i v e r s i t y o f A l a b a mM a e d i c a lc e n t e r , B i r m i n g h a mA,l a b a m a M o r nni g S e ssi ,o n 7:30
R e g i s t r a t i o na n d D i s t r i b u t i o n o f E m e r g e n cDye p a r t m e n t P ro ce d u res
8:3 0
Weco l mi n gRem ar ks ... D r . E . C . O v e n t o,n B ir m in g h a m City Counci lman- Chair man, C o m m i t t eoen E d u c a t i o n H , ealthn and l,le'lfare
8:40
l^lelcomingRemarks. . . J o h nW . K i r k l i n , M . D . ,P r o f e s s o r and Chair man,Depar tm ent of Sur ger y , Unj versi ty of A'labama
8:50
IntroductoryComments A l a n R . D i m i c k ,M . D . ,A s s i s t a n t Pr ofessorof Sur geny U n i v e r s i t yo f A l a b a m a
9:0 0
9:'15
9:40 l0:45
NOON
" Mo ve me nt of the Acutely I' r ' r or Injur ed patient to th e E me rg e n cy Depar tm ent ... C h a r l e sF . F r e y ,M . D . , U n i v e r s i t yo f M i c h i g a n " R e g i o n aP l lanning o f E m e r g e n cMye d i c a ls e r v i c e s " J a m e sR . M a c k e n z i eM, . D . M c M a s t eUr n i v e r s i t y H a ml ti o n , 0 n t a r i o , C a n a d a D i s c u s s i o no f P h i ' l o s o p h yG, o a l sa n d0 b j e c t i v e so f 0 r g a n i z a t i o n ; P l a n sf o r 1 9 7 0F a l l M e e t i n g D e s c r i p t i o n _ oEf m e r g e n cDye p a r t m e n U t ,n i v e r s i t yH o s p i t a l , a n d T o u rs of Emer gency Depar tm ent and RelatedFaciliti es A l a nR . D i m i c k M , .D. LUNCH
ili
- 2 A f t e r n o o nS e ssi o n
2:00
W o r k s h o p s*M : ovement of the Acutely Ill or Injur e d Patient to the Emergency Department *The Emergency Department *RegionalPlanningof Emer gency Medic al Services
3: 4 5
Presentati by Workshop on of Summaries of Workshops Chairmen
1v
MOVn{ENT OF THE ACUTELY tLL OR INJUPJD PATIENT THE EMERGENCY DEPARTMENT T: Those of us responsible but be impressed and gratified of interest
that,
invltlng
you here to Alabana cannot help
at your presence.
The spontaneous outpouring
expressed by your appearance here at thi-s meeting is in rny opinion
not a reflection for
for
Charles F. Frey, M.D.
of the drawLng power of famous names as rire are too youthful
or Alabama ln the springtime,
recognltlon
of the urgent need by all
though it
is beautiful,
but a universal
of us here to improve emergency medical
s.ervices throughout the United States. I hope that by the end of today we wlLl lng emergency uredical services
know something about our exist-
in the Unlted States,
improve emergency medical servlces,
what can be done to
what our organization
achieve those lmprovements, and how can we structure tion
Emergency Medlcal Servlces Systern. task.
Through your active
organlzatlon,
mornLng I believe
we can define
the
Our workshops have a far rnore difficult
participatlon
they must develop the goals of our
and recommendan organizational
and flnanclal
structure
which
implement these goals. I wish to take thls
Jim Mackenzie, along with host,
and finance our organiza-
to 1-mpJ-enentthe goals of our menrbershlp. Through the keynote speeches this
will
can do to help
Alan Dlmick,
opportunity the regional
for maklng this
to thank our hard working secrega.ry, repregentatives,
the founders and our
meetlng possible.
To date we have received 62 emergency medical service have been compiled, reproduced, and are included at the tine
of registration.
in the material
Much of the reproduction
cooperation of the Emergency Health Services Division servlce,
whose representative,
gummaries.
These
you received
has been done with of the public
Mr. wal-ter Hughes, is with
us today.
Health The
the
assembled emergency medlcal services valuable resolve
resource.
summarles represent,
This knowledge of what other universi.ties
problems rnay help us avoid much trial
certain
I believe,
a
have done to
and error
in our own
inetitutlons. I,fith us today are a nurnber of men who, through combinations gence' energy and determlnatlon, surgery.
[,Ie are happy that
medLcal services '
siblLity
for
the workshops thle
afternoon you have recelved
to describe emergency rnedical services which consists
lncludes
of
they cared enough about the problems of emergency
the emergency medlcal gervtces system.
descrlbing
that must be lntegrated
into
a unified
system by regional
It
is my respon-
of two phases
planning.
Phase I
the movement of the patlenL from the scene of accl-dent or tllness
the eurergency oepartmeut of a maJor medi.c.al center. movement of the patient to its
themselves in the field
to Joln us today.
In the preparation
an outline
have dist.lnguished
of j.ntelli-
operat,lng sulte
to
Phase l.L incl.udes the
from the emergency department of fhe ma.jor mecti{-jalcenLer or coronary care un.i.t.
Couponents of an emergen.cyrneclical care system u.nder Phase I include: - that
1) Survelllance acene of lllnees. Training
le the Ldentiflcatlon
2) TransportatLon and equlpment.
of the rescue worker.
under Phase II, of the followlng 1) Physiclans,
of the sf"te of accident
or the
3) Communlcatlons.
4)
Components of an emergency nedicaL care system
which Dr. Rutherford will
discuss,
include
the availabillty
aroqnd the cl-ock in the emergency department and hospital: surglcal
radiology equlpment. Coronary care unit.
and medical specialists.. 3) Blood bank personnel.
6) Shock and/or intensive
Breakdown of any link in increased mortality
2) X-ray technicians 4) Operating room staff.
- 2 -
5)
care unit.
ln the chain of care ln Phase I or Phase II
of the patlent.
and
results
In the United States today there are
dlfferences
Ln the availability
are least
available
the rural
areas of this
hlgher
in rural
and acute ill-ness Wallerts
ln the quality
country.
Deaths from motor vechlle Seventy percent of all
occur ln towns with
lng to the Natlonal
0ften
in the areas where they are needed the most, that
thgn urban areas.
vehLcle accidents
areaa.
of emergency medical services.
a populatlon
Research CounciL.
such as myocardial
v
is in are
deaths from motor
of less than 2r500, accord*
Deaths from all
lnfarctions
accidents
they
types of accidents
are higher
in rural- than urban
Callfornla
study also demonstrated the geographic differences 2/ of emergency medical services in Californit. He found deaths
from motor vehlcl-e accldents were l-7.0/l-00r000 in urban counties of California, 46.8/100,000 in ruraL countles of California, countles of Californla.
Deaths from non-transport
but less pronounced pattern. transport
and 85.5/100,000 in mounrain
from non*
counties 27.3/LOO,0O0,and ln
ln our own countv - and I
to anyone who has not done so - in order
and nature of any deficiencies emergency nedical
a similar
48.7 /L00,000.
We made a study of deaths from accldents recornrnendthis
followed
Deaths in urban counties of California
accidents were 17.9/100,000, in roral
mountatn counries
accldents
services
that
system.
zl
exlst
to a.ffrr"
the extent
ln Phase I or phase II
We found during a six-year
fron l-962 to L967 in Washtenaw County, which has a population
of their experience
of
225,000 in
a land area of 720 square mlles n there were 450 deathe from motor vehicle accidents'
235 deaths from'other
types of accidents,
and' 27 deaths from homicide durlng for
salvage in the 159 patlents
thle
six year period.
We Judged the potentlal
on whomwe had autopsy data to be 18 percent.
Death was caused by airway obstruct,ion, pneumothorax in the 29 patients
166 deaths from eulclde,
hemorrhage, and unrelieved
ln whom there was potential
the 28 deaths only two occurred after
hospital
arrival
for
tension
salvage.
Of
or during phase I of
- 3 -
.l
the emergency nedical patients'
lt
services
system.
In order to salvage t.he other 26
would have been necessary to inplenent
endotracheal intubation,
intravenous
fluid
airway control
therapy,
and relief
pneumothorax at the scene of the accident or in transit order to reduce the mortality
that
the mlninal
of high Level hospital there
loss of llfe
care.
after
in Washtenaw County. hospital
Dr. Rutherford will,
arrival.
In Von l.Iaggonerts study,
on leave and t,reated ln civllian
arrival
in
I arn
is a reflection
Irm sure, mention that
606 soldiers
a
hospltals.
of them died frorn inadequate hospital
two hours after
hospltal
services
system.
satisfactoril-y the acutely
hospital
the inJuries
lnJured patient,
Most urgentr
we felt,
endotracheal- lntubation,
care.
one-
Al1 had survived more than
of our emergency medlcal
care, was adequate.
delivered
we were coping
Phase I,
to us.
the movement of
needed improvement. was the need for
lntravenous
and cardiac monitorlng.
available.
while
arrlval.
Phase rr,
wlth
were injured
Accordlng to the author,
In surmarYr rIâ‚Ź surveyed Phase I and Phase II
tion,
to the hospital
are some areas in the country where many needl-ess deathe occur after
hospltal
sixth
of tension
of those inJured.
There are two maJor teachlng hospitals certain
including
fLuld
Provislon
rescue workers trained
therapy,
for
in
cardlopulmonary reguscita-
such t.rainlng
ls not. presently
Hopefull-y, community colJ-egee and hospLtals will" develpp one- to
two-year prograns whlch will
provide lnetruction
ln the most sophisticated
techniques of resuscltation. As a corol-lary, be equipped wlth resuscitatlon. vehicles
the rescue vehlcles
all- the tools, Further,
servicing
emergency calls
space and personnel necessary to perform
the emergency rnedical technician
should have available
should
instant
communication with his hospitalrs
emergency department through a th/o-way radio - 4 -
in the modern rescue
in order
to receive
instruction
and help ln carrying translt
out resuscitation
to the hospital.
facilltates
regional
delivered
to hospitals
essentials
of patient
The use of the heLicopter
planning of emergency nedical where specialists,
emergency nedical
as a means of transport services.
patients
blood bank facilities
care are not available
a maJor medical center for definitive* what benefits
at the scene of the accident and in
and other
can then be brought rapidly
care.
nay we expect to gain frora irnproving phase r of
servlces?
reductlon
ln mortality
mortality
from accldents
It
has been estimated we can antlcipate
from myocardial lnfarctlon of from 10 to 20 pereent.
r should emphaslze that
ln this
accident vlctlms
unlike
These estlmates are based ana
most of those dying from cancer and
are most often
in the 15-30 age group.
younger age group has greater meanlng in terms of life
and the value of labor
a
of 10 percent and in the
on the studi-es of pantridgerS slesouris and Mores .il ,n"cisserrZ 8/ Heidelbert studies, as wer-r. as our own washtenaw county study.
heart dlsease,
to
to be antlcipated
by society
salvage
expecrancy
from the indivldualfs
continued actlvity. Improved energency medical services costs to the community and lndivldual-s costs of hospitaLization $500,000 over a l0-ro
of the disability
financial
resul-ting
2O-year period. its
leaders
and spokesmen the need
support of Phase r of emergency medical services
Emergency nedical
from inJury.
for paraplegics alone are Judged to be $250,000 to
we must emphasize to the conmunlty, for
can also be expected to reduce the
services
is as much a publlc
utitity
by tax or subsidy.
as the police
of fire
department. My charge then to the workshops and their as indlvlduals'
emergency department dlrectors, - 5 -
chalrmen is whar can we do and as members of t h i s
organlzation equipnent, the trainlng
to lmprove the meane and methods of transport, the comunlcatlon of a highly
between hospltals
sklLled
and the rescue vehicLe,
emergency nedical- technician.
- 5 -
the quallty
of and
PROBLEMSIN OPEMTING AN EI4ERGENCY ROOM IN A UNIVERSITYHOSPITAL Robert B. Rutherford, M.D., Department of Surgery, Johns Hopklns Medical School, Bal-timore, Maryland As part of thls
panel on the dellvery
I have been assigned the task of discusslng operation
of the mergency room i-tself.
touch all
the basis,
I have elected
or issues which are not well which wlIl- nevertheless admlnLstration,
Populatlon
organlzatlon
of deLivery
Explosionrt.
However, rather
and staffing, in this
politan
care,
themseJ-veswith
subject,
but
afternoonts
care and teaehing which workshops. "The Emergency Room
tldal
over the country
wave of patients,
general practice
and particularly
or non-emergent problems.
designed and organlzed to deaL with
emergent
urgent medical problems, the emergency rooms of most major metro-
have also been obliged
By and large,
extent,
to provlde servlces
or house calLs by physiciane surgical
practicing
suburban and county hospitals,
formerly
rendered by offlee
but lt
ls the patients
minor or non-urgent. probLems, who by necessity
time for
the least
to receive with
have to wait
t.reatmentr who are the unsatisfied - 8 -
visits
in the coumunity.
and rnedlcal emergencies continued
reasonably Prompt and adequate treatment,
longest
on thls
emergency rooms all
medical centers and, to a lesser
relat,lvely
to
Because of a number of major changes in the patt,ern
Although they were speclflcatly or at least
patlent
is one which I have labell-ed
of cornmunity health
presenting
than attemptint
to concentrate on three exemplary problens
today are being lnundat,ed by a veritable patlents
the
out many of the aspects of emergency room
brlng
problen
those problems involving
covered in the literature
w111 be the focue of dlscueslon The flrst
of emergency medlcal services,
the the
customers.
These
patlents
cl-og up emergency room operations
emergency room staff responsible hurrled,
for
treatment errors
1og Jarn of patlents
to find
aches and the target
long waiting
for
are outlined
in sllde
r.
the overworked emergency room 1s
ln Sllde
II.
coupled with for ago'
a given populatlon Even the overall
increases,
century,
The prlvate
physictan
than his own office
to most of us.
These
proportlon
which
and more than 15 percent who have specialty
training.
This,
has reduced the number of general practitioners
to approximately one-third
in Table rr
and have been
a eonplete reversal- of the ratlo
of physiclans
from 86 percent to 63 percent over the last causes listed
causes
hear.th studies.
20 years have returned for
population
the
Less than 15 percent of todayts medical school
at the beginning of thls
graduated ln the last
The patient-related
causes are al-so familiar
graduates enter general practice, existed
the patient,,
Most of t,hese are self-explanatory
brought out by the coggeshall and other public
are outlined
major head-
rernarkable upsurge in emergency room utiliza-
and external- forces.
The physician-reLated
erupts
anger.
thls
the institutlon,
creates a
which not infrequently
can be analyzed ln terms of four naJor components:
physiclan,
times,
at the same time one of the hospitaLfs
of publlc
The explanation
and staff
As a result,
itself
is not only
(mainly those of omlssion) but leads to
between patient
unpleasant lncldents.
frustrated
tlon
this
impersonal care which, comblned with
degree of friction into
to keep up wlth
and the constant pressure on the
of what it in private
three decades.
was three decades
practice The rast
has dropped of the
applies more to the use of suburban or county hospitals.
is increasingly
facilities
for
using the hospital
emergency room rather
the treatment of these problems.
- 9 -
The institution-related most inportant
of the factors
ttopen doors' Sency roomts availabllity
causes are llsted mentj.oned here ls
open hourst' policy.
of primary care physicians,
probably the two most important The 'rexternal
forces"
in slide
the convenience of the emer* This,
along with
partlcularly
factors
in this
contrlbuting
probably the
III.
the decreasing
in the inner city,
overarl
are
trend.
to thLs populatlon
explosion are
I-lsted on Sllde IV.
The nost important of these, of course, are the various
private
or state-run
third
offered
some statistics
probleur as it nunlty
exlsts
and hospital
The annual rate
party programs.
On the next three slldes,
to give a perspectlve ln thls
of the dimensions of this
country today, as well
in which I work.
as lts
effect
has increased
In the report
quoted here,
by 1-6 miLllon
(+I75%) from 1954 to 1964, bur rhe flgure
mlllion
in nlne years'
to those seen for
during the 1960fs. current year.
ls the most accurate,
predicted
Regard-
they both indicate
that
For exampl.e, in the former
1952-L964 showed a greated combined j-ncrease than for
of the preceding five
of proportion
menrioned in rhe
or annual lncrease rate of 9 percent per year.
the two years fron
the total
increased
the same period was an Lncrease from 16 mil-l-ion to 53
rate of increase has not been a gradual one.
rePort
one uses.
the annual- rate of emergency room visits
less of whlch of these statLstics this
siruation.
anywhere from 6 to 9
percent Per year over the l-ast decade, depending on the statistlcs
for
on the com-
Slide V summarlzes the natlonal
of emergency room visits
Coggeshal-l- report
I have
Ftnally,
years.
Furthermore, these increases are out
in-patient
this
adnlssLons and out-patient
ls apparently
a contlnuing
visits
trend wlth
the
rate of i.ncrease being ln the neighborhood of 10 percent per
Slide VI reflects
the way in which thls
- 1 0 -
has affected
a typical
Eastern
metropolis' milllon
namely greater metropolitan
and 24 emergency room facilities
The survey showed that
increases.
rooms' and particularly centri.fugally. tines
their
the natlonal
figure
use for
rise
the utilization
greater
is due to of emergency
non-emergent medical problems, decrea6es
flgure
average, with
is only two*thirds
that part of this
shows that
had almost
can be seen to be almost two and one-
the Baltimore County figure
average, and the outlylng
running 20
counties being less than
to one-third.
Slide VII exploslon as it percent
it
The Baltimore City
percent below the national one-half
indicating
Finally,
of two
were surveyed in November, 1968.
Ilowever, the prorated
over the same time interval, population
whosb population
the annual number of emergency room visits
doubled in eight years.
half
Baltimore,
outllnes
the characteristics
affected
increase
slnce the current
of the emergency room population
the Johns Hopkins Hospital
in 1968.
There was a L75
ln the annual- number of emergency room visits
in the 15 years
emergency room facillties
flrst
opened in 1953.
the rate of increase averaged Just over 3 percent per year for years, but ln the last Per year increase.
five
The figures
the Johns Hopklns HospLtal two and one-half
percent could be readlly
generated'
ldentified
i.s, return
average and four
which was times the United
Thls survey showed that up to 65 percent of
as being non-urgent without
our non-urgent visits
visits
10
irnrnediately around
were for non-urgent problerns, although only
20 percent of all that
Baltiurore
the first
averaged almost l-5 percent
showed an emergency room utilization
the same year.
our emergency room visLts
it
taken from the census tract
times the greater
States average for
In addition,
years of that period,
However,
or check-ups.
-11 -
40-45
examlnation.
turned out to be self-
At the time of this
study,
the average "waiting includes
waiting
tlme'r for
2-3 hours to be seen. and was even higher
pati-ent flow.
per day.
X-ray load.
from between 2-3 percent
This has become one of the major bottlenecks
as the day shift
Finally,
ln the last
sector of the clry
the evening shift
recelved
between them accounting for
10 years four prlvate
had relocated
time the number of general- practltLonerb wlth
actuaLly dld wait
Our surveys also showed that about one-third
The survey also showed that
number of patients
Central
The walkout rate had risen
was obvlous that
emergency room t,raffic
to
an equal
84 percent of
hospltals
in the East
in the suburbs, and durlng the same left
in this
area had dropped to 20
approxlrnately
one-half
of this
more properl-y beonged in an out-patient
than ln our emergency room, we al-so surveyed our out-patient of these flndings
suspiclon
over the years our emergency room had gradually
that
of an out-patlent
and staffing
had hardly
number of patients average wait
for
are l-isted ln Sltde VIII.
increased facility
cllnic
The highlights
Fifty
of
an average age of 64. Since lt
chlld
Ilowever, there
received X-ray studies whlch amounted to about 30 percent of the
hospital
the totaL.
so that many of the patients
This
on days when our emergency room census was in the neighbor-
hood of 400 patients
total
r{ras 2.8 hours.
tlme or "tirne in the systemfr.
plus treatment
Idas a skewed distribution,
out Patients
an emergency room visit
rather
operations.
They confirmed our
department whose hours of operation,
become the stepappointment quotas,
been adJusted at al-l to accormodate the lncreasi.ng
seeking aLtention
there.
At the tirne of our survey,
an electi-ve appointment to this
Percent of the patients
group of 48 clinics
scheduled did not keep thelr
the
was 27 days.
appointments and
many of them could be easlly
traced back to the doors of our emergency room.
Thus, at a time of a greatly
increaeed demand, our out-patient
- L 2 -
clinics
were
inefficiently
seeing only about one-half
scheduled. follow-up
The mechanism for
screening and steering
were told
usually
ran out),
the clinlcs
little
nedical
provision
they provlded
l^Iere organized along the lines
us with
of the hospital
that
came out of all
obJective
prescription
of specialty
interests
evidence with
problem, lt
time for
is lmportant
admlnlstrative
important
inertia
at the outset
poJ-icles that will That ls,
one will
experience
to get this
solution.
done as early
and appropriate
for
referral-
as possible
attempts to resolve
providing
It
to allow is also
this
crisis.
come to grips with what it
eornmunlty health
center,
care.
It
deal-ing malnly with
w111 be said that
be warnings that such a practice
In many
and discourage
will
hospital
broadest sense,
only serve to dilute
top ranking
applicants
the
in the
and ones which should
they do not faee up to the reallty
- 1 3 -
the problems
a university
care in its
While these are very understandable sentiments, dlsmissed,
When faced with
fiscal- plannlng.
to provlde cornnuni.ty health
of those in traintng
not be lightly
a high priority
encounter strong sentiments Lo preserve t.he institution
or complexlty.
should not be obliged and there will
resources to it
must be made to formally
aa an academically-oriented lnterest
which to convince the adrnin-
enabl-ed us to obtain
govern the lnstitutionrs
are i-ts responsibiLitles
of speclal
was
to obtain a statement and formal approval- of the basic
the lnstitutlon
academic centers,
these statistics
and medlcal school of the serious dimensions of the
commltment of the lnstltutionts
future.
(the patients
the care of common"garden varletytl
betng made for
emergency room problem and eventuall-y
thinks
chronic problens
problems.
j-stration
this
for
routine
there was no
Just to come to the emergency room when their
About Ehe only nice thing that
refills
that were
was i"neffective,
care of cormon chronic diseases was not provided for,
mechanizm for handling prescription
wlth
of the number of patients
of the changing
medical scene nor help solve the practical
problern of Just who will
masses seeking medical care on the hospitalrs that
in this
age of the dlsappearing ward patient,
of the ward admisslons enter vla discourage this
tralning
these important
begin to come to grips with practlcal r have outlined
instituted
often
the reali
make any efforts
prelininaries,
solutions
one can then finally
to the problem.
For your
to combat our emergency room overroad.
to which the output is directed.
overload
were simply practical
They were prlmarlly
stop-gap measures, severar of which were
lntended to relieve
gain tlme and eLbow room for more effective one of the first
the system
Most of the measures which
suggested to us by our emergency room and out-patient surveys'
to
materi-ar seem inappropriate.
can occur not only from too great an input but to bottl-enecks within
we instituted
zation
some of the basic measures which we have recentlv
at our lnstitution
and the faclLlties
the
that a very large proportion
the emergency room, will
source of clinl-cal
Ilaving dealt with
interest,
doorstep.
treat
department operationar
the immediate pressure and
and long-range planning.
measures undertaken vf,asthe institution
(slide
of a triage
rx). system
operated during the peak l-2 hours of each day by experienced medical assl-stant residents
who were given aLmost open out-patient
privlleges'
It
soon became apparent that
belong in our emergency roon fell non-urgent
lnto
clinle,
exemplified
by the acute self-llrnited
respiratory
infections,
patient For this
referral
those patients
who really
two basic categories.
probJ-emswhich woul-d Justify
out-patlent
department appointnent
dlagnostlc
didn,t
one group had
work-up and treatment
but the other had minor, general practice-type illnesses
gastroenteritis,
etc.)
but which needed slmple,
reason' we recently
bullt
(viral
i.nfections,
on-the-spot
a smalL dispensary-type
- L 4 -
problems, upper
whlch would not Justify
expedient,
in an
out_
treatment.
operation
next to
one corner of our emergency room to handle this hours a day.
It
of our return
visits
is belng run by experienced paid physicians. had been self-generated,
restricted
t,o cases of definite
orlginally
saw them.
Final-ly,
cl-inic
traffic
to.
from whlch it
This attenpt
to shlft
ment ln operatlonal time for
resulted
clinic,
in several- practical-
particularly
traditional of its
techniciansr
xr).
that of the nurslng service,
came from fairly
simpJ-e efficl-ency
equipment utll-izatlon
and staffing
according than the
is being relieved
of some
nursLng personnel and
are belng expanded and upgraded.
improvements in emergency room operations measures, particul-arly of our X-ray facllity
in the mlddle of the emergency room (Slide XII). 9O-second X-omat developer
coverages, but
r,rere revlewed and revlsed
and the auxlllary
and tralnlng
Some of the most notlceabl-e
improve-
which had also lagged
All- rhe staff
The nursing staff
responeiblllties
reeponsiblLitles
the
department to buy
loadlng estabLished by our aurvey rather
three nursing shifts.
adminlstratlve
changes in out-
and expansion.
Load (sllde
to the Patt,erns of patlent
along with
in a slgnificant
Adjuetments luere made in emergency room staffing patlent
traffic
Agaln, these are for
and allowed the out-patient
a complete reorganizatlon
behlnd the iising
refi1l
originated.
measures, but they have resulted efficlency
who
a maJor part of our out-patient
oPerations which are suxnmarlzedin Slide X. short-term
these be
t,riage system, one has to have somewhere to
evidence produced by our survey,
most part
Since 20 percent
the prescrlption
from the emergency room back to the out-patient
patient
15-18
we have requested that
we have diverted
To operate an effective Patlents
for
teaching value to the house officer
directJ-y back to the out-patlent
triage
sort of traffic
which is located right
Even the install-ation
brought about a noticeable
- 1 5 -
lmprovements in the
of a
irnprovement in patient
flow
through the system.
lfe wtll
soon have both X-ray rooms completely
equipped for muLttpurpose use l{l-th two rapid more genior resldent
technlclan
radiologist
coverager as well and a film
cl-erk.
deveLoper X-omats and now have
as an l8-hour
a day coverage by a
Another maJor source of delay in
movlng Patients
through the emergency room system has been the waiting
for
of laboratory
the results
specimens to the laboratory all
studies. quickly,
Instltuting get,ting
a system for gettlng
the l-aboratory
emergency room requests on a ttsTATrrbasis, and getting
quickly
as posslble,
makes a tremendous differenee
spend in the system. sterll-lzation
and dlstributlon
of medical records, physiclans,
all
reduction
of storage, improved avatrlabil-ity
pJ.ates to go with
and X-ray requests can be stamped rather Finally,
waiting
We perlodically
records whlch brings
other vital-
statistics
means of coordlnatlng
The inpact
and sustaining
I think
this
the hour or so spent at
overall
of these measures has been significant
The annual emergency room census at our hospltal
such as
unrecognlzable
our weekly emergency room conrmittee meetlng hae been a most effect,lve practical
load with
run a spot check on the
out otherwise
rn terms of operatlonal- effeciency,
htrstorles,
than filled
survey on our patient
along wlth
etc.
their
to keep on top of our progress
breakdown accordlng t,o disposition, tlmes, wal.kout rates'
back as
Even a sirnple measure like
ldenttfication
we have contlnued to run a weekLy statistical
problems.
the results
central-ization
impact.
out by hand, ie a tremendous tlme-saver.
emergency room treatment
to agree to handle
of the amount of red tape and trsgsgrrwork by the
all- patients
laboratory
the
ln terms of time the patlents
of emergency room supplles,
have aLl had a signlficant
inunediately issuing so that
Other measures lnvolved
time
and
effort.
in a number of regards.
has gradually
risen
from 43,000
in l-953 to 58,000 ln 1963, then to llSrooo in 1968 ar which time rhese measurea
- 1 6 -
were instltuted 1021000.
(slide
The waiting
Ilowever, our current this
tlde.
inpossible
The 1969 figure,
statistlcs
long-range
it
unilateraL
plans for
respite
reorganization
that hae alLowed us Lo
and expansion since lt
lf
the rest
nnunity don,rt aLso change, slnce one wlLl
of emergency room oprations, of the hospitals
as the word spreads around the communfty.
long-term
a staged maJor expanslon into
ambuLatory care facilities type"
with
emergency and the other
function
separate
a walk-ln
and an expanded dlspensary
care facLllty,
thus allowing
operatlon
to
our current
adJacent emergency room-
entrances--one door for
us to return
in the com-
siurply draw more and more patients
the lnProved facillty plan ie for
is
of the value of regi.onal planning,
to improve the efficiency
such as these, r8y be sel-f-defeating
stemmed
changes ln an overcrowded emergency room.
shouLd be sald ln support
attempts
have decreased.
suggest that we have only tenporariJ-y
to make major structural
However' I think
however, shows a drop to
times have lessened and the waLkout rates
Even so' we have galned a brlef
proceed with
that
xrrr).
for
the true
the ambulatory
wil.l- be shifted
"anbulance-
i11.
The triage
to the anbulatory
the emergency roon to Lts originally
lntended purpose. The second issue I have chosen to discuss ls in the emergency room. to an anbitlous
actlvlties
himsel-f thrashing
here for
With thls
emergency room patients
of the house staff, a young faculty
cllnical
keep the academician on the crest
chosen special-ty.
centers,
delegated
The acaclemi.c life
teaching,
- L 7 *
of the
responslbilltles.
are understandably
and so there may be little member, particularly
and
aeslgnment he is apt to flnd
about 1n the undertow of admlnlstrative
most maJor teaching
outlet
that will
of the academician
ls usually
a balanced exletence of reeearch,
advanclng wave of his
"property"
The job of emergency room chief
young member of the Department of Surgery.
ls euppoeed to offer adninistrative
the role
In the
personal clinical
a surgeon.
Also, with
t.he
crowded envl.rons of most universlty neither it
space nor tlme for
ls even difficult
in such a hectlc
sophistlcated
emergency rooms, there
investigative
studies.
to organize and carry out an effective
environment.
The house staff
pressing task of keeping up wlth for
hospital
the latient
can hardly
is usually
Furthermore,
teaching program afford
to ignore the
load long enough to get together
decent rounds. Thls does not mean that
to do.
the emergency room chief
As you w111 see by the Job descriptlon
whlch is outlined
below (Slide XIV),
of obvious questlons arise
accompli-sh these tasks wlthout mental status,
without
emergency roorn budget,
top rate adminlstrative and wlthout
responsibLe to hln rather essentlals?
predicament.
an auth;ritative
a nursing
academic rewards for
these efforts
academLc pursuits
which constitute
for
Ftnal-ly,
advancement?
research,
Can an emergency room chief
and auxlliary just
control
staff
Thirdly,
to name a few of the
just
be effectively
what are the
the more tradltionally
activities
accepted credentials and improve his
ln the setting
of an over-
Lhtnk there are any simple answers to these
questions or a number of others I could have posed, but they obvlously more than the passing attention to develop an effective
room to its
originally
I have given them.
mechanl.sm for
ambulatory care or other health
of the
directl-y
or how can it
how can the academician enlarge
I donft
However, a number
and how do they stack up against other
teaching and personal cl-inlcal
crowded emergency room?
do to.
support, without
not a fuLL-tirne job,
accomprlshed by only 20-40 percent of effort?
nothing
base such as that of a depart-
than the nursing hierachy,
Secondly, Ls thls
with
of an emergency department head
there is plenty
out of this
ls left
divertlng
care facilities,
designed function,
deserve
The obvious courae would be
the non-emergency problems to thus reetoring
the emergency
and then develop the emergency room
- 1 8 -
into
a reglonal
patient
care'
status.
trauma resuscitatj-on
training,
and research program with
However, this
the funds for
money, and the Justification
between teaching
of traumatology as still
university
further
hospltale.
this
situation
On one extreme there are those who say that
carried
on in an atmosPhere of excellent
first.
They point
patient
better,
than the house staff.
They polnt
to this
is essential that
for
approach provides
trainlng
the least
practiees
of oners teachers.
primarily
for patient
it
while
thls
nay eventually
the
studj-es, cheaper
are nov/ covered by thlrd
practicing preferable
program, parti-cularly hTent out wlth
stimul-us for
service'
emergency room practice Finallyn
or at least
comes
they calim that
exceLlent patient
eare
to unsupervised house out that a significant
decision maklng and personal executlon of treatment
to a good tralning
apprentice-type
can care for
type of care, and finaLly
On the other slde are those who polnt
degree of responsibillty
should only be
care where the patient
out that most patients
by assistJ.ng an experlenced physician
practice.
teaching
and by avoiding unnecessary disgnostic
is an acceptable form of tralning staff
patient
may generate two opposing
the more experienced physician
Party programs and have a right learnlng
morning.
that of the apparent conflict
camps.
quicker,
specialty,
care whlch may develop in the emergency rooms of
Unfortunately,
out that
another surgical
this
problern I wanted to broach is and patlent
of
such a venture in these times of tight
of whlch we have time to go into The finaL
departmental or divisional
brings up a number of other problems, not the least
which are; where to flnd
neither
center and run it. aa an integrated
It
a surgeon.
the FLexner report,
lnnovation
SecondJ-y,
and that
the type we are liable
are not likely
of clinicians - 1 9 -
paid
to accept in
to make the best teachers.
approach may produce inrnediate improvements in patient
reduce the caliber
thls
and improving upon the
can also be pointed out that. physicians
or at least
contract,
for
treating
future
care,
generations.
Of couree, as usual, the truth liee eomewherebetween thege two overstated extremes and one has to work out the best posslble compromisewlthin the ground rules of the partlcular I thlnk lt
ls partlcularly
tlnely
lnstltutlon
in whlch he functlons.
to polnt out thls growlng conflict,
However, because
there are bound to be increasing preesures brought to bear by the Lay public through governmentaLagenciee for euch meaeures for lurproving the qual-lty of Patlent care.
These preseures are understandable, and Lt ie pretty obvlous
that we can not ethlcally
ln the faee of this trend wlth-
contlnue nuch farther
out modlfying the way teachlng le conducted in many unlverslty
hospltal
emer-
gency room8. 8o that 8E valuable aB an energency room experlence ie to an lntern, lt must be admltted that Letting an lntern by the prlmary care phyelcian for all patlente entering the emergencyroom oystem ie going to resuLt ln elower, more expenelve and probably lees than ldeal patlent
care.
It
is aleo true that lf
one were to try to meet this lncreaeLng emergeneyroom patlent wlth lnterns,
they wlll
load prlmarlly
eoon have to apend an lnordlnate part of thelr
ehtp ln the eruergencyroon.
lntern-
Rlght noro, for exempLe, Lf we had to increase our
lntern coverage in our emergencyroom t,here would be eomespendlng five months of thelr
Lnternshlp there.
At the noment our lnterne spend one-thlrd of thelr
t,lme, and the resldente one-eLxth of thelr
tlme tn the emergencyroom and a good
deal. of the tlme expendedby the renainder lnvoLveE the Ln-patLent servlces to which thoee patlents are adnLtted.
ThuE the ttme epent ln carlng for petlents
w{th trawra and other problane admitted through the emergeflcyroom ls already htay out, of proportlon to th6t spent {n electlve,
general and speclalty surgery.
Rather than take our lnterns out of the energency roon, we are plannlng to lncreaee the proportlon of eagtetant restdenta on rotatlon
there ln the early
part of the yedr, ellowlng lnterns to graduelly take on tncreaslng reeponElbllltteE
- 2 0 -
wlth
each additional
rotation.
the emergency room, instituted honest morbldlty-mortality tion with
the faculty.
cal-iber of both patient there w111 eventually house staff think
that
the quality
system of teaching
conference and provided A11 these have resulted care and teachlng
be a place for
thls
of patlent
care must be carefull-y
programs.
It
Whether
surgeons to work alongside the with
consldered
certainty,
in regard to the irnpact
teaching do not need to be mutually
and should at alL costs be prevented from conflicting hospJ.tals.
- 2 L -
but I
in the name of improving
worlld seem that, excel-Lence ln patlent
Ln the emergency rooms of teaching
consulta-
in a general upgrading of the
in the emergency room.
salaried
to
rounds, and an
for more frequent
and other measures which may be offered
in student and house staff
other
an lnproved
in our emergency room ls hard to predlct
on our training
obJectives
We have also assigned one senior resident
care and
exclusive with
each
SI.INE I ROOM ''POPUI.ATIONHffIOSION!' CAUSESOT THN EMERGUNCY THE PATIENT
l.
- 1.5 - 2,Q % PERANNUIvI POPUIATIONINCREASES GENERAL
2.
INCREASINGDISTRIBUTIONAT AGE EffREMES (MORETRAUtr\4A, CHRONIC DISEA,SE)
3.
WITH LOWER INCREASINGURBANEATION, ESPECIALTY SOCIOECONOMICLEVET.q
4.
WITHOTIT ESTABMOTTLmY- MOVE FREQUENTLY TNoREASTNG LISHING NE'\MLMD
5.
INCREASEDD(PECTATIONOF ADVANCEDTECHNIQUESAI{D FACITUIES OF I\4ODERNHOSPIIAIS
izz-
g"LIDfi:II CAUSESOF THE EMERGENCY ROOM "POPUI.ATIONE(PLOSION'' THE PITYSICIAN
I.
NUMBER.S DECREASING OF GENENALPRACTI9NERS
2.
PRIVATEP}IYSICIANSIOINING THE ''PLIGHTTO THE SUBIJRBS''
3.
INCREASINGTJMTTATTONS ON NONSCHEDUIEDOFFICEVISITS
4,
INCREASINGSPECIATIZATION \MITH DTSENGAGEME{T OF PHYSICIAN . FROM ''PRIMARYMEDICAL CAF,E''
5.
INSTITUTIONINCREASINGPROPORTION OF MEDICAL PROFESSION BASED
6.
ROOIvI INCREASINGPRIVATEPIIYSIOI,ANUSE OF ETvIERGENCY FACILITIESRATHERTTIANOFFICE
-?3-
SLIS'E III CAUSESOT THE EMERGENCY ROOM ''POPUI.ATIONS(PIOSION" THE INSTITUTION 1.
AVAIIABITITTOF COMPLD(AND COSTLYDIAGNOETICA\ID THERAPEUTICEQUIPMENTOSUBATED BY SKILI,FDPER,SONNEL
2.
PUBLIC IN4AGEAS REPOSITORY OT I\4ODERNMEDICAL MIR.A,CLES
3.
COIWENIENCEOF EMERGENCY ROOM "OPENDOORS,OPEN '' HOURS POLICY
4.
ACCESSABITITY TO CONCM{TRATED CORE-CITYPOPUI,ATION
5.
PRIVATEHOSPTTALS REIOCATING IN SUBURBS
- 2 4 -
SI"ID.EIV CAUSESOF THE EMERGENCY ROOM "POPUI.ATIONFXPLOSION" D(TERNAI FORCES I.
INCREASINGCOVERAGE BY PRIVATEOR GOVERNMENTTHIRD PARTYPROGRAMS
2 . THIRD PARIYCOVERAGE T'ORSERVICFSPERTORMED IN HOSPITAT BUT NOT IN OFFICE
3.
INCREASINGTENDSNCYFORSCHOOI.SAND INDUSTRYTO RETER TO HOSPITAT
4.
LESSPI{YEICIANCONTROLOF AMBUIANCE SERVICES . NO SCREENING,OBLIGATORY TRANSFQRATION TO HOSPITAL
- 2 5 -
gtIDE V DIMENSIONSOF EI\4ERGENCY ROOM '.POPUIATIONEXPLosIoN'' (NATIONAL)
1.
ANNUATRATEOF EIVIERGENCY RQOM VISMS INCREASEDBY 16 MrL rro N (+ 1 7 5 %)FROM 1954TO 1964
2 . ACCEI.ERATING RATEOF INCREA$E. 1962 - 1964 INCREA,SE > PRECEDINGFIVE YEAR,S
3,
. ADMISSIONS*8/O, OPD VISIT$ DISPROPORTIONATE INCREASES +I8%, EMERGENCY ROOMVISrIS +79% (PER1OOO POPUI.ATION D U R IN G1 9 6 0 's
4.
CONTINUING If;EhID - INCREASE IN OPD-ERVISITSTOUR TIMES GREATER THAN INPATIENT ADMISSIONSDURING 1950*1962, PREDICTEDEIGix[TTIIvIESGREATER T]IAN BY LgTZ.
- 2 6 -
S.IIDA VI DIh,IEN$IONSOF EMERGENCY ROOM "PO-PULATION EXPLOSION" (GRF.ATER BALTIMORE- NOVEMBER,I968) I,
ANNUALERVISITSROSEFROI\4356, 272 IN 1960 T O 6 5 9, 0 7 2 I N 1 9 6 8
z. ANNUAL ERvIsITsRosErRoM tgz ro gz;/LoCIo POPUIATIONFROM r 9 6 0T O 1 9 6 8
3. NRUUTEATIONAI{D PHRCENTNONURGENTVISUS DECREASED CENTRIFUGALTY
BALro.crry SArTqt.9q.. ApTACEIII .*-.ff Co..,,s. ANNUAL ERvrsrrg/ tooopopur,ATroN fiIB4-rg0 PERCANT NONURGENT VISITS
57
43
3I-41
S.LIDE]VII CHARACTERISTICS OF ER POPUIATIONEXPLOSION HOSPITAL- 1968) 0oHNS HOPKTNS I . A N N U A LE R V I S M S ROSEFROM 43,OOO I N 1 9 5 3T O 1 1 8 , O O ION I 9 6 8 = 867, BALTIMORE = 2. AI{NUAI ERVISITS,/IOOO POPUI.ATION AVERAGE = 3 2 6 , U . S . A V E R A G E2 1 6 3. 65% OF ERVISMSNONURGENT(20%QF THESESELTGENERATED) 4. AVERAGE WAITING TIME 2.8 HOURS(STTWEDDISTRIBI-ITION) 5. WALKOUTSROSETO > 2% 6. 33% RECEIVEDX RAYS(29%OT HOSPITALEIEAD) 7. DAYAND EVENINGSHIFTSRECEIVEDEQUALLOADS (42% FECH) (AVERAGE 8. ONLY 20 G.P.'s IN EASITERN CENTRATBATTIMORE AGE 64) 9. FOUR PRIVATEHOSPITALSRELOCATEDIN BALTIMORECOUNTY IN IA^STDECADE
-28-
EriIgFr vrrr
FEAT UFGS '3ffi-ff#RIBUT ING ""JJffi ;,l,?fd,?i I.
AVERAGE WAIT TOR EIEqTIVE CLINIC APPOINTMI$IT- 27 DA1F
2. INEFFICIENCY FROM HIGH,,$'NO-BHOW RATES(ca. 50%) 3.
INNFFECTIVE SCRAENINGN{D STFARING
4.
ROUTINEFOLIOW-UP CAREOF'COMfuIONC}IRONIC DISEASES DISCOURAGED
5.
NO MECHANISI\ T.ORHANDTING PRES0RIPTIoNR,EFILLSFoR CHRONIC PROBTEMS
6 . MUI"TIPIE SPECIAITYBTITNO GENERATMEDICATCTINIC 7 . PROBLEMPATIENTSDUMPED ON EMERGENCY ROOM W}IAN
CTINIC CLOSED
-29_
$LID,fr Ix MEASURES TO COMmT EROVERTOAD 0HH '67 - '69) A. ERPATIENTINPUT 1. TRIAGE- RUNBYD(PERIENCED RESIDENTS WITH OPENOPD PRIVITEGES APPOINTMENT - RuN BY 2. ADIACENTOPaN-HOURS Ip.$SHt\I8ilmfOPERATION PAIDFACUTTY 3. RffiTRICTERRETURN VISITSTO THOSIOT TEACHING VALUE 4. RtrUSENONURGENT PRE$CRIFTION REFItt REQUESTS BYOPD CIINIC PATIENTS
- 3 0 -
SIID-UX MEASURES TO COMBATEROVERLOAD(JHH '67 - '69) B. CHANGESIN OPD OPM,ATIONS I. ESTABLISH GENERALMEDICATCTINIC TO HANDLECOMMON MEDICAL PROBLEMS 2. INCREASESTAFFCOVERAGE OF OPD CTINICS 3. INCREASECTINIC APPOINTIVIENT QUoTAs, REDUCEBAOKIOG, OVERSCHEDULE:NO SHOW RATE 4. IDENTITY"HoMa ctINIcs" FoR pRIrvIARy CAREoF PATIENTS WITH CHRONIC PROBLEMS 5. STAGGERED APPOINTMENTSCHEDULESYSTEM 6. D(PEDIENTMICHANISM TOR R"EFILLING PRESCRIPTIONS IN HOME CTINICS
- 3 L -
gtUDNXI MEA,SURES TO COMBATER OVERTOAD(IHH '67 _ '69) C. STAFFING 1. INCRNASED COVERAGE BY FACULIY, ADMINISTRATIONAAID NURSINGAI{D SENIORHOUSESTAFF
2 . REVISESTAFFCOVERAGE ACCORDINGTO PATIENTINPIN PATTERNS 3 . RETIEVENURSINGOT ADMINISTRATIVDRESPONSIBITITIES 4 . UPGRADETRAININGA}ilD RESPONSIBIIMIESOF AUXILARY MEDICAL PERSONNET
5 . MOREAVAIT'ARI"E AI{D RESPON$IVE SPECIALTYCONSULTATION 6 . INCREASEDSUPPORT FOR DSALINGWITH DISPOSITIONPROBLEMS (SOCIALSERVICE,AI.COHOLICCOUNSETINGi DRUGABUSE PROGRAM,ETC.)
- 32-
s,'uDatxfi MEASURES TO COMBATER OVFRLOAD(IHH '67 * '69) D. EFFICIENCYMEASURES IN ER r. IARGERAND I\4OREEFTICIENTX RAYAI{P TABORATORY SUPPORT 2. CENTRATXZATION Of ST&nAcE, STERITIZATION AND DISTREUTION OT ER SUPPI,IES
3 . IIVIPROVEDAVAII.ABITIIY OT MEDICAT R6$MM[DS ''SCUT WORK" 4 . REDUCf, P}TY]SICIAN
5. IfuTMEDIATE ISSUINGOf PATIENT IDENTITICATION PLATES 6. UTILIZATION REVIEWT coNTlNuous srATIsrIcAt suRVEy WEIKIY ERCOMMTTTEE MEETING MEDICATRECORDS SPOTCHECK
- 3 3 -
PATIENT-VISlTS/ YEAR( inthousonds) TU -{
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8I,IDB]XIV ]OB DESCRIPTIONOF ER DEPARTMENTHEAD r . OVERSEE DAY-TO.DAYADMINISTRATIVEOPERATIONS OF ER 2. RESPONSIBIIIWFOR QUALIIY OF MEDICAL CAREBYALt SPECI'I\TTIES 3. RESPONSIBITITY FORAIVNUALBUDGETAND ALt FISCALOPIRATIONS 4. COORDINATEINTERDEPARTMANTAT AI{D SERVICE ACTIVITIES 5. DEVEIOPEFFECTIVE TEACHINGPROGRAMS FOR HOUSESTATT AND STUDTNTS 6. DEVILOPAND COORDINATETRAINING PROGRAIYIS FORAUXILARY MNDICAL PERSONNEL 7. DEVEIOPAND COORDINATTINSTNUTION'S DISASTIRPI,ANS 8. LEADER.SHIP ROLE IN RSGIONATPLANNINGFOR DETIVERYOF EMERGENCYMEDICAL SRVICES 9. REPRESENT THE ERON INSTITIITION'SGOVERNINGCOMMITTEES IO. DEVEIOPAND PROMOTEIMMEDIATEAND I,ONG-RANGE IMPROVEMENTS IN ER FACITITIES
- 3 5 -
REGIONALPLANNINGOF EMERGENCY MEDICAL SERVICES James R. Mackenzie, M.D., McMaster University, HarnLJ.ton, OntarLo, Canada I would like they reflect
to preface remarks on regionallzation
ny or^tnpersonal
literature
on the subJect.
been fornuLated
while
views rather
the early
Program ln Vermont; the effectLveness of both civlllan
and nilitary
emergency services
have
development of the Regional Medical
of the reglonal
casualtles
that
than a summary of the sparse
These views on regionaL
observlng
by statlng
emergency medical- care
in rrlrt corps in Vietnam; and finally,
the development of a province*wlde
pl-an for
emergency cormnunlcatlons and
transportation
Canada.
Interpretation
systems Ln Ontarlo,
gover'nment representatlon
on emergency health
of data concernlng
care counclls
is based upon the
recomuendatlone made by the CanadLan Government Task Force reportg
on the Cosg
of HeaLth Services in Canada. Plannlng need to provide
of energency medicaL care has developed out of the growlng a pJ.anned' progresslve - starting
emergency vtctim definltlve
step-by-step
approach to the care of the
ar the acene of the emergency and ending in
care in the hoepltal.
Regl.onal pJ.anning of emergency medlcal
on the other hand, l-s an attempt to provlde a pLanned, progressive the care of all with nlnLnal this
emergency vlctiurs
duplication
area, for
of personneL and faci.litLes.
taLk to define what I thlnk
distrlct;
ln a spectfled
constltutes
a region;
who should govern the decLslons concernlng
the re8lon;
the role of the untversities
the responstblllties
in regional
of a governing body involved
- 3 6 -
It
approach to
the least is
how it
care,
cost and
the purpose of dlffers
from a
emergency medical care in emergency care, and flnally,
in regional
pLanning.
A region, all
by patrerns
as lt
lines
South CaroLina.
evolving
In contrast
patterns
Political
boundaries such as city
shouLd not be the sole constraint
Reglons presently
reglons,
to emergency medical care, is defined firet
of medical practlces.
countyr or state region.
applies
tn this
of practlce
and the availablllty
As a result,
nedical
practLce t,ransgresses pol-itical
Kansas City'
St. Louls-East
The regional
rocal
to practice
level
referral
in both Quebec and Vermont.
the constralnt
placed upon their
could be a hospLtal or group of hospltals)
aJ-J-categories or femaLe.
of care for
by efflclent
the emergency vtctfuns be they adul-t or child,
transportatlon
Ilke
to dLgress for
with
the regional- referral
the comtunlty
and communl-catlon systems.
a moment and contrast center.
which is defined
the functLon
The dlstrict
hospital
provides services
as an area of about 30-60 mlnutes radius
should be abl-e to provide
servi-ces needed to keep a patlent
until
ment services
it
I would
of the community hospital
Emergency Department in these hospitale
In addltlon,
male
or community hospiLals
the hospital- measured by the speed of the avaflabl"e transportation
hospital.
(and.
center
capable of providlng
This center muet be connected to aLl dlstrict
in the reglon
regi-ons at a
of medlcal practlces.
Sec'ondl-y, the reglon ehould have a maJor medLcal- referral by center lt
center.
the Quebec-Vermont
Lines and have defined the boundaries of their
accordlng to recognlzed patterns
alive
transferred
demanded by the comnunity surrounding
for
from
system.
The
all- of the
to the reglonal
must provide most of the ordlnary
- 3 7 -
and
boundaries as they do in
and lnternattonall-y,
medlcal programs have recognized
programs by etate
to transportation
of a maJor medlcal
where the doctors hold llcenses
and
constraLnte pJ-acedupon these
conmunlcatLon routes
border,
upon the size of the
tend to develop Ln relatj-on
St,. Louis,
linlte,
manner are found in Ontario
to the polltieal
of
definittve
the hospital.
treat-
Thirdly' nedlcal
the region should possess a maJor medlcal center where
and paramedical personnel needed for
emergency vlctlm resldente
can be educated.
The tralning
Ln emergency care demands that
to a medlcal school-. then the staff universlty
If
of this
faeutr-ty.
the progressive
reeidente
this
of medlcal
care of the
students
center be related
and
or attached
center does not necessarily
Ilowever, the staff
of this
have to be part of a
maJor hospital
must be
prepared to educate the paranedlcal. personnel needed for
the reglon,
continuously
emergency care.
update the skll-Ie
Lastly,
within
the region.
proposed for of thls
of the doctors
del-lvering
a region must be able to inltlate
reLated to both the dellvery
functlon
of emergency health
care
ambulance and communlcation systems
and severaL Unlted States
centers
are exceLlent
examples
of a reglon.
In sunrmary, the boundarles of medicaL practice
and referraL
and research which ls care del-ivery.
and to
and evaLuate techniques
and cost effectivenees
The varLous reglonal
Ontarlo
.
and medical students are not invol-ved,
dLrected
The dletrlct
community which resides
wlthfn
of a region and by its
are determtned by the pattern
obLigations
towards better
to uredical education
and more effect,ive
boundarLes on the other a 30-60 mlnute tine
emergency
hand are defined
radlus
by the
of the comnuni-ty
hospltaJ.. Regional- energency care dernands a reglonaL body composed of all interested decisLons.
rnedical and non-medlcaL groups if A1-1 of the hearL-related
medical associationsr the council.
program and thls
profeselons,
as weLl ae hospital
The Latter
is
to nake effective
and viabLe
euch as medlcal- and para-
adminietratlon,
group hae not been very active
ls one of the reasons for
gram ln some regions.
lt
nuet have a volce on in the regional
medical
the sLow progress made by thls
Government at all- leveLs,
- 3 8 -
ineurance and prlvate
pro-
welfare
agencies'
and industry
who supply a great
care must be represented can contrlbute'
on the councLl.
such as the pollce,
the consurner, the cltizen, uLtlnately
Other non-medlcal
fire
and legal
the trade unionlst,
plannlng?
does the unlverslty
Flrst
and research,
representative
wlth
ny bellef
that
Finally,
those who
nust recognize
representatlve
academl.c baakground should be the ideas for
reglonal
the academic nature
part
counclL if
is
nedicaL school- counterperts, pararnedical personneL.
pursues h18 interest obJect of thelr
is left
as interested
in the niddle
obJectlve
of thls
the hoepltal
splendor.
behalf.
groups.
groups at present The patient
rt
rrho is the of
would seem to me an blendlng
In the center of this
in t,he pure white splendor of uneelflsh
- 3 9 -
conml"ssions
barel-y touched by the circle
to fuse these groups together,
on the patientrs
in emergency
them, the medLcal professlon
Each of these powerful
of the powerfuJ-, seJ-f-centered
bathing
The
of the time spent by their
and flnaLly,
lnfluence
society
as shock reeearch.
who elect
in the gtrory of lsolated
interest
of energency
of the emergency counctL power structure.
government and the cltizeng
care:
the patlent,
It
he Ls to be accepted by the other
Three Large groups have been ldentified
efforts
development.
in the development and organlzatl-on
to the regional
nembers as a vital
thelr
of education
Far more importantly,
care systems ls as much an academic pursuit
unLverslty
the voice
the ideae euppj-fed and energy spent by the university
emergency department dlrector
thelr
the pensioner,
must represent
his
who suppJ.les the conceptual
with
emergency groups
departments.
upon the council.
vielonary
and their
medical
play in regional- emergency medical
of aLl", the university
as weLl as servlce
the unlverslty
health
for
use the system, uust have a strong voice on the council.
Vihat part
health
deal of the finance
and dlrectlng
blend would be group cooperation.
Members of thls
association,
lt
is your Job in the workshops and in
our aucceedtng neetLngs to develop practlcal (1)
Defining
(2)
Conetructlng
a region
methods for:
Ln your own area of lnfluence.
effectlve
governlng
councils
emergency heaLth eare ln your region. audLence have experlence do not hesitate (3)
in thls
to rdrlte,
the responelbilitlee
councils
in the flelds
a.
Evaluatlon
fteLd.
Declslon
reLated
ser:vlces and poor deLivery c.
Educatlon of phyelciane the deLiverlng
d.
Evaluatlon
Get to know thenn and
emergency health
care
of:
nethode related
and action
of
thern.
of regional
to transportati-on
systemsr and emergency departnent b.
the dellvery
Many people in this
cal_l_or vlsit
Deftnlng
for
and communlcation
and hoepltal
to dupLlcation
standards.
of emergency
of energency servlces
and health-related
by hospital.s.
profeeelonaLs
in
of energency care.
of coet effectlveness
of emergency care wlthin
the
reglon.
r belleve problens
that
preeented.
not preach to othera and lnfluence
of thie
thls
organlzatLon
I{e are youthful,
hae the human reaources to eorve the
knowl.edgeable and dedlcated.
hte muet
on how to do the Job, but rat,her we must use the resources group to go hone and do the Job oursel_ves.
-40-
PHITOSOPHY, coAl,s, AND OBJECTIVESOF THIS ORGANIZATION PIAI{S FOR FALL MEETING, L970 Diecussion Leader:
Charles F. Frey, M.D.
Thls uorningts workshops.
Progr{m has been ln preparation
rn additlon
to deflning
for
the component parts
thls
afternoonrs
of an Emergency
Medlcal- Servlces System, and some of the problems associated with we hope the three prevlous goale that durlng
this
talks
have done, we want to ldentify
menbershiP may want to entertaln.
theee workshops to feed this
come to thelr flve-rnLnute crlbed
own concl'ustons.
organization? of thls
program wiLl rncluding
rneetlng feel
the provtsion
not an organtzatlon partlcipation ln charge' hospitals
to you.
unlque?
strongly
dlrectly
thls
of emergency medical servlces ln whlch eone indivlduals
in emergency nedLcal services
to the materlal
The question arisee, its
Ln their
and reglonal
garnered here or at future
lrlth
this
existence? orga nrza-
own rocalitles planning.
who have been away fron
This is aetual
for z0 or 30 years are golng to be
we want the peopl.e who are actual-Ly doing the Job 1n thelr and communlties.
for
morning,s meetlngs
the nembers of this
responsible
be trans-
be sent to the member-
How do we Justlfy that
be a
and then returned
r now calL your att,entton
trlhat makes lt
ehould be the lndlvlduals
they have
These sumnarieg wirr
edltLng
under goars that ltas Juet dlstrlbuted
The organizers
for
report,
as the workshop eumnarieg.
why this
tlon
for
Thus todayrs entire
ship eo that you wllr- have a full as well
to the nenbershLp
At the end of the workshops there will
and sent to the workshop chairnen to you.
some of the
back to us after
summary by each trorkshop chalrman.
dletrlbutlon
llsted
information
rt,",rp
Lt which
own
type of membership, any information
meetings wouLd have irmrediate and practlcal
-4r-
applicatlon
ln each membert own hospitar- and conununity. I^rith our menbership, we have a mechanism of feedback to the communi.ty which supersedes anythtng any other organization the Univers ity efforts
has deveLoped.
physicians
I.Ie also feLt
in establishing
that we wanted to assist
an academic basis for his
in the Emergency Departuent and regionat_ pr.anning of Emergency
Medical services'
Thts has been mentioned earlier
and Dr, Rutherford. actuarly
provlding
I{e ar-eo feLt
by both Dr. MacKenzie
that in the past the peopr.e who are
servLces, that is,
the directors
o f E m e r g e n c yD e p a r t m e n t s ,
have not had a spokesman nationaLl-y to present their about regional fortunateLy
pLanning and Emergency Medical services.
too many peopLe on the various
nationar
leveL have been away from actual
services
for a long period of ti.trE.
policy
advisory
consi.derations the organizers
Now, about the specific colLation ments.
These lrere some of the
meeti.ng fel_t were important and
one of them alLuded to earlier
of the Emergency Medical service
pLans from the various
information
heLpful' ln his ovrn emergency department pLanning.
particular
--
the
depart-
prove a valuabLe asset to aLl of us.
Any member now can turn to these plans and find
now of picking
in emergency medical
organtzatton.
goals --
r thi.nk these plans wilL
There are un-
And yet they are makrng national
of this
the devel.opment of thts
of view
comnittees at the
partlcipation
regardtng emergency medLcal services.
required
points
which wiLl be
He also has the recourse
up the phone or wri.ti.ng to someonewho can herp him in a
area.
HopefulLy, he wont t have to repeat the mistakes that
someone
else has already made. our organization
can also provfde a group of consuLtants for defining
the probLems ln any EI"ISsystem as weLl as expLoring soLutlons to these problems'
Thusr our organization
can act as a forum not only for the collectton
of data and development of sol.utions to the probreme of emergency rned{cal. services to assist
individuaL members, but aLso can through the collective
-42:
efforts
of all
0 u r m e m b e r sa c t t o i n f l u e n c e n a t i o n a l ,
academi.c optnions on matters rerated
regionar and
to Emergency Medicar_ services.
rn the handouts you received today, a number of possible interest shops'
are l"isted.
These need to be discussed in the afternoon work-
we need a mandate from the membership as to those areas in which
you would like this
areas of
us to take corrective
organization
Medical care?
group action.
attempt to i.nfLuence legislation
should this
organization
For exampre: should rerated to Emergency
recomrnendthe university
a rore in the regionar. pranning of emergency medicar services? th{s organization the status
make recoranendati.ons to the university
of the Emergency Department physician
should this
organization
of training
progrmls of emergency care for
students, house staff,
partlcipate
take shourd
regarding
in academic medicine?
in the educati.on of and development paramedicaL personnel, medicaL
and graduate physicians?
What should this
organLza_
tion do to educate the pubric regardi.ng the need for financiar. supporr o f e m e r g e n c yr n e d i c a L s e r v i c e s ? standards for Latlonship
emergency department faciLiti.es?
of our organization
emergency medical" services? for
shouLd the organization
thes matters.
or injured?
what should be the re-
to other groups organtzed to improve Should our organization
the communications and transportation
the acutely tLt
help establish
reconunendstandards
systems involved
in the care of
w e n e e d f e e d b a c k f r o m o u r m e m b e r s h i pa b o u t
rn the workshops you wiLL need to tel.l us rvhat methods
our organization
shouLd use tn the lmplementation of the goaLe corlectlvely
agreed upon by our membership. I.le slrould also coneider how we &re gotng to financiaLLy support the activitles and obj ectives of our organLzaflon in those matters requiring colr.ectrve action. T h u s , r ^ r ea r e a s k i n g y o u t o chart the course of this organization. Letrs review the questionnaire you have received today. PLease cornplete and return it after aLL the workshops
- 4 3 -
l
l
have been compLeted. we need your help in naming our organization. have worked with key words rike Emergency Medical services, Planning, University, term.
etc.,
to see if
we
Regional
we couLd come up with somecatchy
The one printed on the questionnaire is names: for the National
Association
of MedicaL Emergency Services.
SPERM,Fln'lEs, etc.
I,le have aLso considered BARF,
None of them seem perfect
and we certainLy
\^rant your
thoughts and recommendations. Regarding the timing of annual meetings and the possibility association with other national
groups, there are a number of considerations
that r think can be discussed in the workshop groups. be unwise for us initialLy constitution
and a better
foll-owing the Association
L970.
(2)
(3)
Before or after
the Comrnittee on Trauma meeting
The timingr
meetingr couLd be one day pri-or to the Association The advantages of this
permit a reduction
A meeting prior
for Trauma and the American col.lege of
of the American ColLege of Surgeons.
meeting.
(l)
of Academic Surgery meeting in November
Betl^teenthe Association
Surgeons meeting.
we have a
regarding the timing
the founders considered.
to or
woul_d
understanding of our
There are three possibil.ities
of our annual meeting that
perhaps it
to associate with any group until
and slate of officers,
m e m b e r s h i p sd e s i r e s .
of
particutar
at least for this
for Academic Surgery
time would be that it
in expense to anybody attending
yearts
both meetings .
would I4any ot
o u r m e m b e r s h i p s , m o s t o f w h o m a r e y o u n g , a r . e a l s o m e m b e r so f t h e Assoc{atlon for Academic surgeons. Because the Association for Academic Surgery meeEing follows
the American college trEeting it
and the constitution
wiLL permit the executive conrnittee
conrnittee the opportunity
problems at the American coLl.ege meeting prior rn preparaLion for regarding
subjects
the Fall
and programs.
to meet and solve someof their to our November meeting.
meeting, we would Like to have your thoughts hle feLt our organLzaELon should not engage
- 4 4 -
in the presentation
of scientific
treatment of injury.
we felt
matters organizational
papers on the patho-physi:or.ogyand
our meetings should be devoted to those
and administrative
deLivery of emergency medicaL service, shouLd be considered.
Do you prefer
related
The format of future
meetings
t h e w o r k s h o p s , p a n e r _ s ,f o r m a r t a r k s
or other vehicLes of communicati.on? our regionar the responsibility
to improving the
representatives
of contacting aLL of you end from the turn out ir
would appear they have done an excellent expand or contract
job.
some of these regions.
However, Iou may wish to
your forder
contains a
Li"st of the regions and the states included in those regions. individuaL
who outlined
a foreigner
to the united states.
of Nebraska had not been
This did cause us some consternation.
To meet the future needs of our organization, pLanned this meeting feLt it
best to recruit
of the founding fathers,
and a few addi-tionar- representatives
the group which had a broadLy-based organizational
the regional
of speciar tarent
taeks by the FalL meeting; that is,
acting secretary,
representatives to perform the
to develop a constitution,
to develop a faLL prcgram, to recommend a slate ship of the organizatLonal
of officers.
caucus rncrudes your acting
Jim MacKenzle, Robert Rutherford,
The member-
chairman, the
the host for
meeting, ALan Dimick, Ray rdathews, George Johnson, Lesrie Rudolf, stahL, Max Rittenbury, Yates, Earr. wilkins,
r^ras
some curious things did happen. Last
somehowthe state
incLuded in any of the regions.
caucus consisting
The
the geographic boundries of these regions,
night we discovered that
following
had
thls Biil.
carter Nance, Herbert Hechtman,Andy Hreno, Adorph
Bilr
sosman, ltrarlan Root, pete canizaro, cuthbert
owens, Bob Lium, Rorand Folse, carl Jer.enko rrr, group can develop a sound constitution
for
this
- 4 s -
and will"iam oLsen. organization
This
and recommend
an outstanding at this
slate
point.
of officers
to run it.
irle could have some discussion
Perhaps someof the other individuaLs responsibLe for
your being here might l^tant to make some cornments. Jim, do you or Bob have any additional
material
that
should be covered?
DR. I'IACKENZTE:There are just have set out a list forrn of regions, university
two or three things.
of the members by a]-phabetical- order,
One is that we and also i"n the
the state or the province to which you beLong to;
and the hospital- in which you had written
department description
from.
the
your emergency
Now, I am sure that with
the mass of in6or-
mation that was coming in to me and then having to be passed on to other people in such a short time that that
some nâ‚Źrmesand addresses are \rrong, and
some people are put under the wrong region,
something like
that.
m i m e o g r a p h e dl i s t s
information
so that you can @rrect
them.
rn addition
to that,
sheet questionnai-re onto the direccory
you to complete so that we could have some more correct
about yourself
and about the area, the activities
emergency department Ehat you are associated with -I would appreciate it new information
or
That is the reason why you have been given these
we have put a new information that !'re would like
the wrong hospital,
if
of the
your University.
And
the people that are here would fil-L out those
sheets and Leave them at the registration
desk.
I think
thatrs aLL. DR. FREY: Bob, did you have any comments? DR. RUTHERFORD:Just one thing affiliation
I wanted to mention in terms of our
or association being in the same pLace as another group.
juet wanted to make a couple of additional be important
in the final
membership,
In regard to the Association
points which r think might
decision which has to be obviously
tion doesn't have a specific
up to the
for Academi.cSurgery, this
role in our area, but I thi.nk it
u s w i t h a m e c h a n i s mf o r v i s i t i n g
r
organLza-
doee provide
in a natuxaL way the various university ' 4 6 '
hospitaLs.
We couLd have an on-site
visit
every year and not get involved
in the san Francisco, chicago, New york, Atlantic I mind the San Francisco - and which would involve of the side trip
between the meetings to visit
have our meeting.
rn addition,
and some of the best talents creasingl-y involved cLubs' etc.,
city
places where we decide to
organization
of this
group
are going to be in-
in committee meetings and council
and aLl- of these things,
not that
maybe an extra expense
r thinle the leadership
in this
--
circuit
meetings, biology
We are using the American Co1-lege
of Surgeons as a place to get together and we might not have an opportunity to have this just
sort of talent
in our midst when we need it
wanted to add a little
be Leaning toward this
more information
one choice,
most.
so r
as to t,he reason r,re seem to
but again, we certainly
want to have
everybodyt s comments on this. DR. YotlI\tANs,Kansas city: prtmari.Ly surgeons as r am. come into
r realize
NevertheLess, most of the patients
our emergency rooms are not surgical
that we Lean too much ln the direction internaL medicine or pediatrics, DR. FREY: I think
this
up and our thoughts are that
the individual
in which we are interested
be he an internist,
institution
that
pedLatrlctan
or
such as a co-
that the emergencydepartment director
We dontt have any intent
anybody who is in any l,rtayresponsibLe for
and
rn other words, there is no
there couLdrft be more than one individual
coming to this meeting.
is
the surgeon plays a secondary roLe, r
the surgeon couLdn't attend this meeting. reason at all
issue that you harze brought
there is a relationship
chairmanship with the surgeon or if dontt see any reason at all
I am concerned
of surgery to the exclusion of
is an important
on the other hand, if
probLems.
that
etc.
the emergency department director, surgeon.
the founders here have been
providlng
- 4 7 -
from a particular to exclude
emergency medLcal service6.
DR' MACKENZTE:Therers one other item. from aLL of the regi.onar d,irectors, contacted seemed to be surgeons. of verrpnt
ar.most arl
been invited
of the peopre that were
as the Director
There are anesthetists
emergency departuents and r think peopre have all
sheets
Now there lrere some, the University
is one, that have an internist
emergency department.
From the information
of their
who are Directors
there are some pediatricians.
to this
particular
of These
meeting and any other
meetings that we have, but there is no doubt about it
that over 99 - 95
percent of the peopr.e who are emergency department Directors. DR. J.T.
sANDy, vancouver, British
i'n a pLea for
representation
constitutional'
organization.
columbia:
r wouLd just
like
to put
of some of the !ilestern part of canada on this r think
there is a big chunk of the country
there that werve ktnd of forgotten about. DR. FREy: r think
that has been taken care of,
Iitas one of the areas that we wanted to further if
ParticularLy requlred. He wiLl
there was additlonaL
Any further
hasnrt it
This
explore in the workshops
regionaL representation
conunents? I think
Jim?
thar lras
Dr. DimLck should have the f1oor.
expLain the tour of the emergency department and how he is going
to intergrate
Lunch somehowinto
this
scheduLe that he has devised.
- 4 8 -
EI"ERGENCY}GDICAL SERVICES coI"ftIITTEE . BIBII"IING}IAM.AL$BAMA
The EMS committee was formed in 1967 by a resoLution of the city council. rt performs in an advisory capacity to the city council, but has no legaL authority. The commlttee is composed of representatives from the fol_lowing agenci.es: American college of surgeons; county MedicaL society; Red cross; civiL Defense; Regional. HospltaL council; county iieaitt, Department; Bar Association; police Department; Fire Depariment; Board of Education; ldotorist Association; Ambulance Association, Cormrunity Services Councll_. ldeetings are monthLy throughout the year at Gity Hatt. standi.ng committees i.ncLude: conmun{cations; Transportation; Emergency Facilities ; Education. This comrnittee has been responsibl-e for: (L) The revision of Btrmtnghamrs ambulance ordinance in February 196g; (2) organi_zi.ng a df.saster plan for the Birmingham Airport; (3) implementatlon of a radio network between the locaL hospitals and between ambuLances and hospital emergency departments; (4) sponsoring training courses for a*ulance and rescue personneL
ALan R. Di.nick, I't.D., Coordinator Emergency l,Iedical Services Comnittee
- 4 9 -
I. II. I1I.
Def ine the probl_ems Ourline
the Solutlons
C o n s i d e r what our organlzatlonrs
1. 2.
rol"e should be in -
Deflnlng and cormrunicatlng thle Helplng out membershtp inlff"r"rrt
H:t;:lrffilti$"ind
lnformation to the public. improvemente in emergency
ieglonatptanntnsar rhe local, "r"tl,
WORKSHOP OUTLINE. I{orkshop I
Movement of the acutery irl Emergency Department. Surveillance Traneport Comnunicatlon Tralnlng reacue workers
and/or lnJured patient
to the
Workehop II
Emergency Department Physiclan staffing Speclality stafflng of radlology equlpnent and sraff fvaflapfUry Availabiliry of operart;; ,oo*" and staff AvatLabllity of blood anl blood bank personneL Dlvereion of_non_emergent medlcal r"d' ;;;;ical iLtness from the Energency Department Dlfferent patterne "".r, ,tth cityr county, and prlvate hoepltals
I'lorkshop III
PJ.anning of Emergency Medlcal Services Emergency Health Councile _ loca1, regional_, and state Coordlnation of ambuLance servtcee Grading of emergency departmentg Postgraduate tralnrng- oi phyelclans in resuscitatlon reehniques and ,eihods'oi hoepdtaf transi", _ Community educatlon and publ_ic relations AnbuLance ordlnances coununlty fundtng and the financlal justlfleatl0n of , Frnergency Medleal Servl.ces Staffing and pJ.annlng
- 5 0 -
!g!4T4AEIITS Or. WORKSHOPSBY WORKSHOP CHAIRMEN - Seattler Washtngton hard to contract the many workshop comments into five.minutes.
Itts
is one of the rnost enthusiastic meetings I have attended in a long time.
This
I think
this is becauee everybody came for a set purpose. At the first of thie workehop we spent the time discussing an organization of the type that has been euggoated, and. it wae the coneeneus of the group tbat it was defi.nitely inilicated but that the organizati.onaL etr;cture tled by a caucus committee. format.
I refer primarily
would best be set-
to the officers,
bylaws and exact
However, congiderable discussion was given toward. what type of rneet-
ing might be beet, and I think there was general agreernent that it should be a struchrred,
but informal meeting in the sense that symposia such as were pre-
gented today would allow individuale to come and discuss mutual problems.
It
wae also fel.t that it should not be just a time when we come year after year to rehash our outn pereonal inetitutionre problems,
but ehould be one that was well
thought out ahead of time and had a specific planned program with topics designed ahead of time which would allow the member's to come with some forethought and possibly with even some presentatione.
The group was definitely againet having
scientific segsions in the senae of papers related to trauma or shock as we have in gorne of our other meetings, but possibly having diecussions relating more to medical care delivery and the adrninistration of ernergency eerviceg, much as have been outlined in the rneeting today.
It wae felt by the group that this could
-51 -
be an irnportant organization for gathering data referable to the emergency delnrtments
of universities
and that some type of opinion poll or data gathering
source shoul'd be initiated very soon so we can bring together some of this information and then possibly sorne type of ongoing data gathering gervice should be available which would enhance a more uniform approach to medical care in manv of the universitiest
settings.
As far as the site of the meeting, it was felt strongly by the group that this should be at a different university center each year, because one of the highlights of this present meeting was being able to visit the ernergency department here in Birmingham.
It wae felt that this did not have to be tacked onto another
meeting and probably would be better not tacked onto another meeting since it was felt that most members could finance a eeparate meeting. ing wouLd allow some variability
A separate meet-
and also would eliminate the problems assoc-
iated with dilution by another meeting.
It wae fett that the results of this meet-
ing and other meetings should be pnrblished and distributed.
one of the problerns
that was touched uPon is how do you prevent an organization such as this from being another academic stepping stone or just another place where one comes to present his papere.
It wae felt that much of thig might be eolved by having
anonyrrrous reports,
by stressing group action, by using the symposium as a form
of presenting ideas, and by publishing detailed data of the meetings.
The re-
mainder of this workshop was spent discussing some of the aspects of medical care delivery and organization of emergency rooms,
the basic problem being one
of the segregation of the non-acute, walk-in patient from the emer gency patrenta. - 5 2 -
Each hospital setting had a different
solution to the problem,
and I think we can
surnmarize that we are not going to find any single method which will be applicable to any hospital. were administratively
It wae stressed that most of our group were surgeons, most responsible for the emergency department, most spent
only a srnall portion of their tirne each day achrally working in tJre emergency deparf,ment, so whether we like it or not, many of us were Snrrely and eimply administratprs
of tJr'eernergency departmeat.
to know about the emergâ‚Źn cy departrnent,
This merely cornporrnds what we need
means that we have to be better in-
formed and have to have sound opinions so that we can cliecuss with the administrators,
and our medical colleagues how the organizatiorurl structure should be.
A number of other items concerning individual problems of reEidency training were touched upon and it was decided that these are items which should be discuesed in greater detail in some of qtrr fuhrre meetings, and in structuring the meetings we should pick out epecific pointe that could be discussed in great detail concerning teaching, concerning the rel,ationship with other hospitals, and a number of other items.
- 5 3 -
- Newyork Clry, Newyork S_UMHARY BY DR._b/lLLlAM STAHL: I c a n e c h o t h e f a c t t h a t t h e w o r k s h o pw a s e n t h u s i a s t i c . h a d s o m e t h i n gt o d a y .
I hope they all felt
Everyone
t h a t t h e y h a d a c h a n c et o
part i ci pate. T h e a t t e n t t o n o f a l l w a s d i r e c t e d t o w a r d p r o b l e m st h a t w e r e v e r y b a s i c , a n d w e d i d n r t t â‚Ź l k v e r y m u c ha b o u t t h e s o c i e t y i t s e l f .
In general,we felt
t h s t t h e s o c i e t y w a s v a l u a b l e a n d : c o u l d h e l p b y p r o v i d i n g a c o n c e r t e de f f o r t t o i m p r o v e s o r n eo f t h e p r o b l e m s t h a t w e a l l h a v e . W e a d d r e s s e do u r s e l v e s m a i n l y t o r a r d t h e p r o b l e m o f s t a f f i n g i n t h e e m e r g e n c yd e p a r t m e n t . l ' / eb e g a n b y s a y i n g t h a t w e a l I h a d t h e s a m ep r o b l e m sm e n t i o n e db y B o b R u t h e r f o r d , o f p a t i e n t s c o m i n g i n t h a t w s r e n o t e m e r g e n tb u t w h o n e v e r t h e l e s s should be seen.
lt was agrecd uponat the outset that one of tte major causes
o f t h i s p r e s s u r eo f p a t i e n t s i n t h e e m e r g e n cd y e p a r t m e n ti s d e f i c i e n c y i n h e a l t h c a r e d e l i v e r y o n a n o n g o i n g a r n b u l a t o r yb a s i s i n m a n yp a r t s o f t h e c o u n t r y . A l t h o u g ht h i s p r o b l e ml s n o t w i t h i n o u r s p e c i f i c a r e a , i t i s a m a j o r f a c t o r w h i c h b e a r s o n t h e p r o b l e m s t h a t w e s e e i n t h e e m e r g e n c yd e p a r t m e n t . p e r h a p s t h i s a s s o c l e t l o ns h o u l dd i r e c t i t s e f f o r t s t o t h i s a r e a a l s o . There were differences of opinions ss to how to train a person to take care o f e m e r g e n c yp a t i e n t s .
lt was felt
t h a t c o v e r a g ea t t h e a t t e n d i n g l e v e l s h o u l d
b e p r e s e n t i n t h e e m e r g e n c yd e p a r t m e n ta t a l l
times.
Suchcovsrageshould be
i n a s m u c hb r e a d t h a n d d e p t h a s p o s s i b l e u n d e r t h e c i r c u m s t a n c e s . t / h e t h e r t h i s a t t e n d i n g s h o u l d b e a s u p e r s p e c i a l i s t , a s o n e o f m e m b e r s u g g e s t e d ,t r a i n e d q u i t e h i g h l y i n a n u m b eo r f d l s c i p l i n e s , o r w h e t h e rh e s h o u l d b e w h a t m i g h t b e g
r
l
c a l I a f a m i l y p h y s i c i a no r " p r i m a r y p h y s i c i a n r t r a i n e d t o a c e r t a i n l e v e l i n - 5 4 -
a l l d i s c i p l i n e s a n d r e l y i n g o n s p e c i a l t y b a c k u p ,w a s n o t d e c i d e d . There are difference of opinion.
T h e r ew a s a f e e l i n g t h a t t h e r e s h o u l d b e a
r e s i d e n c y i n e m e r g e n cm y e d l c t r p , 6 t r a i n i n g p r o g r a mt o t r a i n p e o p l e t o f u n c t i o n i n a c a r e e r i n e r n e r g e n cd y e p a r t m e n tm e d i c i n e . T h e t e a c h i n g v a l u e o f t h e e m e r g â‚Ź n c yd e p a r t m e n te x p e r i e n c e a s t h e f i r s t medical student was stressed.
patient contact for a
In the hospital of one of the people present,
t h e s e c o n dy e a r s t u d e n t w a s e x p o s e dt o h i s f i r s t
patient in thb emergency
department. lt was felt that this wasvaluabletraining on through the residencylsvel. T h e o t h e r a s p e c t o f p b t i e n t c a r e i n t h e e m e r g e n c yd e p a r t m e n td e p e n d s o n a d e q u a t ef u n c t i o n i n g o f a g o o d h o s p i t a l .
lt was felt
that a holding ward
w a s a v e r y i m p o r t a n t p a r t o f e r c r g e n c y d e p a r t r n e n tf u n c t i o n .
W h e r et h e s e a r e
in operation they were well usedandwere thought to provide a vital function. T h e i m p o r t a n c eo f a n a d e q u a t ei n t e n s i v e c a r e f a t l l i t y
in the hospital was
stressed in order to provide a suitable locale for the patient once the acute r e s u s c l t a t i o n w e r e a c c o r n pi sl h e d . T h e i d e a l i z e d f u n c t i o n o f t h e e m e r g e n c y d e p a r t m e n ti s n o t t o g i v e l o n g - t e r m h i g h l o v e l n u r s i n g c a r e , b u t t o r e s u s c i t a t e a n d m o v et h e p a t i e n t t o a d e f i n i t l , f , e c a r e a r e a a s s o o n a s p o s s i b l e . in all,
t h e d i s c u s s i o nw a s s c t i v e a n d I t h i n h c o u l d h a v e c o n t i n u e do n w e l l
into the late hours.
- 5 5 -
AII
- Dallasr Texas We qlso hqd o very enfhusiosticgroup. The first portion of fhe meetingwos spent discusing requirementsfor membership,ond I bring this up only to rep6rt the vofe os recorded. One individuol did remqrkofbr survcyingthle rqthcr lmprcrrlvc group thot he wos not sure he wonfed to ioin any orgonizolion thot would hove him os o m6mbâ‚Źr. The only foct everyoneogreedon regordingmembership wos &hotthe individuols involved should, in foct, be direcforsof their respectiveemergencydeportments. Regordingthe questionobout universityversusnon-universityoffiliofion, only three individuolsrhought itshould be strictly limifed to full-time universityfoculty. The moiority thoughtthot membership shouldinclude port-time clinicol or full-time foculty if the porticulor individuql is the direcfor of the emergencyroom. All membersogreed thot this group shouldform o seporoteorgonizotion connectedwith one of the moior meetingsin time only; thot is, coincident with o porticulor meeting, but seporotein orgonizotionolstructure. Regordingthe content of subsequent meetings, it wos felt by o moiority of the membersthot formol presentotions be held to o minimumwith emphosison workshopsond ponel discussions. In porticulor, presentqtions nof relevqnt to emergoncyroom cone, orgonizotion, tronsporfofion, etc. shouldbe ovoided. The group then discussedproblemsreloting to emergencyroom focilities which shouldbe included os topics of discussionin lofer meetings. Of immediote importonce,os mentionedin the fwo previousgroups, is treotmentof the non-emergentpotienf , This is of porficulor importoncein emergencyroomsthot hondle very lorge potient loods, The solution seemsto revolve orounddevelopingon efficient trioge system os Dr. Dimick hos done here in Birminghom. An ideol trioge sysfemwould sort out thosepotientswho could sofely be referredto ouf-potient clinics or privoie physicions ond frioge thosepotientswho - 56 --.
'
. need immediqtecore bqck to the opproprioteportion of the emergencyroom. A question wos then roisedregordingfhe bosic function of the emergencyroomwhich I think has olreody been onswetedfor us. There is no doubt thqt the emergencyroom hos token the plcce of doctor's offices, ot leqst for colls ofter 5 p.r.,
but I think it is somsthingwo qrr
nof going to be oble to ovoid. Therewos cr concensusof opinion thot the besf woy to hondlethis porticulorproblemis developmentof on efficient trioge system. Anofher point not previouslydiscussedinvolved whether oll hospitols within o given communityshouldbe equipedto hondleoll fypesof emergencies.Thegroup ogreedthot oll hospitolswith on emergencyrrcom,regordlessof the size, shouldbe oble to toke core of the immedioteproblemsond orrongefor tronsportotionto o more complete focility.
lt is proboblyunreolisticto hove o ClossA emergencyroomin every community
hospitol however, qnd the solution is going to revolve orounddevelopmentof integroted regionolfocilities" Relevontto this discussion,it wqs olso pointedout thot monyexisfing ., emergencydeportmentscould be mqde much more efficient with reorgonizotionof existing focilities ot o minimolexpense. Another point which wss discusseddeservesconsiderqtionby this group. One individuol in the workshopdoesnof yef hove, but is in the processof setting up on emergency deportment. He proposedthof this orgonizotionhave on odvisorycommitteethqf on individuol could contoct in this regord.
Thonkyou.
- 5 7 -
SUMMARY BY DR. CAR! JELENKO- Augusta.
Gporsia
Our group dld not addrees lteeLf ralson dretre
of the society,
there ls a rol-e that
thls
indlvidual.
It
ductlve
dlscuesing
tine
to some of the problems of the
soclety
spent considerable portlon
this
such an lndlvidualr
at least
such as the professor
chairnan;
of an academie status,
deflned
It
and delimited;
perheps he ought not be as a chlef
and chairman of a department of surgery,
he would have conslderabJ"y more Latltude
wae felt
of a service, but thaL his
that ln thls
in moving patients
nenbershlp
querled,
of lts
time,
The
depending upon the
to the emergency room and the bulk of the lndividual-s,
as we have heard before, The guestlon,
30 to L00 percent
way
ln and out of his
and that wae coneldered by the group to be a maJor problem.
group devotee approximately
spend the most of their
tlme in adminlstrative
then, came aa to what sort of ataffing
consldered wlth regard to glvlng was discussed regardlng and lt
role
that
department ought to be separate and dietince.
service,
the rol-e - the
was the consensus of
and lt
needed to have hls
he probabJ.y ought to be a departnent
the
very vlgorous and pro-
of its
probLems, beglnntng with
certaln
lndlvldual
the group and for
can serve for
precise roLe - of the lmergency room director, the group that
overwhelmingly that
except to conclude rather
needed to be
care to the slck and inJured,
screenlng
wae the consensus that
pattern
out non-emergency patients
perhape we are doing the lriage
dutlee.
and some question
and triaging, businees all
wrong,
that perhaps we ought to adJere to the deflnitlon
of triagerwhich
the more experienced
perhape our emergency rooma
ought to be staffed year reeldent, selecting
individual wlth
and that
of patlents
does it,
and that
a mfnlmum, at Lea8t in the surglcal the nore experlenced
to go ln the back.
- 5 8 -
lndivldual-
says that
area, of a second-
ought to be doing the
These were the naJor areas that consensus that thls actlon,
organizatlon
serve a useful
functlon
the guoup covered and it
could, by its for each of its
- 5 9 -
was the
interchange and by group individuar
mernbers.
SUMIfARY BY DR. ADOLPHYATES: - Pittsburgh, The hour and a half
passed fast.
anpngst a group of doctors, workshop.
pa.
I have never seen Less disagreement
and particularLy
surgeons, than we had in our
t{hiLe we touched on some specific
room' we certainly
problems regarding
did not nor intend that we shouLd come up with
solutions.
We covered the fi.eld quite widely,
Points that
I think lre got out of our session,
on ltas a name for for a sizable
thi.s group.
It
and I wiLl
polnt
that arose I think group.
cosmunicati-on, trai.nlng
one thing we did not touch
didnr t dawn on us until
lras an Lmportant one.
!,le are starti.ng
and servlc,e than the naJority
leveL.
of that staff.
untversity
lnvolved
that
problem.
reLated to the leveL of
of doctors respon-
We are starting
from a
services;
the emergency room, but rather
The problems are di.fferent
affiLlattons.
in the diesemination
have aimed their
It
Our probLems are not backup or specialty
probleurs are not those of staffing
without
we finished
from a different
sibLe for emergency rooms ln the Untted States.
of trelning
note some
There dtd not seem to be any purpose or identi.ty
uniqueness of this
unlversity
just
specific
group f.ike thts we may not know what we are caLLed, but we
kno^r vhat \de are. The first
the emergency
the Level
tn maJor city
The naJor medical and surgical
our
hospit*Ls
groups
of emergency roomr phiLosophy and standards
broadside pretty
to have often missed the university
much at hospitaLs hospital,
in general;
in particuLar.
they seem
In somesettlngs
we shoul-d put not one but two residents
fulL
We must deaL wi.th probl-ems of financing
for what the medicaL school keeps
caLling
deftcit
spending in the emergency department. These are problems
that nobody has touched upon in national vlctim
time in the emergency servl-ce,
at the university
groupâ‚Ź.
Whtle the major trauma
hospitaL may be at times ttovertreatedtt (many times
one of the jobs of an emergency room director
- 6 0 -
will
be to try
to crear
the area
of aLl the excess heLp) the non-university type of patient is
f,o the university
sometirea true,
hospitaL.
the non-acute.
hospttar
unfortunatery
ls not always
present themselves to the
we are not doing what the patient
good Job wlth the non-acute patient,
that
rn soue large cttLes we are tosing
image with many of people that
emergency room.
tend to steer
The reverse,
and"that-J*6, the university
doing a good job with our public
hospitals
considers to be a
partLy because of interest
of the
people that
are running the ernergency room, but also partl_y because of
the public.
Thts is where the community hospitaLs are often dotng a
better
Another potnt
Job'
about Phase r, Phase rr,
that came up--rhe
the time before the patlent
the part in the hospltar
speakers this
casn to the hospitaL,
they are finished
room and don't
treatment.
and
emergency room , but we thought that
perhaps a maJor concern ehoul.d be calLed 'phase rrrr', after
morntng talked
what do you do
Many peopLe waLk out of an emergency
know when they are supposcd to come back to have a cast
removed;'they donrt know when or whom they are supposed to see to have their
sutures out;
and Lf they are to see someone, itrs
body that had no part in thelr think
need to be discussed,
tnitial-
as this'
we felt
related
and probl'ems.
was
problenrs that need soLvtilon and
There is a need for
such an organi zat1on
that future meetings should not be excLusiveLy scientific
sessions, as the previous speakers have al.ready said, be dlrectLy
organlzation
of the workshop to our group rra6 the
there $tere stgnificant
which we had not even broached,
is an important
we feLt as far as this
concerned, one of the maJor effecte that
Tte se are problems that we
,phase rrr',
and we think
aspect of emergency room care.
rearization
care.
generar.ly some-
but we thought it
to grassroots managementand detivery
we thought that
specific
topics
- 6 L -
care methods
to be discussed at future
should
meetings should be narrowed dswn to a Itmited of us are tnterested attending
because so many
in alX.phaees that we may feel we have lost
some of the other workshope ln which tre may be equally
In sumary, deflntteLy
field,
aLL ln our group felt
that conttnulng
a must.
- 6 2 -
out by not lntereeted.
such a soctety was
- Charl-esron, South Carolina SUMMARY BY DR. MN( RITTENBURY: Our workshop was concerned with asked to discuss emergency nedical
the problems associated services.
reaLized the need for state
level-s.
a different
I thtnk
phase, and we hrere
wi.th regional
that
rul-es, etc.
It
of the avatlabLe services
was suggested that
nati.onal and
could the.n be coordi.nated and
used at a locaL leveL at pLanni.ng. Everyone feLt utiLization
for
everyone tn the workehop
planning at severaL LeveLs, i.e.
The guideLines,
planning
that
the goaLs of better
should be attained.
the criteria
establtshed
for accreditation
of hospital.s and emergency departments in the hospitaLs wouLd then leave the choice up to the hospital and that
this
as to the LeveL of attainment
approach could faciLitate
leveL when you got into
on a local
was aLso brought out that
be done by a council
the areas, or the definition
that
for
survl.val.
i"t was necessary for
locaL pl.anntng to
There wae realLy no definition
of thi.s conunittee, except that tt
broad based in a general. way.
It
of
should be
wouLd vary from community to cotrununity and
of the areas, rdorlld be probabLy aLong natural
or medical referral
gutdelines of,
of saying whi.ch
Thls probLem was separated fro,sr that
or. a comittee.
the slze or the structure
politlcaL
gri.tty
planning when everybody works together
of disaster It
some of the planning probl-errs
the nitty
hospitaL wiLL take whlch patient.
they wished,
Lines,
rather
than upon the cetebll.ehed
i.e. e one conmittee per 501000 popuLation,
Lt wae etressed
the ruLings or the reconmendations of these commi.ttees probabLy shouLd
not be dictatorial that action
mandates (both on the natiaral
or the Local- LeveL), but
on these recommendations should be obtained by having poLiticaL
representation. It councils
was mentioned that by the physicians,
there \,vasa strong leadership but this
did not necessarily
- 6 3 -
role
in these
mean that he had
to chair this
these commi.ttees or counci!.s.
were discussed generail.y,
current
that
he is
what the crlteria involved
vartous
and r think
that
probl-ems associated with it
rras a stong under-
the f,LnaUrguLderrr of the couneil, for
tho one who nayn
performance should be, but he doesnrt
in the routine
of datly
admtnistration.
There is a need for
a strong codmi.tnent on the part of the consumer to this Nor, we Left this the role
topic
counciL.
to discuss the other charge, to discu.ss
of such a group of peopre as have met here today.
No one,
when the question was fi.rst
broached, had a cLear definltion
and alns of or the nead for
this
discuselon
group to meet.
involvement
academlc pursuit
faculty.
this
there
ls a need for
membership at the untversity
feLt
that
thls
should have its the specialties
surgeons should be
or need or ski.ll.
rather
It
was
spectrum of emergency
than Just the probl.ems attendant
upon an emergency
type of hoepltal.,
because lt
that you reall-y cannot separate at 1. of theee problems from your role
as a university
or the patient
care rol,e which you have to parttcipate
member. rt was felt
group would not really
national
not just
the group probabLy should discuss the entire
educational
this
that
membershi.pshould not be inclusi.ve of the non-
department tn a hospttal. or in a unlversity was feLt
the universities
of achievement; that all
Persons except for spectal interest
medicaL services,
though, as the
by members of the university
type of society
i n e m e r g e n c ym e d i c a L s e r v i c e s ,
incLuded; but that university
level
of the goaLs
in emergency medicaL servi.ce planni.ng
and such care is a legittmate
tnterested
r think,
Progressed there seemed to be trends that
are cormtitted to cormunity
heve to Bat
groups; ol either
the emergency services
that
dupllcate
these types of acttvities
the activities
the Association
for
by
of other well-known
the surgery of Trauma, because
are much broader based than just
- 6 4 -
in
treating
tnJuries;
or the American College of Surgeons Conunitteeon Trauma, because they deal at a different
lreveLand nlth certain di.fferent emphasisupon
other types of probLemsrather than those this group wouLd deaL with. feLt that these groups would overlap in someof their activitles
We
and
probabLy fi-l'l in somevac&nt spaces, but would not be true dupLicates. rt was felt
that the time is ripe qoy for the formation of such a group
and that this covers alL spectra;. of the medicel and the tay problems.
- 6 5 -
SIft{MARYBY DR. JoiIN J. voNDRE&Ii,- Milwaukee, We spoke about the utll-ization bit
of detail,
talklng
inpractical-ity multl-mlssion
prlmarily
in using it vehlcle,
for
around some of the legal
feastbiLlty
of landing
surveillance,
problens with
in the city,
except for
hoepltal's
and gity
property'
and we mentloned an example of this
governments wll-l
l-and ambulance company. from MlLwaukee lnto
proJect.
occurrLng
The reaaon we feel for
whether varlous
recently
on rheir in a
wanted to take a
carrlers
at the
incrudlng it
will
the ambulance attendants
by the group that
land amburances, rs
end up betng a municipal
operators
and the ambuLancea, the cost may
can no longer cope with
Lt liras more important
than it
property.
thile way is that as we keep adding more rules
the lndlvldual
scene of the accident
to have an expert
was to have a rapldly
scene back to the hospital.
Therefore,
movlng vehicre
away from the accident slte.
- 6 6 -
thls.
rt
at the from the
we should probably work
harder for havtng experts brought to the scene than we shouLd for transport
of
owned and operated by
and the lngurance
golng to get so expensive that
get eo high that
accldent
factor,
The ambuLance operators
wieconsin
we
and the
of wleconsin obJeeted to the hel-lcopter landlng on thelr
and regulations
was feLt
the helicopter
Jet hellcopter
The cost of any ambulance servlce, probably
ambulance, etc.
al-low you to land a helicopter
I'Iisconsin area where we do have a Bell
unlverslty
must be used as a
the expreseway system.
Another problem we taLked about wae the J-iabiLity
Patlent
It
a
and its
on the expressr^rays, and the non-practicarlty
the heLicopter
a private
ambulances in quite
an amb6lance.
for police
also talked
utllizlng
of helicopter
about the cost of the helicopter
solely
e.g.,
wisconsin
hellcopter
Next,, we rilent into
the communication systems.
We spoke briefly
the II.E.A.R. systen-.and some of the problems the various hospitals Some sets are not turned on and the people are afraid have to pick up a mlcrophone and talk companles produclng this companies are produclng telephone for
instead
of a hand mf-crophone like
communicatlons Bystem.
lietening
and deLlvery being printed good ldea lf
roon.
as well
a few mlnutes,
it
I^le thought
it
mlght be practical group on
types of training good.
rotations
was nentLoned that
programs for
rescue
They are uslng a two-year,
in emergency room, operating
thls
booklet
surnmer a tralnlng Surgeons.
plan lnetead
It
room, ls
might be a
of every com-
teachl.ng progran.
by having Mr. Dowllng speak about the program {n Jacksonvllle,
and I think
best rescue units
for
us a
perhaps Nebraske ls ahead of
everybody used the same instructLon
We flniehed
Waters.
ln-hoepltal
own llttle
easier
fron Nebraska told
to hlm talk
by the AmerLcan Acadeury of Orthopedic
munlty havlng lts
Florida'
It
nakes it
Thls wouLd be at our next rneetlng, hopefully.
about dlfferent
program wlth
It
Nebraska to speak to the entlre
people, and agaln Nebraeka looked pretty part-tine
not Just Motorola-*GE and other
much unanlmous â‚Źrmongthe group that
We aLso talked
one of the
Because of this,
Our representatlve
hin or one of his membere fron
thelr
to use t,hem because they
I an holding.
everybody el-se ln the cornrnunication system. for
are having.
sound equlpment) has changed to hand sets much l-ike a
about hls eytenr, and after
was pretty
it.
type of system (its
peopJ-e uslng the equLpment.
llttLe
lnto
about
most of you w111 agree that
in the country.
they probabl.y htve one of the
Thts le operated,
They have a superb program using physicians as theLr own technLclane
tralning
ae we aL1 know, by CaptaLrt in the tralnlng
people to use backboards,
etc.
- 6 7 -
progratr, splinting,
our group addressed itserf atructure
and the establldhnent
country'
rt was pointed
counclls
of councils
of these councils
w111 be publlshed was the feellng
we felt
are necessary.
of our group that
that
in conmunltles
and we felt
by the Al'lA council
in the dlrectlon
to Emergency care councir_
th18 0rganizatlon for
structure
we felt
from attaek, that
regl0nal
euch as De' Mackenzle outllned vary ln slze and Politlcal lnclude
a naJor receiving
dLrect lteelf
Servlces,
shoul-d protect
should be estabLlshed ln hle excellent
special
facility.
lnterest
ln emergency medlcal servlces
rt was felt
that
that
sub-
basis
These would
the council
in Batel-lite
rt was fert
actlvltiea
practlce
- 6 8 -
or a
a1r areas of the best
rt was the feeling
of
by the appropriate
that many of the councils
are aet up to gulde varlous nedlcal actlve
buttressed
shoul-d
hospitals
patlent
ln the cornmunlty, and that
ln the cormunity shoul-d participate.
people who have no current
interests
on an lndlvldual
the council- should include
rhe councLl shoul-d be heavily
cLinlclans.
but it
when change occurs.
rt wae also felt
source'
actlve
which
aspects but should, ae Dr. Mackenzie pointed out,
referral
the group that
the
and politlcal
preeentatlon.
toward lmprovLng the care of patiente
avallabl-e
have
should partlcipate
whlch mlght aerve as a prirnary source of care of a partlcular
talent
the
such counciLe in the future.
whlch is frequentJ-y lnltiated councils
for
There are guldelines
on Emergency Medlcal
of guldelines
the council
that guidelines
ln the comnunity such as the medlcal school or the local divlslons
throughout
out that very few communlties in the country
such as we 8re dtscussion,
estabrlehment
actlvely
principalry
or conrmlttees whlch
are set up and governed by
ln the area in whlch they are lnvolved.
-
It
was strongly
suggested that
ln the emergency medical service and thereby the activLtles The councll
those of us who are activeLy
area direct
ehoul"d survey the cormunity problems.
changee ln the conmunltyrs
for
itself
lnltlal
relations;
of the need for
of the council 1.e.,
function
structure. ltself in order
goaLe.
wlth to garner
One of the
ln each comrnunlty, our group felt, in the comnunity of an appreciati.on
improvement in our emergency medlcaL servlces.
was etressed that
council
inttlal
moves to recommend
to implernent lts
the generation
the orientatl-on
importance of the conmunlty health services
lt
economic and otherwlse,
as much support, as poselble
was publlc
before
Its
such a councilrrehouLd ldentify
of the comrunlty,
responslbllitles
It
exlst
emergency servlce
wae ernphaslzed that
power structures
of the council
of the community.
should be to survey the problerns that
It
the activities
working "
and its
activlties
service
of medical students to the aspect of the emergency medLcal
earl-y in the currlcul-um ls
important.
The councLL, we feeLe ehouLd address lteeLf, to the general problems of: 1.
Cornmunicatlon and transportation
2.
Individual
3,
Pl-annlng for coununities.
4.
Continuing education for physlclans.
5.
Establishing personnel requirement.g for emergency care, not only Ln the hospltal but in the varlous agencLes, ambulance, police and flre departments.
6.
EstablishLng educational prograns for emergency personnel for paramedical personnel ln the hospltal, for poliee and fire peopl-e, ambulance drivers, and the l_ike.
7.
Dieaster planning.
8.
Iligh lntensity
hospltal
for
emergency servlces
emergency care. in the communlty.
energency care in the outJ.ylng or referrlng
treatment unlts.
- 6 9 -
9,
Laboratory servtces,
brood banking, and forensi.c nedr.cine.
10.
Addttion of a legal lnportant.
It.
Flnancla]- resourcea.
L2.
A contlnulng revl.ew conmlttee the council_.
advlsor
We focused our attentlon was polnted funde for
out that
polnted
funds for
programs.
It
The Natlonal
for
Dr. 0wen
comnunicatlon
was aLso polnted out that
there are
area counclL of Govern-
as one of their
prlrnary obJectlves
the year 1970' and they may be counted on to heJ-p wlth Safety
heve to actively
JAYCEEShave addreesed themseLves to the
problem of energency nedlcal- services
The National
It
may have available
Defense money available
through conmunity or metropolitan
ment organlzatione.
the council.
of monlee to operate such a council.
there rnay be CivlL
prograns and transPortat,lon monles available
on sources for
to be
the progress of
Local government, of course, wiLl
in the production
out that
to evaluate
the Department of Transportation
such councils.
participate
on the council- was felt
probleurs tn this
Council ai.so has an actl.ve interest
organlzatlon and deflne
hae a definlte
area and we feel
rol-e to play,
what the needs are currently,
in our universitles organization properly
to meet these needs.
of activeLy
should offer
partlcipatlng
dlrectlon
that
thls
We
particular
not onLy to study the problems but to try
probleme w111 be ln 1990, and to proJect
regard.
in the general problem.
We' J-lke the other workehop groups, onJ-y ecratched the surface. sensed the tremendous need ln this
for
and define
our plannlng Ln addition,
rf,hat the
in our conmunltles we feel
that
and
this
surgeons ln the emergency medical field
for emergency medlcal services
- 7 0 -
in the eountry.
RNFERENCES 1.
N a t i . o n a L A c a d e m yo f S c i e n c e s . 1 9 6 6 . A c c i d e n t a l d e a t h a n d d i s a b i l - i r y : The neglected disease of modern society. Committee on Trauma and Commigtee o n S h o c k , , D i v i s i o n o f M e d i c a L S c i e n c e s , N a t i o n a L A c a d e m yo f S c i e n c e s , National Research Council-, Washiongton, D.C.
2.
Wa1ler, J.A. L967. Control of accidents in rutaL areas. 2OLzL76-L8L.
3.
Frey, C.F., HueLke, D.F., Gikas, P.W. Resuscitation and Survival in motor vehicl-e accidents. The JournaL of Trauma. 9t292-3L0, 1969.
4.
Von Wagoner, F.H. 1961. Died in Hospiral: A three year study of deaths following trauma. J. Trauma. 1:401_-408.
5.
Pantridge, J.F. T h e m o b i . I - eC o r o n a r y C a r e U n i t . August, 64-73, L969.
6.
Sissouras, A.A., Moores, B.: Planning for Coronary Care Services in a Corununity. Progress Report No. I and No. 2. The University of Manchester Institute of Science and TechnoLogy. Department of ManagementSciences, Health Service OperationaL Research Unit, L969.
7.
Wassner, U.J./Ecke, H. Moglichkeiten Einer Intensivierung Der Ersten Hilfe Fur Unfallverl-etzte In Stadten Mit Landlicher Umgebung. Chirurgischen Universitatsktinik Giessen. Monatsschrift fuer UnfalLheikunde Versicherungs, Versorgungs und Verkehrsmedizin, Vol. 67, Jan. L964rpp. 32-44.
8.
Mahler, l{. Der Operationswagen Der Chirurgischen Universitatsklinik Chi"rurgischen Universitatsklinik Heidelberg. Chirurg,
- 7 *
J.A.M.A.
Hospital Practice,
Heinde lberg. 3Lz42L-425, 1960.