UA UNIVERSITYASSOCIATION FOREMERGENCY MEDICAL SERVICES
EMS PROCEEDINGS
SECONDANNUAL MEETING: MAY 72-13, 1,972 WASHINGTON, D. C.
CONTENTS
Personnel I Training of EmergencyDepartment
1.
Rittenbury A. Goals and Levels . . . Max FreY Charles B. Curriculum
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1 13
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on I D. Workshop Summary
Services to EmergencyMedical II LegislationRelated R o g e r s( D - F l a ) ' A . C o n g r e s s m a nP a u l G ' I
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Summary
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III Nuggets'72 " W h o i s t h e E m e r g e n c yP h y s i c i a n "- R o b e r tD a i l e y ' 'n' C a l i fo r n i a U"lu.tti,y of Souihern
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Laboratory Data,, by ,,The Transmission.of Closed Circuit Television Emergency B.
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VanderVeer,Jr.""awrrii"*S.Fl"tche.,ij^i'.,,i.vof-oregoni',r.Ji."iSchool C',,TheFollow.UpNurseinanEmergencyRoomSetting,,.sheldonJacobson,BertrandM.Bell, a n d W i l m a K e I I y ; A l b " r t E i n s t e i n c o l l e g e o f M e d i c i n e . . . . . . . . , . . 2 7 Cleve Turner' Roger Johnson and "EmergencyTriaS^eby N,urses"--FredericW' Platt' William D. Trimbie; Dlnver GeneralHosPital " " ' 31' E . , , A n E d u c a t i o n a l P r o g r a m i n a n E m erutJitTi6;;;;;i rgencyDepartme n t , ,York -WilliamF.Mitty,Jr.,andThomas N"* urla Hospital Vincen-t's st. F. Nealon; Platt and CleveTrimble' " F o u r H o u r S u m m a r i e s "- W i l l i a m T u r n e r ' RogerJohnson,Fred ""'36 HosPital Denver General H' M-eredith'and Richard T' "EmergencyServices- A Sectionof a Department Jesse " " " "38' "' G. rorestUniversitv
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of Vermont ,,EmergencR y o o m R e c o r d s ,-, D a v i d B . P i l c h e r ,U n i v e r s i t y "The PhYsician'sRole in EmergencyDepartment Nurse Education Chicago, Illinois "
39, S c h o o lo f M e d i c i n e. . . . . ' .
G e o r g eT . A n a s t ,
49,
IV OrganizationalBusiness A. ExecutiveCommitteeMinutes' ^" ' B . O f f i c e r s ,7 9 7 7 : l ' 9 7 2 ' " " "' C. Committees,L971-797Z " D. Of ficers,l972-7973
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from the assistance of a grant have been published with Edmeeting this Health' "5t'u.itt'' of of presentations The Public Health service; Defartment Fi;;lih College the Division of r*""'i"''';; Department of Surgery, Medical Carl Ueienko' III'' M'D' Welfare"iJtt'' and ucation of Georgia,Augusta, Georgia 30902'
PERSoNNEL: TRAINING oF EMERGENCY DEPARTMENT GOALS AND LEVELS MAX S. RITTENBURY,M.D. PROFESSOROF SURGERY CAROLINA MEDICAL UNIVERSITY OF SOUTH
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laier discussion speak-ersis to stimulate thought f or My My charge as one of the keynote t{ i:' it tftft"tln i hop" 'offer'-suggestions' and 1",citi*ute by you, not to pro,,tal^ut"*t"' university in to training, the goals of this organi,utio,' relative "tn.'*p|rro""ut remarks will concern departments' or units" in emergencytogT:, that ,.*. upon affilitated hospitals, for tlie laiter' Unfortunatelv' statistics ;r;t;;lt; .i Each of you may pi.t';.;;.;;;; and sc-anty'and thereimperfect are this the effective performanceof emergency'...^ O?i:onnel ideas of *u.,v p..rons interestedin u'. u"..J ;.;-^,h; fore, most of my ,;;;r";;r. journals' form' pr.if.*, my own pr"iJit"t, and a few professional relative to training?This' in its simplest organization this the goal of First, what is,.to personnel"' emergencyroom afJord the appropriatetraining to appropriate is as follows,
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labor? Only tthlth tu.iiiti.r'itt Second, where are the emergen.y small comor suburbs in either living city,'^in"- "*ui"der a ii ti,r. populaiio.r are our of 3ITo Therefore' most of our population it''^"""i^-"""t' with munities surrounding the cities, or available inu, have large emergency d1nar1me1-t1. not in the large metropolitan- areas it' who to train to serve this ;i'";;'^"io'"ptoUt""i'' full-staffing patterns. Thlrein lies one when -we consider our "othing statistics, ho*et'e'' meutt' 69% of ou, poprrlJo.r. it," overall or departments while 'oJ^'. "if "*ttg"tty *itnZn6'i.tptt"i' individual states. Michigan has over i iff .,f these sirould have the I am not certain have sufficient South Carolina has just over -+0,^ 1nd J^'o"' hospitals in South Carolina emergencyrooms ;"';;r,g;;d. full-time' Four .b.ly'z^ utilized be efficiently phyri.iun .""tfi-p"ltiUly u patients';h.td; emergency has emergency with emergency room coverage'- one (1)' I of these have residency traininS programs u"cull"^tytit^ for tlie hospital staff "^;^';*;"ha,re hope I and room physicians working full-time, variable' tt"f f i;; ttttd' u" ]-,"iiti"irv,'-tnt probrem' mention these only to lllustrate tn.t, this to one, easv the is no singre u.'"r*.r, ru., th;;';[;;; emergency that my remarks *ill;";^;;i^.n" of p"ison.,el needed to staff the .ut"go.iu, ;;; the different best? And, third, *h; function probably they tutt ""a'*n"'" .";";i;;it Emergency room or department, what are- th.i, the three: u^d I will discuss we have different categories of p"rro.,l""i";;';;;r;"r, Assistant' Physician's the Profession'alNurse' and the i'i.;t-";,
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EMERGENCY PHYSICIAN A n e w t y p e o f p r a c t i c i n g p h y s i c i a n h a s a p p e a r e d , ' t h e p h y si^ptoved i c i a n w h training o . d e s i r in e s torder o w o r to kfull_ and ;h., i'' ^o*'dt*uiJ-it'g department emergency an in vigorous a time is Physicians Emeigenry A^;;iJ^"" i"1ftg" of fulfill his practice othguiio.,r. Th. the f irst a dif f erent types of training curricula: two -;;;;;i." requesting and and growing organization practice' of type to thii .n""gl"g , enter to refresher course for physicians in ,"""."f phvsicians new the tiains that adequatelli pr.;;;; ^^'.rrr.i.,rtu 'r.r partially the second a graduated residency in.r.-- p.o-g.u*' .hut" been . r"t pattern. subject' into this type of career my to but this .it ".,t real"ly pertinent gr*p', have we developed by this and othei interested person th" besi irained ui''i' po"*iv greatly The physiciu., ir- t'i''"- *ost highl,'.,1'til5,' be may he that add Ao*.,r.., I must quickly to serve in an emergency department. or sick patients ih.r" ir' a large ttu^bti of emergency unless area ^;; this over-trained to serve in tf provide- medical care in the ilttn"J ;i;" u ..tutiu.ty";p;;t;t;requiring care. Til giving complete f ive of . these physicians, or four u..urrr. emergency a.puri*.,, Various schemes yearly' each -u"a $50'OOO hospital '*ol,r"d, require U.i*..,i^gaOpOO full-pav fee-for-service' 24-hour coverage, presently the tv iime .to vaiying f;;;'i"li cost' Most for payment have justify the to load emergency 'oo^ Oltltttt assume well and both schemes require a significant we but pJt a"V in the emersencY room' this figure of our hospitals ,e" 1es, than LbO P"ii;"i; a t c l o s e l y l o o k ' under piesent concepts'-Hoit""i' that figure is a'break-even" point
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and it means that the average patient must, therefore, pay $11 1 to the physician or to the hiring hospital (based upon a rough assumption of a basic salary of $40,000 each for 5 physicians, a 75Vo fringe benefit allowance, 157o overhead for collection by the hospital or physician's practice group, and a collection rate of Tovo). This fee is for the physician only and is in addition to the other emergencydepartmentcharges,etc. I believe it is appropriate here, just f rom the standpoint of medical care costs, to consider an alternate system. Approximately ZOVoof these patients are some type of major or minor emergency, and one to four percent, in most areas, are ill enough to require hospitalization. The eighty or so patients in this group who do not need immedicate care might well be handled by trained non-physician personnel, and at a much lower cost. In our own Emergency Room one-half of these patients are safely referred out without drug or appliance treatment or referral to another physician. The estimated l1%o that do need some type of treatment for a minor emergency could also probably be handled by a trained Physician's Assistant. Unfortunately, we do not have objective data to compare the relative performance efficiency in this areaof physicians and physician's assistants(2). I feel that we must give careful consideration to both the economics of emergency care and also the utilization of the total number of available physicians' time. In this day of third party payment for medical care, like it or not, we must be aware that excessively expensive methods of carewill not be toleratedby the third party dispensersof funds. Other aspects of the needs for the Emergency Physician are also being carefully scrutinized. Is an Emergency Physician needed for triage? Is an Emergency Physician needed for administrative duties in the emergency room? Is an Emergency Physician needed f or the development of community medical services? The answer may be yes or no, according to the community situation. But other physicians, nurses, or hospital administrators are also perfectly capable of carrying out these functions. Even surgeons have become deeply involved in community care plans. Therefore; although the Emergency Physician may function in these other important capacities, this f act alone may not be justif ication for their presence in a given community emergencyroom or department. What are the relationships of the Emergency Physician within the medical community? Can they do certain surgical or other procedures that are usually taken care of by the specialties? Will these specialties accept, in return for the immediate care available to must patients, their initial treatment of the diseasesor injuries that have historically come to be within each narrow specialty range? The usual fee for service charged for emergency care includes follow-up, and will the Emergency Physician charge a lesser fee because they do not see patients in follow-up? Will this affect all fee schedules under third-party payment schemes? And the last question I wish to ask is probably the most important. Will a physician be huppy in this career pattern for 40 years? The follow-up care of our patients is primarily instructive, and we all like the expressions of appreciation f rom a gratif ied patient. Will the lack of this f ollow-up, plus the need to refer the more complicated patients to other physicians, afford sufficient professional satisfaction to the Emergency Physician? I can f ind no data relevantto this question. I have asked these questions, not because I am antagonistic, but because they are among the legitimate ones that must be answered by each community and region before a decision can be made concerning the need for us to train large numbers of physicians to practice only in an emergency department. It is obvious that some areas will need and can best utilize the Emergency Physician, especially those communities with large numbers of emergency department patient visits, and the universities and other teaching programs must respond to this need. However, it is not obvious that the Emergency Physician is needed for all communities and that specific residency training programs must be set up by all medical teachingprograms.
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THE NURSE The first consideration of the role of the Emergency Room Nurse is whether or not her traditional role is adequate. What should the Emergency Room Nurse be capable of doing? Should she perform endotracheal intubation? Subclavian venous punctures? CPR? Administer IV medications that are potentially lethal? Have the freedom to give emergency drugs prior to or without the direct order of a physician? All of these questions are pertinent due to
the rapidly expanding health care needs in this area. In many highly structured hospitals with adequate resident and intern staffs, the nurses do not do these tasks, but in small hospitals without readily available physician coverage most of them have been and are doing theseprocedures. Many physicians f eel that the nurses' roles should be greatly extended, especially in the intensive nursing care units, and I include the emergency area under this category. However, as usual with physicians, we may often fail to ask the nurse if she wants to assume an increased technical and therapeutic role. The more established nursing associations have not yet aggressively responded to this need in a visible manner although they say they wish to develop their own expanded role in patient care, but often not under the direction of the physician (3). This is a logical expression of their desire to extend the role of their profession, but the response of the nurses in many hospitals to the courses that have been offered to them by the physicians (and the formation of EDNA) all indicate that these aggressive and dedicated nurses do desire a direct expansion of their role in the emergency care area, are anxious to do it now, and are very receptive to post-graduate training from the physicians (4). We frequently ask if the nurse is capable of functioning independently. This is not really a very practical question. I say this because over two-thirds of the nurses in the last of our courses in Emergency Nursing definitely had to f unction independently because of the lack of physician availability in these small community hospitals in which they lived and worked. Their average emergency room load was ten to twelve patients per day, of all types. Therefore, in the communities of this size the nurse must be given the training to f unction independently, and in many instances therapeutically, in the emergency room. The nursing profession seems somewhat ambiguous in responding to the role of the physicians a s s i s t a n t .T h e A m e r i c a n N u r s i n g A s s o c i a t i o n o f f i c i a l l y s t a t e s t h a t t h i s i s n o t a n a p p r o p r i a t e role f or the registered nurse. But at the same time, and as I have recently been told by the deans of two nursing schools, they f eel that the nurse practitioner must come f orward as a member of the health care team. In one of the proposed curricula for this new type of nurse, the student will need a 4 year Bachelor of Science Nursing degree, a 1 year internship, and 2 years in a Master's Degree Program. A total of 7 yearst With the limited role of a person who has been trained for 7 years, why not utilize the M. D. curriculum and have a fully qualif ied physician within the samelength of time? It is obvious to me that the nurse can maintain her traditional role of dedication to her patient and also improve the range of her services. Our problem is both to seek the means whereby this can be done, and to help those now beginning to formulate the necessary guidel i n e s( 5 ) .
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PHYSICIAN'S ASSISTANT "The
Physician's Assistant is a skilled person qualified by academic and practical training t o p r o v i d e p a t i e n t s e r v i c e s u n d e r t h e s u p e r v i s i o n and direction of a licensed phvsician who i s r e s p o n s i b l ef o r t h e p e r f o r m a n c eo f t h a t a s s i s t a n t "( 6 ) . Presently there are several categories of Physician's Assistant, beginning with the Medex program, and extending up to the two and four or five year college level t r a i n i n g p r o g r a m s . Thirty or forty of thesetraining programs will be functioning within the next year. Medicine is now grappling with the problem of where and how best to utilize these personnel, and we must help decide both how to give them the necessary skills, and what skills are needed. This is critical when we realize that we must use those persons in the emergencydepartmentsand in other areasof emergencymedicalservices. The Physicians Assistant, at whatever level of training, working in a large metropolitan emergency department under the direct supervision of the appropriate physician, of fers no insurmountable problems. These can be effective at all levels of training, and, with increasing utilization, can widen the scope of the physicians' abilities. Studies of the effectiveness of the least trained of the Physicians Assistant, the Medex, has shown a 30% to 40% increase in the number of patients that a physician can see in his office. This probably would also apply in the emergencydepartment(7, 8). The problems, however, arise when we discuss the status of the Physician's Assistant who functions without the direct physical and continuing supervision f rom the physician. Legal, ethical, and moral questions arise with this type of function. The American Medical Association
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has defined the role of these persons and agrees that they can f unction if the physician "responsibility takes and direction." The V. A. has issured guidelines for the utilization "f of dif ferent categories of Physician's Assistants, unctioning as the direct representative of the physician". Their directive outlines a wide range of procedures that this person may do in the V. A. Hospitals, including the writing of orders that must be countersignedby a physician within 24 hours (9). This is, historically, the last prerogativeof physicians to f all. Is it legal for a non-physician to diagnose and treat? Eleven states, and probably more by now, have passed legislation allowing the delegation of patient care f unctions. It has been stated by the director of one very successful Physician's Assistant Program that in his state legislation will not be necessary for them to practice because the law can also be "usual changed by and customary procedure", and there are now sufficient numbers in his "usual state to make thier performance and customary". However, not all of his co-professionalsin that stateagreewith this intepretation. What can the Physicians Assistant do? It varies according to his training. At the present time there is a prof usion of speciality training courses that are available so that he may be a surgical assistaht, an internal medicine assistant, a primary care physicians assistant, a pediatric assistant, etc. Despite the recent categorization of these programs, I feel that the universities should exert leadership and develop a standard level of basic training, with later specialization if desired by additional training. The level of training, based upon previous experience, must be defined in order to adequately utilize these persons. It is refreshing ihat a larger number of the corpsmen now being released f rom the armed services are interested in continuing a career in the para-medical f ield. A danger, however, is that the Class A Physicians Assistant, with four years of college-leveltraining, may well become dissatisfied with his role unless adequatleystimulated. The well-trained Physicians Assistant can probably take care of TOV, to Sovo of the patients seeking health care delivery. This immediately suggest both a direct role for patient care "independent-duty" in the large emergency room, and an type role in the smaller community hospitals with lesser numbers of emergency patients. The salaries range from 10 to 15 thousand dollars per year and this is a significant decreasein the cost of health care delivery in an emergency room. I strongly urge that careful consideration be given to this in your deliberationsupon whom and how to choosethe person you needto train.
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SUMMARY I hope that I have been able to bring out some of the predominent features concerning each type of person who staff s an emergency department. I believe that each university should survey the medical area served to determine the emergency health care personnel needs prior to beginning a preconceived curriculum f or training one of more of these personnel categories. In addition to the objective date needed (the numbers of patients needi^g emergency care, the f acilities available, and the coverage patterns already established in the communities) subjective data should be obtained concerning the attitude of the physicians and citizens of these areas relative to emergency medical services. The methods of f inancing that are available in the communities should be evaluated, and only af ter this inf ormation has been evaluated by the university, should a decision be made to determine what type or types of persons should be trained to f unction in that particular region or area. I believe that it is obvious that each state or geographical region will find a somewhat dif ferent answer. I am, therefore, pleading f or a logical look at the needs, a close evaluation of the desires and capabilities of the categories of personnel, and an objective determination of the level of care obtainable and needed in your regions. Then, and only then can you begin the next step, the formulation of appropriate curricula and programs. Plan on these bases and not, as has happenedso often in the past, upon the availability of the Federaldollar.
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1. South Carolina StateCommitteeon Trauma, American Collegeof Surgeons,Survey of Emergency Rooms and Facilities, 1972 revision.
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3.OfficiallySpeaking..ThePhysician'sAssistants'RN'pp'57'OclobetL9To' pp'37' Novembet'l'970' 4. The New E. R. Nursing - Is It for You? RN' for Nurses, Extending the Scopeof Nursing 5. Secretary'sCommittee to Study ExtendedRoles P r a c t i c e .I A M A 2 2 O : ' 1 ' 2 3 L1,9 72 ' Assistant and RelatedIssues' 6. Todd, M. D. and Foy, D. F. Current Status of the Physician's IAMA 22o:7774,1972. Physician Productivity and the 7. smith, R. A., Anderson, J. R., and okimoto, J. T. Increasing p.u.ti."t A ProgressReport' Northwest Mede><"Uting Hospitalization Ci',ur".t"ristics of Med.7o: 7o7,197'1. 25' (January)197O' 8. Can Doctor's Aides Solve the Manpower Crisis? Med. World News, Medicine' (May) L97L' 9. VA IssuesHospital Guidelinesfor Physician'sAssistants,U' S'
EMERGENCY HEATTH SERVICES EDUCATION OF THE MEDICAL STUDENT CHARLESF. FREY,M'D,, F.A.C.S' FROM THE SECTION OF GENERAL SURGERY UNIVERSITY OF MICHIGAN MEDICAL CENTER ANN ARBOR, MICHIGAN
SCOPEOF THE PROBLEM: neglected diseases of modern society' Accidents and acute illness have been called the illness 1nd injury are known to members -ftf.ailut The scope u^d ,.rutrirJ ;-i ih; problem of acute Services.ioduy, in the United States' for f*"rgJ;.y of the University erro.iution gg '. Mvocardial inf arction kills 400'000 accidentsare the f.uaing l",rr. of a"ut"n "p to ?8e, .!"i.7utu"t iniuries in rural than urban areas' ;;h;;;'" -tvt*iot, annually. Deaths "rt-'n?tpr ?; ambulances,ambulance tq:iP-T:lt:-"1t1; - are inadequacies"'r communicati* There ancr lack of toordination between transPortation systems ;e i"g "f ambulanie ;;;;".ifrom toll financial The injured' and ill care to ;i. ;"ly 'and -alone hospitals capable of providingestimated to approach Z'l' billion anur. .,to'*ous disabling and t"tnui ir,;,rries related V"t, only $ '50 per patient is spent in research a;;l.li. nually by the Nuti*ui''JJ;y from deaths Even patient' on the cancer to the injured puai.ni, ;ht1;' $iZO/patient'it--tpt"t system our in worth life a human of cost accidentsseem to exciie little attentibn. Whut it the accident, it does not prick the conscienceof f;;;-; i, J""i1, Appare-Jv,--i-i priorities? of concerned about the 4s,oo0 killed in Viet tfntrv l"i" r*a"".r -proiest American society. p;it.i.i; marchesor appearedon -national television Nam over the last 10 yearq have mounted no alone. It is'estimated that 250'000 could about the 45o,oo0 killed from rnotor u"i'ti.t"-"i.idents or 9o,ooo salvaged by an improved cars their in have been salvaged by better puckagiif medicalcaresystem' emergency but, are without cures, the remUnlike some diseaseswhose symptoms we can describe, are -unknown and could be injured ttl Tq edies which will improve the care .f ;i; ;;t;il of lives lost unnecessarilv rulrug. for purchasedu, u r"ul'5,11il[ oit."'",,,.".,"T;. fi"-pt*".ial Medical pitttior of the Emersencv "acciients Fi;;it.v' ilfi' in the United States has been estima."ittyand f'o^ of the fiOpOO tilltd ServicesDivision of H. S. M. H. A. to be z2,5OO emergency hospital improving costs of 35,oooof the 4oo,ooodying from *y-o.urdiuf infarition. The now dying f rom acute illness persons 55,500 salvage annually to systems medical services of the billion dollars ot 27/z%o 2 be to and injury has been estimated by Henry Iiuntley, 1
presentB0 billion dollar health budget. IMPROVEMENTS NEEDED IN THE EMERGENCY HEALTH SERVICE SYSTEM: t'o q
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In order to increase.patient salvage consideration should be given to the use of air and land transport in regional planning' of emergency r;;;i..r. -equipm*ent vlhicle design should include adequate space fol and the necessJry io, intravenous fluid th;;"py, endotracheal intubation, relief of tension pneumothorax, cardiai monitoring and defibrillation.' Communication capability between hospital and ambulance and between" hospitals ;h;;i; be d.;;i;;;. Emergency medical technicians need to be u.,d gi,r..r medico-legal protection to per.trained form intravenous fluid- therapy, endotracheal l.,t.rbutio.,, ?ardiac -."it".i"g ?a d.fib.illation. Educational programs for medical students, residents anJ postgruduut. should be ff;yJ.iu", developed' State-wide planning, of an emergency medical service system is necessary to cothe components u.td avoid duplication of expensive hospital 9rd.ln1te and transportation facilities. THE MEDICAL SCHOOL AND ITS RELATIONSHIP TO EDUCATIONAL PROGRAMS FOR MEDICAL STUDENTS IN THE CARE OF THE ACUTELY ILL AND INJURED: The medicat schools of the United states have been no different from the rest of American Society in their neglect of problems associated with the care of the ucutJy ill and injured patient' Until 10 years ago, most medical schools had no programs in emergency medical care or of fered "1ly f irsi aid programs more appropriate ; 6o, scouts and housewives. Historically, much of the stimulus and interesi il developing ..,o." ^ .o^prehensive educational programs in. emergency medicine for medical students" *"r g."*ra.a by indivi. d u a l s a s s o c i a t e dw i t h . d i s a s t e i p l a n n i n g , . t h e _ M E N D l'on M.ar.ut Education ri, Nutlo.,ul Defense) or professional organizations such as the Committee Trauma of the American College of S u r g e o n so r t h e A m e r i c a n H e a r t A s s o c i a t i o n .T h e e f f o r t s o f t h e s e i " a i " t a u u i r - a n d associations were aug.mented by ,h9 following concomitant social and technologicai-.t ung., which acc e l e r a t e tdh r o u g h t h e 1 9 6 0 ' s . :
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1' The potential for salvage among acutely ill and injured was constantly being .the increased by improvement in methods of ..rur.itutio.., resuscitation equipment, transportation,communication and hospital care. ? Plrysicians and - government become concerned with the delivery of "n""rin health care. Funds were shifted from basic research to impro,ru th. a.tl*.y- ir services including emergencyhealth services. 3' Medical students and physicians- have long recognized that their individual ministrations to patients do not have the .otnpuibl" iirpact of public Health measures, such as clean water and air, or a small po*, o. pol'io vaccine in reducing mortality from diseaseor injury. 4' In contrast, medical students and. -physicians have only recently recognized they could not improve emergency health iu." u, t"Jr"iar"irl -local ""L'rr'in., became involved with national, state ind government with regard t" "^lri""ce ordinances, regulation, Iicensing, personnel tiaining and certific"tr.", .."..g!i.y ,".ri.., funding, etc. The effect of the ,social changes and - technological advances enumerated was to alter the perception of medical studentl and physicia;;';;"rJi"g their roles and responsibilities
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while the climate for curricular change was f avorable in medical schools f or introduction of new educational programs during the 1960's, emergency medicine p;;;;;"r; had to com_ petewith non-emergencyprograms of high priority. other practical problems have hl.tdered. rapid proliferation of educational programs in some medical schools. Programs for medical studenis in the care of the acutely ill and iniured have to compete.for-faculty and funding ;ith-th;e-^for emergency medical technicians, postgraduate courses for physicians and .,uir.r, M"ai.ul so.i.ty programs in emergency medicine, internship ""L programs in emergency medicine, and physician assistants i.:idllcy in emergencymedicine' (Table I.) Most of th" faculty tI provide this compler uiruy of educational
programs in emergency medicine are members of the Departments of Surgery, Medicine and i'ediatrics, whose iirst-allegiance is a commitment to the programs of their own Departments. Furthermore, participation ln programs outside one's own department r,nay not be encouraged by the department. In f act, this may even be resented by the Departmental or ..*u.d.i Chairman who may be having diff iculty staff ing his own departmentalprograms. The wide ranging demands f or educational programs in emergâ&#x201A;Źncy medicine are reason enough to justif! f-ormation of an Emergency Department within both the hospital and the mediialschoolwitirstatusequivalenttotheDepartmentofMedicineandSurgery Among the array of educational programs in emerge_ncy medicjne directed at emergency medical technicians, nurses, postgraduate physicians, house staff and medical students, those for medical students pariiculirly freshmen, deserve to be given in my opinion, a high priority by Universities. Educational programs f or f reshmen medical students in emergency medicine will provide these f uture phyriciu.,s with a f rame of reference and basic set of principles ..guidi.,g the delivery of emergency health services which will make their later experiences and training more meaningful. The very ,presence of programs on emergency in the f reshmen curriculum gives the medical student a more realistic perspective *.di.in. regarding the relative importance of acute illness and injury in our society with respect to If we hope to continue to improve the delivery of emergency health care in otf,". d["ur"r. the United States, we shbuld start with the freshmen medical student. The dynamism of our society and the rate of technologic change is so great that present medical students have the opporiunity and most likely will be tomorrow's policy makers, spokesman and teachers in this new field of emergencymedicine. The status of emergency medicine in medical school curriculum is improving but uneven. Existing medical school educational programs in the care of the acutely ill and .injur,ed leprur..ri a diverse hodge podge of programs as recorded in the Stephenson report. (Table II.) The majority of the educalional programs in emergency medicine are electives, or clerkships-usually sponsoied by the Surgery Department. The clerkships in emergency medicine are of ten unsupervised by senior rtuff . For the most part, these programs still represent the eff orts of interested individuals who have recognized the need for educational programs in emergency medicine rather than a f irm institutional curriculum commitment by the medical school. On the other hand, it is gratifying to those of us in the University Association for Emergency Medical Services to f ind some medical schools have educational programs in emergency medicine which include didactic content defining the patterns of illness and injury, the physiologic and metabolic response to injury, the emergency medical care system uld the economic- and emotional sequlae of injury, coordinated with a supervised emergency department clerkship. The f aculty of these medical schools recog4ize the emergency department representsa vast, -previously untapped sourceof clinical teachingmaterial. In the absence of published criteria for educational programs in emergency medicine _for medical students, the University Association for Emergency Medical Services hopes to define guidelines, and objectives of educational programs in emergency medicine appropriate for medicalstudents and useful to medicalschool curriculum planners. The medical student should be provided with an understandingof : 1. The scope and nature of the problems of acute illness and injury and the inadequacies of the presentsystem of care. 2. The pathophysiology and treatment of acute injury, shock burns, fractures, myocardial inf arction, pulmonary and renal insuf f iciency, poisonings, emotional illness, drug abuse,the unconsciouspatient. 3. Those techniques, essential f or the initial resuscitation of the acutely ill and injured patient through actualpracticeand implementation. 4. The emergency response system, its components, and organization, and the necessity for statewideand areawideplanning of emergencyhealth services. 5. The need for emotional and physical rehabilitation and the effect of workmen's compensationon the temporarily and permanentlydisabledvictims of injury. 6. The role of hospitalization, income and property insurance in protecting groups of individuals againstthe costs of catastrophicillnessand injury. 7. An analysis of the mounting social and political pressures to reduce the cost of injury and illness through various National Health Insuranceformats.
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Adequate resources exist in most medical centers to implement educational programs in emergency medicine for medical students. These resources include a multidisciplinary faculty, professional societies, contacts with government agencies at the federal, state and local level in emergency services, highway safety and regional medical programs, comprehensive health planning, the emergency department, intensive care and coronary care units and their staff , cardiacarrestteams,anesthesiaand the community ambulanceservices.(TableIII.) Specific programs and curricula will vary with the individual medical school, but can of ten be structured around existing programs or expertise, e. g. in disaster preparedness, highway safety, clerkships in the emergency department, coronary care or intensive care units. Elective programs should also be available to the medical student in emergency health servicessystems,and the pathophysiology of trauma. (Table IV.) The curricula in emergency medicine as implemented in medical schools should be adjusted and integrated to the student's level of understanding. The f irst year curricula should be devoted to didactic material defining the patterns of acute injury and illness, the emergency medical care system, the economic and emotional sequlae of injury and illness. This didactic material should be supplemented by practice on the manniken in cardiopulmonary resuscitation and movement of the patient with spine injury. Material on the metabolic and physiologic response to injury and principles of definitive treatment should best be reserved for the second year or late in the first year of medical school. At the University of Michigan we have given this material late in the first year and have been careful that the anatomy and physiology of a particular body area such as the heart have preceded our presentation and practice in cardiopulmonary resuscitation. Supervised clerkships in emergency medicine and electives w o u l d b e a p p r o p r i a t et o t h e 3 r d a n d 4 t h y e a r so f m e d i c a ls c h o o l . SUMMARY Educational programs f or medical students in emergency health services are recommended. These programs should include an overview of the problems of acute illness and injury in our society during the f reshman year of medical school. The students can be introduced to the pathophysiology, diagnosis and treatment of acute illness and injury during the later part of the f reshman or early in the sophomore year of medical school. Didactic presentation should be supplemented by actual practice in the initial resuscitation of the acutelyill and injured patient and well supervisedclerkships in emergencymedicine. REFERENCES: 1 . H u n t l e y , H . C . : P r e s e n t a t i o na t t h e D e p a r t m e n t o f E m e r g e n c y H e a l t h S e r v i c e s M e e t i n g i n BethesdaMaryland December2, 7977. 2 . S t e p h e n s o nH, . E . : B u l l e t i no f A m e r i c a nC o l l e g eo f S u r g e o n s5 6 : 9 - 7 7 , 1 9 7 7 .
TABLE I EDUCATIONAL PROCRAMS IN EMERGENCYMEDICINE COMPETING FOR FUNDS AND FACULTY EMERGENCYMEDICAL TECHNICIANS POSTCRADUATECOURSESFOR PHYSICIANSAND NURSES MEDICAL SOCIETYMEETINGSAND PROGRAMS CLERKSHIPSFOR MEDICAL STUDENTS RESIDENCYPROCRAMS IN EMERGENCYMEDICINE RESIDENCYPROGRAMSIN SURGERY,MEDICINE AND PEDIATRICS 6
TABLE II IN EMERGENCYMEDICINE PRESENTSTATE OF EDUCATIONAL PROGRAMS ron io.ooo uNITED sTATES MEDICAL STUDENTS
DIDACTIC COURSE ELECTIVE
33 SCHOOLS
1ST YEAR
11
,ND YEAR
,
3RD YEAR
2
4TH YEAR
N
2 OR MORE YEARS
1s
REQUIRED COURSES
10*
*PERSONALCOMMUNICATIONWITHHUGHSTEPHENSoN
TABLE III PROGRAMS RESOURCESFOR EMERGENCYMEDICINE PROFESSIONALSOCIETIES MULTI-DISCIPLINARY FACULTY GOVERNMENT: AGENCIES FEDERAL- H. S. M. A., D. O. T. AND 98 OTHER PLANNINC _ STATE - OFFI.i Oi COT"TPREHENSIVE OFFI.E OP UICHWAY SAFETY PLANNING REGIONAL MEDICAL PROGRAMS HEALTH SERVICESCOUNC ILS ETT/TNTITTICY STATE HEALTH DEPARTMENT COUNCIL LOCAL - EMEiT-GiNCY HEETTH SERVICES HEALTH DEPARTMENT THE HOSPITAL EMERGENCY DEPARTMENT
iNilNswr
AND coRoNARY cARE uNIr
CARDIAC ARREST TEAMS ANESTHESIA AMBULANCE SERVICES
TABLE IV EMERGENCYMEDICINE PROGRAMSFOR MEDICAL STUDENTS DIDACTIC INSTRUCTION TRAINING PROCRAMS D I S A S T E RM E D I C I N E CLERKSHIPSIN EMERCENCYDEPARTMENT CLERKSHIPSIN CORONARY AND INTENSIVECARE UNITS - EMERCENCYHEALTH SERVICESSYSTEM ELECTIVES PATHOPHYSIOLOGYOF TRAUMA
TRAININC OF EMERGENCYDEPARTMENT PERSONNEL- TECHNIQUES
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U n i v e r s i t y A s s o c i a t i o nf o r E m e r g e n c y - M " d l c uSle r v i c e s M a y 1 2 t h - 1 3t h , 7 9 2 2 ,W a s h i n g t o n ,D . C . JAMES R. MACKENZIE, M.D. The. previous speakers (us an rntroduction to the workshops that , f o l l o w ') h a v e d i s c u s s e d the philosophy of educating Emergency. Department p"rrorrn"l. They hu,r. .o.r..ntrated on 'i-his who, why and what should Le taug"ht. talk *ill ttierefore concentrate upon the techniques that could be used to translate eJucational philosophy and. objectives i.,to'lituut emergency medical care programs- In order to limit the ,.op. of ih. tulk, i will discu* o,.rly those techniques used to teach emergency medical care to medical students at McMaster University since they are now considered- part the Emergency Department pu.ror,.r.l. However, 9f techniques which are used in their training can u.rJ ur. being applied to the training of physicians, nurses and emergency medical technicians 1.utt"a Senior Ambulance Attendants . in Ontario) in graduateand continuing educationprograms in the Emergency Department. The first major objective of the Emergency liledical Care gteltive n.ogr; ut McMaster is to encourage the students be responsible for their own education i.r .*".g"rrcy medical .to . care' We have therefore asked the siudents under the guidance of the edrlulio., committee to develop .an appropriate curriculum. Th"y have lde,itlfied the .o;rr. ;;j..ri,r.r, the resources needed, and the techniques used to teach the objectives. Each class has' changed the objectives, course content or method of teaching, ac-cording to th.il. ",ruluution of the effectivenessof the course as their legacy to the class"that ,rr...".d, them. They even prepare many of the educationalresourcesruch us rllde-tapeshows used in the elective. Another method which encourages self education is to ask the student to solve hypothetical problems b-ased upon real life emergency medical care situations. Each problem covers one o]'. of the co.u-rseobjectives and by solving the problem, the rtuaJ"i-u"aerstands T?tt , the obJective The problem also contains objectives which will relate the .-"r*"^.u medical l0
rFor example, . a problem concerning the care program to the rest of the M. D. pfogram. contain an objective concerning the realso -;"r;rof chest trauma *ight' emergency management the lungs, a respiratorv unit learning of ventiiation io ..gio.tul. oi bf"ood "problem i;t";;hi; the student learns about emergency medical care the objective. Thus, by :;i;i"g aspects of the patient care as the ,"lutlo.rshif of .ai" in that setting to the other "r'-*.ff conf ines of the EmergencyDepartment' provided outsideof the-;;in conjunction with -a multidisciplinary The problem ".,"y "u ;"l"ua UV the sfudent uio.t" o, attendants, nurses, Emergency Departambulance of co-pored tutorial group, i. u. ;;;"; "non-expert". tutor, i' e' by a group is -usually lead, by a pniri.iu.,, u.rd str.idents.The ".ather ^."i than knowledgeable in the subject matter being person skilled in gt;;--;a;.uiior, expert advis6rs in the problem at hand' If the its own as tni group acts [i;;;;;"i.-^ih.rr, "exPert" tutor' i' e' one rom the g..rp fr stymied bV ih" problem then. it can tuin to advice f i.rr.d in the subjectmatter being discussed' educational objectives of ,the The interdisciplinary tutorial setting accomplishes two other respect between the student emergency medical care plogram. First, it generates mutual the nurse and the "tp"iiully care team, m"dlul . and other members of the .*u.g..t.y' when the remembered be wiil respect emergency medical i".h.ri.iu.,. It i! nJp.J that this medium subtle a provides setting tutorial mixed if't" S".ondfp -psychosocial, student becomes th.";h;ri;iu.,. emergency of legal and epidemiological concepts for teaching .o.. Uiotigi*i ""a personnel. health allied and physician gradua"te the medical.ur"io student to evaluate his own attitudes' The second objective of the program i; i; .";;;;age the the effectiveness of the course' evaluate and"to acquisition of skills u.rJ .o.r..ptu"al knowledge; "problem solve" as described "f in9 student to Conceptual knowledge is tested by the ;;iiil' line in the Emergency Department' above. Skills and uititrrd., are best tested on the f iring in the major resuscitation room' Thus, we have installed a television and tape recorder performl,":. u"1 that of his team his tape can arrives, the student When a major "*;;; "the match" at his leisure replay and then, like the f"ootbalt coach on Monday morning,..can team' A variation of the of u, *1ll as those"perand pick out his flaws in his own p.rfo.*u.,.. their membels of one observe group this evaluation technique is to have the tutorial room' The perthrough u o.,"-*uy wind]ow next to the treatment forming" with a p";[;i has left' forman"ceis then criticizedin group"discussionaf ter the patient is to educate student -and the casualty officer (one of whose duties Finally, of course, the pep.artEmergency the in treats student the all cases that the medical ,t.rd..ri) iir..rrr", and their performance officer's) casulty (and the ,ttd..tirment, thereby .r;l""ai";-ih; "Uifiti to relateclinical problems to basic scientific phenomenon' is needed by the student so that he can The acquisition of Emergency Department skills believe that taking care of the patient We treat patients in ih" e *Jrg"n.y- Department. spurs. the student into applying the patien^t,. the tieating llse rather than oUr.ruing ;;;;"" baiic biological concepts. It also preproblems identified ii the patient to his k"nowled^geof when he is a graduate physician' patient oares him to be comfortable in treating the emergeicy The skills that we teachare as follows:
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to the student in 1. Recognition of the priority of the emerSency. This can be taught a t l e a s tt w o w a Y s ,f o r i n s t a n c e : problems, i' e' teaching a) by programing patients. to _simulate emergency medical care medical, surgical or acute with -i;. Emergency De-partment actors to arrrve in the to f ake uncongirl a programed have, .*uripl.," we prv.t oro.iul dlr."r". and overdose' trauma, head ,.i,orrr.t.r, due to hypoglycemia, under the direct supervision of a physb)' by working in the Emergency Department iclan responsiblefor the students'
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2. Diagnosis of the emergency under emergency conditions. This skill is best taught by clinical exposure in the Emergency Department although the use of the programedpatient can supplement the clinical situation. Audiovisual aides such as movies, slide-tape shows or T. V. tapes which demonstrate history taking, physical diagnosis or diagnostic procedures in the Emergency Department are also of benefit in teaching skills. The American College of Surgeons has a series of movies which illustrate these points as they apply to the trauma patients. The American Heart Association and American Academy of Orthopaedic Surgeons and others have the same type of films related to subjects in their specialty. 3. Treat minor conditions with expertise - the course on how to manage lacerations is the most popular part of the elective. The student is first taught how to scrub, gown and glove himself and then to prepare and drape the patient. He is then taught how to tie knots and to debride and sew representative wounds made in pigs' feet (obtained f rom the local butcher). Finally, he acts as f irst assistant to one of the plastic surgeons who allows the student to sew up several simple wounds on Iive people. Only after this, is the student allowed to suture wounds on patients in the Emergency Department. He is also taught how to take blood and start intravenous fluids by the nurses on the I. V. team; and to take arterial blood bv the IntensiveCare Unit Resident. 4. Resuscitatelife threateningproblems until help arrives. a) The student first learns the anatomy and physiology of the cardiopulmonary system before applying his knowledge to the arrest situation. He then practices ventilation and endotracheal intubation and airway clearance and cardiac massage and defibrillation on the appropriate plastic models. b) Next, the student learns airway management and endotracheal intubation in the operatingroom on anaesthetizedpatients. c) Finally, the student accompanies the in-hospital cardiac arrest team on its resuscitation calls. Only then is the student considered ready to resuscitatepatients on his own in the Emergency Department. The third major objective of the elective is to constantly remind the student that as a physician, he is only one person in the Emergency Department team and that successful emergency medical care depends upon how effectively he can use the team. He is also taught that the Emergency Department team stands with one foot into the community and in. other into the hospital and therefore he must learn how rhe Emergency Department reIates to the other emergency medical care facilities, both in the community and the hospital. He learns these facts by being taught by and working with members of the team both in the community and the hospital. Thus, part one of the Emergency Medical Care Elective is taught by the ambulance attendants in conjunction with clinicians and basic scientists. The student rides as an ambulance attendant during the course and writes his First Aid Certif icate at the completion of the course. He is then qualified to ride ambulance as first attendant on his own and can even earn money for this work. In part two of the elective, he is taught that the skills used by the emergency physician in his work by those who are the most skilled and in the appropriate specialized unit. These people have been mentioned above, e. g. plastic surgeons, anaesthetists,casualty of f icers, etc. - ln part three of the elective, taken during the last year of medical school, the student applies his knowledge of emergency medical care as a clerk in the Emergency Department. He acts in place of, or on, an equal footing with the intern. He, in turn, uses his knowledge and skill to teachothers in the tutorial setting and the circle begins again. In summary, I have used the Emergency Medical Care Elective for medical students at McMaster University as one model for developing techniques used for training emergency department personnel. The objectives of the program have been identified and some oF the methods used to teach the objectives described. The course is given in three parts - the t2
attendants tbgether with principles of f irst aid are taught in their f irst year by ambulance epidemiological, legal, biological, of appiication" clinical personnel and basic scientists. The second part' - The in. the taughl is .utt .n.di.ul "me.ge.,cy economical and clinical skills to to basic problems his skills to the emeigency department patient and their student applies ^frinciples. emergency in clerkship a as in"- ,nita part oI tlte elective is taken ,.i.*ifi. department physician who is remedical care under the direct supervision of an emâ&#x201A;Źrgency his patients' to the stu.dent by given care and "*o.kshop ,p""riff" f.r the students'education on the philosophy of education improve to inthe p""pfe io" It is my .hull..rgu V." but appropriate techimmaginative, p"rson.t"l . and to develop ^^;hll;;"pi..u1 f or emergency a.p"ri^'""i need to train program's the of objectives and educational niques to meet th. EmergencyDePartmentPersonnel.
REPORT OF WORKSHOP H.D. ROOT,M.D. ANTONIO THE UNIVERSITY OF TEXAS MEDICAL SCHOOL AT SAN
be expressed under the following items: The summary opinions of the morning workshops may Emergenry Roo.ms of" the institutions 1. An rnventory of the teaching activities in the pattern of haphazard teaching f or the medical the .o.n*o^ represented iho*, of the teaching for the students students, fo.- ihu interns u.td r"rid"nts, with *u.i Room', This perpetuates Emergency the. to being done by the house staff assigned. In one institution error' and trial through ga-ined is inadequate teaching. Experience was much students the for experience the and teachei R. E. full-time there was a ^;iih Emergency institutions a planned program. In most a;".hi.rg more orderly ,by. considerable with rotations, clinical Medical Care was a stepcnlid of the ^i1otvariations. a separate Emergency Medicine 2. There was a strong feeling that there should be pottiblt in the. medical school Departmerit ut lerst" in tnJ notfit"l and wherever the major clinical departments' o f c a d e m i c . u r r k " q , r i , r a l e n t. t o . t h a t , p r o v i d i n g f u l l a -ru.h on the basis of training' inchosen be should a department The faculty-Io. to those with surgical terest, and teaching ability u-rrd-.ot necessarily restricted i" inir way, an .orderly -programmed..teaching curriculum -;;;;;;A training ;".k;;;e. staff' It and delivered ib medical siudents as well as house could b. early solve least at or eliminate to selve and cale would also enhance patient Emerin the departments the administrative problems that arise between clinical gency Room. found for the Emergency If separate or supplemental funding sources. could be chairmen and the Deans departmental p"pu.,*""f clinical other the ,n"" Medical in the curriculum as long might be more willing to forfeit some amount of time budget. current the as it was not costing u ^ujo, sum of money f rom so. that the faculty has 3. The Emergency Medical Department should be organized dependent upon disinterested input into'the' medical schooi lurriculum and not be of teaching programs consist -ir;;;. chairmen. The curriculum should clinical departmental M' Department The people' paramedical also staff, and .E' for rt"d"i;the general for community thewith function liaison would serve an important problems of emergencymedicalcare' 13
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4. There is needed a position paper regarding the education of medical students to medical in emergency medicine. A liaison committee f rom the UA/EMS schools,possibly through the AAMC, was suggested. 5. The medical students in most institutions are now demanding early training in emergency medical care. They feel f rustrated in not having some knowledge and ability to manage common emergency problems. Because they are labeled by "doctor" neighbors as f rom the f irst day they begin medical school they are of ten looked to for handling emergency problems and feel grossly inadequate. It was found that rarely do any students have full-time assignments in the Emergency Room and the most common pattern was that of a fourth year elective which was popular in most schools. There was a definite consensus that students should get training in Emergency Medical Care throughout all f our years of their medical school training. It was suggested that an advanced f irst aid course could be taught to freshmen students early in the year and then in addition curriculum input covering such items as epidemiology, sociologic impact and implication of costs f or emergency medical problems should be included. Cardiopulmonary resuscitation and time f or practice with plastic mannequins should be provided in the f irst year. In addition, a f irst year elective in the Emergency Room for observation only was suggested with other possible electives such as operation room time or intensive care unit rounds to provide for continuity in their observation of patients they may have seenin the EmergencyRoom. For the second year it was suggested that in the blocks of time f or Systems Pathology that Emergency Medicine should have it's input into each of the systems since trauma and emergency problems do bear upon all organ systems. It was suggested that injury and drug effects should be established as pathologic entit i es . agreement that Emergency Room could be used There was an area of as an excellent clinical resource f or teaching of physical diagnosis to the sophomores. Such techniques as video taping and replay of resuscitative efforts in the EmergencyRoom might provide vivid demonstrationsfor the students. For the third year emphasis on Emergency Medicine should be put in each of the major clinical rotations. There was division of opinion as to whether there should be separate blocks of time f or f ull-time Emergency Room participation outside of the major clinical rotations. This could be especially helpful since less and less Ambulatory Care Medicine is now being taught in the major clinical departments. Students could get good experience in routine out-patient medicine in this manner. For the f ourth year Emergency Room electives in all disciplines should be made available including f ull-time emergency medical care rotations in the Emergency Room under the guidance and training of a f ull-time Emergency Medicine Dep a r t m e n tD i r e c t o r . 6. There was a strong feeling of definition of the boundaries and end-product desired for each group to be taught in the Emergency Room. A suggested curriculum outIine f or the medical students as well as the house staff and paramedical personnel would be most helpf ul. 7. The final area of consensus was that there was a definite need for evaluating the teaching of Emergency Medical Care to medical students. There should be selected questions put on state or national boards to evaluate the knowledge of the students about the management of emergency medical problems. Another suggestion of defining end-point and deciding on adequacy of teaching was the functional testing of the students by taping resuscitative eff orts on video tape and replaying it and grading the studentson their activities.
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