1970 SAEM (UAEMS) Annual Meeting Program

}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 -

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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.