1973 SAEM (UAEMS) Annual Meeting Program

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PROCEEDINCS

University Association for E m e r g e n cMy e di c a l S e r v i c e s

T hi r d A nnu a l M e e t i n g

May 23-25,1973 H a m i l t o nO , n t a r i oC , anada -

UA/EMS LEADERSHIP

OFFICERS:

President Vice-President Secretary Treasurer

RobertB. Rutherford,M,D. JamesR, Mackenzie,M,D. WilliamE, Matory,M.D. RonaldL. Krome.M.D. COUNCILMEN: PeterCanizaro, M.D. CarlJelenko, III, M.D, AIan Dimick, M.D. GeorgeJohnson,M,D. CharlesFrey,M.D. GeraldLooney,M,D. PROGRAM COMMITTEE: LeslieR. Rudoll M.D., Chairman LocAL ARRANGEMENTS CoMMITTEE: JamesD. Davidson.

M.D.. chairman JamesR. Mackenzie,M.ti.

RobertL. Ruderman,M,D. REGIONAL DIRECTORS:RegionA William Sereda,M.D., Alberta,Canada RegionB RobertRuderman,M.D,, Toronto,Ontario,Canada RegionC EdmondMonaghan,M,D., Montreal,euebec,Canada RegionI EarleWilkins,M.D., Boston,Massachusetts RegionII-A GeraldShaftan,M.D., Brooklyn,New york RegionII-B RobertHall, M.D., Syracuse, New York RegionIII-A William Matory, M.D,, Washington, D,C. RegionIII-B William DeMuth,M.D., Hershey,pennsylvania RegionIII-C LesRudolf,M,D., Charlottesville, Virginia RegionIV-A GeorgeJohnson,M.D., ChapelHill, North Carolina RegionIV-B Carl Jelenko,III, M.D., Augusta,Georgia RegionV-A William Olsen,M.D., Ann Arbor, Michigan RegionV-B RobertZollinger,M.D,, Cleveland, Ohio RegionV-C ClaudeHitchcock,M,D,, Minneapolis,Minnesota RegionVI-A PeterCanizaro,M.D., Dallas,Texas RegionVI-B HarlanRoot, M.D., SanAntonio,Texas RegionVII Allen Klippel,M.D,, St. Louis,Missouri RegionVIII CleveTrimble,M.D., Denver,Colorado RegionIX RobertLim, M.D., SanFrancisco, California RegionX TrevorSandy,M.D., Vancouver,BritishColumbia,Canada The UA/EMS expresses its.appreciation to: EthiconSuturesLimited (Canada),The Upjohn Company,Workmen's CompensationBoard, Provinceof Ontario, for their genâ‚Źroussupport.

Editedby the Publications Committee: Carl Jelenko,III, M.D., Chairman RonaldKrome,M.D. JohnH. Morton,M.D, CleveTrimble.M.D. Addressfor Reprints: ACEP, P,O. Box 1241,EastLansing,Michigan4gg23 (Pleaseenclose$5,00for costof printing)

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TABLEOF CONTENTS l.The Dr. Robert H. Kennedy Lectureshipin EmergencyMedical CareFraser Gurd, M.D., Associate Secretary,Royal Collegeof Physiciansand Surgeonsof Canada in honorof RobertH. Kennedy,M.D., for the work he has hasbeenestablished This lectureship carethroughoutNorth America.Beginningin 1931asa doneasthe pioneerin the field of emergency memberof the AmericanCollegeof Surgeons- Committeeon Trauma (thenknownas the Committeeon Fractures),he workedactivelyuntil his retirementin 1969at age81 to improveemergency "the fatherof emergency medicalcarein North healthcare.Dr. Kennedyhastruly earnedthe title departmentof the hospital America." As earlyas the 1950'she spokeout identifyingthe emergency medicalcarechain.After focusingattentionon this neededimas the weakestlink in the emergency His conprovement,he turnedhis effortstowardupgradingthe caregivenby ambulancepersonnel. tributionsto this field of medicineare too numerousto be adequatelytreatedin the limited space availablehere. theneedto supportthe improvementof Smith and NephewLtd. of Lachine,Quebec,recognized emergencymedical care, and has agreedto sponsorthis lectureshipon an annual basis.The will helpto furtherthe its gratitudeto Smithand Nephewwhosecontribution UA/EMS expresses training and educationof men and womenin emergencymedicalcare. lI. Worksho p I Guidelinesfor Programs Which Train Full-Time Emergency Physicianr . . . .

SectionLeaders: J o h nH . M o r t o n ,M . D .

L o u i sG . B r i t t ,M . D .

Morrison,M.D. Jonathan , .D. J o h nA . C o l l i n sM StuartM. Poticha,M.D. , .D. N o r m a nJ . D i a m o n dM JosephE. Snyder,M.D. ChristineE. Haycock,M.D. WilliamMitty, M.D. C v r i lT . M . C a m e r o nM. . D . lll. Emergency Medical Care in a Prepaid Health CareSchemeFrank Miller, M.P.P., Parliamentary

Assistantto the Ministerof Health IV. Worksho p ll Guidelinesfor the Core Training Programsfor the Specialty Resident and General Prsctitioner in the Emergency Department Section Leaders: T h o m a sJ . T a r n a y ,M . D .

J o h nH . M o r t o n , M . D .

A . C . S t r i c k l e r ,M . D .

Luigi E. Dagnone,M.D. Edmond Monaghan, M.D.

J o h nT . S a n d yM , .D. WilliamGhent,M.D. B . W . H a y n e sM, . D .

AllenP. Klippel,M.D. RichardM. Peters, M.D.

Address The Academic Surgeon and the Emergency Department Robert B. Rutherford, V. Presidential M.D. VI. Nuggets: 1) ThePediatricEmergencyLYard:Midnight to SixA.M. CharlesQ. McClellan,M.D. ' Case-Western Reserve.

Ohio Cleveland.

2) IncorrectX-ray Interpretationby EmergencyDepartmentPersonnel A. C. Strickler,M.D. Hospital,Hamilton,Ontario St. Joseph's 3) Geographicand TemporalTriageof EmergencyPatients , .D. C . R . F .B a k e rM Emory University,Schoolof Medicine,Atlanta,Georgia 4) Do You ReallyKnow How Much a Visit to Your E.D. Costs? , . D . ,R . M . Z o l l i n g e rM, . D .

R . F .W i l l i a m sM , . D . , M . R . C a m m a r nM Ohio Reserve, Cleveland, Case-Western 5) Transportationofthe Sick and Injured by Helicopter W. Evans,M.D., R. Ruppert,M.D., R. Orr, M.D. Ohio State,Collegeof Medicine,Columbus,Ohio .

6) A SystemsApproach to EmergencyMedical Services D . R .B o y d ,M . D .

Departmentof PublicHealth,Springfield,Illinois 7) ComputerDiagnosisin the EmergencyRoom B. Houtchens, M.D., H. Warner,M.D., F. Chang,M.D., F. Moody,M.D. Universityof Utah, Salt Lake City, Utah

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8) TheEmergencyMedical ServicesMorbidity and Mortality Conference F. Platt,M.D., CleveTrimble,M.D. 38 DenverbeneralHospital,Denver,Colorado e) The Role of the Ombudsmanin the EmergencyDepartment William Mitty, M.D., Rev. D. G. Lothrop,Rev. D. S. Lothrop S t . V i n c e n t ' s , N e w Y o r k , N e w. .Y. .o. r. k. ....... 39 10) The TeamConceptin the (JniversityAffiliated EmergencyCenter K. Mattox,M.D., G. Jordan,M.D. 4l BaylorCoilegeoflMedicine,Houston,Texas .

1 1 ) Conceptsin the EmergencyCareof Children with Major Injuries: Organizationand Stffing of SpecialFacilities J. Issacs, M.D., D. Gann,M.D., J. White,M.D., J.A. Haller,M.D. JohnsHopkinr,Bultirnor.,Maryland.............. ...... 44 r2) A Shock TeamApproach to Resuscitation PeterRosen,M.D. Universityof Chicago,Chicago,Illinois . . . . 40 l ? \ The Useof the Videotapein ldentifying EmergencyDepartmentProblemsand in theEducation of the EmergencyTeam M.D., J. Bulette,M.D., A. Palmer,M.D. G. Schwartz, MedicalColiegeof Pennsylvania, Philadelphia,iennsylvania .... ... 49

VII. "EmergencyMedicalServicesin the USSR . . . A Resident'sEvaluation" Larry Reithaus,M.D. andRobertScribner,M.D. "In order to meet Proceeding's deadlines,the Editorial Board has authorized publicationof the manuscriptat Page3l whichis unedited.The format and contents is solelythat of the authors".

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DR. ROBERTH. KENNEDY LECTURESHIPIN EMERGENCYMEDICAL CARE THE EDUCATION OF THE GRADUATE PHYSICIAN IN EMERGENCY MEDICAL CARE

FraserN. Gurd. M.D.

My title is the title of this conference.A key-note address,it seemsto me, should borrow from the art of music. This I propose to do. My themes will be impressionistic,will repeat themselveswith variations,but will provide, I hope, basic ideas which we can orchestratein subsequentdiscussions.You will find appendeda selectedlist of referenceswhich have helped me in the preparationof the paper,which I acknowledge gratelully.

The invitation to addressthis meeting was a special honour and pleasurefor me. It has beenmy privilegeto have known your founders when they were junior membersof their respectivefaculties,charged with the administration of emergency departments, and laying their plansfor the initial organizationof the Association.

For my own part, five years of army servicein the Second World War, followed by twenty-five years of surgical practice in an academic setting, form the reasonablebasisfor this invitation to be heretoday. Two other qualificationsmay deservespecialmention. One is a lifelong interest in the scientific base supporting critical care medicine,along with someexperiencein the educationaland administrative aspects.

The secondspecial privilege which I have enjoyed is a long friendshipwith Dr. Robert H. Kennedy.My father, Dr. Fraser B. Gurd, introducedus when I was a student at McGill. At that time both men were active members of the Committee on Trauma of the American College of Surgeonsand were engagedin foundingthe American Associationfor the Surgery of Trauma. From then until a year or two ago I talked with Dr. Kennedytwo or three times a year about our common problems.He neverfailed to challengeand encourage.In particular, during the yearswhen I was responsiblefor the EmergencyDepartment at the Montreal General Hospital, and Dr. Kennedywas devoting all his energiesto the problem of emcrgencyfacilities, he was a constant source of excellent advice.

I have decidedthat this talk should set out upon the route which emergencymedical care has followed in the lifetime of our patron. However, no one would bb more annoyed than Dr. Kennedy if I stopped there, so I proposeto forge ahead with some abandon, seekinga logical projection of the course which he has set.

To my mind, Dr. Kennedy would have completedthe design which was the main considerationof his later years had he been able to retire at 90, instead of only at the age of 80. He brought the conceptual framework for a system for emergencyservicesso close to a completely

integrated form that we must pausea moment to consider his accomplishments.

Dr. Kennedywas trained a generalsurgeonand in the early 1920'sand early 30's he was an innovativeoperator in the lield of cancer surgery,writing extensivelyof his experiencein cancer of the oropharynx,then a common and intractable disease.His appointment as Surgical Director of the Beekman-DowntownHosoital in New York City turned his attention more towirds trauma.

From 1939to 1952he was Chairman of the Committee on Trauma of the American College of Surgeonsinterrupted by serviceas a Colonel in the SecondWorld War. The 1950'ssaw the expansionof what might be termed Phase I activities by Dr. Kennedy and his concerned colleaguesin the field of trauma. I am referring to the contributionswhich havebeenmade to the careof the injured and acutely ill betweenthe site of an accidentand the threshold of the hospital. So much still needsto be accomplishedin relation to PhaseI that we are liable to underestimatethe forward strideswhich can be recorded in the past few years.This list includesadvancesin first aid and vehicle extraction procedures,ambulancepersonneland equipment,ambulanceordinances,helicopter evacuation, telecommunication, automobile safety features,cardio-pulmonaryresuscitation,fire and explosion disastermanagement.Above all, we have seenthe build-up of public recognitionof the preventableloss of liveswhich could be savedby betterwork within PhaseI. Telephoneand radio triage to the location,the growth of special mobile units capable of life support as well as rescueare now part of the acceptedreal world of Phase I. I shall spendno more time on this phase,not becauseI deem it unimportant, but becauseI wish to consider other matters in the short time available.

Having contributed a normal lifetime of energy to PhaseI promotional activitiesas a public-spiritedvoluntary surgeon,and having at the same time conducteda trauma service in New York which was a model for all others, in 1960 Dr. Kennedy attacked the area of weakness between Phase I and the inpatient services within the active treatment hospitals. He became the Director of the Field Program of the Committee on Trauma of the American College of Surgeonswith a special charge to assist hospital Emergency Departments.The establishmentof such facilities has been pursuedwith such enthusiasmin the past ten years that questionshave beenraised regarding the desirability of their continuedproliferation.

It seemsto me that we should ask ourselves,as we open this important meeting, how we might re-examine the Emergency Department and its requirements for supporting staff, together with their educationalneeds, "The Emergency" came about as an extensionof outpatient clinics in many hospitals.It is now not only a community convenience,but a matter of local pride for hospitalsto have a brightly-lightedinvitation to all comers. Thus the Emergencyhas become a drop-in centre not only for desperatecitizenswith a need for the immediatecorrection of life-threateninginjury and illness, but for the entire spectrumof seekersafter care. Thus it caters to a mixture of clinical problems ranging from citizenswho simply feel they need to seea doctor to the most hazardousof crisesdemandingexpertmanagement without delay. The burden of the vocal majority who are better suitedto a definitiveambulatory treatmentcentre may constitutea threat to the silent majority of genuine disasterpatientswhosefutures in truth dependnot upon cliches such as smooth entry to a bright and shining health care system but upon a guaranteeof an instant accessto active treatment.

I am concernedfundamentally in this talk with the latter group, the critically ill and injured, the patients who get well or die dependingon the treatment they receive,and for whom time is of the essence.Are we training men and women adequatelyfor the care of such patients? Whatever else we talk about during this meeting let us not forget that question.

ThereforeI make a olea to commencewith the critical patients. Gear the syitem to receive them as the top priority, leaving aside for the moment the larger numbers of non-critical patients. Picture a city or a region where no one is mildly ill or slightly injured, but w h e r ee v e r y c a s ei s a g e n u i n ee m e r g e n c y .

What would we do? Surely, we would organize by regions.Surely,we would organizeour rescuesquadsfor on-site resuscitation.Surely, we would insist on radio contact with the rescuepersonnel,and put at their disposal expert and sophisticatedadviserswho must decide on the immediate action to be taken on the site,the dispatch ol special support teams, and where to take the patient.

It is an axiom that the more we refine emergencyor critical care the more we tend to eliminate the middleman.The multiple injury patient belongsin either a trauma unit, or in a pre-operativeintensivecare unit, or in the operatingroom. It has beenshownthat survival of liver injuries is inverselyproportional to the time lag between injury and laparotomy, which should be less than an hour if at all possible.

The patient with the evident myocardial infarction should not lie in an emergencydepartment for an hour or two, inviting cardiac arrest. Ideally he should be instantly transportedto an indoor monitoring unit where shock could be detected and defined, placement of an aortic balloon undertakenif indicatedand consideration duly given to emergencyaortocoronary bypass.

We might not be stretchingour projectiontoo far were we to foreseea time when it will be consideredmorally wrong, in any civilizedcommunity possessing the power

of choice, to send a patient to a hospital which is unpreparedto provide for all his needs.

One can conceivethat when initial life supportis ably handledat the site and in the ambulance,and the indoor hospital staff have been alerted, there is little need for any stop-overin the emergencydepartment.In such an ideal situation the emergencyroom would receivesuch patients but not delay immediate admission into the hands of a prepared and forewarned indoor staff. I realizethat at this time the capability to resuscitateand stabilize is inescapablefor any emergencydepartment worthy of the name, regardlessof the category of the hospital. Therefore we must plan for it for the foreseeablefuture.

Regional categorizationof hospitalsmeans little unlessthe primary decisionswhich governcasualtycollecting in PhaseI are monitored through someform of communication network, so that the initial triage is effected at the site. I can well appreciatethat triage on site to different hospitalsimpliesthat certainhospitalsplay certain roles according to a plan based on assigningeach patient to the hospital which meetshis needs.Therefore, we must define the needsin each community, develop rational arrangements,and measuretheir effectiveness.

Dil'ferentareaswill requirediffering patterns,indeedfor somea strictly regionalapproachmay not be right at all.

In any breakdown of emergencieswe may recognize three classesof patients.On one end of the scaleis the minority of extremelycritical, whom we have beenconsidering.On the other end is the majority of more or less ambulatory cases in search of medical assistance.

Betweenlies the third group, whoseclassificationwithin the spectrumis unclearinitially. Thus, we may recognize three primary coloursin the spectrum.At the red end are critical emergencies.Far over at the other end are patientsin the blue and violet, evenultravioletbands,the subacuteand chronic and the worried seeking reassurance.Between is a large group of problem patients flashing a predominantly amber light, calling fbr caution.

The solution to the effectivehandling of this complex spectrum, and the defining of the educationalback-up required,is the question before this conference.

The ideal plan for the extremely critical, the red patients,would be a civilian variant of modern military practice,such'as we have already mentioned.Why hai this adaptationnot been made on a broader scale,since recentwar experiencehas demonstratedthe advantages of virtually instant injection of the patient into an active treatment centre'?

Those in search of medical assistunceon a nonemergentbasissurely require a prtrr,arymedicalfacility designedto take care of the initiai needsof the patient and to follow-throughin arrangingfor continuingcarein terms of further diagnosisand treatment.

In my opinion, the problem group lies in the middle of the spectrum,the patientsin betweenthe two extremes, whosediagnosisis unknown when they come through the door. Theseare the patientswho do not by their obvious critical nature proclaim their needfor immediateadmission to hospital, but who cannot be dischargedwithout

somestudy.They constitutethe patientsunder suspicion of potentially disabling injury or less acute but serious disease.They demandtime and skill in interviewing,examination,choice of investigationand degreeof observation. It is thesepatientswho must be accommodated in an identifiableemergencyfacility, who consumethe greatershare of space,time and professionalattention and who are the sourceof most of our lapsesof judgment and medico-legaldifficulties. Who should take care of this large and troublesomegroup, and how shouldhe be trained to do it?

Here again I must return to a further developmentof the conceptol planning for a finite populationgroup or region.If we would list our needsfor personnel,studies must be conductedwhich will quantitate the call upon emergencyresources.Each community or region must defineits best approachto a solution.The citizensmust be involvedfrom an early stage,and must be persuaded that it is in their interests to forego certain prerogatives related to convenienceand local traditions in return for better treatment. Above all, the people who will be operatingthe plan must acceptthe whole idea, or it will not succeed.

The regionalcouncil must have the power to innovate.

One physical layout which appealsto me is that which may be seenat the McMaster University Medical Centre. The arrangementallows for the immediatediversion of patientssuitable for managementon an ambulatory basisto the primary care unit which is adjacentto the emergencyroom. Cases ol the intermediate or amber group can be studied in a well-equippedobservation area,while critical red casescan be admitted directly to the indoor treatment services.The plan in use at the Montreal General Hospital calls for a rough division of the patient flow into medical and surgical sections, although stretchercasesof any disciplineare placedin a large acute care area. The medical section handlesthe n r a j o r i t yo f b l u e a n d s o m e o f t h e a m b e r c a s e s .

The Parkland Hospital in Dallas has an Emergency Departmentdivided into five divisionson a disciplinary b a s i s ,a m a m m o t h f a c i l i t y u n i q u e i n m y e x p e r i e n c e .

However, as a city, neither Montreal nor Dallas has a well-developedplan of the type which is emerging in Hamilton. designfor any regionwill make good A well-conceived use of hospitalsin categoriesbetter suited to houseambulatory facilities,thereby providing centresconvenient for the public while sparinghospitalsin categoriesI and II some of the burden of the blue and amber patients.

My purpose in lingering on these alternative approachesis to bring out the point that different types of medical personnelare required to fulfill varying roles dependingon the dominant flow of patients into the different settings.For, in the very act of identifying the typesof medicalpersonsneededwe can reachsome conceot of our educationalobiectives.

The spectrum of, profeisionals to be trained must match the spectrumof patients.The blue patientswill be served best by general physicianswho may double as family doctors. The red, or critically ill or injured, should be in touch with specialistcare within minutes of

onset.The educationalthrust of a flow diagram for the red patients should be first towards perfecting radiotriage and care on site and in transit through the training ol the personnelor mobile units. Next, these patients should be met at the door of the most appropriate hospital by agents of the indoor specialtyservicesand sweptinto PhaseII for activeindoor treatment.I strongly lavour providing specialistcare for critical casesin the emergency department. In particular, red surgical emergenciesshould be seenby surgeonsfrom the moment that the ambulance arrives. The care ol major trauma must be surgicalfrom the beginningof PhaseII, and I mean adequatelytrained surgeons.

The Collegeof Family Physiciansof Canadasupports the education of general practitioners for emergency wopk. There need be no restrictions on the training availablefor generaldoctorsto provide a specialform of expert care for patients from the blue end of the spectrum.

The Royal College ol Physiciansand Surgeonsof Canada has recently re-emphasized experience in emergencyareasfor those in training in specialtieswith a significant content of emergencywork.

Therefore,on the faceofit, existingpatternsshouldbe able to provide for training personnel of satisfactory competenceto managepatientslrom the two endsof the spectrum of emergencies.Do not forget that in my reckoning I am including highly-qualified rescuetrained non-medicalpersonnelmanning the ambulances and the receptionareas.Each regionalcouncil must give top priority to the developmentand maintenanceof such people.

You recognizethat I am over-simplifying,but please note that if we assignthe milder ambulatory patientsto the specially qualified practitioners,and the red cases enteringPhaseIl to specialistsdevelopedby established training programs, there still remains a gross hiatus in our framework, namely the questionof the type of doctor who will deal effectively with amber patients, and how he should be trained. He, or she,may well prove to be the principal subject of this meeting.

The person whom we seek must be a paragon, who must evaluate the various and interdisciplinarypot pourri of patientswho are neitherclearly candidatesfor acute admission to hospital, nor safe for discharge without reasonablestudy. Examples are the citizensin pain of every type, visceral,skeletalor anxiety-related; patients with fever, suspected fractures, suspected poisoningsand drug and alcohol abuses;head injuries, chest and abdominal injuries without too drastic initial manifestations,suspectedsuicideattempts and manias.

Creative sorting-out and disposition of these people calls for an expertiseof a high order, the leader being the emergencyphysicianin charge.

This is the person who requiresthe specialtraining.

He should be no less skillful at life-savingprocedures than are the ambulanceattendantsor the nursesin the coronary unit, yet he will have a more sophisticated judgment. He should possessthe socialawarenessof the general practitioner, sharing his concern for followthrough. Falling as he does between conventional

specializationand the usual forms of primary medicine, he requires not only special knowledgebut a range of clinical competencebeyondthe usual. He must be a particularly keen observer, quick by nature, emotionally stable yet patient and compassionate.

How can one formulate a schedulefor the recruitment, educationand training of the personnelwe need?

The anchor point must be the medical school.The faculty has little choice but to accept the extra load of educatingpersonnelto man the crucial functionsin the system. A matrix managementdesign, with functions analyzedagainst the disciplineswhich must participate, should help the school and the regional council to construct a basic program for emergencyservicesin their area. It seems to me that the approach used by McMaster University in building up its well-regarded clinical programs for the Hamilton region could be consideredfor our purposes.

Such a solution would ensure the neededacademic base.It would perhapssave us some ol the wasted motion entailed in seeking answers to unanswerable questiond(unanswerableup to now at any rate) about whetheremergencymedicineis a specialtyor not. Status would come to those who are faithful to the program; in lact, directors of such interdisciplinaryprograms seem to have outdistanced chairmen of conventional departmentson the academicscene.

I am in full agreementwith the view that universities by becomingtoo involvedin may losetheir independence the uniserviceor the workings of society.Nevertheless, versity is the repository of our resources for both teachingand research.Its graduatetraining programsin Medicine are one expressionof its new role in education which has been acceptedthroughout Canada. Its entry into fields involving small-scaledemonstrationmodels may also serve the purposes of both research and teaching.Guidelinesare neededfor the developmentof training programs, university-related,in order to meet needsas they are recognized.

The primary objectiveof this Associationis improvement in the quality of care of the acutely ill and injured.

The listed meansby which this objectiveis to be pursued are nine in number. They include data gathering, reseq,rch,administrative planning in cooperation with other authorities,guidelinesfor education,and evaluation ol the servicesas they emerge.The academicvalue of servicein this field is to be recognized.Keep each of these in mind in your discussions.

As we concludethis talk a word would be in order on the role of the Royal College in the areas of interestof your Association and of this conference.The College works by activating the interplay betweenthe specialty groupsofthe country and the universitymedicalcentres.

The catalytic role played by the Collegeis proving most productive at the level of residencyeducation in some thirty specialties.Up to the presenttime the Collegehas accepted that a specialty is characterized by research and developmentin depth of a circumscribedarea of biomedicine not shared by others. Nevertheless,it is quite likely that the recentrecognitionofwhat are called areasof specialcompetencemay open up a pattern into

which critical care and emergencymedicine can be introduced and given recognitionas a specialcompetence within a broader specialty framework such as internal medicine or general surgery.

Canada is probably lesshomogenousthan the United States.Detailed planning lor medical care and the supporting educationalestablishmentis tied to local needs.

Thus each province, and the regions of each province, will be found to differ in proportionate requirements for the varying classesof trained personnel,including doctors,nursesand auxiliaries.Fortunately for Canada, we have a universitymedical school more or lesshandy to each district.

Despite the wide variety of needsacrossthe country the Fellows of our College seem to feel that common basicprinciplescan be adducedto serveas guidelinesfor those charged with mobilizing educationalresourcesin eachregion.

The College has a new Committee on Emergency Medical Care which has chosenas its principal objective to identify the educationalrequirementsfor emergency and critical care medicineand to establishguidelinesto assistthe universitiesto meet these needs.

As all of us move into a new world of new relationshipswith our societywe must adapt the patterns w h i c h h a v e s e r v e du s i n t h e p a s t .T h i s m e e t i n gm a r k s a s t e p i n t h i s a d a p l i v ep r o c e s s .

Little that we shall talk about will not reflect the influence of Dr. Kennedy, to whom we owe as to few others the best featuresof our presentsystem.

The final chord which I shall strike in key-notingthis m e e t i n gi s i n a m a j o r k e y . O n y o u r b e h a l f I w o u l d p a y t r i b u t e t o t h i s a c c o r n p l i s h e dm a n , n o t o n l y m u c h respected,but also deeply loved.

The spiritual heritageof Robert H. Kennedy appears to me, as I survey the scene,to be alive and well.

References Kennedy, R.H.: A Dilemma in EmergencyDepartment Coverage, J o u r n a l o l ' T r a u m a , 9 : 8 2 1 - 8 2 2 ,1 9 6 9 .

Procecdingsof the Airlie Conference on Emergency Medical Services, C o m r n i t t e e o n T r a u m a , A m e r i c a n C o l l e g e o f S u r g e o n s ,a n d C o m rnittee on Injuries, American Academy of Orthopaedic Surgeons, C h i c a g o ,1 9 7 0 .

G u i d e l i n e sf o r D e s i g n a n d F u n c t i o n o f a H o s p i t a l E m e r g e n c yD e p a r t , hicago, m e n t . C o m m i t t e eo n T r a u m a , A m e r i c a n C o l l e g eo f S u r g e o n sC I970.

F i t t s , W i l l i a m T . , J r . : M e n f o r t h e C a r e o f t h e I n j u r e d :A C r i s i s F a c i n g t h e 7 0 ' s , B u l l e t i n , A m e r i c a n C o l l e g e o f S u r g e o n s ,D e c e m b e r 1 9 7 0 .

Frey,.C.F., Dimick, A.R., Johnson,G. Jr.: Organizingto Improve EnrergencyServices:Birth ofthe University Association for Emergenc y M e d i c a l S e r v i c e s J, o u r n a l o f T r a u m a , l 0 : 8 0 6 - 8 1 0 ,1 9 7 0 .

Hampton, O. P. Jr.: Categorization of Hospital Emergency D e p a r t m e n t so r H o s p i t a l s ,J o u r n a l o f T r a u m a l 0 : 1 8 3 - 1 8 4 ,1 9 7 0 .

Categorization of Hospital EmergencyCapabilities, American Medical A s s o c i a t i o n ,C h i c a g o , 1 9 7 0 .

S h i r e s , G . T . : C a r e o f t h e I n j u r e d - T h e S u r g e o n ' sR e s p o n s i b i l i t y , B u l l e t i n , A m e r i c a n C o l l e g e o f S u r g e o n s ,F e b r u a r y , 1 9 7 3 .

A S y m p o s i u mo n I l l i n o i s P l a n f o r T r a u m a C a r e ; J o u r n a l o f T r a u m a l3: April, 1973.

R o b e r t s o n ,H . R . : H e a l t h C a r e i n C a n a d a : A C o m m e n t a r y , S c i e n c e C o u n c i l o f C a n a d a , S p e c i a lS t u d y N o . 2 9 , M a r c h 1 9 7 3 .

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GUIDELINESFOR PROGRAMSWHICH TRAIN FULL.TIME EMERGENCY PHYSICIANS DELIBERATION OF WORKSHOP William F. Mitty, Jr., M.D.

"Guidelinesfor Programs which The l0 workshopson Train Full-tirne Entergency Physicians" were given five chargesfor discussionand possiblesolutions.Thesewere: Will the full time EmergencyPhysicianhave a I. viablecareerin the future if other nrethodsfor eitherwithin providinghealth careare developed or without the government.

II. What are the educational requirements for training the full time EmergencyPhysicianbe he a new graduateor a man or woman embarking upon a secondcareerin EmergencyMedicine.

IIL What type of programcan be developedand can "BasicPrototype" programbe set up in viewof a the l'act that there are now programsboth in the comtnunity hospitalsas well as in University Centers.

IV. ts therea needfor accreditingtheseprogramsand if so by whom - the University - a Specialty Board - or the University Association lbr Emergency Medical Servicesor other similar interestedgroups.

V. Should the Emergencyfull-time Physicianbe given academicrecognitionby the Deansof the Chairrnen. schoolsaswell as the Departntental To the first charge concerninga future viable career,it was the consensusof most groups that within the next decadeor two they will have a viablecareer.For thosewho seefit to depart from the ranks of full-time Emergency Physician, it was the opinionof the groupthat two avenues are availableto them, narrely (a) to pursue u careeritr family practice,or (b) with further training they could becomeboard certified in their chosenspecialty.Sorne about the future viabilityof this uncertaintywas expressed specialty;and therefore, some participantsfelt that it would be saferto continuesomesort of outsideactivitiesin their chosenpreviouscareer.It was felt by most that to insure viability in the future, the complete full-tirne Physicianwill not only be caring for patientsbut must as assumethe role of teacherand do someclinicalresearch well.

The secondchargewas the educationalrequirements for the full-time EmergencyPhysician.Opinionsvaried as for theseDoctors. to the exact edueationalrequiretnents should Most of the participantsthought that the Specialist do the vast majority of teachingwhile a minority felt tl'rat the FamilyPractionershouldbe chargedwith the education of the full-time Emergency Physician. Most of the participantsthought the teachingshould be under the aegis Hospitalsince of the Universityand not at the Comn.runity depth of personnel for teaching is not availablein the

Hospital.It was thought that someof averageCornn.runity the educationalrequirementsshould be in the field of hospital administration and some exposure to the rnechanismof Systems managementsas well as to community problemsand to the businessaspectof the E m e r g e n cD y e p a rnt r e n t .

For the Physicianwho is seekinga secondcareeras a full{ime EmergencyPhysicianhis retrainingshouldconsist of a formal courseof didacticlecturesfulltime for a period of one to two monthsand then havehis trainingcontinued in the ErnergencyDepartmentunder the usual working conditions,but he must be supervised constantlyuntil his coulpetencyis attestedto by his teacherwho shouldbe a fq,'rrltrr

mpnrhcr

It is of paranrountimportancethat both the new graduateand the physicianseekinga secondcareeras an EmergencyPhysicianshould be well motivatedto pursue this type of careerand'toavailhiurselfof all the facilitiesof the Universityso that as a flnished graduateall can be proud of him.

The third topic under discussionwas what type of program should be developedfor the training of the fuli-tinrePhysician.This was the only areawheretherewas near unanimityof opinion. A11participantsfelt that either two or three years of training would be necessary depending on whether or not the rotating or mixed for the studentashis first yearof internshipis still available post-graduatetraining. If he takes an internship,then anothertwo yearsshould suffice to rnakehim a safeand Physician;otherwise,his competentfull-time E,mergency progranrshould be of three yearsduration.His rotation shouldencompass all the disciplinesbut only as they relate to the diseases and traunrathat they can expectto seeitr the EmergencyDepartment.Prototypeprogranrssintilarto thosenow in existenceseernedsatisfactoryto mostgroups providedthe teachingis done by board certifiedspecialists In the in all the disciplineand not by the FamilyPhysician. rotation schedulernore time should be alloted to those which will providethe studentmore knowledge disciplines of the diseases which he will encountermost conluonly and The fourth and fifth chargesnanredaccreditation academicrecognitionare so interrelatedthat many groups discussed thern conjointly.A rnarkeddichotornywasnoted will eventuallycorne here.Sonrethought that accreditation as lnore University progran$ beconreoperationaland the finished product can be better evaluatedby the various accreditingagenciesand thereforedo nothing in the next few years.Some participantsthought accreditationis an absolutenecessitynow by examinationwith no grandfather clausefor the developmentand growth of the programsas

r

well as to attract the bright, young medical student to pursue a careeras a full-time EmergencyPhysician.Those in the secondgroup thought that at this presentmoment and time the accrediting body should be the section of EmergencyMedicineof the AMA. Then at a later time the Council of Medical Education should be petitioned to review the program and ultimately attain the status of a specialtywithin its own right.

Most participants did not think that either this organization or the American College of Emergency Physicians should be the accrediting agency. It was frequently mentioned that ultimately all residency programswill be accreditedby the Universityand not by a SpecialtyBoard.

All participants agreed that academicrecognitionis necessary and important to obtain asit relatesto the Dean's Office as well as the Departmental Chairman. If these physiciansare to be on a level with their colleaguesin esteem,they absolutelyrequireacademicrecognition.Most participants felt that the Directors of the Emergency Departmentshould be on the ExecutiveCommittee of the hospitalwith all the rights and privilegesof other Directors in the hospital, Most participants thought that the Director of the EmergencyDepartment should also be Chairman of the Departmentin a MedicalSchool and sit as coequalwith the ExecutiveCouncils.

EMERGENCY MEDICAL CARE IN A PREPAID HEALTH CARE SCHEME

Frank Miller, M.P.P.

Before I talk about EmergencyMedical Serviceas an insuredbenefit, I should explain how medicalservicesare financedin Ontario. The ProvincialGovernmentis involved in much more than simply paying claimsfor hospital and medical services-- the usual concept of a prepaid health careplan, Through its Ministry of Health, the Ontario government has statutory obligations for assuring the avaiiability of adequate preventive, diagnostic and therapeuticmedical servicesto all its citizens.Capital and operatingcosts for a broad spectrumof institutionsand healthagencies,including the whole public hospitalsystem, are funded through a mix of direct services,grants and transferpayments.

Payment for physician'sservicesis made largely by reimbursementon a fee-for-servicebasis -- though a significantnumber of physiciansnow receivesalariesfrom universities,hospitals,health units and community clinics fundedby the Ministry.

Governmentis committed to financing not only the deliveryof health services,but the educationaland training programs necessary to supply adequate numbers of qualifiedmedical,allied and paramedicalpersonnelto staff the deliverysystem.

Inevitably, any publicly funded health deliverysystem is prone to abuse,not only by patientsand physicians, but by all personnelinvolved. The smaller the facility that is permittedautonomy, the greaterthe degreeof parochialism engendered.

This is NOT to say that the total systemmust be operatedby one giant, central,bureaucraticagency.

However,it doesmeanthat governmentmust,on behalfof all its citizens, ensure that the system provides the right type of facility or servicein the right place.

It also meansthat eachmust be operatedasefficiently and economicallyas possible,keepingin mind that all types of servicemust be availableto all, even though the highly specializedlevels of investigationand treatment cannot be established in every town or village,or even,in somecases, in every city. One must inevitablyequateprobabledemand for care with planning the location of facilities for its provision.

Assistance in overall planning for such a systemhasto come from regionalor district councilsthat cover enough areaand populationthat most levelsof careshouldlogically be provided within them. At some point, we must obviously determine the authority and autonomy such healthcouncilscan be expectedto assumewithin the total system.

The establishmentand maintenanceof standardsfor

each type of serviceor facility, we believe,should restwith the Ministry. Operating efficiency must be among those standards.

Over the past few years,there hasbeena greatdealof discussionabout the idea of community health centres.

While all l0 provincesin Canada,as well as the provincial government,are agreedthat this type of facility will assume a significant role in both the planningand the deliveryof health care, a great deal of planning and study and evaluationwill be neededbefore we introduce the concept on a wholesalebasis.

The HastingsReport,with which I'm suremost of you are familiar, has many interestingthingsto tell us, but here we find endorsationwithout enough actual statisticsto form a soundopinion on how they canfit into our system.

Researchis also neededon whether the emergency room of today'shospitalshouldbecomeeitherall or part of an evolvingcomrnunityhealth centre.

There are argurnents,suchas capitalcosts,in favour of this approach;there are also argumentsagainstit, like the dangerof the centre becomingsinrply a feedingstation for the hospital.

The Ministry of Health is well aware of these argumentsand the province is going aheadwith District Health Councilsand community health centres- both on a limited and experimental basis.

It is our feeling that the Community Health Centre will tend to be different in one community from the next, and we expect that the district health councilswill have a lot to say in how the local emergencyservicesare best co-ordinatedinto the local plan for health caredelivery.

Let us now turn to the questionof emergency medical service within an insured health program. Provision of adequate care for the victims of traumatic or medical emergencies is complicated tremendously by the suddenness of the need.

Although the definition of an emergencydependson whether it is made subjectivelyor objectively,there is no doubt that an effective health delivery system must be capableof res.pondingto the sudden cry for help, and be preparedto sort out the true emergencyvictims,who require care urgently, from those whose treatmentcan be deferred.This processof sortingis well understoodby your group. It's a processthat beginswith receiptof the call and continuesthroughoutthe prograrnof care.

Emergencymedicalservice,asI understandit, involves deliveringeffectiveprimary care to the casualties aswell as deliveringthem to appropriatedefinitivetreatmentcentres. lt may also,I presume,involve careand movementwithin

the complex of treatment facilities. The care and transportationof the sick and injured is a significantaspect of emergencymedicatrservice,one that must be integrated into a total program.

I believe Ontario is the first jurisdiction of its size to accept the concept of an integratedsystemof ambulance servicesand communications,designed to assure all its citizens availability of quality emergency care and transportation,as an insured benefit. Since 1968, the government, through its emergency health services,has beenevolvingjust sucha system.

I am pleasedto find that a demonstrationof someof the equipment, vehiclesand communicationsis on your program. Evolution of this programhas involved emphasis on all aspects of the service - personnel, equipment, vehicles,communications,data collection and operational research. It has involved the development and implementation of standards for all the foregoing components,as well as a new approachto a province-wide system, This system envisagesthe ultimate developmentof linked mutually supportingregionallyadministeredservices, together b! a network of despatchcentresspanningthe province. These,in turn, are linked with other emergency agencies,including police and fire servicesat appropriate points. I'm sure you'll learn more of the details of this ambitiousprogramduring your conference.

From the patient's viewpoint, and of particular interest to a group such as yours, education and training programsfor personnelinvolvedin the delivery of careare significant.

Starting from a point where no training or other qualifications were required, basic training in the fundamentalsof casualtycarehas now been given to more than 1600 ambulance workers. Advanced training for experiencedmen has beendevelopedthat will producetrue paramedical professionals, capable of dealing more effectivelywith a wide rangeof emergencysituationsunder the general supervisionof physicianssuch as yourselves. of The curriculum was developedby representatives the Ontario Medical Association, the Ontario Hospital Assocjation and our own Emergency Health Services Branch. Hopefully, this coursewill becomea requirement for all new entrantsinto the system.

A part-time coune is also to be offered at community colleges and contract hospitals to upgrade the basic education and patient-careskills of those alreadyworking in servicesthroughout the province who have qualifiedin our own fundamentalsof casualtycarecourses.

Net capital training and operating costs of this comprehensivesystem in 1973 will cost the taxpayers about 1% of the provincialhealth budget.Sinceour records show that the system transported more than 405,000 patients in 1972 and that at least two hundred patients apparently dead were revived and delivered to hospital during the year,such costsdo not appearout of line.

I said earlier that an ambulanceservicesystemshould be integratedwith other elementsof an emergencymedical servicesystem.I'm sure you'll agreethat the development of such a systemin a meaningfulway is generallylessthan adequate.There is little point in providingeffectiveon-site emergency care and delivery of emergencycasualtiesto treatment centresif the latter are not organized,equipped and staffed effectively to peak capacity for reception of all emergencycasualtiestwenty-four hours a day.

Here, then, we are talking of an effective system, designedto assureavailabilitynot only of emergencycare and transportation, but of properly equipped, staffed facilities at which patients can be assuredof prompt, competent,definitiveprimarycare.

I suggestthat if we plan such resourceson a district or regionalbasis,much more can be done without significant escalationof costs.Sincestaff is the prime dollar consumer, perhapswe can do much better for less.

To sum it all up, emergencymedicalserviceMUST be providedin a health caredeliverysystem.Thereis an urgent need to organizeit as a system of mutually supporting districtsor regions,and to integrateour emergencycareand transportationserviceinto it.

Trauma has been described as the most neglected diseaseof modern society, I suggestthat care of true of all types could be improved.I hope you will emergencies agreethat we recognizethe problem, and are attemptingto do somethingabout it -- within, if you will, a prepaidhealth careplan.

GUIDELINES FOR THE CORE TRAINING PROGRAMS FOR THE SPECIALTY RESIDENTAND GENERAL PRACTITIONER IN THE EMERGENCY DEPARTMENT REPORT ON WORKSHOP II Allen P. Klippel, M.D.

ln consideringthe guidelinesfor training physiciansin the EmergencyDepartmentof any hospital this workshop felt the most importantrequirementwasthe availabilityof an adequatenumber of patients.In a sensethe idea of "turf" was paranrount. Many university hospirals are extremelywell staffed, but it is possiblethat there are not enoughpatients with emergencyproblems to prclvidean adequate experience both for the specialtyresidentand also for the residentin emergencymedicine.It was considered that, should this be a problem, affiliations with other institutions including municipal hospitals should be considered.

Some participantsexpressedthe need for adequate supervision of the house-staff in the emergency department.

It is no longer consideredproper medicalcare to leavea

new intern "muddle through" thereby increasing his experienceto the detrimentof the unsuspecting patient.

This is true also for the first year resident.Supervisionby an attending physician or at least a third year residentis required to meet the guidelinesof the AMA "Calegorizalion of Hospital EmergencyFacilities." At the sametime, it is hoped that the non-elnergent patientcouid be treated in an area removed from the emergency department.Someuniversities and affiliatedhospitalshave developed ambulatory carc areas where treatment is provided by residentsor attendingphysiciansfrom the Family Practice Programs.This policy would help in the training of emergencyand specialtyresidentsby allowing them to focus on the emergencyproblem and not be obligedto provide"service."

THE ACADEMIC SURGEONAND THE EMERGENCYDEPARTMENT

Robert B. Rutherford,M.D. I askedthe programchairmanif I couldn'thavean opportunityto presentto the membership, the resultsof a surveywhichI conducted thisyearamongmy surgical colleagues who wereED directors.It wasa bit too long for the "nuggets"andsomehowit hasnowturnedinto a "Presidential Address,"but I hopeI havenot established a precedent to whichmy successors are committed.

As you well know, the emergencyfacilities of hospitalsthroughoutthe UnitedStatesand Canadaare currentlythe sceneof great changeand unrest.Major quantitativeand qualitativechanges in the patientpop"rooms," ulationsof theseemergency or departments, have forced equally major adjustmentsto be made.

Many, if not most EmergencyDepartmentdirectors, havebecomeintimatelyinvolvedwith suchmattersas emergency departmentdesign,physicianstaffingplans, categorization,triage, screeningor walk-in clinics, poison control, drug abuse,psychiatriccrisis care, e m e r g e n c yc o m m u n i c a t i o ns y s t e m s ,h e l i c o p t e r specifications, ambulancedesign,and much more. It may be legitimatelyasked,what hasall this to do with surgeryandparticularlyacademic surgerysincethevast majorityof ED directorsin teachinghospitalsare still surgeons.

The surgeon's roleasan ED directoris a legacyof the dayswhenthesefacilitiesfunctionedalmostexclusively for the careof the seriouslyill or injured.But now the academic surgeon,originallydrawninto the emergency department out of a naturalinterestin traumaand other surgicalemergencies, often finds himself being drawn farther and farther afield from purely surgicalinterests or, indeed,from any traditionallyrecognizedacademic pursuit.As the demandsof the director'spositionsrow with the sizeof his emergency departmeni, the suigeon may frndthat he can no longerdo justiceto both it and his dther clinical and academicinterests.Many academic surgeons still feelstronglythat theemergency departmentshould be "surgical territory" and that it takesthe "surgicalapproach"to emergency problemsto a.ssure effectiveED operations.Others,while resenting the intrusionof minor medicaland other ambulatory care problemson the ED nevertheless feel that public p r e s s u r e sa r e i r r e s i s t i b l e a n d t h a t e m e r g e n c y departments will neverbe the same again.They are thereforeunwillingto fight to restoreor retainthe status quo.

I perceived,from my own personalexperiences and from conversations with my colleagues, that serious problemsexistedin the relationshipbetweenmany academic surgeons andtoday'semergency departments, so to shedmore light on this matter, I conducteda sur-

veyof all ED directorsin the UA/EMS who werelisted assurgeons.

Forty-six(46)replieswerecomplete enough for groupanalysis, and I hopethoseof you who aresurgeonswill find the resultsnot only interesting but helpful. Thoseofyou whoarenot surgeons, but haveto coexist with theselovablecomrades, will not onlyunderstand them betterbut discover,to your surprise,that you do have much in common, even if it is only common headaches. f ) A profile of your 'oaverage" academicsurgeonED directorindicates that he is 42,nineyearsout ofresidency, hasheldthe positionfour years,andmostlikely,(i,e.

537o)holdsthe rank of associate or full professor.

2) His major clinicalinterestsare led by traumaand generalsurgery.Only l3%olistedEMS as their primary interestand40Vodidn't list it at all.

3) Our averagesurgeon-ED directorspendsl4 hours a weekphysicallypresent in his ED andan extra8 hours workingoutsidethe ED in its behalf.This 22-hourtotal represents 30Voof effort of the average70 hour/week.

Half their time is spenton administrative work, onequarterin teaching,20Voin directpatientcareand only 570in chemicalresearch.

4) More interestingis the fact that 76Vowould not wishto continueas ED directorif requiredto spendat least507oof their time physicallypresentin the ED and 58%wouldnot wishto continueif theirothersurgicalactivities had to be significantlycurtailedto meet increasingdemandsfor attentionby the ED. 5) lSVoof respondents foundno satisfaction with the job of ED director;another1870 foundlittlesatisfaction; 28Voweremoderatelysatisfiedand36Vowereso satisfied they had neverthoughtof quitting.

6) Professional satisfaction was providedto 64Voof the respondeesby; first, serviceto patients and the hospital and teaching experiences,followed by the challengeof runningan importantclinicalserviceand personalclinicalexperiences.

Clinical researchopportunitiesand increased financialrewardsrankedlowest.

7) What werethe sourcesof professional dissatisfaction?First rankedwaslack of academic recognition for the EE activities.Administrativeimpediments to getting thejob donewasa veryclosesecond.

Closeto half (415070)listedlack of opportunityfor chemicalresearch in the ED third. Fourth were impedimentsto developing goodeducational programsin the ED and fifth waslack of personalclinicalexperiences in the ED. A fewjust felt they didn't haveenoughtime to devoteto the ED. Further; 64Vofoundthe job frustratingand annoyingmuch of the time

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5l7o would stepdown if a qualifiedfaculty member offered to take the job 31Vosaid they won't stay if their situation doesn't lmprove 24Vosaid they won't stay if major changesin the EMS system do not come soon l2vo said they would quit right now if there was some reasonableway out l3Vowould probably stay on if their ED was given departmentalstatus.

44Voincriminated their deans 42Votheir clinical faculty 36Vothe headsof other (i.e. non-surgical)services, and 27Voeach felt that their hospital administrator and their house staff let them down only 11Vofelt their surgical chairman was not supportive, and 9Vofelt their nursing service had let them down 70Vowanted a better coordinated regional EMS system 687owantedmore funds and/or facilitiesfor chemical researchin the ED, and 4870desired a separatetrauma or acute surgical serviceunder their direction.The latter ranking higher (ff4) as a primary objective.

Desired improvements included: Increased income.

However, in answer to another question, 36Voakeady felt they were receiving a greater income than they would havewere they not the ED director. Of these6070felt the amount was not an appropriate enough incentive and 63Voof thosewho receivedno particular recompensefor their efforts as ED director felt that some financial incentive was appropriate.

There is obviouslya certain degree'ofbias introduced into a surveysuch as this, just in the selectionand wording ol the question.I cannot keep bias out of my interpretation and discussion.I don't apologizefor this and I know the readerwill draw his own conclusionsand select those findings which support his own beliefs. I guess there is a little somethingin it for everybody.

Hopefully, the deans, administrators and surgical chairmen and future ED directorswho read this will not simply dismissthe entire matter as being nothing more than a reflection of today's society, where so many appear to be organizingfor greater recognition,a sense of identity, more authority, a greater role in their own self-determinationand better compensationfor their efforts. Rather, I fleel that there are some important specific issuesinvolved here that should not go unheeded.

First of all, there is obvious evidenceof widespread dissatislactionamong academicsurgeonswith the position of ED director. Most spendrelatively little time in their emergencydepartmentsand are unwilling to make a greater commitment of time and effort to the job of director unlessit is made more attractive to them: administratively,clinically, and academically.At the moment, many are apparently staying on only becauseof the lack of a qualified replacementor out of a feelingof obligation to their department chairman. On the other hand, the majority apparently derivesome measureof professionalsatisfactionfrom the job, feel a surgeonis the most appropriate faculty member for this position and would stay on under other than the currently existing circumstances.For many, the main issueappears to be lessone of whethersurgeonsshouldbe directingthe emergencydepartmentsof teaching hospitals,but how the position can be made professionallymore satisfying and attractive to the academic surgeon. Based on the responses to this survey, several recommendations

Why are they stayingon?- For 58Voit is the enjoymentof runningan activeclinical service 44Voareexpecting majorimprovements in thenear future, but 40Voare staying on becausethey feel an obligation to their departmental chairman, and 29Vo simply lack a qualified replacement In the face of all this disillusionment. who do academicsurgeonsfeel should run the ED's of teaching hospitals?- A surprising 64Vostill felt that a surgeon was the most appropriateman for the job. Thoseagainst surgeonsas ED directors were also equally divided among 3 reasons: (l) surgeons can't spare the time (35Vo),(2) surgical problems are in the decidedminority in today's ED (307o),and, (3) today's ED requiresa fulltime emergencyphysician. lSVosaid, anyone interested and motivated, l2Vonamed a full-time emergencyphysician and only 6%ovoted for an internist of GP. The respondeeswere asked to list and rank those changeswhich would most significantly improve their lots as ED directors.An effectivemeansof keepingnonemergency,general medical problems out of the ED ranked firstl and some who didn't list this noted that they had already accomplishedit. 4lEo desired to encourage more traumatic and surgical emergencies.In answerto anotherquestion,54Vofelt that the educational value of the house staff rotation in their ED was significantly diminished by the high percentageof uninstructive,minor medical problems they were required to see.

Next in importancecame hospitaldepartmentalstatus or its functional equivalent.

In this regard, 93Volelt the ED director should be renresentedon the governingmedical body of the hospitalor be always consultedon matters affecting the ED only 64Vohad this representation 82% felt the ED director neededto play a major role in the ED budget o n l y 3 l % oh a d t h i s i n v o l v e m e n t- a n d "hiring 60Vofelt that the ED director should have and firing" privileges over their nurses and c l e r k s ,a n d only 20Vohad this authority It is not surprisingthat most felt they neededa bigger ED (10Ea).8070wanted greater faculty support for ED p o l i c i e sa n d p r o g r a m s .

It is interestingto list just where these men felt that s u p p o r to f E D p o l i c i e sa n d p r o g r a m sw a s m o s t l a c k i n g .

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deserveconsideration.

Of all the suggestedchanges which might improve their lots as emergencydepartment directors,an effective means of diverting non-emergencytraffic from the ED ranked the highest.It is becomingdifficult to defend the ED of a teaching hospital as "surgical territory" when neither surgicalnor evenemergencyproblemsconstitute a majority of those beingtreatedthere. In spiteof significant increasesin trauma, it is the non-emergent, general medical problems which are overloading our emergency departments. These facilities, originally designed,equippedand staffedto care for the acutely ill and injured, now find themselvesinundatedwith patients with relatively minor problems,who either have not establisheda functional relationshipwith physicianspracticing in the community; find it more convenientto use the emergencydepartment; were unable to reach their physician; were sent there by him or simply find the emergencydepartment'sconveniently"open door" to be t h e i r o n l y r e a s o n a b l ep o i n t o f a c c e s st o t o d a y ' s h e a l t h c a r e d e l i v e r y " s y s t e m " ( o r " n o n - s y s t e m , "a s i t s h o u l d m o r e a p p r o p r i a t e l yb e t e r m e d ) .

None of us wishesto deny thesepatientsappropriate medicalcare at reasonableconvenienceand cost, but the wisdom must be seriouslychallengedof allowing them to continueto clog up emergencycare facilities,wherethey rnust suffer long treatment delayswhen forced to compete for medical attention with more urgent, higher prioity problemsT . h e u s eo f a n E D f o r t h e m a n a g e m e n t o f n o n - u r g e n tg , e n e r a lm e d i c a lp r o b l e m se n d su p b e i n g "episodic, ineffectiveand expensivemedicalcare." Even il this trend can be reversedby a resurgencyofgeneral or family practice,the developmentof health maintenance o r g a n i z a t i o n so r o t h e r i m p r o v e m e n t si n t h e s y s t e m , more adequate and accommodating ambulatory care facilities will be needed in most of our hosoitals.

However, il these facilities must share spacewith those devotedto emergencymedical care, eveiy effort should be made to have them be adjacent but functionally separate, with a good triage or screening operation fronting the entire complex. An equally, if not more effectiveapproach,in major population centersat least, would be the establishmentof trauma and emergency care centers in selectedteaching hospitals through a processof regional planning.This could evenresult in a shifting of non-emergentpatientsto hospitalswhich are not adequatelyequipped,staffed or in some cases,even motivated to managethe seriouslyill or injured. Unfortunately, reactions to perceivedthreats to prestige or economy may seriouslyimpede acceptanceof this approach. However, the development of trauma and Emergincy Care cenlers would not only improve e m e r g e n c ym e d i c a lc a r e ,b u t p r o v i d ea s o u n d b a s i sf o r a major career interest and professionalcomrnitment to this field by academicsurgeonsand evenby faculty from other academicspecialties.It would provide the opportunity for clinical experienceand research,and provide stimulating educationalexperiencesfor the house staff and the faculty who superviseand train them. In other words, it would establishan appropriateenvironmentfor training programs for all physicians who will be the

future providers of emergencymedical care.

Failing this, the ED should at least be restoredto its original functionl Reducing the number of nonemergencypatientsby providing alternativeambulatory care facilities elsewherein the institution or even in the community and have such facilities stay open on eveningsand weekends.Thereby the administrativeand non-educationalservicerequirementsof the ED could be reducedto a level which could be manased adeouatelv on a part-time basis.

Our survey suggeststhat few surgeonswith serious academicaspirationswill be willing to continue serving as the director of an every expandingambulatory care facility whose operation demands an inappropriately large expenditure of his time in proportion to the professionalsatisfaction and academic recognition he receivesin return for his efforts.

While the foregoingmay be consideredof vital importance to the academicsurgeon,suchchangesalone may fail to produce a completelysatisfyingenvironmentfor the academic surgeon in the teaching hospital ED. However, most of the other changeswhich this survey suggestare desirablefor any ED director regardlessof his prolessionalbackgroundor specialtyaffiliation. This survey indicated that administrative impediments and the lack of widespread institutional support for ED programs and policies are other very major sourcesof frustration and job dissatisfactionfor the ED director.

This is expressedin the desirefor hospital departmental statusor its functionalequivalent,for better coverageby supervisoryfaculty, for more support from the dean and those clinical chiefs other than their own department head and for a better opportunity to improve the educationalprograms for the houseofficersand medical students assignedto the emergencydepartment. It is equally clear that although an enlarged ED facility, a bettercoordinatedregionalEMS program, facilitiesand lunds for clinical researchin the ED and increasedfinancial "the incentivesare all listedas desirableimorovementsbv majority of the respondentED directors (and I'm sure are important objectives)their individual lack does not constitutethe major source of their job dissatisfaction, since a combined total of less than l07o of the respondeeslisted any one of these as their most desired improvement.

In summary, it would seem that more than materialisticincentiveswill be necessaryto attract or retain qualified academicsurgeonsto serveas directorsof the emergencydepartmentsof teachinghospitalsin the future. The necessaryingredientsappearto include,(l) a more effectivefunctional separationof ambulatory and emergencyhealth care problemswithin the institution if not the community, (2) an opportunity for academically rewardingprofessionalexperiences,sufficientat leastto balancethe administrativeand serviceoblieationsof the job, and (3) the administrative and facultly support and the authority - to get the job done. Time is of the essence,for the rate of turnover of surgeon-EDdirectors in teaching hospitals is already high and for many academic surgeons,their hospitals' emergencydepartment has alreadybecomea matter of "fight" or ..flight."

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THE PEDIATRIC EMERGENCY WARD: MIDNIGHT TO 6 A.M.

Charles O. McClelland,M.D. I.

Introduction Reportsby Kirkpatrick, Torrens,and Perkoff indicatethat urban-based hospitalemergency wardsfill severalfunctions:(l) treatmentof acutemedicaland surgicalemergencies; (2) provisionof surrogatephysician care for non-available private physiciansin the community; and (3) provisionof a familyphysicianrole for the urbanpoor. Hilkovitz suggested that university hospitals emergency facilitiesattemptto definethe appropriatephilosophiesof function of their patient clinentele to avoidcompromising the qualityof medical care.As a part of a broaderinquiryinto theutilizationof ambulatorypediatrichealth servicesby severalpopulations,this inquirywas undertakenand attemptedto answerfour questions:(l) Who uses the university hospitalpediatricemergency rooms betweenmidnight and 6 a.m.?(2) To what extenddoesthis population "at risk" populations? represent (3) What life stylescontribute to the patient's utilization of the pediatric ward duringthesehours?(4) To whatextent emergency doesthis populationrequireemergency medicalcare?

II. Research Setting,Methodsand Materials: Thepediatricemergency ward locatedin a separately housedfacility at University Hospitals is reached throughthe generalhospitalemergency entrance.The staff,consisting of the departmentof pediatrics, School of Medicine,CaseWesternReserveUniversity,house staff,and full-timepediatricemergency room nursing personnel, providesemergency services for all children from birth to 16 yearsof age.

All patientsregisteredin the pediatricemergency wardbetweenmidnightand 6 a.m.for a sixweekperiod in the spring of l97l were interviewedby the staff pediatricnurse.Sheexplainedthe researchprojectand permissionwas obtainedfor the participationin the studyprogram.

After a consentform wassigned,data wascollected on patient identificationand demography,medical history,family profile,parentemployment, baby sitter andtransportation was resources.

A medicalevaluation completed by the houseofficer,who alsowas askedto assigna rankingof illnessseverityas follows:(1) no diseasefound,(2) mildly ill, (3) moderatelyill, (4) acutely ill, (5) life-threatened illness.The followingmorning chartswerereviewedby the investigator and houseofficerso that concurrence wasreachedon the assisnment of severityof illness.

III. Results: Duringthestudydatawascollectdon 170patients.10 familiesrefusedto participatein the study.It was not possible for the nurseto registerall familiesduringtimes

of high patientload.Lessthan25 familiesfailedto participateduringthis periodof time for this reason.

A.

DemographicDescriptionof the Population: Figure l.

Age of Patlents: B i r t ht o s i x m o n t h s S i xt o t w e l v em o n t h s One to two years Two to five years Fiveto twelveyears O v e rt w e l v ey e a r s Race of Patlentg: Black White Sex of Patlents: Male Female GeographlcDlstrlbutlon: Glenville Hough Central M t .P l e a s a n t Other MarltalStatus ( 1 5 8F a m l l l e s ) : S i n g l ep a r e n t D o u b l ep a r e n t s PublicAsslstance ( 1 5 8F a m l l l e s ) : ADCFamilies N o n - A D CF a m i l i e s

Number 12 14 34 50 43 17

Percent 7 I 20 30 25 10

159 11

94

YZ

EA

78

46

64 40 31 17 18

38 23 18 10 11

82 /o

52 48

81

c l

1-'

49

Figure2.

Placeof Blrth Number OY zo

14 7 30 24

UsualHealthRegource Number Percent 4 1 U n i v e r s i tH y osp.

107 Metropolitan 3 G e n ' lH o s p .

8 M t . S i n a iH o s p .

1 4 S t . L u k e ' sH o s p .

0 1 8 O t h e rH o s p i t a l s : 1 4 N o D a t aA v a i l a b l e P r i v a t eP h y s i c i a n 30 C i t yH e a l t hC l i n i c s 8 N e i g h b o r h o oH d ealth 6 Center

63 2 '

l 0 18 4 3

To What Extent doesthe Midnight to 6 a.m. User "At of the Pediatric Emergency Ward Represent Risk" Populations?

Teachingof ambulatory pediatricsstressesthe needto "Is there anything about this patient'spast medical ask history, present illness, family or social structure that suggeststhat the courseof this illnesswill be at variance to that of the expectedgeneral population?"

Among suchpotential risk groups are includedinfants (l) with iow birth weights,(2) without apparentillness, and (3) those previously hospitalized. l. Low Birth Weight Infants: Of the 87 infants lessthan 30 months of age,only 8 infants were found to have birth weights less than 2'25 kilos. These were all classifiedas mildly ill.

2. Infants Without Apparent lllness: The fourteenpatientsclassifiedas having no apparent disease,had no differenceswith regard to percentageof single patients, ADC parents, parent employment p x t t e r n s .p e r s o n a lt r a n s p o r t a t i o n e. t c .

3. PreviouslyHospitalizedPatients:

B.

28

53

77

66

25 53

47

40 117

34

Figure 6.

Non-HosPitalized Previously Patients HospitalizedPatients Number Percent Number Percent

X, -

Figure 5.

SiblingsPattern Number Percent N os i b l i n g s 39 23 1-2 siblings 78 46 O v e r3 s i b l i n g s 39 23 Unknown 14 I FamilySitler Resources P a r e n to r r e l a t i v e 110 65 Neighbor tc v Nositters 9 5 N o ti n d i c a t e d 36 21 Twenty-three percent of the families had single chilrJren,whtle 23Voover 3 siblings.Approximately 213 useda Darentor relativeas a sitter resourceand only 570 i n d i c a t e da l a c k o f a n y s i t t e r r e s o u r c e .

3. TransportationResources D a t a o n t r a n s p o r t a t i o n r e s o u r c e sa r e s t a t e d i n F i g u r e6 .

Figure 3.

Groups 1 & 2 Groups 3,4,5 Total

l. Parent EmploymentPatterns: F i g u r e4 , d a t a o n e m p l o y m e n tp a t t e r n so f t h e p a r e n t s are presented.Approximately 5070of the familiesdefined one or both of the parents as employed,40% of the f a n r i l i e sd e l i n e dn o p a r e n t a le m p l o y m e n t .I n 5 2 %o f t h e f a n r i l i e st h e e m p l o y e dp a r e n t w o r k e d f r o m 7 a . m . t o 3 p . n r . a n d l 2 % oo l t h e f a m i l i e sf r o m 3 p . m . t o l l p . m .

2. Siblings and Sitter Resources In Figure f5 are presentedthe data on siblingpatterns and baby sitter resources.

3 . 2 p V a l u e l e s st h a n . 1 0

Filty-three (3170)patients had been previously h o s p i t a l i z e dt ;w o - t h i r d so f t h e s ea t U n i v e r s i t yH o s p i t a l s .

S i x t y - s i x p e r c e n tw e r e f o r n o n - s u r g i c aal d m i s s i o n sI.n c o n t r a s tt o o u r e x p e c t a t i o n sa,l m o s th a l f o f t h e p r e v i o u s ly hospitalizedpatientswere classifiedas moderatelyor a c u t e l yi l l . ( F i g u r e 3 ) Life Style Patterns of the Patients: C. Data were collectedon parent employment patterns, presence a n d n u m b e ro f s i b l i n g si n t h e f a m i l y , a v a i l a b i l i t y o f b a b y s i t t e rr e s o u r c e sa,n d t r a n s p o r t a t i o nr e s o u r c e s .

Figure 4.

Number ParentEmploymentPattern 38 F a t h e re m p l o y e dr e g u l a r l y 27 M o t h e re m p l o y e dr e g u l a r l y 19 B o t hp a r e n t se m p l o y e d 84 T o t a lp a r e n t se m p l o y e d F a m i l i e sw i t h o u tp a r e n t a l 70 employment t ata P a r e n t ael mp l o y m e n d to unKnown Hoursol ParentEmployment 52 TAMto3PM 10 3PMto11PM 3 11PMto7AM 19 N o ti n d i c a t e d 84 Total

Percenl 45 32 23 49 A 1

9 62 12 4 22 100

TransportationResource P e r s o n aal u t o m o b i l e Friend/neighbor automobile P u b l i ct r a n s p o r t a t i o n P o l i c ea m b u l a n c e Taxi N o ti n d i c a t e d

Number 95 42 14 1 7 1'l

Percent 56 25 1 4 o

Filty-six percent indicated that the personal automobile was the sole mode of transport to the hosoital: while 25Vo borrowed an automobile. The r e n i a i n d e ru s e d - s o m ef o r m o f p u b l i c t r a n s p o r t a t i o nI.n C l e v e l a n dw h e r e h o s p i t a l a m b u l a n c e sa r e n o n - e x i s t e n t and police arnbulanceservicesare severelyconstrained, o n l y o n e p a t i e n ta r r i v e d b y a m b u l a n c e .

D. To What Extent Does this PopurlationRequire EmergencyMedical Care? l. Medical DiagnosesEncountered: Figure 7.

MedicalDiagnosis U p p e rr e s p i r a t o r iyn f e c t i o n Trauma O t i t i sM e d i a Asthma A c u t eG a s t r o e n t e r i t i s Pharyngitis A c u t eN o n - S p e ciicf V i r a l Disease

14

Number 37 16 15 14 14 13 13

Percent 22 I I I 8 tJ

Croup S k i nD i s o r d e r s Pneumonitis/Bronchitis C o n t a g i o uDs i s e a s e s Hemophilia S i c k l eC e l lD i s e a s e N oD i s e a s e Found Other Total

9 6 q

4 z z

14

fr

1

patients

5 4 z

1 1 8 1 100 percent

In figure #7 are summarized the diagnoses encountered in the I 70 patientsT . w o _ t h i r d so f i h e p a t i e n t s p r e s e n t ew d i t h s o r n ef o r m o f r e s p i r a t o r yd i s e a s e .

Almost l0% presented w i t h s o m e s e q u e l a eo f i r a u m a . . D u r i n gt h e c o u r s eo f t h e s t u d y 5 o f I l 0 p a r r e n t sw e r e a d n t i t t e dt:w o w i t h c r o u p ,o n e w i t h h e m o p h ' i l i a , o n ew i t h a s e p t i cn l e n i n g i t i s a , nd one with acutemastoiditis.

2. Ordinal Scale of Severity of lllness: I n F i g u r e# 8 a r e l i s t e dd a t a o n o ; d i n a l s c a l ec l a s s i f i c a _ . t i o n o f ' s e v e r i t yo l p a t i e n t i l l n e s s .

Figure 8.

Number Percenl 14 8 91 54 50 30 t4 I 1 <1 .Sixty-two_percentof the patients registeredbetween m i d n i g h ta n d 6 a . m . w e r ec l a s s i f i e da s e l t h e rm i l d l y illor well. 9Vowere acutely ill which is higher than the usual expenencereported.

IV. Summary: This report presents medical, social, and demo_ graphic information on 170 patients registeredin the pediatricemergencyward of University ilospitals from midnight o 6 a.m.

Sixty-two percent of the patients were classifiedas e i t h e rm i l d l y i l l o r w e l l .

There.isno significantdifferencein severityof illness, o r t h e a b o v e s o c i a l v a r i a b l e sa c c o r d i n gt o i h e t i m e oi registrationin the pediatricemergency,iard. These data suggestthat emergencymedicalneedsare indeednot the m a J o r d e t e r m i n a n t o f t h e p e d i a t r i c e m e r g c n c yr o o m betweenmidnight and 6 a.m. and may reflJct informa_ t r o n ,p h y s i c a a l n d p r o g r a m b a r r i e r st h a t t e n d t o i n h i b i t m o r e a p p r o p r i a t eu s e o f t h e h e a l t h s e r v i c e sb y u r b a n poor.

B a s e do n t h e s ed a t a , t h e d e v e l o p m e not f a l t e r n a t i v e informationservicesand organizatibnof care services to expanded h o u r sa n d c o n t i n u _ i tgyr o u p sa r e b e i n gp r o p o s _ ed and evaluated in an effori to facilitate more ap_ p r o p r i a t eu t i l i z a t i o no f t h e e m e r g e n c yw a r d .

N oD i s e a sF eound M i l d l yi l l M o d e r a t e l iyl l A c u t e l yi 1 1 L i f eT h r e a t e n e d lllness

References L e e , S . L . , S o l o n , J . A . , a n d S h e p s ,C . G . ; H o w N e w p a t t e r n s of Medical C a r e A f f e c t t h e E m e r g e n c yU n i t , M o d . H o s p . 9 4 : 9 7 , 1 9 6 0 .

Shortliffe, 8.C., Hamilton, T.S. and Noroian, E.H.: The Emergency "i9_r^h" Changing patterns of Medical iare, New Eng. J."Med'. l:^"1 258:20,1958.

S k u d d e r ,P . A . , M c C a r r o l l . J . R . , a n d . W a d e ,p . A . : H o s p i t a l Emergency F a c i l i t i e sa n d S e r v i c e sA , S u r v e y . B u l l . A m e r . C o l l . S u r g . 4 6 : 4 4 ,1 9 6 1 .

W e i n e r m a nE , . R . , R a t n e r ,R . S . ,R o b i n s ,A . a n d L a v e n h a r , M.A.: yale Sludies.in Ambulatory Medical Care V. Determinants of Use of H o s p i t a l E m e r g e n c yS e r v i c e s ,A m e r . J . p u b . H e a l t h 5 6 : 1 0 3 7 , 1966.

V a u g h a n , H . R . J r . , a n d G a m e s t e r _C,. E . ; W h y p a t i e n t s Use Hospital E m e r g e n c yD e p a r t m e n t s ,H o s p i t a l s ,J . A . H . A . 4 0 : 5 9 , 1966.

R e e d , J . 1 . , a n d R e a d e r ,G . G . : e u a n t i t a t i v eS u r v e y o f N e w y o r k H o s p i t a lE m e r g e n c yR o o m , I 9 6 5 , N . y . S t a t el . n 4 e d .o l : t : : S . tqOZ. B , r o w n ,B . S . . :R e g _ a r d i n g t h e E m e r g e n c yR o o m , L e t t e r t o t h e E d i t o r , N e w E n g . J . M e d . 2 5 8 : 5 0 7 ,t 9 5 g .

B e r g m , a nA. . B a n d H a g g e r t y ,R . J . ; T h e E m e r g e n c y Clinic:A Studyof i t s R o l e i n a T e a c h i n g H o s p i t a l , A m e r . J . O i - s .C i i l a . rc4j6, 1962.

Alpert, J.J., Kosa, J., et al.: The Types of Families That Use.an E m e r g e n c yC l i n i c , M e d . C a r e 7 : 5 5 . l - 9 b 9 .

Robinson,G.C. and Klonoff, H.: Hospital Emergency S e r v i c e sf o r "at C h i l d r e n a n d A d o l e s c e n t s :A O n e - y e i r R e v i e w tie Vancouver G e n e r a lH o s p i t a l ,C a n a d . M e d . A s s . J . 9 6 : 1 3 0 4 ,1 9 6 7 Wingert, W.A., Friedman, D.8., and Larson, W.R.: The D e n o g r a p h i c a l a n d E c o l o g i c a l C h a r a c t e r i s t i c so i a Large Urban P e d i a t r i cO u t p a t i e n t P o p u l a t i o na n d I m p l i c a t i o n sf o r I m p r o v - i n g Comm u n i t y P e d i a t r i cC a r e . A m e r . J . p u b . i j e a l t h . 5 g : g 5 9 , I96g.

K i r k p a t r i c k ,J . R . , a n d T a u b e n h a u sL, . J . : T h e N o n _ U r g e n pt a t i e n t on t h e E n r e r g e n c yF l o o r , M e d . C a r e 5 i 1 9 . 1 9 6 ..1 Torrens, P.R., and yedvab, D.G., Variations Among Emergency Roonr PopulationsA : C o m p a r i s o no f F o u r H o s p i t a l si n N e w y o r k City, Med. Care 8:60.1970.

P e r k o f f , G . T . a n d A n d e r s o n ,M . : R e l a t i o n s h i pB e t w e e nD e m o g r a p h i c C h a r a c t e r i s t i c sP, a t i e n t ' sC h i e f C o m p l a i n t ,a n d M e d i c a l Care Destinat r o n i n a n E m e r g e n c yR o o m , M e d . C a r e g : 3 0 9 ,1 9 7 0 .

H i l k o v i t z , G . : V . T h e E m e r g e n c yR o o m i n t h e T e a c h i n g H o s p i t a l ,J .

M e d . E d u c .4 l : 7 2 4 . 1 9 6 6 .

F a n d W i n g e r t , W , A . : p a r e n t a l A t t i t u d e s A s s o c i a t e dw i t h l qel l li ", ^ ! ", *W Child Visits to pediatric Emergency Rooms. Ambulatory P e d i a t r i cA s s o c i a t i o nM e e t i n g , 1 9 7 2 ,W a ; h i n f u o n , D . C .

K l e i n b e r gW , . M , , H i l d e b r a n d tH , . M . , a n d H a g e ,M , : T h e y o u n g I n _ f a n t i n t h e E m e r g e n c yR o o m : A M o t h e r , s C r y " f o r Help. Arhbulatory P e d i a t r i cA s s o c i a r i o nM e e r i n g , 1 9 7 0 ,A t l a n t i c C i t v .

Ni-r.

B . c r g n . eLr . . l n d Y e r b y . A . S , : L o w I n c o r n ea n d B a r r i e r s t o [ J s eo I H c r n n 5 c r v l c e sN. e w E n g . J . M e d . 2 7 g : 5 4 1I.9 6 g .

H u n s h l r g c r .L , C . : p e r s o n a cl o m m u n i c a t i o n .

S o l o . n ,. 1 . A . .a n d R i g g , R . D . : p a t t e r n so f M e d i c a l C a r e Among Users o l H o s p i t a l E m e r g e n c yU n i t s , M e d . C a r e I 0 : 6 0 , 1 9 i 2 .

Roth, J.A.: Utilization of the Hospital Emergency Department, . l . H e a l t h& S o c . B e h a v .l 2 : 3 1 2 . l 9 i l .

N i g r o , S . A . : A P s y c h i a t r i s t , sE x p e r i e n c e si n G e n e r a l p r a c t i c e l f o s p i t a lE n r e r g e n c R y o o m , J . A . M . A . 2 1 4 : 1 6 5 7 ,1 9 7 0 .

S a t i n , D . G . a n d D u h i , F . J . : H e l p , l :T h e H o s p i t a lE m e r g e n c y Unit as C o n r n r u n r t yP h y s i c i a n ,M e d . C a i e l 0 : 2 4 g . 1 9 7 2 .

S o l k y .C . C . , a n d H o e k e l m a n R , . A . : T h e p e d i a t r i cE m e r g e n c yD e p a r t _ ' ] l . l ! , . L o 9 l , l o r R e c o g n i t i o no f p s y c h o s o c i a lD i s a b i l i i y , Clin.'ped.

I 0 : 5 2 4 .I 9 7I

I

INCORRECTX.RAY INTERPRETATIONBY EMERGENCYDEPARTMENT PERSONNEL

A. C, Strickler,M.D.

INTRODUCTION

ITS MANAGEMENT:

S t . J o s e p h ' sH o s p i t a l ,H a m i l t o n , O n t a r i oi s a 6 5 0 - b e d general hospital having an Emergency Department volunreof 50,000patient visits in 1972.h is part of the t o t a l u n d e r g r a d u a taen d g r a d u a t et e a c h i n gc o m p l e xt h a t i n c l u d e st h e M c M a s t e r U n i v e r s i t yM e d i c a l C e n t r ea n d o t h e r H a m i l t o n h o s p i t a l s .T h e r e i s , t h e r e f o r e ,a l a r g e consultantand residentstaffl.An active Department of F a m i l y M e d i c i n eo v e r s e e tsh e E m e r g e n c yD e p a r t m e n t .

The Department is staffed by 6 full-time physicians w h o w o r k 4 0 h o u r sa w e e ko n a s h i f t b a s i s T . heirrespons i b i l i t i e sa r e f i r s t , p a t i e n tc a r e , a n d s e c o n d ,t e a c h i n go f n i e d i c a lu n d e r g r a d u a t easn d i n t e r n s .

T h e D i r e c t o r ' sr e s p o n s i b i l i t i ei ns c l u d ea d m i n i s t r a t i o n , t e a c h i n g ,d e v e l o p m e n a t n d r e s e a r c hw i t h o n l y a s m a l l c o m p o n e n to f d i r e c t p a t i e n t c a r e , u s u a l l y r e l a t e d t o teaching.

S o m e m e c h a n i s mf o r c o m m u n i c a t i o nm u s t b e s e t u o . t h e r e f o r e ,t o l i n k t o g e t h e rt h e p a t i e n t w h o w a s m i s i n f o r m e dt h e e v e n i n go r n i g h t b e f o r e ,a n d t h e r a d i o l o g i s t ' s i i n d i n g st h e m o r n i n g a f t e r .

W e d o t h i s t h r o u g ht h e E . D . D i r e c t o ra n d t h e p a t i e n t ' s lamily doctor.

Radiologist

t

E,D. Director_---> L- - - -----

FamilyDoctor Patlent

- - -- +

T h i s e l i m i n a t e st h e r a d i o l o g i s t ' sf r u s t r a t i o no f t r y i n g to locate the Emergencyphysicianwho saw the patient the night before and now the following morning is a s l e e p ,a w a y , o r u n a v a i l a b l ef o r w h a t e v e rr e a s o n .

A l l l i n k s i n t h e c h a i na r e f a i r l y c o n s t a n t I. f t h e p a t i e n t has no lamily doctor, then the Director notifies the patient directly and arrangesfor appropriatefollow up.

In the eventthat the Director is away, then the respons i b i l i t yo f i n l o r m i n g f a l l s t o t h e E m e r g e n c yp h y s i c i a no n d u t y . A l l o f t h e f u l l - t i m e p h y s i c i a n sw h o s t a f f t h e EmergencyDepartment are aware of the system.

The resultsof this systemare listedin TablesI and IL

THE PROBLEM: Radiologista s r e p r e s e n itn t h e h o s p i t a lf r o m 8 : 0 0a . m . t o 5 : 0 0 p . m . T h e r e f o r e ,t h e E m e r g e n c yp h y s i c i a ni s o n h i s o w n l o r l 5 h o u r s o f t h e d a y . W h i l e t h e r a d i o l o g i s its o n c a l l d u r i n g t h i s t i m e , t r a d i t i o n a n d c o n d i t i o n i n gd i c tate that he is rarely called.

If the radiologistwere called for every case,he would r e m a i n i n h o s p i t a lv i r t u a l l y 2 4 h o u r s a d a y e v e r y d a y .

W e s e ea p p r o x i m a t e l y8 5 p a t i e n t sd u r i n g t h o s e 1 5 h o u r s of whom 30 percent require some form of x-ray examination.

TABLE I C L A S S I F I C A T I O& N D I S T R I B U T I OO N F M I S I N T E R P R E T EXD- R A Y S (False NegativesOnly)

19 7 3

Axial Skelelon

JAN

6

FEB

6

MAR

4

APR

2

Total

17

Epiphyseg

1

1

o

Chesl

z

Associated Lesions

z

lncidental Findings

Extremities Dislallo W r i s t& Ankle

z

16

Total

1

A

1

3

I J

4

I

1

4

Other

17

1

11

1

1 1

2

50

correctx-ray result,generallywithin l8 hoursof the patient'sE.D. visit.

Therefore , the worsteffecton the patientwasthe unexplainedcauseof his discomfortand whateverinconvenience was involvedin carryingout the follow up.

3. These findings would tend to support the Radiologist'sposition that extendedinhospital coverage is not essential to betterpatientcare, 4. Falsepositives alsooccurred but onlyrarelyandthese werenot recordedin this study, 5. Thewellknownfactthatx-rayinterpretation of some anatomicalregionsis more difficult than othersis documented.

Teachingshouldbe directedto these areas, 6. If you don't seeit, or don't look for it, thenyou may very well missit.

TABLE II T H E S C O P EO F T H E P R O B L E M , M I S I N T E R P R E T EX D. R A Y S

CONCLUSIONS& IMPLICATIONS: l. None of the misinterpretedx-rays produced catastrophic results.

2. Familydoctorsor theirpatientswereinformedof the

17

GEOGRAPHICAND TEMPORAL TRIAGE OF EMERGENCYPATIENTS

C. R. F. Baker,Jr., M.D.

The number of patients utilizing hospital based emergencymedical servicescontinuesto increase, perhapsat a rateevenfasterthanpreviously suggested.t From 1968to l9'72the patientstreatedin the fivemajor emergency clinicsof GradyMemorialHospitalhaveincreasedfrom 206,000to 266,000per year. It is meaningless to argueaboutwhichof thesepatientsconstitute real emergencies and which are non-emergent.

Thesepatientshaveplacedimmediatedemandson our medicalcaresystemby their entranceinto the system.

To meettheseimmediate demands of thepublicmoreeflicientlymustbe theprimarygoalof emergency medical servicesystems.Rutherfordhas pointedout that as a result of unilateral improvementin efficiencyin emergency care,morepatientsareattractedinto theimprovedportionof this system.2 No onewouldseriously argueagainstsuchimprovements in medicalcareon this basisbut the secondary increase in patientsmustbe anticipated.It may be that thosehospitalsnot seekingto improveemergency medicalservices will not continueto attract other patientswhen the public recognizes that suchinstitutionsare providingonly limited services.

PRACTICAL SOLUTTONS Faced with the continuallyincreasingnumbersof patientsin all emergency clinic areas(TableI) Grady Memorial Hospital has sought to triage patients geographically and temporallyas other hospitalshave done.3 Sortingthepatientsto differentclinicareasofthe hospitalis performedby clericalpersonnel on the basis of easilyunderstoodcriteria (geographic triage).The Surgical Emergency Clinic (SEC) and Medical EmergencyClinic (MEC) are located on the ground floor oppositethe clericaltriageareawhichis just inside the hospital emergencyentrance.This triage system works effectivelyand it is unusualfor patientsto require transferto a secondemergencyservice.

Approximatelyhalf the patientswithout appointmentspresentthemselves between 4 p.m. andmidnight.Arrangingfor additionaltreatmentareasin clinics

normallynot in useduringthesehoursand establishing eveningclinics to meet specificneeds(temporaltriage) have divertedlarge numbersof patientsfrom the ,five m a J o r e m e r g e n c yc l l n l c s - s u r g e r y , m e o l c l n e , pediatrics,obstetrics,and psychiatry.Probablythose same factors operatingto increasepatient loads in hospitalsproviding efficient emergencycare serveto reinforceutilizationof theseadditionalclinics. emergency clinicanda separate In 1970a psychiatric unit were establishedremovingthese drug dependence patientsfrom the medicalemergencyclinic. Similarly a night medicinegeneraladmissionclinic (GAC) wasestablishedat this time further divertingpatientsfrom the are treated MEC. Currentlygynecologicalemergencies in the SEC. Thesepatientsconstituteaboutten percent of the daily patientload in that clinic. In 1972GYN clinic beganacceptingpatientswithout appointments during the day and in March 1973a night GYN clinic opened.Theseancillary clinics divertedapproximately clinicareasin 72,000patientsfrom the major emergency 1972(TableII). Theseclinicsarestaffedwith permanent nursing service personnel.Faculty, fellows, and housestaffphysiciansare attracted to staff theseadditionalclinicsprimarilyby financialreward- currently at the rate of $10.00per hour. This competeswith communityrates between$12 and $18 per hour for emergency room physicians.

CURRENT GOALS areaincreasing numbers In any particularemergency in efficienresultin a decrease of patientswill eventually centersit in severalemergency cy. From observations clinicis able appearsthat no singleunit of an emergency to efficientlyhandlemore than approximately50,000 patientsperyear.This numberof patientscanbe handled efficientlywith proper organizationas has been demonstratedat George Washington University Hospital, Freedman'sHospital, and Providence Hospital in the District of Columbia.To reducethe numbersof patientsseenin anyclinicareato thislevelis

TABLE I G R A D YE M E R G E N C YC L I N I C S P A T I E N TV I S I T S YEAB

sEc

MEC

PED

1968 '1969

89,085 90,883 92,411 88,177 97,959

64,878 65,135 60,788 46,111 53,496

36,694 34,415 38,603 46,264 82,239

1970 19 7 1 1972

OB 1s,630 15,768 19,326 19,667 21,317

PSY

TOTAL

2,182 11.312 11.526

206,493 206,231 213,310 211.547 266.537

availabilitycan divert significantnumbersof patients from over-crowded emergency areas.It is hopedthat furtherutilizationof theseconceptscombinedwith local and. regional planning can reduce the numbers of patientstreatedin thoseemergency clinic areastreating more than 50,000patientsper yeir.

TABLE II U N S C H E D U L E DP A T I E N T S_ 1 9 7 2 (Non EC Areas) Started 1972 1970 1970 1972

Med GAC DrugDependence Unit M e dG A C N i g h t cYN

g4,7\z

BIBLIOGRAPHY

26.695 11,971 4,124 72,502

a current working goal in Grady MemorialHospital,

SUMMARY Geographic triage and

extensionof clinic

l9

I. NationalResearch Council,Committeeon TraumaandCommittee on Shock.AccidentalDeathand Disability:The Neglected Disease of Modern . ,Society.Washington,D,C.' Nationai Academy of Sciences, 1966.

2, Rutherford,R. B.: problemsin Operatingan Emergency Roomin a Univ-ersilyHospital,UniversityEmerge-ncy OeparimentDirectors proceedings.

C^onference University of iUUirr, Birmingham, t970, 3. Canizaro,P. C.:.ryllllg-ementof the Non_Emergent patrent,Jour_ n a t o J I r a u m a ,I l : 5 4 4 - 5 5 11.9 7 1 .

DO YOU REALLY KNOW HOW MUCH A VISIT TO YOUR EMERGENCY WARD COSTS? R. F. Williams,M.D., M.R. Cammarn,M.D., R. M. Zollinger,Jr', M.D.

In 1970, a seriousfinancialsituation becameapparent in the Ambulatory Patient Servicesat University Hospitals where an open door emergencyward facility is providedfor an urban pbpulation. The combineddeficits of the Clinics and the Emergency Ward consumed all the gifts and endowment income plus the depreciationallowance,and "never-never"land of net, thus the hospital arrived in the net deficit.

Not surprisingly,the physiciansdirecting ambulatory servicesfound that the cost figures, as prepared by the hospital's traditional accounting procedures,were of little assiitancein pinpointing the problems. In particular, the financial ledgerswere not readily understandableto the physicians and managerialpersonnel -lowering who were charged ambulatory costs i"iftr ttte responsibiht! for without turning - patients away or lessening. services.

Furthermore, because of increasing third party involvement,it has becomenecessaryto presenttrue costs for all the components: in-patient, out-patient, research, and teachins.

Accordingly the first maneuverwas to restructurethe cost accounting system into categorieswhich were more comprehensibla to physicians and which accurately refleited all componentsof cost for our emergencyward service. Additionally, a separate business office was developedfor the ambulatory services.This was and is an essentialkeystonefor analyzingand controllingemergency waro costs.

Seventeencost centerswere identified and divided into three categories: (l) Patient Related; (2) Space Related; and (3) Supporting Services.The cost centers within each of thesethree categoriesare presentedin Table 1. Thesefiguresreflect the cost per patient for 4,560 visits in Janrnry, 1973 in an emergencyward occupying7,000 square'feet within Univenity Hospitals. These figures reflect the operationalcost of purchasinggoodsand services from diversesourcesand departmentswithin the hospital' In brder to make comparisons,these cost centersare tabulatedfor both the current month and the year'to-date as shown in Figure 1, a simplifiedversionof our emergency ward accountingledger.The first column showsthe current month's cost; the secondcolumn, the budgetedprojection for 1913; and the third column, last year's cost. It is obviouslyeasy to calculatethe cost per visit for eachitem, as well as the percentageof each item relativeto the total emergencyward cost.

Having once establishedthe various cost centersby function, each was then thoroughly investigatedas to the method of allocation and the validity of each allocation.

Significant errors were found in the efsting traditional allocations, and in most instances the erron were disadvantageousto the ambulatory services. Wherever possible,we tried to changefrom estimated, or sample derivedpercentageapportionment,to actualdirect cost. As an example, housekeepingcosts were shifted from an

Table I Patient Related N u r s e s& A i d e s Clerical HouseOfficers X-ray Laboratory EKG B l o o dB a n k Pharmacy Space Related Housekeeping Utilities Maintenance ProtectiveService Depreciation Supportlng Servlces MedicalRecords C l i n i cA d m i n i s t r a t i o n Credit& Collections Supplies

$5.80 1.70 4.10 2.60 3.50 .10 .60 .60 1gT0$ .go .50 .70 .50 1.20 -330$ .30 .20 2.20 .70 340

to EW costs per patientv i s i t i n J a n u a r y ,1 9 7 3according major categories within 3 17 cost centers allocation based on square feet to the actual cost of the man-houn involved. The methods used for determining these cost distributions were not unusual;however, these analysesdid make inequitiesapparent.

This system has yielded severalbenefits. The cost figures for operatingan emergencyward are more realistic and closer to the actual plant and operating costs. these costsare hidden in the operatingcostsof Frequently ^hospiial itself. There is a clear distinction between the emergeniy service costs and hospital costs.Current costs are eisily and quickly identified-, and this capability has been particularly helpful in detecting trends such as utilization of the laboratory, radiology, and increas-ed. medications. This sytem enables monitoring the effectivenessof new programs designedto control rising and costs,the financial eff6cts of personnelre-assignments, of moving - to largerphysicalquarters.

We believe that this system of cost analysis is reproducibleand leads to more effective emergencyward Its most important contribution, however, ad^ministration. is that it can be readily understood by physicianswho have minimal experience with traditional cost acco-unting methods but who are now being held accountablefor the of emergencyward care. cost effectiveness

20

Flgure I UniversityHospitalsol Cleveland

Mr.

T o t a lE . W .A c t u a lv s . B u d g e t Monthof-

Dr..

& Year-to-Date1973

Year-to-Date Category Patlent-Related N u r s e s& A i d e s Clerical HouseOfficers X-Ray Laboratory EKG B l o o dB a n k Pharmacy Total SupportingServlces MedicaR l ecords C l i n i cA d m i n i s t r a t l o n C r e d i t& C o l l e c t i o n s Supplies Total SpaceRelaled Housekeeping Utilities Maintenance ProtectiveService Depreciation Total TotaB l i l l a b l eE x p e n s e N u m b e ro f B i l l a b l eV i s i t s C o s tP e r B i l l a b l eV i s i t

21

I

TRANSPORTATIONOF THE SICK AND INJURED BY HELICOPTER William E. Evans,M.D. RichardRuppert,M.D. R. Orr. M.D. Since1967,The Ohio StateUniversityand the Ohio National Guard have cooperatedin a program of helicoptertransportof acutelyill and injured patients.

Although varioushelicoptershavebeenused,currently Weighing9,500lbs.,it is the Huey UH-1 H is available. provides amplespacefor patient and mobile extremely care in higtrt. the helicopteris currently capableof carryingtwo or three litters, Equipmentfor monitoring are available. and resuscitation All requestsfor the Medicopterare funneledthrough the Directorof the programto screencaseswho might benefitfrom this service.A daily call rosterofvolunteer physiciansis maintainedand thesemenprovidemedical coveragewhen necessary.In addition, E.M.T. and paramedicalpersonnelare available,Both helicopter crew chiefs are E.M.T.-trainedand are working on Paramedicstatus. During regular duty hours, Ohio NationalGuardpersonnelform our flying teams.In offduty hours, theseservicesare providedby thesesame personnel, again,on a voluntarybasis.

Two types of helicopterservicesare provided.The transfer of the most common is hospital-to-hospital acutelyill or injured,requiringtreatmentat the University Hospital.The secondis emergencyhighwaypatrol.

On weekends, the helicopterand crew are on alert and actuallyairbornefor mostof thedaylighthours,respondgroundrescueunits. ing as requested by conventional to existingstandard a supplement Theunit is considered groundrescue units,servingprimarilyin thosesituations wheregroundtransportation cannotmeetthe needsof the specificpatient'sproblems.

A previousreportby Roberts,et al.,routlinedthefirst 50 patientstransportedin our program. In all, approximately150 patientshave been transportedby helicopterto the Universityand ColumbusChildren's with 35 patientsis reportedto inHospitals.Experience during operadicatethe typesof problemsencountered tion, These patients were seen in November and December1972and January1973. to As notedin Figure1, 20 patientsweretransported ColumbusChildren'sHospitalwhile 15 adultsentered the UniversityHospital.Therewere a total of 19 surgical patients,10 of whom requiredoperationsand 16 with primary medicalproblems.Trauma accountedfor 14 admissions,six from the accidentscenewith eight transportedfrom communityhospitals. t . n o b " r , r , S . , B a i l e y , C . , V a n d e r m a d e ,J . R . , a n d M a r a b l e , S . : Medicopter: An Airborne IntensiveCare Unit. Ann Surg, 172:325-33, I970.

Figure l.

November- December- JanuarY 35 patients 15 Unlveralty

20 Chlldren's

MEDICINE SURGERY U N D E R W E NOTP E R A T I O N DEATHS

13 7

1

5

c

3 2 C

.

t

In Tablel, datapertainingto the 35patientsis outlined. There were five deaths among the 20 patients to The Children'sHospitalwith threedeaths transported in the adult group.Sevenof the eightdeathsoccurredin group whereasone patient the hospital-to-hospital of an accidentexpired on from the scene evacuated room from a crushingchestinarrival in the emergency jury.

CASE REPORT R. B. is a 25-yearold whitemaleinvolvedin a onecar accidentin northernFranklin County (15 miles from Hospital)at2:05p.m.,March 10,1973.

The University The Medicopterwasairborneat thetime in thehighway surveilanceprogram. A fire rescuesquadreachedthe sceneof the accidentat2:09p.m.Thepatientwasrapidly assessed by the fire rescueteam and the Medicopter was notified at 2:12 p.m. of an injury requiringimmediatepickup and transfer.The Medicopterarrivedat the sceneat 2:18p.m. The MissionReportby the onshowedthat the boardphysicianE.M.T, and paramedic He waspaleand patientwasdisoriented andcombative. wereshallow the skin wascool and moist.Respirations andrapid.Pulsewasweakand rapidat 120per minute, The crew-assessment wasunobtainable.

Bloodpressure wasthat of headinjury,intra-abdominal summarization injury and lower extremity fracture. His fracture was splinted and Ringer's Lactate was started through a was largeboreintracath.Oxygenwas administered,.he restrained,and spinalimmobilizationwasinstituted.He arrivedin the UniversityHospital EmergencyRoom at 2:25 p.m. During the inboundflight, the emergency room was contactedby mobile telephonein order to alerta surgicalteam.Theoperatingroomwasprepared.

On admissionto the University Hospital Emergency was I l0/70; pulse Room, the patient'sblood pressure was strongwith a rate of I10. He was movedto the operatingroom area,x-raysweretaken,andexploration wascarriedout. He wasfoundto havea rupturedspleen, and splenectomywas done. Traction apparatuswas

22

appliedfor treatment of his femoral shaft fracture. The patientmade an uneventfulpostoperativerecoveryfrom his intra-abdominal procedure. On the eighttl postoperativeday, an intramedullary nail was inserted for control of his femoral shaft fracture, He was dischargedon the 20th postoperativeday.

COMMENT Severalfactors in this specificcasepoint out some of the principal advantagesof helicopter transfer. First is the factor of speedof response.Although not the most important factor, it was clearly demonstratedhere that columbus children's Hospital-

Pt.

Sex

MedicopterMissions-

Age

Pickup Sits

the ability of the helicopterto reachits destination unimpededby the local traffic conditionsis a distinctadvantage.Secondly,it providesthe deliveryof trained emergency medicalpersonnel to thesceneof theaccident so that treatment can proceedduring the period of transport.In this particularinstance,the ability to provide resuscitativeefforts may have been of critical importance.

Thirdly,the abilityto communicate directly with the hospital receivingthe patient allows for mobilizationof the proper medicalor surgicalteams decreasingdelay once the patient has reachedthe hosnital.

N o v e m b e r ,1 9 7 2 t h r o u g h J a n u a r y , 1 9 7 3

Distanco from Columbus to pickup in miles

Nature of illness/inj.

0.N.

M

M.t\4.

B,K. S.S. J,B, O,B,

F. M IVI M M

8 yr.

NB 7 mo.

12 yr.

8 yr.

S.M,

M

4 da.

B.F,

M

NB

B,H,

M

NB

J.D.

M

NB

R.D.

M

10 yr.

c o t i c a lc o n t u s i o n meo.

T-E fistula surgery T-Efistula surgofy drug ingestion med, m u l t i p l et r a u m a / f r a c t u r e s surgery subdurah l ematoma expired 9 O d i a p h r a g m a t iec v s n t r a t t o n med. mild prematurity M t . V e r n o nO , .

30 s e v e r ei d i o p a t h i cr s s p i r a t o r y e x p i r e d d r s t r e s ss y n . - p r e m a t u r e L i m aM e m . H o s p .

90 cyanosis-respiratorydistress med. heartmurmur M a r i e t t aM e m . H o s p .1 1 2 g a s t r o s c h i s ipso s s i b l es e p s i s surgeryexplreo G a l l a p o l i sO,.

1OO possible ncephalitus med.

J,H, R,B,

F IVI

11 y r .

12 yr.

B a r n e s v i l l eH o s p .

G a l l a p o l i sO..

F.B.

M

J.H, C.S,

M M

9 wk.

NB

B.S.

M

2 da.

J,C. R,W, A.B,

F F M

50 da.

8 yr.

2 da.

4 m o . E R - M I .V e r n o n ,O .

E R - P o r t s m o u t hO, L i m a ,O .

I n d i a n a p o l iIsn,d .

G a l l a p o l i sO,.

Mem. Hosp.N e w a r k ,O .

P o r t s m o u t hO , .

7 mo. Lima Mem. Hosp.

30

s u b d u r a lh e m a t o m a

Naturo of troatmant

exotreo

90 90 177 106 30

1 11 106

4 da.

3 m o 2 m o 'I da.

4 da.

13 da, 1 da.

9 da.

4

da.

7 da, 7 da.

7 da.

G a l l a p o l i sO ,.

S c i o t oV a l . H o s p .

106 90

s e v e r ec o n g e n i t ahl e a r td i s e a s em e d . pneumonra pneumonia/bronchiolitis med.

L , d i a p h r a g m a t ihc e r n i a surgery

D o v e r H o s p . ,O

1O7

C o n g e s t i v eh e a r tf a i l u r e

expired

T o l e d oH o s p . s c e n eo f a c c i d e n t T o l e d oH o s p .

141

e p i d e r m o l y s ibsu l l o s a s h o c k / w r i s li n j u r y c o n g e s t i v eh e a r t f a i l u r e

med. med. med.

36 da 1 da b da

med. med.

8 da 8 da

T h e O h i o S t a t â&#x201A;Ź U n i v e r s i t yH o s p i t a l -

90

h i g h f e v e r / r a p i dr o s p i r a t i o n med.

R e y e ' sS y n d r o m e / p n e u m o n i a m e o .

13 da.

141

17 da.

1 1 da 36 da 1 d a

Length of stay

Discharge Diagnosis

b a t t e r e dc h i l d s y n . c e r e b r a cl o n t u s i o n - e x p . c e r e b r a cl o n t u s i o n T - E f i s t u l a / i m p e r f o r aat en u s T-E fistula p e n t o b a r b i t ai nl g e s t i o n b r a i n d e a t h / r u p t u r esdp l e e n L. diaphragmatic eventration IRDS/prematurity severe hyaline membrane cyanotic heart disease cong. heart failure congestive heart failure encephalitus iron def. anemia diabetes ketoacidosis Reyes Syndrome bilateral pneumonia congenital heart disease bilateral pneumonia L. diaph. hernia/ven. hernia congestive heart failure probable hypoplastic heart congestive heart failure e p i d e r m o l y s i sb u l l o s a ' wrist fracture respiratory disease c y an o s i s

ModicoptorMissions

R.Z.

M

54 yr.

W e s t U n i o n ,O ,

85

W.S,

F

21

Pickerington,O

15

skulllacerations f r a c t u r e so f s p i n e and manubium h e a di n j u r y

T.B,

M

18

Athens, O.

77

cerebral contusion

med.

4 da,

rvl.s.

R.G.

F F

50 17

P o r t s m o u t hO , .

S t . R i t a ' s L i m a ,O .

90 90

med, meo.

2 da, 7 da.

C.C, tvt.K.

F F

65 16

Galena-auto accident 20 S . W e b s t e r ,O .

114

m u l t i p l ec o n t u s i o n s v a g i n a lb l e e d i n ga f t e r C - s e c t i o n / a bp.a i n p o s s i b l eh i p f r a c t u r e c r u s hi n i u r v

L.tvt.

lvl

73

S t . R i t a ' s ,O

r u o t u r e da o r t i ca n e u r v s m

EB , , T.tvl.

F M

71

J ,F .

J J,

F M

1l 25

C i r c l e v i l lO e ,.

25 A t h e n sH o s p . O , .

77 UnionCo. Hosp.

30 h i g h w a ya c c . O h i c , G a l l a p o l i sO,.

1OG

R,B,

M

25

C.G.

M

58

highway Westerville, O. highwaySugargrove. O.

90

15 35

heart attack lung disease skull fracture crush injury-chest renal failure multiple trauma ruptured spleen fx-L. femur face lacerations acute cervical strain

med. su rgery

1 da.

16 da.

surgery exprred expired med, med. e x p i r e di n E R med.

2 10 6 t 27

surgery

20 da.

med.

1 da. hr. da. da. hr. da.

5 da.

fx. manubium h e a d t r a u m a& c o n t u s i o n s k u l lf r a c t u r e h e a dt r a u m a p r o b a b l es e i z u r ed i s o r d e r depressive neuroses anemia bleeding from suture line muscle pain & spasm diffusepulmonaryhematoma d iabetes

r u p t u r e da o r t i ca n e u r y s m c a r d i a ca r r e s t m y o c a r d i ailn f a r c t i o n unobtainable s k u l lf r a c t u r e m u l t i p l et r a u m a / c r u s hi n j u r y b r o k e np e l v i s f r a c t u r e dL . f e m u r c e r e b r a cl o n t u s i o n a c u t e c e r v i c a sl t r a i n

SUMMARY Thefeasibilityof sucha projectis greatlyenhanced by the availabilityof a multipurposehelicopteroperation suchas the Ohio NationalGuardwhicheliminatesinvestmentcosts.

In assessing our modesteffort of helicoptertransport of the sickandinjured,it wouldappearthat benefitsare derivedwhen the helicopteris usedas a supplemental serviceto the standardgroundambulanceand frre and rescuesquads.In the majorityofinstances, thesestand-

24

ard servicesare quite satisfactory,expeciallywhen welltrained personnel man these vehicles.The helicopter does have the advantage of speed under certain circumstances,especially in the situations of congested traffic and transfers involving long distances.In addition, the availability of physicians, E.M.T.'s and paramedicsmake resuscitationduring transport possible. The ability to assessthe patient's problem and to mobilize neededpersonnelat the site of deliveryhasbeen an important factor in this program.

A SYSTEMS APPROACH TO STATEWIDE EMERGENCY MEDICAL SERVICES

David R. Bovd. M.D. . Emergency death and disability can no longer be justifiably classifiedas an insolubletreatthproblem.

Medical expertis,e and technologyare now availablewhictr can eisity

communicationssystem,a reorientationand upgradingof the transport_ationcapability, and an ongoing 6valuaiion proces.s for all patientstreatedwithin the sfstem. uppltgdro this previously "rgf..irt All trauma centers are staffed by a new health 119,.,_.lfi.j,.l,ly .be^ neatrnproblem.In lact, it is only with the betterutilization p r o f e s s i o n a l , t h e T r a u m a C o o r d i n a t o rl. l t r r . of presently available ,erour.es through areawide professionalsare military-trained medical personnelwith , rmprementatron that an immediatebeneficialimprovement many years of casualty experience. Theie new health can be effected in a badly organized emergericyhealth are employedby the Illinois Divisionof Emergency glperts" system.In Illinois,the development of a Stateividjfrauma Medical Servicesand Highway Safety, and are locat"edit rrogram has shown that through regionalization,expert trauma centersto assistin the various administrativeand care,which was previouslyavaitibleolly in tt . uniuriiiv managerial aspects of the Trauma program. Trauma centers,can now be effectively and efficiently providel Coordinatorsare responsiblefor the ongoin-g collectionof the, state, especiallyn tne ruiai communlry. data fbr the Trauma Regrstry.They have aTsoestablished Hr^":g!:-", program ltre success ot'the Trauma on a statewidebasishas basic training course' for imbulance emergency providedthe-gro.undwork th., forlhe developmentof a Totai technicians.At present,Illinois has the largestnumder of tmergency Medical Service System ln the State of r e g i s t e r e d E m e r g e n - c yM e d i c a l lalignally Illinoic.4,lU 'Iechnicians-Ambulance (EMT-Ak). Workingwith hospital ^and on health care,GovernorRichard ^ ^In.aspgcialmessage me di cal chiefs of staff, trauma Jurgeons, B. Ogjlvie discussedthe future developrnentof some 40 administrators,the Trauma Coordinators are"developing specializedcenters for the care of th6 critically iniured improved liaisons with the community and ambulancel patient rescue,and law enforcementpersonnel. lo bg- designatedthroughout the srate.lj' fl.,e Theseprofessionals lraumaLare Flanwas to be the first componentof a Total have been instrumental in developing thi Statewide 'which Emergency Medical Service i, U.i.,g Programat the community level,and hav6madesisnificant .System2, developed on a controlledand systemaiicimplementatiofi contributions to the care of -the critically inj-ured by sched ule. th^e organization of the Illinoii Emergency iynlovlng A controlledsystemsapproachto the problemsof an MedicalCareSvstem. emergencymedicai service is the most practical and Special educationalprogramsfor trauma eare,e.g., sensible,and will yield the most return. The Iliinois Trauma grand rounds, symposiums,and conferences surgical f6i Lareyrogram has been developedin stagesby: defininga physicians,surgeons,and medical students,nurses,and "Th. specific problem, Critically I"uiur.a patien?'i ambulanceattendants(EMT-A's) are being offered at the developinga plan basedon establishedpriricipiesof clinicai trauma centers across the state. The Trauma Nurse m a n a g e m e n r ; . a .i m n dp l e m e n t i n g this planin a systematic IntensiveTraining Courseis providingpostgraduate'training ma1nelDy,utttlzlngand augmentingexistingcarefacilities, at the RegionalCentersfor-nursesacross"the state.Thes6 proresslonai talent,and techilologicresources within a giverr nurses have returned to their commur.ritiesto provide communitl,.The Illinois Trauma_program is continuSusly improved patient care to the accident victims ai their rnonitoredby a specially_designed infolrmationalsystemfo'r hospitals. It is these educational efforts that will accldentali1jury.t,),6 Becauseof the statewidesystems continually improve the quality of trauma ano emergency developmentoi a trauma care network, a healthy and medicalcarein everypart of Illinois. practicalimplementationenyironmenthasdevelopedwhere ^^ The newiy expanding total emergencymedical care problemshave been approachedon an empiricalbasisand etlort is extendingthese educationalefforts to include as ongoing eventsby the entire health community. more.centers providingthe trainingof EMT-A,sand mobile *:9t.d -lne successtulimplementation of the Illinois Trauma Ieaclltng vans tor ntore remote rural communities. The Progranl is now leadingthe way for a similarregionalization trauma-nurseprogram is expandingto include all other o l a l lc a t e g o , i eo sf e l n e r g c n c l ' h e a cl rahr e . areas ol emergencyand critical care medicine. There has been the establishmentof two residencyprogramsfor Status of the Trauma ProgXram emergencyphysicians,and 20 stipendsfor-Triuria Critical The Illinois TraumaProgrrrinpla,t lrrs i,ecn previously Care and EmergencyMedical ServicesFellows have been reported in The Journal o.f |iuttrtr^t.I r-he trauma care provided to variouscommunitiesand universityhospitalsto plogramhas to datebeenimplentented in almosteverypart support,young.professionais in their pursuit of'special of the state with the establishrnent of 2I Local.-eisht knowledgejn.their respectiveclinicaifieids.Moreovei,the Areawide,nine Regionaland two specialResionalCenti.rs.

Division of Emergenry Medicat Services and Highway From eachtraumacentertherehasbeena reo-rganization of Salety have trained 1.2 million Illinois citizensin medic;l the communiti.wide patient distribution Ind referral self-helpto date. patterns,the initiation of trauma care education and training efforts for ali professionalsand allied emersencv Program Evaluation personnel,implernentation of a urliform and disciflined In the first year of operation(July 1971throughJune

25

lg72), 12,000 patients were admitted-to 20 Trauma irnijir with an overallmortality of 2'0%.1 The anticipated number of patients to be treated in this system in the secondyearis over30,000patients,asmore traumacenters comeinto it.

An evaluation of the hlghway deaths in a l5'county area of central Illinois has shown significant results.oAll hishwav or vehicular-relateddeathsof calendaryeat 7971 an-dof ihe first 6 months of 1972in RegionIII-A of Illinois were studied. Region III-A, an l8-county a-reain ceutral Illinois, was chosenfor this study becauseof the initiation of the Statewide RegionaiizationProgram in this area.Itr the well-definedcential I 5 -county portion of this area,four trauma centers were designated between July 1 and D e c e m b e1r, 1 9 7 1 .

The patient ^area distribution of all vehicular'relateddeaths has been studied for the effects of in this resionalizationof patient carefor the critically injured. The spicial emphasisoi this report is the effect of the changing characterof patient redistribution and the time constants surroundingthese changes.There are 290 patient deathsin this study.-Information for evaluationwas obtained from the hospital and emergency records, autopsy reports, recordsfrom the Illinois Highway Department,StatePolice Department, Department -These of Vital Records, and county patient recordswere investigatedin cotoner reports. was piaced on vital statisticsand detail. Specialemphasis epidemiologic information (ilcluding time and trinsportation factorswhen availabie),statusof the patient on admission,time and type of operation,areaof ir.rjurY, organinvolvement,and major contributing causeof death.

Af patient information was entered into a computerjzed infoimational system, the Trauma Registry,which utilizes direct entry and retrieval through remote video terminals.

A highway fatality study was chosen to establish baselinedata for future evaluations.One major problemin evaluatingthis new program is that of obtaining baseline^ information. The study- period includes the first year of operation,July 1971 through June 1972, and the 6-month p6riod just prior to this. Corolers' reports,state police iecords, and autopsies from the pre'program (control) period"Januarvto June 1971, were analyzedto providethe Laselinedata oi this study. This information, alongwith the hospital and emergency patient records from the estabtshedtrauma centers,was utilized. Threecasesin this studv. in which conclusiveevidencewith regard to the meciranismof injury (vehicte)could not be determined,are not included in ihii report. Severalterms are usedin this study relating to time/death factors' An accident victim within minutes at who was killed instantaneouslyor died "Death at Accident" the accident scene if defined as (DAAC). "DOA" refers to a victim who was considered alive during transportation but died before arrival at a hospital emergencyroom and was pronounced dead on arrival.All other pitients deathsin this study occurredafter hospitaladmission.

MortalityEvaluation Patient Redistribution. Evaluation of the Trauma Programhas shownseveralpositivefindingsin the first year of operation. The 290 deaths studied were divided into three groups:(1) the pre-programperiod from January1 to June 30, 1971;(2) the programimplementationperiod for July I to December31,1911; and (3) the first 6 months of full operation between January 1 to June 30, 1972. The programwasimplementedat hospitaltrauma centersin this

area,in Springfieldin July l97I,In Litchfield and Lincoln in August 1911, and in Jacksonvillein December1971.

This -phase development necessitateda commitment by these communities for the designation of the hospital trauma centers. Becauseno trauma center had been designatedin the far western three-county area, the data reportedhere refer only to the central l5-county areaof II-A. Reeion There has been a definite changein patient flow in Regton III-A. A generaldisarray of patient tratlsportation after critical injury in the III'A Region was noted during the control (pre-program) period. During the program implementation period, it was evident that there was an ori-entationof the critically injured patients to the Local Trauma Centers at Jacksonvilie and Lincoln, with secondarytransfersto the Regional Center in Springfield.

In the Springfield area, particularly, there was a striking changein pafient distribution. This trend has been further substantiatedin the third period from January to June 1972. ln this period, 15% of all nonsurvivingaccident victims taken to Springfieldwent to the RegionalTrauma Center. The number of patients directed toward trauma centers increased 60% during the two periods of implementationand fuii operation. The number of dying 20% for paiientsgoing to the nontrauma centersdecreased the sameperiod.

Highway Mortality Rate. The Departmentof Statistics of the National SafetyCouncilhas reporteda declineof 8% in highway fatalities for the State of Illinois for the first 6 monthsof 1972as comparedwith the sameperiodof 1971.

An increasein highway accidents(8Vo)and personsinjured (9%) was also reported for this period over the entire state.

During this same period, the 15 counties in Region III'A haveexperiencedan increasein accidents(27%), a:rincrease in persons sustaining injury (l6V), and a decreasein highway deaths (15%). Of particular significanceis the steady decline in the percentageof deaths per person injured -- a decreaseftom 2.8% to 2.1% for the study period. Although the accidentreporting rate to the Illinois Department of Transportation is up 23% for the first 6 months of 1972, this does not affect the percentageof personsdying in RegionIII-A after accidentalinjury, which is reportedhere(Figure1).

Time of Death. During the implementationand full operationperiodsof the trauma system,there hasbeena significant changein patient survivaltimes. In conjunction in the numberof vehiculardeaths, with an overalldecrease the total number of victims who die at the accidentscene (DAAC) has dropped fron 42 during the first period to 26 of 38%.The numberof Dead in the third period,a decrease on Arrival at Hospital (DOA) and the number of patients living beyond admission to the designatedcenter have increased.Of those admitted to a traullu center, the number of those dying within the first hour has decreased from 44.4%to 32.1%,with more patientsliving longerin the hospital while in a better treatment environment (Figure2).

Gross Anatomic Involvement. An evaluation of the type and magnitudeof injury to these dying patientshas been undertaken.The gross anatomic part, including the central nervous system (CNS), face chest, abdomen, extremities, and those with multiple (undefined) injuries to the recordedtime of death.So have been cross-indexed far there have been no significant changesin the types or magnitude of injuries sustainedin these dying patie,ntsThesedata indicatethat CNS and chestiniuriesareinvolved

26

I

t

t

t

in, and account for, a majority of the highway fatalities in thisstudv.

The beneficialeffects of improved patient survivai,in spite of increasedac_cident una in1u.y rates,have been accomplished by the developmentof a irospitainetworkoi trauma centers.The reported improvern'ents in patient redistributionand length-of patieni survivalare secbndary effectsof this effort to.designateone strategichospitaiii eachareafor the specialcari of the accideiit nctim. The program activities for the first year have been directed almostentirelytoward the hospiial phaseof the accident care systen. The apparent improvernerrt in the transportatio^n phasecan only be attributed to ar.rindirect secondarv ellect,

developedin conjunction with community collegesand universities acrossthe state. ernergencies other than traumaarebeingadded , - fledigal atong reglonaldesignsin a time_phase sequence.

Additional crnlcat regtstnesare being developedto evaluatethe progressin each category.In Illinois an unstructured p.rogramfor pediatric enrergerrcies arrd ptlison corrtrol aheady exists, ald is being phased info the trauma emergencymedical servicesnetwork. Clinical cardiacand c r i t i c a lc a r ep r o g r a m w s i l i b e i n t e g r a t eidn t o t h e T o t a lE M S r y s r e m a t o l l gw i t h t h e i r c o r o l l a r yt r a i n i n ga n d e d u c a t i o n go_gl-.*: Psychiatric.emergency iare in Illinois is currently Iraglnented,scrttered,and nonregionalized.

Considerabli time will be necessary_ for the planning with tt.

Department of Mental Health for impiovej' .,rl.rg.n.y Systems lmplementation by Model Building services in most of the geographic areasoi Illinois.

The suCcess of the Traumaprograrncan be measuredir.r The initial results of tle Trauma program are very termsof localhealth-planning, satisfactory_:a iA% decreasein death irom hlghway regionaiizatiou of care,and, more recently, the development of a uniform throughoLrrthe srate and 15.4%in the {egoi ?:.i.d?tj, communicationssystenl upgrading lhis regionalapproachto accidentcarecandecriase -laythe transportatron ljt-A;Y capability, and establishmeii of rne. tugn death rate now being experieircedacrossthe and professional educationalprogrsms.Thesesub-systemcomponentshave nation. The changein patient distribution,as well as the beensequentiallyintegratedinto the trauma systemover trnre_ta.ctors^in patie^ntdeathsin this study, point to the the pastyear,and will be evaluatedfor their effettivenessin Denerlclaleltects ot a controlled systemsn]odificatior.r the very nearfuture. approach.The.ntajor emphasisin the trauma systemhas Tlr. TraumaProgramhasidentified the terms Regional, beenthe establishment of an interrelatinghospital(trauma ^ Areawide,and Local for trauma ceuters(Figure3).'These center) network. The secondary,benefi"tseained'in the definitionsarenow beingbroadened transportationof the criticallyill includethe-redirection in scope"toinciudethe of entire community. The levc.lof clinical care capability, patient llow and a changein the time constantsfor the time communications and trausportation ,esourcei, arid o l d e l r h a f t e ra f a t e li n i u r v . educationalpo-tentialare now laking on a comniunity and . Approxirnately 6Ci%bf all heart attack ractirrudie of areawidesignificancefor all other categoriesof ernergency therr major s).ntptontswithin the first hour.9 Deathusually medical care. The developmentof i Regonal tiealtir occurs outside the hospital and without professionil Systernhas been an ex^citingproposition, a.,idits benefits assrstants in attendance.The hospitalcorouarycareunlt havebeen anticipatedfor sometime. The Stateof Illinois (CCU) has reduced the in-hospifaldeath iate for hear.t programfor the Careof hasembarkedon a Regionalization attacl<s by 20% through arrhythmia detection and the.,CriticallyInjured Patient, and is" r.rowdevelopinga treatnrent.vMuch of this highiy specialized careis givenby similar.prograitron a wider spectrumfor all emergellcy well-trainednurses.The total impict of the hospitaiCCUis medicalcare.Programdevelopmentand overallresultiwlil lirnited.by the fact thar the nrijority of patientsdo not requlre adequate monitoring and documentationwith rerch rhe hospiralalive.It is rheinteritof the IilinoisTotal supportiveevidence.On-linedata acquisitionand analysis tnrergencyMedicd CareSystemto improvecoronaryand usingthe Regstry approachare esseniialfor the succesiof critical care medicinein remote communityhospit;ls tt program,and arenow beingdeveloped. suchâ&#x201A;Ź_ establishingOurlying Criticat Care Units fbCCU). il1# reltote lrospital intensive care units will be lii*ed to The basictrauma sys^tem is now funciioning as a model advanced Regionrl Centers for expert on_line medical of emergencymedical-care, e.g., lor,9th91. categories, Cardiac(Figure4), _Pediatri collsultation.z cs,Poisoning,Drug Into icatio"n, Psychiatry.

By expanding the prinliples of the OverlandCriticalCareVans(OCCV),a regionallybased lnd Statewide*-Trauma System, a Total Emergency Medical mobile intensivecareambuiancewill facilitat"etne ,i.li;;;t -all System(EMS) is now being establishedfor the citizens of sophisticatedcritical care_during the prehospital ani of Illinois.Categorization of all emergencydepartments is periods. The Overland Criiiiat iare Van i{:t!-C:O!lu, n o w m a n d a r o rby y l l l i n o i sl a w ( p . A . Z O - l S 5 S ;a. n d m u s tb e ( O C C V )( F i g u r e4 ) i s a m o b i l e ,r n u l r i p l e - p u r p oisnet e n s i v e done ln concert with areawide EMS planning. All careunit that will utilizethe specialnreOicat tiient available calegorization_proposals must be approved6y the llinois at eachRegionalCenterto provideoptimal intensrvecritical ot Emergency prptor] Medical Servlces and Highway carefor a largegeographic areaol responsibil il;2 Satetyby Jar.ruary1913 and implementedby July"1975.

Thesevanswill be basedat the ilegionalind Areawide Laregonzatlon und areawide planning are being w i l l p r o v i d e t h e u l t i r f i a t ei n s p e c i a l i z e d 9:n,.p,i,lg accomplishejl by local planning agencie"sand newli (lite-support).care for patients while they are -Co estab Plensiye lishedEmergency Medical Service unciis. Becauseoi Delngtransportedto advancedfacilitieswhere specialized the Trauma Program,many communitiesin the state have definitive care is available. OCCV,s will provide an alreaoy_galned a great measure of sophisticationin extension of the Intensive Care Unit (ICtf iritical area comprehensive areawideplanningand implementation. capability of Regional and Areawid. horpituls to other Technicalimplemeniation of the cornmunicationsand mstitutions.In the OCCV, patientswill reieivecontinued transportation,subsystems hasbecomeachievable,now that ard many times enhancedcritical careduring transfer.The an areawideplanningmechanismis working. Educationof threat of lossof continuityof patient.*. Of.ing necessary nealtn personnel is an ongoing program throughout the transferswill not occur. Uniform resuscitationequlpment, statewidesystem. These educationai programs1re being fluids, drugs,ventilators,and critical laboratory aidswill be

21

priori which subsystemwill eventuallybe consideredthe most important. Instead,an arbitrary decisionwas madeto proceed initially along the line of categorization of b-rtg.n.y care facilitiei for the critically inJuredpatient.

In each major community and strategic geographic district the local Health Planning authority was asked to select the one hospital best suited for the care of the seriouslyinjured. In addition to this initial designationof -a trauma'-cenier,all hospitals,professionaland allied health personnel,and community leaden have started the task of trauma integratingother subsystemsinto a comprehensive care system by developing areawide Emergency Service Councils. It is anticipated that every hospital will have its capability for all aspectsof emergency self-categorized medicalcareby July 1, 1973.

Calegorizationis only the first of the necessarystepsto a true regionalEMS system.The goal of this approachmust be the continual upgrading of trauma ar.rdemergency medical capability in communities with substandard resources. This approach will produce other benefits including better cost effectiveuessand improved resource utilization in those communities which are unnecessarily duplicatingtheir efforts, monies,and medicalmanpower.

The second highest priority in the Illinois Trauma System is the developmentof a comprehensive,uniform, capability. simple, practical, and w orkablecommunicationsThii wili by necessitybe pluralistic,and will includesimple two-way ridio voici:, teiephone patch, dedicated phone lines, and in some instancesmicrowave capabilities.The most important aspectof a communicationssubsystemis that it complimentsthe medicalneedsof the entire-system.

It must lnilude central dispatch and controi of mobile elements of the system. A medical tesource guidance system is being developed for patient care advice' interpretationof bioelectricaidata' and triageat-the scene of th-eaccident and during transportation to a designated treatment facility. Necessaiyengineeringcan be effectively adapted to serve medical requirements as they are identified.

Solutions to the problem of providing upgraded ambulanceservicesmusi be stylized to meet the specific needs and capitalizeon the existing resourcesof each community. In Illinois, each Trauma. Coordinator is Discussion working with local govemments,municipalities,arid private to what ambulairceoperatorsto developworkable answers It has been anticipated for some time that improved "insoluble" considered were communities many in a by obtained be could care emergencymedical traumaand problems. By identifying existing medical resourcesin approachto this pro-blem. betterorganizational iommunity hospitals,colleges,industries,and evenprisons, Trauma Statewide of a the d6velopment In Il'linois, and by assistingin federal grant appiications,the Trauma Programhas shown that regionalizationof expert care, Coordinator lias beeu instrumental in introducing university the in only previously available which was ambulalces of nationally accepteddesign criteria for the centers.can now be effectively and efficiently delivered first time to many rural ateas.Previously,many of these community. rural in the especialiy state, the throughout communitieshad no real comprehensionof an acceptable The iiitlal successof the Trauma Programon a statewide In addition to improving primary ambuiance ambulance. for the.developmentof groundwork provided the basishas Illinois is developing a secondary capability, the response a Total E'mergen.yMedical Service(EMS) System in which includes helicopters, fixed system transportation Srateof Illinois. intensivecarevans. mobile and airplanes, wing *The-lasting The system for trauma care is being developedby medical programdependon the of benefits hospital essential components: following integrating the providing those essential personnel thJmedical quality of (trJuma- center) categorization; communications; has placeda major Program Illinois The services. etnerg-ency bothlrofessionals of education iransportation;training and empliasison the training of emergencyirealthand trauma and ihe public; and program evaluation. The essential careworkers at all levels,including: the EmergencyMedical subsystemi must be integrated into a comprehensive (EMT-A) and the advancedEMT-A; Technician-Ambuiance pa.kag. which supportsimproved patient careand furthers her educator, the Trauma Nurse nurse and the trauma exists as cotitroversy Some designs. developmentof regional Coordinator; and a new administrativeprofessional,the to which is the most important subsystem.The Iiiinois Trauma-EMS Coordinator. Educational programs for trauma care approach has not attempted to establisha

installedin thesevans.They will have an operationalrange of approdmately 50 miles. Beyond a radius of 50 miles, helicoptersand fixed wing aircraft arebeing employed. ^ T[e core staff for these vans consists of certified emergencymedical technicians.The techniciansreceive,in addition to the nationally prescribed82-hour course' a 4-hour seminarwhich emphasizesmanagementof the van equipment, resuscitation (mechanics and drug ad-ministration), and therapy of cardiopulmonary insufficiency. Training is continuous, and specialcourses feature pediatric and coronary care. The EMS technical staff is augmented when necessaryby specially trained respiratory therapists, nurses, and physicians. These professionalswill be used to satisfy the specific needsof inv individual patient being transfened. When transfer involvesa high-riik or prematureinfant, specialnursesand physicians from the Regional High Risk Center will accompanytne van, A-critical care van should have the capability of carrying two patients of any age or size. There must be enoughfloor areaand headroom so that the attendantscan administer critical care readily to both patients. The practice of critical care necessitates a smooth ride. As the van systemhas the samecapabilityas any specialcareunit, a hijh rate of speed is not only unnecessarybut also undesirable.

It is the aim of the Illinois statewide effort to demonstrate an emergencyhealth delivery system with good care at the sceneof the accident,during primary-and iecondary transport, and at the specialcare units which meet the specific needs of any critically ill or injured patient.

A trauma system,as impiementedin Illinois, can stand alone, or be an integral part of a total emergencymedicai servicessystem.Each componentof a traumasystemcan be independ-entor be integrated in varying degreeswith the components of a critical care system' The cofiImoll of denominatorsof thesesystemsare: (1) regionalization planningand care;(2) communicationsand transportation; ind (3t educationat all levelsof the society. The efficacy of eachprogram componentmust be objectivelymeasured on a continuousbasis.

28

emâ&#x201A;Źrgencyphysicians,Trauma and Critical Care Fellows, and trauma surgeons arc also being developed as postgrad.uate. training programs.young- traumatologists, well-equi_pped_and trainedin the teamapproach -that to accildent care,will further the apparent progresi is now being realizedin this field.

Evaluation at all levels of the system is necessary. pionee,rejl in this areawith tfie deveiopmentof a ![nois Qs Irauma^Registry.l Data are now availablewhich document someof the results of changein patient distribution and demonstratethe need for sp-ecialtyUu.f.up-u, well as the allocationof criticai caremanpow6r.Thesdstudiesare also pointingthe way to better cost and clinicaleffectrveness in traumacare.Theseevaluationprogramsare beingextended to measure_public awareness-andaccessibilityto entry routesinto the trauma-EMSsystemin times of need.

In order to initiate a total systemapproachto trauma and.emergency medical care,a simple,piu'.ti.u1,controlled im?,lemen"tatiol. pl?n. was -developea.ny O.fining it, p:91:T tor criticalty injured.patienrs,, and by categoiizing nospltal emergencycapabilitiesfor this group, significanl progresshas been realized.One enthusiasri;iridividual. ?gency,or associationwill not solve this massiveproblem.

It will require a consortiumofall interestedhealth agencies working together rather than in competiiion. -These participantswill need to realizethat individualefforts must be consistentwith the overallpro$am.

Figure 2.

T I M E D E A T HI N D I C E S (Region

z

G

3 Aov" E .a 0 (J

ttttt'

G---------

----att"ttt'

DAAC (Deod ot occident) .-----.DOA (Deod on orrivol ot hospitol) nilnnilnAn

Tofol Deofhs, AZ ftriod, Jon.alune, l97l

Figure l. ( R e g i oInf A ( l 5 C o u n t i e s ) _r_---_-'

,-aat'-----

o

-autt'

e'-

,---.

ffi

Admined

b

hospitol

96 July-Dec.,l97l

70 Jon_June, 1972

Thetime of death:Deadat accident(DAAC ), Deadon arrival at hospital(DOA), and those dying after admission to trauma centers.

Shownis the deueasein DAAC from 5l.2Vo to 37.t%o, whiletheDOA andaftir admission deathscorrespondinglyincrease,

H I G H W A YD E A T H R A T E -llb_rr-,

A(15Cotrnties)

IOO%-1

Tolot occidenls

font personsinjuled

E

Figure 3.

c

o

Speciol Core C e n t res Tolol Deolhs' 82 P e r i o dJ,o n . - J u n e1, 9 7|

96 J u l y _ D e c ,l 9 7 l

70 J o n . _ J u n1e9, 7 2

A graphic conceptuqlization of the areawide categorization of hospitqls in the Trauma Program. Small "Local" and medium-sized " Areawide" Trauma Centersselectivelvrefer patients to the larger Regional Cenier.

Patients with unique problems leave the basic catchment area to Special Trauma Treatment Centers.

Highway accidents, injuries, ond mortality Note the increase in the number of accidents (auto) and injuries (individuat) during rhe study period. The percentage of patients d_eathsper individuals injured (pC beaths/ Injured) has decreqsedfrom 2.8Vo to 2.1% in this study period.

29

Figure 4.

Goal VI. To develop a total system that will be financially and administiatively self-supportingwithout continued subsidizationfrom external sourcesor reliance on a stateor federalbureaucracy.

Fortunately for the State of Illinois, a vastamountof e xperience in problem identification and systems remodeling in the area of emergencymedical servicehas been gained. With the successfuidevelopment of the Statewide Trauma Care Program, specific problems and their solutionshavebeenidentified and tested.By usingthe positive and negativefeedbackapproach,the entire health community of the state hasgaineda considerabiedegreeof sophistication in the area of emergency care systems development. Because of the statewide systems developmentof a trauma carenetwork, there has beenthe emergence of a healthy and practical implementation environmentwhere problems approachedon an empirical basishave been studiedas on going eventsby the entire health community.It is the effort overthe past2 yearsthat is enabling lllinois to step forward to a total systems approach to emergencyand critical care medicine on a statewide basis. Emergency medical care is no longer a neglected disease in Illinois.

Pre Hospitol trmo.nann.

en'o

A graphic conceptualization of the developing Cardiac Care System. Multiple hospitals in each local, areawide, and regional community will be involved with primary emergency cqrdiac care. Outlying Critical Care tJnits (OCCLI's) and Overland Critical Care Vqns (OCCV's), as well as prehospital emergency care programs, are being developed. As emergency coronary care improves, including acute open-heart surgery, a referral system will be implemented as shown.

References

Summary The following is a list of prograrn goals which are beingimplementedin the Stateof Illinois'Total Emergency MedicalServiceSystem. . Goal I. To provide accessibilityand emergency medicalserviceto everycilizenof Illinoisin orderthai thev may receive benefits of emergencyand critical car-e medicine.

Goal II. To developa comprehensive energencyand critical care _system which will fully utilize existing resourceswhile stimulating the developmentof new care capabilitieswhere theseare insufficienior totally lacklng.

Goal III. To developpracticaland workablesolutions to the_ ^emergencymedical service problem utilizing acceptedforms of healthcareapplication.

Goal IV. To plan and develop all phasesof the programutilizingcommunityand areawideplanning.

Goal V. To evaluate and monitor programs continuously in order to determine all critical factors to providefor ongoingmodificationsand analysis.

30

L B o y d , D . R . : C o m p u t e r i z e dt r a u m a r e g i s t r y ( e d i t o r i a l ) .J . T r a u m a ll:449-450.1971.

2 . B o y d , D . R . : A t o t a l e m e r g e n c ym e d i c a ls e r v i c es y s t e mf o r I l l i n o i s : a p r e v i e w . I l l . M e d . J . 1 4 2 : 4 8 6 - 4 8 81, 9 7 2 .

3 . B o y d , D . R . , D u n e a ,M . M . , a n d F l a s h n e r B , . A , : T h e I l l i n o i sp l a n f o r a s t a t e w i d es y s t e m o ft r a u m a c e n t e r s . J T . rauma13:24-31,1973.

4. Boyd, D.R. and Flashner, B.A.: The Critically Injured Patient Concept and the Illinois Statewide Plan for Trauma Centers.

S p r i n g f i e l d ,I l l . , D e p a r t m e n to f P u b l i c H e a l t h p r i n t e r s , 1 9 7 1 .

5 . B o y d , D . R . , L o w e , R . J . , B a k e r ,R . J . , a n d N y h u s , L . M . : T r a u m a r e g i s t r y :n e w c o m p u t e r m e t h o d f o r m u l t i f a c t o r i a l e v a l u a t i o no f a m a j o r h e a l t h p r o b l e m . J . A . M . A . 2 2 3 : 4 2 2 - 4 2 81, 9 ' 7 3 6 . B o y d , D . R . , L o w e , R . J . , a n d F l a s h n e r ,B . A . : A c o n t r o l l e ds y s t e m s approach to statewideemergencymedical servicesimplementation.

P r e s i d e n t i a l - e l e cpta p e r p r e s e n t e da t t h e A m e r i c a n P u b l i c H e a l t h A s s o c i a t i o nm e e t i n g N o v e m b e r 1 4 , 1 9 7 2 .

7. Boyd, D.R., Mains, K.D., and Flashner, B.A.: Status report: I l l i n o i s s t a t e w i d et r a u m a c a r e s y s t e m .I l l . M e d . J . 1 4 l : 5 6 - 6 2 ,1 9 7 2 .

8 . B o y d , D . R . , R a p p a p o r t ,D . M . , M a r b a r g e r , J . P . , B a k e r , R . J . , a n d N y h u s , L . M . : A c o m p u t e r i z e dt r a u m a r e g i s t r y :a m e t h o df o r c o m p r e h e n s i v ei n v e s t i g a t i o no f a m a j o r h e a l t hp r o b l e m .P r o c e e d i n gos f S a n D i e g o B i o m e d i c a lS y m p o s i u m , F e b . , 1 9 7 1 , p p . 2 0 9 - 2 1 8 .

9. Con, R.D.: The prehospital care of medical emergencies.

P r o c e e d i n g so f M a r y l a n d N a t i o n a l C o n f e r e n c e o f E m e r g e n c y H e a l t hS e r v i c e s , D e c . 21, 9 7 1 .U . S . D e p a r t m e n t o fH e a l t h ,E d u c a t i o n , a n d W e l f a r e , 1 9 1 2 ,p . 1 1.

1 0 . F l a s h n e r ,B . A . a n d B o y d , D . R . : T h e c r i t i c a l l y i n j u r e d p a t i e n t :a p l a n f o r t h e o r g a n i z a t i o no f a s t a t e w i d es y s t e mo f t r a u m a f a c i l i t i e s .

I l l . M e d . J . 1 3 9 : 2 5 6 - 2 6 5l.9 ' 1 1 . l l . M a i n s , K . D . , B o y d , D . R . , a n d F l a s h n e r ,B . A . : A n e w h e a l t h p r o f e s s i o n a tl :h e t r a u m a c o o r d i n a t o r .l l l . M e d . J . 1 4 2 : 1 5 8 - 1 6 0 , 1972.

1 2 . N a t i o n a l A c a d e m y o f S c i e n c e sN , a t i o n a l R e s e a r c hC o u n c i l C o m m i t t e eo n T r a u m a a n d C o m m i t t e eo n S h o c k :A c c i d e n t a lD e a t h a n d Disability: The Neglected Disease of Modern Society.

W a s h i n g t o nN , AS-NRC, 1966.

1 3 . O g i l v i e , R . B . : S p e c i a l m e s s a g eo n h e a l t h c a r e . S p r i n g f i e l d ,I l l . , State of lllinois Printing Office, 1971.

t

-

STUDY OF THE EFFECTIVENESSOF COMPUTERIZED MEDICAL SYSTEMS REVIEW AND DISEASEDIAGNOSISIN THE EMERGBNCYROOM SETTING

BruceHoutchens,M.D.

THE PROGRAM AND THE HARDWARE

INTRODUCTION In the summer of 1972,a study of the effectiveness of computerized medical systems review and disease diagnosis,in the emergencyroom setting,was conducted at the University of Utah Medical Center.

The emergencyroom settinghas not previously,to our knowledge,been the site of attempts at computerized diagnosis.However,in severalrespects,it offers an ideal settingfor evaluatingsuch attempts, both for accuracy and usefulness.In contrast to a hospital admissions screeningclinic, most non-trauma cases of acute or emergencyroom medicinepresentwith unknown or self "guessed-at"problems, and many require immediate considerationof differential diagnosesbefore an appropriatedispositioncan be made.

In the E.R. setting, physicianshave not time to take thorough histories;and at all hours and under all circumstances,cannot consistentlytake into account all facts potentially at their disposal.A computer can be effectivein this environmentif it ( 1) gathersinformation in minimum time and with minimum interferencewith emergencyroom routine; (2) organizesinformation for presentationin concise,logical printout; (3) minimizes both falsenegative(missed)diagnosesand falsepositive diagnoses(which, in engineering jargon, constitute "noise").

The basic logic of the computerprogram usedin this study consists of a sequential Bayesean approach, modified by various lists of linked questions.tThe heart of the Bayesdecision-makingdata bank is a probability s y 1 3 2d i s e a s e s . m a t r i x t a b l e ,c o n s i s t i n go f 2 9 2q u e s t i o n b To eachpositionin the matrix table (Figure l) is assigned a number: the probability that a patient having the "yes" diseaselisted on that row would answer to the q u e s t i o nl i s t e d i n t h a t c o l u m n . "yes," the following equaFor each questionanswered tion is solved:

to,

oej

(pnor)

to, n s---t p ' ^u i

L

too

Di

Po Dr.

( o n t h e l e f t ) i s t h e p r o b a b i l i t yo f t h e p a t i e n t where "yes" h a v i n gd i s e a s ei a l i e r g i v i n ga a n s w e rt o q u e s t i o nj P^ ( a n d u i o n t h e r i g h t i s t h a t p r o b a b i l i t yp r i o r t o a n s w e r i n g q u e s t i o nj ) ; a n d P Q i i s t h e p r o b a b i l i t yt h a t a p a t i e n t l)i w i l l a n s w e r" y e s " t o q u e s t i o nj , g i v e nt h a t h e h a sd i s e a s e i ; a n d t h e d e n o n r i n a t orre p r e s e n tnso r m a l i z a t i o no v e r a l l dis e a s e s .

I n e a c ho f l 0 b o d y s y s t e m s( i e , G - 1 , G - U , e t c . ) t h e r e "key."

A sampleset are setsof 5 questionsdesignatedas ol' such questions,for the G-l system, follows: Do you have difficulty swallowing Have you recentlyhad pain in the abdomenor groin Have you recentlv been bothered by nausea or vomiting A r e b o w e lm o v e m e n t se v e nd a r k b l a c k c o l o r , o r w i t h red blood Have you recently been having diarrhea Befbre beginning the history, the patient is asked to selectthat area which he feelsis botheringhim most; so that the first set of key questions with which he is presentedwill hopefully contain his chief complaint.

When "yes" answersto key questionsare obtained,ads r e b r o u g h tu p ( i n g r o u p so f a b o u t5 a t d i t i o n a lq u e s t i o n a a time) according to severalconsiderations.

The first consideration in selecting those next questionsare the lists of linked questions.If a patient responds"yes" regarding pain in the abdomen, then

O B J E C T I V E SA N D P A T I E N T S E L E C T I O N Initial objectivesof the study were three: (1) to see ' how well the comoutercould do "asainst the housestaff (2) in evaluatingpreviously undiagnoied problems; to obtainhousestaflreactionregardingusefulness of having the computer printout as an aid in reachinga diagnosis and making a disposition;(3) to find out what sorts of additionalproblems and information could be elicited from an emergencyroom patient population by fairly thoroughand systematicquestioning.This last objective wasexpectedto raisesomeinterestingquestions;as most of this sort of information probably currently goes undisclosedin the emergencyroom setting,thus obviating the need for decisions.

Patientsselectedfor computerizedhistory taking were simply those who presentedwith an initial complaint which appeared would necessitateconsiderationof a differentialdiagnosisbeforea dispositioncould be made.

A common complaint of this nature is abdominal pain; hencemuch of this study focusedon that problem in particular. Obviously excluded were the very young, the very old, those too seriously ill to give a history, and trauma victims.

3t

Figure1: Sampleportion of probabllltymatrlxtable (abdomlnalpain linkedquestions) Peptic Ulcer Disease

D o y o u g e t p a i nw h i c hi s made-worseby lyingflat D o e sb e n d i n go r s t o o p i n g b r i n go n y o u r p a i no r m a k ei t w o r s e ls your pain made worsebv f o o do r d r i n k y l s o u r p a i nr e l i e v e do r m a d eb e t t e rb y f o o d ,m i l k , antacids D o e sy o u ra b d o m e nh u r r more when you movear o u n do r c o u g h D o y o u h a v ep a i nm a d eb e t ter or worse by a bowel movement D o y o u h a v ea b d o m i n a l p a i nw h i c hg o e sa w a y a f t e rv o m i t i n g

Acute Gastroenterltls

5

Hlatal Hernla

Gholecystitls

70

pancreatitis

15

10

50

'10

40

15

70

20

20

10

on

10

50

10

5

15 20

20

(before a calculation is made regardingthe probability of particular G-I or G-U disorders) sets of questions having to do with when it occurs,its location,its nature, and what makes it better or worse will be presented.

(The "what makes it better or worse" questionsfor ab_ dominal pain appearin the leftmost column of Figure l, above.)

The next consideration'in selectingadditional ques_ tions is that of maximizing probabiliiy ratios. It is this concept which permits moving to diagnosis relatively quickly, avoidingthe time consumingnJed to follow oui long branchingarrangementsinherenl in binary decision (Boolean lo.gic)programs. It also offers the ability to quickly get back on the right line of questioning,despite an erroneousanswer early in the history. .Sequencesof questionsare presented until either the probability for a diseasereachesat least 90Vo,or one runs out of questionsthat are ,.worth" asking.Then the ne;(t set of key questionsis brought up.

The probability ratio concept functions as follows: When all linked questionshave beenask_ ed, diseaseprobabilitiesare calculatedand the two most probablediagnosesare selected.For each of these diseasesa new question to be asked is selected, which maximizes the ratio of the probability of a patienthaving that diseasegiving a "yes" answer,compared to the averageproUabit_ ity of a "yes" answerin the generalpopulation.To attempt to distinguishbetween the two diseases. three additional questionsare selectedwhich max_ imize the ratio of the probability of a ..yes" answer for one- disease,to the probibility bf a ,.yes" answer for the other. For instance,ior the caseof abdominal pain, referenceto Figure I showsthat to attempt to distinguishbetweenpeptic ulcer and

32

5

cholecystitis,good questionsto ask are "Is your pain made worse by food or drink" and "Is your pain relieved or made better by food, milk, antacids."

A disease is considered ,.diagnosed" (and is suggested on the printout) when probability reaches90Vo.lt is consideredthat thire are no more questionsworth asking in a systemwhen the maximum ratio of probability of a .,yes" answerto a question for the most likely disease,to a ,,yes,' answerfor the next most likely disease,is lessthan |.2 for all (yet unasked)questions.In this event, the most likely diseasewill be suggestedanyway, provided that the sum of the probabilitiesof tie Iwo most likely diseases exceeds 0.5. If the probability of the secondmost likely diseaseex_ c e e d s0 . 2 , i t w i l l a l s o b e s u g g e s t e d .

Whenevera new set of key questionsis ..brought up," all diseaseprobabilitiesare reset to nomiial values so that additional diseasescan later be diagnosed"independently." (Note, however,that previous positive answers are o.remembered"by the machine; and all subsequentcalculationsare b a s e do n a / / p r e v i o u sa n s w e r s . ) The essentialhardwareitems presentin the emergen_ cy room were a computer terminal with a large cathode ray tube screen;a high-speedprinter; and an extension telephoneand data link unit. Each of theseitems fit con_ veniently on a separateshelf of a small castor-wheeled supply cart, and each (non-trauma) room in the E.R. had an extensiontelephonewall-jack receptacle.Thus a patient could work on the computer histoiy in his room while waiting to be seenby a doctor (or whiie waitingfor l a b f x - r a y r e s u l t s .e t c . ) .

To connect the power cords, dial the data-link

telephone number(to make connectionto the central "enter" the patient computer), into the system,and ex_ pfainthe movesto the patient,all took about l - llz minutes.

After makingthe first coupleof moves,most patlentsnever requiredfurther assistance-theywere left alonewith the terminaluntil the historywas completed.Mediantime requiredto completethe historyin

the emergencyroom study was l l minutes.

A printed copy of the diagnosticsuggestions,under each of which were listed those positive risponseswhich contributed to those diagnoses;and a list of other positive responsesin the systemsreview (organizedaccording to appropriate system); was obiained immediately following completion of the history.

Flgure2: Sampleprlntout SELFADMINISTERED PATIENT HISTORY S M I T HS A D I E

6006860 H I S T O R YS U G G E S T S

7/ 1 8 / 7 2

CHOLECYSTITIS -__BECAUSE THE PATIENT H A S P A I N A G G R A V A T E DB Y F O O DO R D R I N K I S A W A K E N E DA T N I G H TB Y P A I N E X P E R I E N C EPSA I N W H I C HI S S H A R PA N D S T A B B I N G H A S R E C E N T L YB E E NB O T H E R E DB Y N A U S E AO R V O M I T I N G E X P E R I E N C EAST T A C K SO F C R A M P YA B D O M I N A LP A I N H A S H A D S T E A D YC O N T I N U O U S A B D O M I N A LP A I N H A S H A D R I G H TU P P P E RQ U A D R A N TA B D O M I N A LP A I N E X P E R I E N C EP SA I N F O L L O W E DB Y N A U S E AO R V O M I T I N G H A S H A D A B D O M I N A LP A I N O F G R E A T E RT H A N 3 0 M I N U T E SD U R A T I O N H A S H A D S E V E R A LO T H E RE P I S O D E SO F S I M I L A RA B D O M I N A LP A I N C A R D I A CF A I L U R E _ _ _ B E C A U S E , I N A D D I T I O NT, H E P A T I E N T I S O F T E NS H O R TO F B R E A T H I S S H O R TO F B R E A T HL Y I N GD O W N B U T N O T S I T T I N GU P HAS DIFFICULTY BREATHING A F T E RF L I G H TO F S T A I R S H A S H A D H I G H B L O O DP R E S S U R E

S Y S T E MR E V I E W

THEPATIENT ALSO 1 CONSTITUTIONAL 2 SKIN 3 EENT 4 N E C KA N DN O D E S 5 BREASTS 6 HEART 7 LUNG 8 G-l

H A S H A D D I A R R H E AR E C E N T L Y 9 G-U 1O M-S G E T SL O W B A C K P A I N 11 ENDOCRINE 12 NEURO 13 PSYCH P A T I E N TC O M P L E T E DH I S T O R YI N 6 M I N U T E S

RESULTS In evaluatingthe data, it is convenient to makethe followingdefinitions:A "primary diagnosis"is defined to beonewhichcouldbe an explanationfor the patientrs chiefcomplainton presentation in the emergency room.

A "secondary diagnosis"is takento be on! whichexplainssomeconditionother than directly relatedto the chiefcomplaint.A "true" diagnosisis takento be one confirmed in oneor moreof the followingways:(l)..Indisputable" clinicalimpression by morethanonedoctor at the completionof E.R. evaluation(copiesof each E.R. sheetwere attachedto the computerprintout and

kept on file); (2) convincingevidenceby later inpatient or outpatientstudies(ulceron UGI x-ray,M.I. by ECG and blood chemistries, etc.), which, when done,were followed-upfor eachpatientin the study;or (3) evolved clinical impressionafter one or more follow-upoutpatientclinic visits(chart reviewseveralweekslaier).A "false'o_ diagnosis is onedisprovedin thosesameways.

"Signal-to-noise ratio" is numberof correct(primaryor secondary) diagnoses: numberof incorrect(primaryor secondary) diagnoses.

The data are presentedin severaltables,for further discussion.

33

TABLE A: Break-downof primary dlagnosesaccording to appropriatesystem ol chief complaint system for which chiel complaint wag given

numberof patlentslor whom PrimarY dlagnoslt wa8 mlssed bY compuler

numborof patienlslor whom cottect primary dlagnoaiawas made by computer

7 Constitutional ( m a i n l yf l u ) 21 EENT 30 c-R 92 G - la n d a b d o m i n apl a i n 24 G-U 5 M-S 0 Endocrine 15 Neuro lc Psych 209 Total

Percent accuracy

3

7110= 70To

1 15 16

21/22 = 96Vo 30/45 = 67Vo 9 2 / 1 0 8= 8 5 V o

4 0 1 3 2 45

24/28 = 5/5 = O/1 = ' 1 5 / 1 8= 1 5 / 1 7= 209/254 =

86Vo 100Va 0Vo 83Vo 88Vo 82Va

254 patients constitutedthe study. Overall-accuracy diagnoseswas 82Va'Accuracy of primary lor primary 'for 108 patients presentingwith abdominal diagnoses p a i n o r G - l d i s t u r b a n c ew a s 8 5 % .

TABLE B: Break-downof all dlagnoeeslor all patlents,accordlng to sgont maklng dlagnoals agent maklng dlagno!l!

fallo prlmary dlagnotlr

lruo prlmary dlagnoatr

c o m p u t e ra, l l i n v o l v e d housestaff , and susPected by patient

4

2

0

c o m p u t e ra, n d a l l i n v o l v e d housestaff c o m p u t e rb , u t m i s s e db Y at leastone of involved housestaff housestafb f ,u t m i s s e d bycomputer k n o w nt o p a t i e n ta, n d m a d eb y c o m P u t e rb, u t l ousen e g l e c t e db y i n i t i a h staff physician Total,all agents T o t a l ,c o m p u t e r

163

16

35

165

37

22

truo lecondary dlagnolls

lalse secondary dlagnotls

no dlagnosls

2

11

9 219*

226

1

226 226

13 12

58

2 7 7* * * 240

203 181

294 288..

* 1 0 4 o l w h i c h a r e p s y c h i a t r i cd i a g n o s e s * * 1 8 4w h e n c o m p u t e r - o n l yp s y c h i a t r i cd i a g n o s e sa r e e x c l u d e d *"* There are more totat primiry diagnosesthan patients,as some patientshad more t h a n a s i n g l ep r i m a r yd i a g n o s i s- f o r i n s t a n c ec, h e s tw a l l p a i n a n d a n x i e t y

An overallprimary diagnosisaccuracyof 82Vowas at this stageofdevelopmoie thanacceptable considered was not withoutits priceto level ment.But that accuracy was pay in "noise."For ofien,whena correctdiagnosis diagnoses incorrect more iniae ty the computer,oneor in general(Table werealsomade.For primarydiagnoses B ) , t h e " s i g n a l - t o - n o i s e ' rna t i o i s s e e n t o b e 240:l8l = 1.3.For the abdominalpain problemin parof this ticular (TableC) the ratio is 1.2.Consideration

accuracy;for, after all, ratio is important in accessing the more diugnot.t listed, the greaterthe-pr.obability that the "tru;" one will be includedon the list (thus "false negatives");yet the lesserthe ability eliminating to distinguishwhichone to pick from the list' It shoild be notedthat Ttble B permitsdetermining "signal-to-noise" ratio. The falseprimary an "overall" columi containsa numberof caseswhereno diagnosis wasmade'Another coriectprimarycomputerdiagnosis

34

way to look at noise factor would be to first catesorize all caseswithout a correct primary computer diagnosis as simply erroneous;and then define as noiseonly those falsediagnoseswhich occur on printouts which c/so contain true diagnoses. Such analysis is done below, specificallyfor the G-I/abdominal pain case.

TABLE C: Noise factor analysisfor patlents presentlng with chief complalnt of G-l dlsturbance and/ot abdominal paln 92 patienls tor whom coarect prtmary compuler diagnoelemade

n u m b e ro f t r u e p r i m a r yd i a g n o s e s

16 pailentslor whom coarecl prlmary compulel dlagnorl! nol made

92 + *

n u m b e or f a d d i t i o n af la l s e p r i m a r yd i a g n o s e s

0

49

28

. N o t e :o c c a s i o n a l l y more than one primarydiagnosis w a s b o n s i d e r e dc o r r e c t Overall signal-to-noise ratio for this group is 92:(49+ 28; = 1.2, which is essentiallythe same as for t h e g e n e r a lp a t i e n tp o p u l a t i o n .E x c l u d i n gt h o s ep a t i e n t s not correctly diagnosedby the computer,signal-to-noise ratio for successful diagnosesis92:49 = 1.9.This significant improvement probably representseffect of exc l u d i n g p o o r h i s t o r i a n sa n d " t o t a l l y p o s i t i v e , ,s y s t e m s reviewpatients,wherediagnosisis alwaysmore difficult.

S u c he x c l u s i o nh, o w e v e r i,s u n f a i r i n a n a l y s i so f a-and pplication of the method to the general population; a s i g n a l - t o - n o i srea t i o o f a b o u t 1 . 3 f o r p r i m a r v d i a s n o s e s is probably a realistic figure at this stage bt O"-u"topment.

TABLE D: Further break-down of pailents presenilng with chief complalntol abdomlnalpaln or G-l disturbance; accordlng to approprlate system of correct llnal prlmary dlagnoole Ey8temto whlch correct final primaay diagno8ls belong8

numbetof patlentstor whom coarecl p r t m a r yd t a g noslawaa made by computel

number ol patl6nl! for whom prlmary dlagnollr wa! mlered by computer

number of patlent3for whom cottecl prlmary dlagnollr wa! mllred by al loalt one ot Involyed houlertaft, but mado by the computet

gastro-intestinal 50 genital 21

6

6

3

6

unnary

5

1

2

n o nG - | - G - U , medical psychiatric

1

1

11

1

4

4

92

to

n od i a g n o s i s (etiology unknown) Total

14

35

It shouldalso be pointedout that, as long as this ratio remainsgreaterthan 1.0,a relativelylow signal-to-noise ratio is not necessarilysuch a bad thing. It prevents "l'alse negatives."This ratio can be adjustedrather freely by changing the percent probability required for diagnosis;but better to accept an erroneousdiagnosis along with eachcorrect diagnosis,than to set diagnostic criteria so strictly that neitherdiagnosisgetsprinted-out.

It is important to recognizethat "system for which chief cornplaint was given" (Table A) does not always imply system in which final diagnosiswas made. Note that for the abdominalpain/G-I disturbancecase(Table D ) , 1 0 8X 5 6 = 5 2 p a t i e n t so, r 5 2 / 1 0 8 = 4 8 V oo f p e r s o n s s.opresentingturned out to have other than primary G-I olsgase.

For abdominalpain, the fraction of time the computer out-diagnosedat least some member of the housestaff ( 1 4 / f 0 8 = 1 3 V ow ) a s e s s e n t i a l l yt h e s a m e a s t h a t f r a c tion of time the computer failed to make the diagnosis ( l 6 i 1 0 8 = l 5 V o ) .T h i s a s s u m e sm o r e s i s n i f i c a n c e when it is.recognizedthat the housestaifhad the advantage o f p h y s i c a le x a m i n a t i o n . l 7 o l ' t h e s ep a t i e n t s( l 6 V o )c a m et o s u r g e r yw i t h i n 2 4 h o u r so l ' a d m i s s i o n( f r o m t h e E . R . ) t o t h e h o s p i t a l M . ost o 1 ' t h e s ew e r e l b r a p p e n d i c i t i so; t h e r r e a s o n sw e r ea c u t e c h o l e c y s t i t i sr,e n a l s t o n e , p e l v i c i n f l a m m a t o r yd i s e a s e with suspicion of tubal pregnancy,and intestinal o b s t r u c t i o n I. n o n l y o n e o f t h e s ec a s e sw a s t h e c o m D u t e r diagnosisproved incorrect (ovarian cyst instead of appendicitis).

I n s e v e r ao l l ' t h e s ei m m e d i a t es u r s i c a lc a s e st h e c o m p u t e r h a d o u t - d i a g n o s e di t l e a s t o n e h o u s e s t a l ' 1 ' n t e m b e rI:n o n e c a s e , t h e i n t e r n , g y n e c o l o g yr e s i d e n ta, n d c h i e fs u r g i c a lr e s i d e n a t ll d i a g n o s e da p p e n d i c i t i st;h e c o m p u t e rd i a g n o s i so f P . l . D . w a s p r o v e n a t s u r g e r y .I n a n o t h e r c a s ea senior surgical resident diagnosedacute c h o l e c y s t i t i sc; o m p u t e r d i a g n o s i so f a p p e n d i c i t i s w a s p r o v e na t s u r g e r y .I n a n o t h e r( d r a m a t i c )c a s e , t h e i n t e r n h a d d i a g n o s e du r i n a r y t r a c t i n f e c t i o n , and Lhe patient was in the processof being discharged when interceptedby the senior surgical resident;at surgery, compute diagnosisof acute c h o l e c y s t i t i(sg a n g r e n o ugsa l l b l a d d e r )w a sp r o v e n .

I t s h o u l d b e n o t e d t h a t i n t h e a b d o m i n a lo a i n g r o u p , t h e c o m p u t e rd i d v e r y w e l l ( a s w e l l a J t h e housestafl in f act) in discriminatingpelvicinflammatory disease(seenfrequentlyin the E.R.) from o t h e r p r o b l e m s , p a r t i c u l a r l y a p p e n d i c i t i s .E a r l y suggestionof this diagnosisis helpful in preventing thesepatientsfrom coming to immediate surgery.

In evaluatingsecondarydiagnoses,two interestingand somewhatunexpected- facts appeared.

The iirst of these was the disappointinginability to pick-up meaningl'ulorganic illnessunrelatedto the ihief c o m p l a i n t . W h e n c o m p u t e r - o n l yp s y c h i a t r i cd i a g n o s e s were excluded, the overall signal-to-noiseratio for secondaryorganic diagnosesis 184:226= 0.8 (Table B).

This representsjust too much chaff to sift through, in g e n e r a l t, o m a k e m o s t s e c o n d a r yp i c k - u pw o r t h w h i l e .I t confirms conclusionsfrom other (non-computer)studies

t h a t t h e y i e l d i n g e n e r a l p o p u l a t i o n s c r e e n i n gf o r on),thingis very low when there is not a spebiliccomplaint. There were a very lew notable gems - such as c o r n p u t e rs e c o n d a r yd i a g n o s i so f h y p e r p a r a t h y r o i d i s m o n a p a t i e n tw i t h k n o w n u l c e rd i s e a s ew; h o s ea c u t er e n a l stonewas the primary computer diagnosis,and the only d i a g n o s i sm a d e b y t h e h o u s e s t a f -f t h a t s i g n i f i c a n t l y a l t e r e dt h e p a t i e n t ' sm a n a g e m e n t H . o w e v e r( T a b l e B ) , 5 8 / I 8 4 = a b o u t o n e - t h i r do f c o r r e c t c o m p u t e r s e c o n dary organic diagnoses were already known to the p a t i e n t s ;a n d " u n c o v e r i n g " m o s t o f t h e r e m a i n i n gt w o t h i r d s o l t h e s e s e c o n d a r yo r g a n i c d i a g n o s e sm a d e n o diif'erencewhatsoeverin patient management.

e n e r g e n c y r o o m s c e n e .T h e m a c h i n ep r o b e st h e p s y c h i a t r i cr e a l r nw i t h t h e s a m et h o r o u g h n e s sa,p p a r e n itn t e r e s t , a n d l a c k o f j u d g m e n t o r e m b a r r a s s m e n tw, i t h w h i c h i t q u e r i e st h e G - l t r a c t .

HOUSESTAFF AND PATIENT RESPONSE Housestaff'reaction to the study was favorable.The r e l a t i v e l y s h o r t t i r n e r e q u i r e d t o c o m p l e t et h e c o m p u t e r i z e di n t e r v i e wa n d r e l a t i v ep a t i e n ti n d e p e n d e n ci e n o p e r a t i n gt h e t e r m i n a l m e a n t m i n i m a l i n t e r f e r e n c w e ith e m e r g e n c yr o o m r o u t i n e .T h e a v a i l a b i l i t yo f a c o m p u t e r d i a g n o s i sp r i n t o u t w a s t h o u g h tt o b e r e a s s u r i n g in most c a s e s ;a s t h e h o u s e o f f l c e r c o m m i t t e d h i m s e l f t o a d i a g n o s i so n t h e E . R . s h e e t .I n m a n y c a s e st h e p r i n t o u t s u g g e s t e da p r e v i o u s l yn o t t h o u g h t - o fd i a g n o s i s (. T h e n u n r b e r o l ' t i n r e s t h e c o m p u t e r i s r e c o r d e da s h a v i n g "out-diagnosed" housestaff the i n t h i s s t u d ym a y a c t u a l ly be on the low side; since lrequently the houseofficer k n e w t h e c o m p u t e r i n r p r e s s i o nb e f o r e h e c o m m i t t e d h i r r s e l lt-o a d i a g n o s i s . ) P a t i e n ta c c e p t a n c w e a s e x c e l l e n tM . o s t p e o p l es i m p l y a c c e p t e di t a s a n i n t e g r a t e dp a r t o f t h e i r e v a l u a t i o na, n d w e n t a b o u t i t i n a b u s i n e s s - l i kfea s h i o n .W h e n p a t i e n t s l b u n d t h e p r o c e d u r er e m a r k a b l e ,i t w a s a l m o s t a l w a y s I ' r o n rt h e s t a n d p o i n to l b e i n g a l a v o r a b l e" e x t r a . " SUMMARY AND CONCLUSIONS Many non-trauma casesof acute or emergencyroom medicinerequireimmediateconsiderationof differential diagnosesbefore reaching disposition. In this setting, physicianshave not time to take thorough histories,and at all hours and under all circumstances,cannot consistentlytake into account all facts potentially at their disposal.A computer can be effectivein this environment, as a clinical tool and a teaching device,if it (1) gathersinformation in minimum time and with minimal interferencewith E.R. routine;(2) organizesinformation for presentation in concise, logical printout; (3) minimizes both false negative ("missed") and false p o s i t i v e , ( " n o i s e "d) i a g n o s e s .

In this study, a computer program employing a sequential Bayeseanlogic system was used to interview 254 E.R. patients. Median time to complete histories was I I minutes.Overall accuracyfor primary (relatedto chief complaint) diagnosis was 82Vo,with an overall signal-to-noise(!rue, to falseprimary diagnosis)ratio of t.3.

Accuracy of primary diagnosis for 108 patients presentingwith chief complaint of abdominalpain or GI disturbancewas 857o,with signal-to-noiseratio 1.2, 48Voof these patients turned out to have other than primary G-l disease.Sixteenpercentcamc to immediate surgery;the computer had made a correct diagnosison all but one of these.The fraction of time the computer out-diagnosedsome member of the housestaffon these caseswas essentiallythe same as the fraction of time the computer was out-diagnosedby the housestaff.This last observationis even more significant when housestaff advantageof a physicalexaminationin reachinga diagnosisis taken into account.

Ability of computer history to pick up otherwiseunsuspectedsecondaryorganic diseasewas disappointing.

PSYCHIATRIC ASPECTS The secondfact relatingto secondarydiagnoseshas to d o w i t h t h e s u r p r i s i n gc a p a b i l i t yo f t h e m a c h i n et o e l i c i t s y n r p t o m so f e m o t i o n a ls t r e s sa n d p s y c h i a t r i cp r o b l e m s .

A n a l m o s ts h o c k i n g l yh e a v yi n c i d e n c eo f s e c o n d a r yp s y c h i a t r i cd i a g n o s e s- m o s t l y a n x i e t y a n d d e p r e s s t o -n occurred. There were 109 secondarypsychiatric d i a g n o s e s :o n l y 4 o f t h e s e w e r e f o r m a l l y n o t e d b y h o u s e s t a l ' { ' of rre e l ya d m i t t e db y t h e p a t i e n t .T h u s e x c e p t f ' o rc o m p u t e r" p i c k - u p , " t h e e x i s t e n c e o f t h e s es i t u a t i o n s "secondary problems" as including several depressionssevereenough to admit being suicidal would have almost always gone unrecognizedto the e n r e r g e n c yr o o m h o u s e s t a f fd u r i n g e v a l u a t i o no f t h e "primary" problenrT . h i s i s d e s p i t et h e f a c t t h a t e v e nt h e b r i e l ' e s ti n t e r v i e ww i t h m a n y e m e r g e n c yr o o m v i s i t o r s o l l e n r e v e a l st h e i r e m o t i o n a ls t r e s ss i t u a t i o nt o b e m u c h n r o r e d e s t r u c t i v et o t h e i r l i f e , i n a . l o n g - t e r mo r o v e r a l l "primary" problem for which they s e n s e ,t h a n t h e i r presented.

This capability is formidable in the primary diagnosis area, as well. Ten percentof all patientspresentingwith strictly organic chief complaints turned out to have s t r i c t l y p s y c h i a t r i cp r i m a r y d i a g n o s e s[ T a b l e A : 2 4 1 ( 2 5 4- 1 7 ) : 0 . 1 1 . A l l b u t t w o o l t h e s ew e r e c o r r e c t l y d i a g n o s e db y t h e c o m p u t e r . l n t h e a b d o m i n a l p a i n c a t e g o r ya l o n e , l l % o f p a t i e n t sr e c e i v e da s t r i c t l y p s y c h i a t r i cp r i m a r yd i a g n o s i (sT a b l eD : 1 2 l l 0 8 = 0 . l l ) ; a l l b u t o n e o f w h i c ht h e c o m p u t e rc o r r e c t l yp i c k e du p . E a r l y c l u e st o t h e s ep r o b l e m s- h e n c ea v o i d a n c eo f c o s t l ya n d t i m e c o n s u m i n g( s o m e t i m e sh a r a s s i n ga n d r i s k y ) G - I w o r k - u p s- a r e o f o b v i o u sb e n e f i t .

I t w a s o b s e r v e dt h a t a n u m b e r o f p a t i e n t s w i t h p r i m a r y p s y c h i a t r i cc o m p l a i n t s- a n d w h o w e r es e v e r e l y d e p r e s s e db, e l l i g e r e n t ,o r e v e n a l m o s t c a t a t o n i cs e e m e dm o r e w i l l i n g t o o p e r a t et h e c o m p u t e rt e r m i n a l t h a n t o t a l k t o a d o c t o r o r n u r s e .A n u m b e ro f p a t i e n t s were willing to divulge to the computer information regardingdrug use, family or sexual problems,trouble with police, or severedepressionand suicidal thoughts - while they (purposefullyor not) withheldthis sameinformation from the doctor or nurse.Among other possible explanations,these responsesmay have to do with anonymity the computer affords; or may reflect a relativelymore concernedinterestor "appropriateness," a n d n o n - c o n d e m n i n gm a n n e r t h e c o m p u t e r p r o j e c t s , compared to a physician, in the hustle-bustleof the

36

Housestaffand patient reaction was quite favorable.

In general,the machine was felt to be uleful both as a clinical tool and as a teachins device. dary psychiatric problems and emotional stress urprisinglygood, and this area offersgreat promise

furtherapplications.

37

REFERENCES L Warner, Homer R., Rutherford,Barry D., and Bruce Houtchens. *A Sequential Balesean Approach to History Taking and Diagnosis," Conlputers and Biontedical ResearchS, ZSO_ZAZ, SlZ.

THE EMERGENCYMEDICAL SERVICES MORBIDITY AND MORTALITY CONFERENCE

FredericW. Platt, M.D., F.A.C.P and CleveTrimble,M,D.

The teaching and audit demands of an Emergency Department may be partially satisfiedby regular conlerinces which iriticilly assesspatient morbidity and mortality. Over the past three years we have varied our weekly iessions in an attempt to develop-a format which is appropriately analytical, informative, educational,fast-moving,and encouraglngoI group particioation. The result of this endeavorhas prompted the following descriptionof method.

Departmental activities ate analyzedfrom Sunday to Sunday with the agenda (Table) preparedo-nMonday, distributed on TueJday,and the formal conferenceheld on Thursday. This allows those houseofficerswith case presentationsan opportunity to prepare succinct reviews, to gathei appropriate laboratory and radiographic results, and to followup on patient outcomes.

Statistical data are clerically-maintainedon a daily basisand thesetabulationsfor each of the Departmental Units serve as a review of'encounters,of patients who reouire four hours or more in the Department,rof oaiients who leave without being seen(LWBS), and of admissions.These data are then utilized in a formula which providesa coefficientof Departmentalproficiency.

Every death en route to or within the Department is immediately by the responsibleresidenton a describ-ed which analyzesambulance and field acform detailed tivities as well as resuscitationalmethodology. These clinical features are then evaluatedin light of autopsy iindings which are available by conference.time' Malerial for case presentation is submitted on predistributed forms by the house officers themselves after they have identified areas of problem or interest' Eisht to ten casesare then selectedfor their teaching rnJrit. Th.t. usually focus on errors and include topics which are both mundane and sophisticated.These discussionsare presentedin a staccatofashionrather than as exhaustive dissertations. Every effort is made to "experts" of divergent stimulate controversy, with ooinions invited. A collection of such vignettesover a on. y.ut period has comprised a text on the salient featuresof EmergencYMedicine.2 These methods have proven not only to serve as a worthwhile daily data collection base but more as a

catalyst to stimulate discussions.We have found that when emphasisis continually placed upon the value of error anaiysis,no one feelsthreatenedwhen the limelight comes hij way. The staff participants purposely open themselvesto criticism and seek a peer identification rather than an authoritarianstancein relationshipto the other participants, which include Emergency Medical Technicians,nurses,medical students,interns,residents, policemen,social serviceworkers, et cetera. It has also b".n uppur.nt that a circular and non-structuredseating arrang^ementhas stimulated individuals to involve themselves. An attendance often exceeding 65 has suggestedaccePtance.

Table ETIERGENCYDEPARTIIENT aDd [tor'bidit-y Confe!ence llortality \tay Lt ' Lrt' Thursday 8 AII

I.

ics

Statist

Patientsi Over 4 Hours: LWBSI Adiliss ions I h.of iciency

Coeff tciâ&#x201A;Źnt:

Alfred Nelson Everett Barnhill Donald frbb6 Thoilras Wright Beletta Jenkins Case

(MaY ?-13,

4l 29 55 30 22

1973)I

u-4!It 334 2 9 86

Unit I 467 6 7 39

3 2

uni! -I l I 803 4 2 26

3 3

ro!?r 1604 3 8 15r

0.8?

I1-3?-48 Ig-27-69 44-64-19 46-00-02 14-80-38

Sarcoldosia Electrocution Court Fit GSw Gsl{

Sanford MunkreE Robertson Klein Klein

45-94-63 I1-3?-I4 17-52-37 45-97-33 46-00-47 44-98-99 45_98_?3 4I-47-98

Cafe ColonuY Hyateria hychotlc Impaled Alm Gonococcal Phdyngitis Coma lFng IlDger Dlslocated

Kleinman llannery Scott Moncy Glanzer Schsu'tz BoaI Flanrery

Presentationsi

Schalk Robert tlascarenes Cecelia kna tlelander Coleman Patti tlylan Charles oili Rintala Roy WoodE Dean wllliam

73 13 69 13 51 19 70 65

S a m p l ea g e n d af r o m w e e k l yM & M C o n f e r e n c e .

References L Turner, W., Johnson,R., Platt, F., and Trimble, C : Four Hour S u m n r a r i e s .P r o c . L I A I E M S , 2 : 3 0 - 3 1 ' 1 9 " 1 2 .

2 . P l a t t . F . ' . C a s e S r u d i e si n E n t e r g e n c l 'M e d i c i n e L i t t l e B r o w n a n d C o . . B o s t o n ,l n P r e s s .

38

F

-

THE ROLE OF THE OMBUDSMAN IN THE EMERGENCYDEPARTMENT William F. Mitty, Jr., M.D., F.A.C.S. Reverend Donald G. Lothrop, 8.A., 8.D., M.TH. Reverend David S. Lothrop, 8.A., B.D.

St. Vincent's Hospital and Medical Center of New York City Emergency Department treated 46,488 patientsin the year 1912. The community boards are very active and sophisticatedin regard to consumers' rights.They are extremelyconcernedabout the delivery o f q u a l i t y h e a l t h c a r e a n d m a k e t h e i r d e m a n d sw e l l known to the hospital authorities. To serve the comm u n i t y ,t h e h o s p i t a lA d m i n i s t r a t i o na p p o i n t e dt w o O m budsmenfor the EmergencyDepartment.According to W e b s t e r ' sD i c t i o n a r y , a n O m b u d s m a ni s , " A g o v e r n ment official appointed to receiveand investigatecomp l a i n t sm a d e b y i n d i v i d u a l sa g a i n s ta b u s e so r c a p r i c i o u s a c t so f p u b l i co f f i c i a l s . "T h e i r h o u r sa r e f r o m 4 : 0 0 P . M . t o M i d n i g h t ,w h i c h a r e t h e b u s i e sht o u r si n t h e E m e r g e n cy Department.

T h e r o l e o f t h e O m b u d s m a no r P a t i e n t ' sR e p r e s e n tativeis now becomingmore acceptedin many hospitals t h r o u g h o utth e c o u n t r y .T h e i r n e w r o l e i s n o w r e c o g n i z ed by virtue of the lact that there is a section ol the American Hospital Association called, "Society of P a t i e n t ' s R e p r e s e n t a t i v eo f t h e A m e r i c a n H o s p i t a l Association."

T h e p r i m a r y r o l e o f t h e O m b u d s m a ni n t h e E m e r g e n cy Departmentis to identify patient care problems and to expeditethe flow of patients in an orderly manner.

T h eg o a l o f t h e O m b u d s m a ni s t o h u m a n i z et h e p a t i e n t ' s EmergencyDepartment experience.They act as the patient'sfriend from the time of his admissionuntil his dischargeor hospitalization.They are the liaison officer betweenpatients,the professionalstaffs and the clerical personnelworking in the Emergency Department. The O m b u d s m a nm u s t h a v et h e p o w e rt o g e t t h i n g sd o n ei f a defectin patient care exists.

A major problem presentin most active Emergency Departmentsis the prolonged delays of patients being seen,treatedand dispositiondetermined.A major factor ior the prolonged delays of patients in St. Vincent's Hospital and f4edical Center of New York is the minimal physical space available in the Emergency Departmentfor the care of these patients.

The Ombudsmen aid in the alleviation of the overcrowdedconditions by the following means: l. They see that all visitors wait in the designated v i s i t o r sl o u n g e .

2. They keep the patient's families informed as to the progressof the individual patient's work-up, thus preventingthe relatives and friends from visiting the treatmentrooms to inquire as to the patient'scondition.

3. When the house officer has made a tentative

d i a g n o s i st,h e O m b u d s m a ne s c o r t st h e d o c t o r o u t t o t h e w a i t i n g r o o m t o m e e t t h e f a m i l y a n d e x p l a i nw h a t i s t o happennext with the patient,thus alleviatingcongestion i n t h e t r e a t m e n ta r e a s .

4. They notify both the houseand nursing staffs of a n y i n c o m i n gc a t a s t r o p h e s .

5 . A n o t h e r i m p o r t a n tr o l e o f t h e O m b u d s m a ni s t h e management of the press and police officials. It is c u s t o m a r yi n t h e c i t y o f N e w Y o r k t h a t w h e na p o l i c eo f f i c e ri s s h o t i n t h e l i n e o f d u t y t h a t t h e M a y o r a n d P o l i c e C o m m i s s i o n e vr i s i t h i m i n t h e E m e r g e n c yD e p a r t m e n t ol the hospital in which the officer has been taken, c r e a t i n g h a v o c d u e ' t o t h e n e w s a n d t e l e v i s i o nm e d i a d e s c e n d i nugp o n t h e h o s p i t a l T . h e O m b u d s m a ns e e st o i t t h a t t h e M a y o r a n d o t h e r h i g h c i t y o f f i c i a l sa r e h a n d l e d i n t h e m a n n e rc o m m e n s u r a t ew i t h t h e i r p o s i t i o ni n t h e conmrunlty.

A m a j o r c o n c e r no f t h e O m b u d s m a ni s t o c h a n g et h e a t t i t u d e s o l a l l E m e r g e n c yR o o m p e r s o n n e lt o w a r d s people as patients,since the EmergencyDepartmentis constantly inundated with the same patients being rea d m i t t e db e c a u s e of drugoverdose a n d a l c o h o l i s mT. h e y assistthe professionaland non-professional staffs in understandingthe needsof these unfortunate people and have them treatedwith kindnessand compassionas well as medical expertise.

When the Ombudsmen were first appointed by the A d m i n i s t r a t i o no f t h e h o s p i t a l ,m a n y p r o b l e m sb e c a m e immediatelyapparentparticularlybetweenthem and the houseand nursingstafls.The professionalstaffsbelieved that they were placedthere to act for the Administration and did not trust them.This was due to a lack of comm u n i c a t i o na n d k n o w l e d g ea s t o t h e i n t e r - r e l a t i o n s h i p betweenthe Ombudsmen,patients,and the medical and nursingstalfs.This lack of trust was at first compounded by the lact that the Ombudsmenwore as identificationa badge on their lapels inscribed"Administration" on it.

The houseand nursing stafls immediately thought that t h i s m e a n tt h e i r r o l e w a s n o t t o s e et h a t t h e n e e d so f t h e patients were properly cared for, but that the medical and nursing stafls did their work in a more proficient n r a n n e r .A l s o , t h e p a t i e n t s u , n a w a r ew h a t t h e c o n n o t a tion on their badgemeant, resenteda strangercoming up a n d a s k i n gt h e m q u e s t i o n cs o n c e r n i n gt h e i r h e a l t hn e e d s .

The matter was promptly settledwhen it was suggested to both the Administration and the Ombudsmen that their name badgeread "Patient's Representative ." Since this changeoverall of the groups now know the true role of the Ombudsmen and all of the previous conflicts

3g

between themhaveceased andnow all work in harmony tryingto improvepatientcare.

Otherwaysin whichsomeof theproblemsweresolved wereby invitingthe Ombudsmen to attendthe monthly Emergency DepartmentAdvisoryCommitteemeetings wherepertinentproblemsof the Emergency Department arediscussed by thedirectorsof thevariousdepartments personnel. andkeynursingandadministrative Theyalso attend the monthly Orientation Seminars for the Emergency Department'shousestaff.To circumventthe problemswith the NursingStaff that had occurred,the Ombudsmen now make roundswith the nursesat the changeof nursingshiftssothat theyareappraised ofthe problemspresentin the EmergencyDepartmentat the time theirtour of duty starts.It is of interestthat within threemonthsthe nursesnow seekout the Ombudsmen patientcareand to relateto them problemsconcerning are most cooperativerather than by-passing them as they weredoing at the start of the program.

The Ombudsmen render a writtenmonthlvreoortto

the DeputyExecutiveDirectorof the hospital.

At St. Vincent'sHospitalwe areconcerned especially in our EmergencyDepartmentwith treatingthe patient's total needs.We thusinstructboththenursingandhouse staff that whateverthey do for a patientas part of their regularduties,there'ssomethingextra you can add:A big dose of patienceand understanding.

There is a special.medicine our patientsneedthat onlyyou candispense. . . understanding.

Understanding whatit's like to be worried.Understanding whatit's like to be confused.

Understanding what it's like to be afraid.Peoplewho studyhumanbehaviortell usthat thesearetheemotions most patientsbring to the hospital, In conclusion,sincethe Ombudsmenwere first appointedby the hospital'sAdministration,the entireatmospherein the EmergencyDepartmenthas changed becauseboth the nursingand housestaffsunderstand completely that patientsareconcerned andworriedpeople in needof expertmedicalcarerenderedin a compassionate manner.

THE TEAM CONCEPT IN THE UNIVERSITY AFFILIATED EMERGENCY CENTER

KennethL. Mattox, M.D. GeorgeL. Jordan,Jr., M.D. A team concepthas been initiated at Ben Taub GeneralHospital EmergencyCenterto providegood carefor the patientand a worthwhileeducationalexperience for the houseofficer.Earlyidentification ofthe patient'sproblem is providedby initial triage, after whichthe patientbecomes the responsibility of a coordinatedfunctioningteam which consistsof physicians, nurses, andclerkswith supportfrom orderlies asneeded, Sincethisprogramhasbeenin effect,patientflow, divisionof responsibility, and identificationof developing problemareashavemarkedlyimproved.

Teachingrounds with alternateteams allows the remainingteamsto continuenormal activity.Hospital administration, nursingservice, consultingservices,^and housestaff haveenthusiastically supported this system.

Theproblemof the adequate provisionof emergency medicalcarehas beenan areaof concern,not only to thoseinvolved,but alsoto the generalpublis.t,z,r Atien,'ulegislation,a tion has beenfocusedon epidemiology, 6,7,8 education, ambulance systems,a communication0 and categorization.r0 Medical and surgicaltechniquesto manageurgentillnesshavebeenwidelydescribed.

The presentchallengethen is to devisesystemswhich optimizethe availablecare.

Depending on one'sperspective, theterm "Emergency Physician"stimulatesvariousimages.lrThe full time contractualemergencyphysicianin a rural 100 bed hospital is faced with an entirely different set of organizationalproblems than that of Director of EmergencyMedical Servicesof a universityaffiliated 1000bed city/countyhospital, The university-affiliated emergencycentermust be designed to serveall of the functionsof the medical school, includingpatientcare.A systemmustbedevised to accomplish thegoalsof prompt,efficientpatientcare in a settingwhich providesa good educationalexperience.

Theseemergency departments are frequently publiclyfinanced,and are alsounderthe closescrutiny of thepress.Categorization of Emergency Departments withina largecity encourages communitycooperation.

In a rural hospital, categorizationof the emergency departmentmerely identifies the scope of services available.

Replacement of internsand residents in theuniversity emergsncycenter with certified physiciansallows for morerapid,and perhaps, bettermedicalcare.However, thismaneuver may not only be financiallyuntenable in thebusycity/countyhospital,but may alsoprecludethe

41

houseofficer from developingclinical judgement in the emergencysetting.However,a systemwhich emphasizes staff supervisionis desirable.

The chaosand pathosof city/county hospitalsat midcentury are well remembered.5,12'r3 Jnternsworked long hours in "the pit" on charity patientsunder the theory that patients getting free care could not be choosers when it came to physicianselection.They becamevictims of a "catch as catch can" systemfrequentlydevoid of empathy.'3House staff would designateone room as a "tank" for alcoholics and drug abusers.Patients with vague complaints rnight wait several hours before an adequateevaluation discloseda hypertensivecrises, a basal skull fracture, or that the unconscious"drunk" h a d d i a b e t i cc o m a .

Systemsto expeditepatient flow are ovolving.r'r,tr,ts,to Specializedareas within a hospital (or even specialized h o s p i t a l s ) f o r d i f f e r e n t e m e r g e n c i e sm a y b e o n e solution;r{ but, the more the specialization,the more sophisticatedthe patient (and/or ambulanceemergency medical technicians) must be in discriminating the nature of his illness.The introductionof a triage nu-rseat the registration area is gaining popularity.a'1,r,1?

The application of both specialtyareas and nurse/physician triaging may eliminate congestion at the emergency department entrance and even identify the patient's urgent medical problem; however,without a continued systemsapproach,confusionmay developin the secondary areas.Standardsof designand function have been suggestedby the American College of SurgeonsCommitteeon Trauma.18 Specifically,all haveseensuchlogisticproblemsin the university affiliated emergencycenter as a) overcrowding, b) long waits, c) inequitabledispersionof work load, d) difficult teachingenvironmentand e) poor coordination between nurses and physicians.We, therefore, sought to devise -an internal operations system which would encompassthe following parameters: a. Allow for earlier identification of illness. b. Provideorderly, rapid, and equitablepatientcare. c. Developjudgement among house staff. d. Assure control of patient records. e. Provide programmed teaching utilizing the unprogrammed sporadic work load.

The Harris County Hospital District, associatedwith Baylor Collegeof Medicine,is municipallyfinanced,and provides care for an estimated 400,000 people. The emergencycare is providedin five areaswhich allow, for

the most part, self-triageby the patient. These include neighborhoodclinicsfor treatmentof minor problems,a separate institution for obstetrical emergencies,the treatment of non-traumatic pediatric problems in the pediatric clinic, and an acute medical clinic. The fifth area is designatedas the emergencycenter,in which all traumatic lesions,acute surgical problems, and serious m e d i c a lp r o b l e m sa r e m a n a g e d .

T h e 1 0 , 3 1 4s q u a r ef o o t c e n t e rh a s t w o s h o c k r o o m s , eight specialtyexamination/treatmentrooms, two utilit y e x a m i n a t i o nr o o m s , a 1 4 b e d h o l d i n g a r e a ,a 3 2 b e d observation ward, and two radiographic examination rooms. It is staffedwith three secondyear residents(two surgical and one medical), four interns, four students and a stafl physician director. Fifteen per cent of the averagedaily censusof 200, arrive by ambulance.

rooms contain only those tearn membersworking with the patient.

Consultations, referrals for admission, etc. are accomplishedon separateforms. The patient record stays in the team chart rack or with a team member.Frequent chart reviews help the intern to assessthe status of patients awaiting disposition.

Peer and Chart Review Team physicians, residents, consultants and the emergencymedical servicedirector have ready accessto the chart rack. Time/effectivenessevaluationson each patient and team are routine and unannounced.Record analysisincludesconsiderationof team function. Supervisory personnelcan ascertainat a glancewhich team is moving patients slowly and institute the appropriate s t e p st o i m p r o v e e l f i c i e n c y .

Anatomy and Mechanicsof Teams

EducationalTechniques

Analysis of daily patient loads and nursingservice assignmentsheetsprovided a guide for the construction o l i n d i v i d u a lt e a m s .T h e n u r s i n gs u p e r v i s o rt,h e m e d i c a l residentand the surgicalresidentassumethe supervisory roles and are responsiblelor subordinateactivity. All patient dispositionsare reviewedby the residentswho are responsibleto the chief resident(medicaland/or surgical) as well as to the director of emergencymedical services(Fig. l). Patient recordsare subjectto audit, and all emergencycenterdeathsare presentedin conference.

Each team is composed of an intern, a registered n u r s e ,a w a r d c l e r k , a n u r s i n g a s s i s t a n a t nd a student ( F i g . 2 ) . E a c ht e a m h a s i t s o w n c h a r t r a c k , a n d h a n d l e s i t s o w n c h a r t s .T h e p a t i e n t ' sa r m b r a c e l e its m a r k e dw i t h team identification. The patient's movementsthrough the emergencycenter are indicated on his chart.

Ambulatory patients with emergency problems or acutemanifestationo s f c h r o n i c c o n d i t i o n sa r e i n i t i a l l y triaged at the registrationdesk. The chart is given to the t e a m n u r s e ;t e a m a s s i g n m e nbt e i n g d o n e o n a r o t a t i o n b a s i sb y t h e r e g i s t r a t i o nc l e r k s .

U t i l i z i n gh e r n a t u r a la n d t r a i n e di n s t i n c t so f e m p a t h y , protector of patient charts,team leaderand guardian of the physician,the nurse becomesthe logical initiator of i n t e r n a lp a t i e n tm o v e m e n t .S h e i s s i m u l t a n e o u s layw a r e o l l ) t e a m p h y s i c i a nw o r k l o a d ,2 ) a v a i l a b l ee x a m i n a t i o n areasand 3) urgencyof patient problems.Furthermore, b e c a u s er e s i d e n t sa n d i n t e r n s r o t a t e , s h e i s b o t h a s u s t a i n i n ga n d s t a b i l i z i n gf o r c e .P a t i e n t sa r e s e e nb y t h e t e a m m e m b e r s ,a p p r o p r i a t et e s t so r d e r e d ,a n d t h e c h a r t g o e st o t h e t e a m r a c k . A s x - r a y a n d l a b o r a t o r yd a t a a r e available,the ward clerk presentstheseto the intern who makes a dispositionafter consultationwith the resident.

I f a t a n y t i m e t h e i n t e r n o r n u r s eb e c o m e sa w a r et h a t t h e patient'scondition is urgent or that he might need h o s p i t a l i z a t i o nt,h e r e s i d e n ti s s u m m o n e da n d d i s p o s i tion is made.

P a t i e n t sa r r i v i n g b y a m b u l a n c ea r e c h e c k e db y t h e team physician.Only one team directstheir attention to t h e n o n - a m b u l a t o r yp a t i e n t ' sc a r e ;a l l o w i n go t h e rt e a m s to continue their work undisturbed. Should several u r g e n tc a s e sa r r i v es i m u l t a n e o u s l yt h, e t e a m sa r e r e a d y m a d e i n t o a s s i g n e du n i t s .T h e s h o c kr o o m s a n d c a r d i a c

Our program is basedupon the conceptthat education in emergencycare is best provided in an atmosphere which allows those participating to observe and participate in treatment. Thus, the emergencycenteris not geographicallydivided into areas,so that a patient with a surgical problem may be adjacent to one with a medical problem. Each intern sees the spectrum of emergencyproblemsand gains insight into prompt care, regardlessof his primary career orientation.

In addition the concept of both medical and surgical supervisionallows for a broader clinical experiencethan can occur in an emergencycenter with a high degreeof specialtyspacedesignation.The working relationshipestablished between the surgical and medical residents servesto provide cross-fertilizationas well as mutual respectfor individual competence.

Surgical and medical servicesmake teachingrounds, as well as unannouncedappearancesin the emergency center for the purpose of conducting rounds with one team. The unannouncedrounds take approximately l5 minutes and are designed to not affect patient care a m o n g t e a m sn o t m a k i n g r o u n d s .

Nursing ServiceParticipation For the non-shockroom emergencypatient, the team n u r s ei n i t i a t e st h e p a t i e n t ' se v a l u a t i o na n d c a r e .S h ec o n tacts the physician on her team as new patients arrive a n d d i r e c t sh i m t o t h e i r l o c a t i o n .A t a n y g i v e nt i m e , t h e team has approximately 6-8 patientsunder their direction, and an average ol 2 new patients are seen each nour.

The nursing service has found that this system provides(l) division of responsibility,(2) equitabledispersion of the work load, (3) identifiable lines of communication, and (4) early identification of patients whose dispositionis prolonged.

Transfer of Responsibility Residentsare on a rotating 24 hour shift, interns are o n a r o t a t i n g l 2 h o u r s h i f t , a n d t h e n u r s e sa d h e r et o t h e c l a s s i c8 h o u r s h i f t . T e a m n u r s e s m a k e e n d - o f - s h i f t r o u n d s o n l y o n t h e i r t e a m p a t i e n t sa t 7 : 0 0 a . m . , 3 : 0 0 p . m . , a n d l 1 : 0 0 p . m . w i t h t h e o n c o m i n gn u r s e s .T h e

42

charge nursemakesend-of-shift roundson all natientsin thecenterwith the new chargehurse.Medicaland surgical residentsaccompanythe chargenurse on full emergency roundswhile the internsmake roundswith theirnursesonly.As the internschangeshifts,usuallyat 7:00 a.m. and 7:00 p.m., they again make formal roundswith their team nurseand the oncomingintern.

Thechangingresidentsmake full roundstogetherdaily at 8:00a.m.

Figure 1 D i r e c t o ro f E m e r g e n c yM e d i c a lS e r v i c e

N u r s i n gS u p e r v i s o r S u r g i c a lR e s i d e n t

AdjunctiveSystems

M e d i c a lR e s i d e n t

This team concepteasily dovetailswith the new designsfor the provisionof emergencycare, Under currentevaluationareareadispersion of patients,an innovative packaged recordsystem,expansion ofthe floor spaceand house staff assignedas well as more sophisticated triage.Noneof these,in theory,appears to adversely affect or be affectedby the team concept.

Summary

TeamA

I

I

TeamB

|

|

TeamC

Flgure2

Advances in ambulance systems, telemetry, triage,administrationand treatmentmethodshavebeenwidelv circulated.

Problemsof internaloperationpromptedui to adapta divisionof responsibility andreorientation of theclassicapproachto a city/countyuniversityaffiliated emergency center.This team conceptallows for improvedpatientcare,providesuniqueeducational opportunitiesand stimulatesa competitiveespritde coips.

References l. Fitts,W.T.:Men for theCareof the Injured:A CrisisFacingthe 70's. Bulletin, American Collegeof Surgeons,December,igZO, pp.9-18.

2. Shires,G.T.:Careof the Injured-The Surgeon's Responsibility.

Bulletin,AmericanCollegeof Surgeons,5S:7-21, February,1973.

3. Hampton,O.P.: The Committeeon Traumaof the American Collegeof Surgeons,1922-1972.

Bulletin,AmericanCollegeof Surgeons,57:7-13,June,1972.

4. Proceedings of the Airlie Conference on Emergency MedicalServices,Committeeon Trauma,AmericanCollegeof Surgeons, and Committee on Injuries, American Academy of Orthopedic Surgeons: Chicago,1969.

5. Walt, A.J. and Krome, R.L.: Of WickedStepmothers, Ugly Sisters,and AcademicCinderellas.

Journal of Trauma ll:5545 5 7 ,t 9 7| .

6. Rittenbury,Max: Trainingof Emergency Departmentpersonnel: Goalsand Levels.Proceedings of the UniversityAssociationfor EmergencyMedical Services,Washington,D.C., May l2-13, 1972,pp. l-5.

7. Mackenzie,R.: Training of EmergencyDepartmentpersonnel: Techniques.Proceedingsof the University Associationfor Emergency MedicalServices, Washington, D.C., May l2-13, 1 9 7 2p, p . l 0 - 1 3 .

8. Mitty, W.F., Nealon,T.F.: An Educationalprogramin an EmergencyDepartment.Proceedings of the UniversityAssociation for EmergencyMedical Services,Washington,D.C., May 12-t3,1972,pp. 3l-36.

9. U.St Departmentof Health,Education,andWelfare:Emergency M e d i c a l S e r v i c e sC o m m u n i c a t i o n sS y s t e m s ,R o c t < v i t t e , Maryland,August,1972.

0. Recommendations of the American Medical Association Conference on the Guidelinesfor the Cateeorization of Hosoital Emergency Capabilities, Chicago,lg7l.

43

physician?,' Dailey,R.H.: A Metaphor:"Who is the Emergency Proceedingsof the University Associationfor Emergency MedicalServices, Washington, D.C.,May lZ-13,1972,pp.25-26. t 2 . The Emergency Room and the OutpatientClinics.Rejidentand Staff Physician, pp. 94-106,January,1970.

1 3 . The Great EmergencyGame.Medical Llt'orldNews,pp. 35-42, M a r c h5 , 1 9 7 1 . t 4 . Canizaro,P.C.: Management of the Non-emergent Patient.The Journalof Traumall:544-51,1971.

1 5 . Turner,W., Johnson, R., Platt,F., Trimble,C.: FourHour Summaries.Proceedings of the UniversityAssociation for Emergency MedicalServices, Washington, D.C.,May 12-13,1972,pp.36-37.

1 6 . Platt,F.W,, Turner,W., Johnson, R., Trimble,C.: Emergency Triageby Nurses.Proceedings of the UniversityAssociationfor Emergency MedicalServices, Washington, D.C., May l2-13, 1 9 7 2p, p . 3 0 - 3 1 .

1 7 . Rudolf, L.E.: The Non-emergentPatient in the Emergency Room.?Ffte Journalof Traumal,l:552-53, 1971.

1 8 . Guidelinesfor Designand Functionof A Hospital Emergency Department.AmericanCollegeof Surgeons,Chicago,1970. ll.

CONCEPTS IN THE EMERGENCY CARE OF CHILDREN WITH MAJOR INJURIES: ORGANIZATION AND STAFFING OF SPECIAL FACILITIES

,1ff i:ii;:::|iiX:?;,f,7T,!!.',,";:: i{:,*; A numberof major conceptsmust be heededin order to^^organizeand staff emergencymedical servicesin an efficient and humane- manner. At least flfteen such

separate Harriet Lane Home Clinic for-Edward children. The children's facilities are housed in a new A. park building, w_hichhas a Comprehensive ChilJ CareCtinii on one floor, the Walk-InHarri6t Lane Home primary Care and Specialty Clinics on another_floor, and tfr. nrn.rgrn.y or a,sep,arate floor. The ROutt nmeigencyservice, !.?r,1,:._: wnlch was attending105,000parientsa year,-has now been

:fll"Ti.:"'TiJ,.,o',nli,!5"f,?ry,,J;[i*,'f .lt]'.H#*ti

-.aiiur;.r;. ii) .emergen.y fl,,:,.,:lltijt] 9::le'.9,for

rall inro lwo basic categories: :::yj:i,_" :mergencles accloenrs 1or trauma)_and acuteiilnesses (obstetricallabor ts an,ex.ception).(3) children are differeni because of their small dimensions,immature râ&#x201A;Źsponsesto trauma, and preciousemotionalreserves, and s^hould be separated'from adults as emergency patients. (+) Ff,Vri.i.ns providine "broadly 'UurrJ-li emergencymedical servicesshould be medical and sursical training una .upuUitiii-ri, i... primary physician care s[outd not b? ;;;gi;i;;; :,medical,,, but appropriate for the. .patient_ iopulation. (5) Nu;;

about75,000'a yea'r. r";;;b;; 11d,19.?9',o be lower.

mayprovero

The Children's Emergency Servicehas a section for -Center) accidents_(Children'sTrauma and a section for Primary physiciancareis renderedLy pediatricians ilrl.l::r, tn oo^tnsectlons, includingsuturing and initial " of lacerati,ons carefor multiplemajorinjuries.

The new JohnaHopkins Schoolof Health Serviceshas matriculated its first classof fifty students,of which iix

j;l,ln"'lffia'i$f.T#:* ilSFlf':ti1:,itstl':i!:1, ,T::9, I l!l".rymedical.orprrnin'ur.i" tr;fi ngassurgical

-irrrt19, physicianand nurse.(6) Intensive,*r general operating.. faciiities,and a biood bank ur. n...rruru

(nearth) assistants.The Trauma Coursefor th6 Schojl of Health.Servicesis taught in the Childr.nl, Tiurrnu Center.

Ieglqgc.nu.rse practitionersare now at work in the park rJultolngln the non-emergency sections.

The PediatricIntensive-Care Unit has 14 bedsunder Medical Services should have its ;; ;;;. diagnostic the of a pediatric anesthesiologist facilities for X-rays and simple tests. f"Uorutory who also .supervision resultsof conducts. a_ training -ourse for nursing ind technical other.typesshoutdue rapidty;;.il.bl;.-i;i si!.irj,iy personnel.In the same area there is a p-ediatric consultants Surgicai andteams r;;ay dh.i10i Recovery Room and a special section ior Children,s TTr b..lrovideilon TheEmergency Medical Servic6r,h;;ldhuuJ-urrono_ou, NeurosurgicalIntensive carb. The ourruit lntensive care departmentalstatus in the plan of hospital organization. ca.pacityin The Johns Hopkins Hospital is 42 beds (11)rhereshould for be a.deffi;a-Chi;i-;i E;;6;;;; adults and children. There'are utro ,?,fuiui. Surgicai MedicalServices..(12) and ' There;h;"lJ Url-air.to, of any MedicalIntensiveCareUnits for adults. separate unitssuchasadultor children's emergenc)/ rooms, celle.rl,etc. with a sizable.rnrrr. ii? Oti..to. oi ^ lttq GeneralOperatingRooms are near the Intensive lruy*u Care Units and Blood Ban[ and huue un udiucent sucha unit ideallvshould.befull_time.

25 bed (t3) A ,"riOrn.V RecoveryRoom. There is a pediatric Surgi.lufDivision trainingprogramshouldu..o-u.iop.J'i; ;;;;r"ry of medicat ,^h^.^,l1g.t.*Dep.artmentwirh a pediatricSirgicaf servic-es.

(14) A regionalcommunication, Resideni, iiunrportation, As$stant Residentsand Interns rotate frori the Generai and dispatchplan ii optimarto .ootoinuil -u.-Urtun.r, iniiuicuoi .ur.

Surgicaland PediatricServices.ttrere are-also General gng mass disaster handling. notf, and and helic.opters equippedwirtr i'ppropiiur.-'.oirnunicarion lneglatjV Surgical Resident staffs roiating- ttrrougtr ilie Adult EmergencyService. capablities arereqiiredror a moderntransportation service.

A Poison Control Center operatesas (15) Ambutance^ -foia part of the and h.li;;p;;' ;.rr""i.i'rrr"uld have Children's Emergency Service. fn.iupy advanced trainingand continuingeducation overdoseis -a pru&i., in availablein borh itre aAuttund child;;;i;r;;. first aid andreslscitative technilu* l".i"Jirg'lntravenous diagnostic. facilities (radiology and small therapyaswellascardiopulmonary , ,. .9org, methodology. mqlviouat laboratories) are present in both the Adult and At the presenttim6 only u few taigeciii& unOseveral -_.-, .::{.1.:s The Emergency Laborarory in,the u{Je{ Statesfraveacknowledged :^1lq]:n's lm:rgelc{ Services. t"o:^tlr li::: hospitalis locaredin the par-kBuildingon thl tded the proper organizati"on'trmergency :l!ir: iloor. Consultantsfrom all the special-ties il'ff "r:":i:oti..?il,lrrn'^o are assigned and available promptly to the Childrefis and aaull tmergencyServices. progresswhich has been made at The fofrns Uopf<ins new, position as Chief of EmergencyMedical Hospital.in the light of theseconcepts. "^,_,1 has )ervlces been designated and appointment -tjiir.tmade.The Episodicand chronicpatientjhave been channelled to Child re.nt Emergency 5ervice tras a fi,it _tim. a new (Walk-In) primary iare Clinic for ;duiis, or. and to a lne rlrst step in a ResidencyTraining program in

q,i:J :t#fr:1:. l.1', d3:.;il, ;.Tff[],]. !:r.ffi1 [H:l

servicei.p*hqi,;.1;';,1,"J#Tlt:ff ,;:l'ir"'t:{.,il'.riix

Emergency MedicalServices beganJuly l,1973,with a full yearappointmentof an AssistantResidentin the Children's TraumaCenter.

Intimate cooperation between the University of Marylandthe The Johns Hopkins Schools of Medicin'ehas produceda coordinatedplan(under the Baltimore Regional Planning Council (BRPC) for individual and mass emergency servicesin the greaterBaltimore area.This plan hasprovisionsfor enlargementto a state-wideprogram.

The -Baltimore Universityof Maryland-Trauma Center and The City HospitalsBurn Unit and NeonatalIntensiveCareUnit arecoordinatedwith The JohnsHopkins Children'sTrauma Centerand Adult EmergencyServiceunder this plan. The hospitalsof greaterBaltimore havebeen categorizedby the BRPCaccordingto capabilitiesfor handling of emergency patients.

Communications and (ambulance and helicopter) transportationsystemsand policies have been extensively reviewedunder the auspicesof the BRPC. Planshave been

made for coordination under grants-in-aidfrom both federaland state sources,with technicalconsultationfrom The JohnsHopkins Laboratoryof Applied Physics.

Educational programs have been underway for training of ambulance and helicopter personnel in resuscitativetechnics under the auspicesof the American College of Surgeons (Regional), the various Baltimore hospitals and Baltimore Fire Department, and The Johns Hopkins Schoolof Health Services.Disasterdrills havebeen insfigated on a city-wide basis and carried through for constructiveimprovement and practical experiencein all facetsof emergencymedicalservice.

The conceptspresentedhere are not all inclusive,not entirely applicable to every locality, but are guidelines which have servedThe Johns Hopkins Medical Institutions in implementingtheir responsibililiesfor providingeffective regionalemergencymedicalservices.They are presentedas such in order to encourageother institutionsand regionsin the developmentalstagesof their systerns.

45

SHOCK TEAM APPROACH TO RESUSCITATION PeterRosen.M.D.

To anyonewho has had responsibility for management of a busy EmergencyDepartment,it is clearthat decision-making and responseto the acuteemergency are different from that wtrich is conventionally

Step2: The Patient'sAirway.

We all know how importantthe airwayis, but action requires practice.6 We have made videotapes of resuscitations and it is amazinghow long the airwayis learned.2,3,6,8 neglected.

It is now standingorderto applynasalcanOne must react rather than act, and usuallyon little, nulaandfull volumeO, flow immediately.We acceptthe or no information.He mustalsomakean instantaneous risk of theemphysematous patient.Our traumacaptains decisionabout the level of physiologicderangement. are preparedto breathefor the patient.By this time the Systemratherthan organpatfioptrysiology is oflmportteam is on the sceneand undercontrolof the captain. ancein this setting.The properquestionis: ..Whaf lifeThe followingstepsare parallel: threats need to be dealt with?"' not ,,what is the Step3: Undressthe Patient. diagnosis?"Only after stabilizationis achievedis it then Patients should be completely undressedcutting appropriateto ask questionsleadingto a specificlabel. clothesif necessary.

Patientshave been.thrown into After studyingour resuscitative techniques, and conprofound shock by sitting up or standingto remove cludingthat we werefailing in our initial appioach,we clothes.Once nude, the patient shouldbe coveredfor evolveda shock-team.Similar techniquesare used warmth and modesty,Severelyinjuredpatientsare still elsewhere, but we felt it might be profitableto shareour very awareof their surroundings. experiences.2'3'8 Step4: Obtain Blood Pressure and Pulse.

As presentlystaffed,the shockteam consistsof one Theseare obtainedby the nurse who reports them resident,one intern, one nurse,and one emergency loudlyto the captain. technician.'Adaily staffassignment, andwhenthe shift Step5: Start a CVP line.a changes, it is teamcaptain'sresponsibility to knowwho This is donein the right arm by the intern,who im: the new nurse,intern,etc., are. Selectionof the team mediatelymeasures theCVP andreportsto thecaptain. captainvariesdependingon the situation,for trauma, During thesesteps,the captainis managingtlie airthe Surgicalresident;for cardiacarrest,the Medical wayr he is ready to intervene immediately with resident.Eitherresidentis ableto manageeitherteam. mechanicalassistance for respirationandsubsequent inThe team captain functions as the overseer,If he tubationif necessary.s If thecuplineis not obtained, the becomes involvedin a specificchore,(e.g.,intubationor traumacaptainimmediately will makea decisionon the insertion of a chest tube) the overseerduties are insertionof an internaljugular or subclavian line. delegatedto another team member. He must be Shouldhe opt for these,the intern becomesthe team aggressivein his control of the resuscitation,Major captainuntil the procedureis finished.Simultaneously, trauma and cardiacarrestinvariablyproducea wealth the nurseandlortechnician starta secondconventionll of on-lookers.

Thesemust be removedfrom the areaif large-bore I.V. in the left arm, If morelinesareneeded. resuscltationis to occur smoothly.The team captain they can be added.t'e mustcontrolthe environment.For the team to function The only alterationis for the cardiacarrestteam, as a unit, as it must, a strongteam captainand exwhenthe initialdetermination of absentpulseandcoma perience are necessary.

The traumateamis summoned wouldhaveproduceda closedchestmassage, as well as by ringing a bell throughoutthe EmergencyDepartthe airwaymanagement.6 ment. A full resuscitationis carried out before any At this point in the resuscitation,the captain can diagnostic procedures are begun. pauseand assess extentof injury. He can delegatethis, Eachmemberof the team hasspecificdutiesrelating or quickly perform the examinationhimself. to our trauma protocol(seefigure l). This is a conHe will make a decisionaboutthe necessity for Foley tinuingprocess,as by the time we haveonegrouptraincatheterization,nasogastricintubation, thoracostomy, ed, we rotateand start a new group of physicians. paracentesis, or peri-cardiocentesis.2,s'5'8 By now, blood Stepl: Gettingthe Patientto the ShockRoomand will alsohavebeendrawnfor type and crossmatch,and Summoningthe Team. if the situation warrants,type-specificbut unmatched This is no trivial problem.Ambulancedriversare bloodcanbe started.We prefernot to useO (-) blood. frequently more concernedwith retrieval of their At this time, the patient shouldhave respondedto stretchersthan the welfareof their patients.On more resuscitation.

Pericardialtamponademay be considered, than one occasion,they have announceda ',dead on and pericardiocentesis performed.2,3 arrival" in a patientwho was fully resuscitable.

By now too, the specialtyteamshave beennotified The technicians who performour initial triageusually and the operatingroom madeready,surgerycanbe perbecomeawareof the casefirst. They, therefore,are the formedin the EmergencyDepartment,whennecessary. onesto pushthe traumabell andto assistthe ambulance Injuriesthat survivelong enoughto reachthe Emergenpersonnel. cy Departmentcan usuallyreachthe operatingroom, so

46

thatit is rare for surgeryto be necessary.

Theremainderof our protocolis includedfor infor. Figure I

TRAUMA PATIENTS

(l) Disrobecompletely, alsoimmediatebloodpressure andpulse.If statusof spinenot known,cut clothing away.

(2) Airway (a) Oral airway. (b) Ambu bag. (c) O' - openwide. (d) Endotracheal equipmentat directionof Trauma Captain. l. laryngoscope 2. E T tubes 3. Procaine2Vo,3cc.for transtracheal injection 4. Succinylcholine,40 mg. at discretionof TraumaCaptain (3)I.V.'s (a) Lactateringersonly. (b) #14intracathfor CVP. #14 intracath. (c) Subclavian line at requestof TraumaCaptain.

(4) Openwoundsto be bandaged at directionof Trauma Captain.

(5) Fractures to be splintedat directionof TraumaCaptain.

(6) Consultations, x-rays,EKG, and laboratoryat discretionof TraumaCaptain.No diagnostic X-raysor EKG until patient'sconditionis well stabilized!!!

(7) TetanusToxoid, Vz cc. lM - all patients. (a) On minor trauma,no toxoidif boosterwithin l2 months.

Figure2

(b) On majortrauma,all patientsto receive booster.

Human antitetanusantitoxin,500 u. IM if no good historyof prior tetanusimmunization.

(8) For all penetrating thoracicand abdominaltrauma, antibioticsto be startedas follows: Thoracic:1,000,000 u. PenicillinI.V. pint bottle, and 250,000 each following bottle; Vz gram StreptomycinIM. If Penicillinallergy,Lincocin4 cc. I.V. Abdominql:I gm. Kanamycin,first I.V. bottle and 250 mg. eachfollowingbottle,but no more than 2 gm. to be given in EmergencyRoom.

Give 4 cc. LincocinLV. in first bottle.

For all patientsin shock,i.e., blood pressureless than 100/60,pulsegreaterthan 100and clinicalsigns ol diaphoresis, cold clammyskin, weakpulsepressure, and apathyto surroundings. (l) Foleycatheter, (2) Chesttube138Fr. insertedin R,, L., or both5thintercostalspaces in anterioraxillarylineat discretion of TraumaCaptiin, (3) N-G tube at discretionof TraumaCaptain.

(4) Type and crossmatch6 units of wholeblood.

(5) Stat CBC, electrolytes, and bloodgases.

(6) One Amp NaHCO3,LV. push- additionalat discretionof TraumaCaotain.

(7) Abdominal paracenteiisat discretionof Trauma Cantain.

ABDOMINAL STAB WOUND PROTOCOL

l. Observetraumaorotocol 2. If patientindicat-es shockat any time, or if obvious peritonealpenetration(EG bowel of omentum evisceration or signsof peritonitis)all thesepatients must be exploredin the operatingroom. If patient financiallyineligible,admissionmust be mandatory.

3. The remainingstab wounds will be handled as follows: In the EmergencyRoom the wound will be prepped and sterilely draped. Under local anesthesia the stabwoundwill be enlarsedandexplored.

Figure 3

mation. We have seenmany deathsensuefrom efforts to diagnose,when active interventionwas needed.

a) If the fasciais penetrated theprocedure will be terminated,the wound packedopen,and the patientexploredin the operating room.Admission will be mandatoryif the patientis financially ineligible. b) If thereis no fascialpenetration, thewoundwill be closedprimarilyand if no otherindication for admission, the patientwill be discharged.

4. Tetanusprophylaxis will be carriedout. (seeTetanus Protocol) 5. Under no circumstances is the stab wound to be probed.

DIAGNOSTIC PARACENTESISPROTOCOL

Abdominal trauma (any injury below a line drawn throughthe nipples).

A. Gunshot wound - mandatory exploration.

B. Stab wounds l. Peritoneal signs - exploration 2 . N o p e r i t o n e a ls i g n s : Explore wound locally a) penetration of fascia explore in Operating Room. b) no penetration- observeor discharge.

C. Blunt trauma l. Consciouspatient with no abdominal signs observeor discharge.

2. Consciouspatient with abdominal signs- explore or observe,(if questionablebruise of abdominalwall).

3. Comatose,inebriated patients with abdominal signs - explore in Operating Room.

4. Comatose or inebriated patients with no peritoneal signs or equivocal signs:

Abdominalparacentesis a) peritonealdialysiscatheterinsertedin midline below umbilicus.I liter lac_ tated Ringer,sRUN in (500 cc. in children)I liter, then RUN out. b) if return grossly bloody, explore in OperatingRoom. c) if fluid-clear or pink,thendo following: RBC, WBC, Amvlase. d) if RBC > 100,00b/mmr_ explorein OperatingRoom. if RBC < 100,000/mmr_ observe (repeatparacentesis if indicated). e) if WBC OperatingRoom. fl if Amylase) l00y/l00ml,explorein OperatingRoom. _ All_ patientswho underfo_paracentesis with dialysis catheterare admittedfor-obs-ervation, if paracentesis is negative.

Summary: . A team approach for the stabilizationof life_ threa.tenlng pathophysiology is recommended.

Once stabllrzatlonhas been achieved,more conventional diagnosisand therapycan be introduced.

48

References L

2.

3.

4.

5 6.

7.

8.

9.

10.

Baxter, C.R., Canizaro, p.C., Carrico, C.J., and Shires, G.T.: Fluid Resuscitation of Hemorrhagic Shock. postgrad.

Med., 4 8 : 9 5 - 9 9 ,S e p r . , 1 9 7 0 .

B e a l l ,A . C . , B r i c k e r , D . f . , C r a w f o r d , H . W . , a n d D e B a k e y , M.E.: Surgical Management of penetrating Thoracic Trauma.

Dis. of t h e C h e s t , 4 9 : 5 6 8 - 5 7 7J, u n e . 1 9 6 6 .

B e a l l ,A . C . , D i e r h r i c h ,E . B . , C r a w f o r d , H . W . , C o o l e y , D.A., and D e B a k e y , M . E . : S u r g i c a l M a n a g e m e n to f p e n e t r a t i n g CaiAiac lnjuries. Am J Surg, 112:6g6_691,Nov., 1966.

C o h n , J . N . : C e n t r a l V e n o u sp r e s s u r ea s a G u i d e t o Volume Ex_ p a n s r o n .A n n l n t e r n M e d , y o l 6 6 : 1 2 g 3 . 1 9 6 7 .

C:l]'... J.A.. and Lloyd. J.W.: pracricalpoints in the Treatmenr o r L n e s t f n J u r r e sA . n e s t h e s i a .y o l . 2 2 : J 9 2 , 1 9 6 7 .

G i l s t o n , A . , a n d R e s n e k o v , _ L -C: a r d i o r e s p i r a t o r yR e s u s c i t a t i o n , 1 9 7 1 .F . A . D a v i s & C o . , p h i l a d e l p h i a .

H a d d a d , G . H . , p i z z i , W . F . , F l e i s c i m a n n ,8 . p . , a n d Moynahan, J.M.: g r a m sa s D e p e n d a b l eC r i t e r i a . A b d o m i n a l S i g n s a n d S i n o-Wounds for SelectiveManagement of Stab of the Abdomen. ,4nn S u r g , 1 7 2 : 6 t - 6 7 ,J u l y , 1 9 7 0 .

M c N a m a r a , J . J . , M e s s e r s m i t h J, . K . , D u n n , R . A . , M o l o t , M.D., a n d S t r e m p l e ,J . F . : T h o r a c i c I n j u r i e s i n i o m t a i C a s u a l t i e si n Vietnam. Ann Thoracic Surg, 10:399_401,Nov., 1970.

Moyer, C.A., and Butcher, H.R.: Burns, Shot[ and plasma V o l u m e R e g u l a t i o n , 1 9 6 7 .C . V . M o s b y , S i . L o u i s , Perry, J.F., DeMeules, J.8., and fioot, H.O.: Diagnostic P e r i t o n e a lL a v a g e i n B l u n t A b d o m i n a l T r a u m a . S u r g , 6 y n , & Obst, 13l:742-744, Oct., 1970.

USE OF THE VIDEOTAPE IN EMERGENCY MEDICINE

GeorgeR. Schwartz, M.D. . The portablevideotapeis a relativelynew technical development in medicini,much of its usebeingil;;t_ chiatry.z'0 Professionally preparedprogramshavebeen tr and iti use to improve employedwith somesucCess', teaching techniques has beendescribed.r,12 presenting our useof videorape in emergency --*l::: medrclne generalconsiderations and cautionsshou-ld b! mentioned_ The potentialfor the constructiveuse of vloeorape ln emergency medicaleducation is largelyuntlpp.a. Onemust rememberthat it is a tool, un-A ii, ,f_ ficacymust be demonstrated beforeit is'adoptedfor widespread use.Ryan and Budnerfound that live case presentations in neurologywerelesseffectivethan their videotapepresentations,-in terms of subsiquentreten_ tion. Thereis this caution:the television-monitor can_ not and shouldnot replacethe skilledclinicalteacher because he doesmuch'morethan si.pt/-impurt facts.

Theteacherprovidesthe studentsstimuiaiion,the excite_ mentof l llbj"g!, the logic behindit, and un identifica_ tronmocteltor his students.A televisionimage cannot do this.

Theemergency physicianspecializes in the immediate to.alteredpathophysiologyand ,r:.^:9:lrlon.und,response ln systems rnvolvedin the initial careof lhi emergency patient.The key wordshereare immediate recognition, response, and systems.

The physicianspendsmany yearsin an educational system whichserves not_only to provideneeded facts,but alsoto providelogicalthoughtp.orrrr", unOint.nriti.i ooservatlonal capacities.

Nowherein medicinearethese cnaractenstlcs neededmore than in emergencymedicine.

In the first videotapesegmentwe observea child in respiratorydistress.After watchingthis patientstudents andclinicians are askedto list theii oUr"iuuiionr.As the camerafocusesin, the tachypnea,the intercostalretrac_ tions, the abdominal rejpirationr, it "- suprasternal the flaring.of th-ealae nasae,the prolongeJ Ilrj,llt i: phase, explratory the hunchedovershoulders,-increaied carotidpulsation,are all seenclearly.the siuAents are asked,to go througha logicalthoughiprocess to arriveat :..ll.,ll gl"g"osis.Questionsabouthisroryand physical examlnatlon may be asked.

Objective evaluation of the effectsof suchexercises _ is difficult.When shownadditionalvideotad the follow_ ing week,the studentswere able to detectmore abnor_ mal findings. The twenty-four medical students and

physicilns"*po*a io it i, prog.urn glu,guut:, P:.1..",1 naverhe teetrngthat they

their patients.With the videotape we are attemptingto improveobservation, The next elementis the response of the staff to the patient.In emergencymedicine,this often is a team response.

Videotapereviewenablesthe team to review thelr own actions,and betterunderstand the patient,s pathophysiology.

The functionof the team members may be analyzedand discussed.

Tapesmay be usedwith medicalstudents, and as the case evolves,it may be stoppedand the medical r.esponse, alteredphysiology andleaminteraction canbe discussed at lensih.The third key-issystems study.Theresponse to a dis_ asteror disasterexercises can be videotajedin orderto help future planning.The videotap"rniy be usedto record the activities of room, patient .the emerg'ency flow, problemswith waiting .oorr] etc. This ."n b" un effectivelever for changc.

Some of our studeits did a documentaryof the emergency.facility at the Medical Collegeof penn_ sytvanla.I nls was shownbeforethe emergency room committeeand the medicaldirector.Somitimes,the mirror of realityis painful.

Thereare manyothersituations whichcanbe filmed, andwe,havevideotaped someunusualor rareproblems.

I ne vldeotapgmay be u-sed for programdescriptionfor potentialapplicantsor foundatibn lrants.

Although objectivetests of pir"n." of learning enhancement, increasedobservational capacities,ani improveddecisionmakinghavenot yet beendone,the subjective responses have beenuniformly favorabie.I believesuchuseshould.be_encouraged ani comparative testingemployedto seeif the subjeciiveresponses canbe borneout.

Summary- The videotapemay be effectivelyusedin EmergencyMedicine.particulai usesinclude: 1..Enhancingobservational capacities of emergency . physiciansand teachingon undergiaduate and postE;;;: uate level.

2. Evaluation of the Emergencyresponsein life threatening illness.

3 . I d e n t i f i c a t i o n o f E m e r g e n c yD e p a r r m e n r prob.lems.Quantitative evaluatio-nof'the benefits in medicaleducationis necessary.

References l. Perlberg, Arye et al.: Microteaching and Videotape Recordings: A New Approach to Improving Teiching, J. Med. Ed. 47:4i_SO,

t972.

are looking more cioseiyat

2. Chodoff, Paul: Supervisionof psychotherapywith Videotape:pros

49

and Cons,Amer. J. Psychiat.128:819-823, 1972.

3. Cline, David W.: Video Tape Documentationof Behavioral Changein Children,Amer. J. Orthopsychiat.42:40-4'1,1972.

4. Ryan,JamesH., Budner,Stanley:The Impact of Television:An Evaluationof the Use of Videotapesin PsychiatricTraining, Amer. J. Psychiat.126:1397-1403, 1970.

5. Suess,JamesF.: Self-Confrontation of Videotaped Psychotherapy asa TeachingDevicefor Psychiatric Students, J. Med. Ed.45:271282, 1970.

6. Wilmer, Harry A.: Televisionas ParticipantRecorder,Amer. J. Psychiat.124:| | 57-l 163,1968.

7. Sigafoos,Thomas, Jordan, Judith: Staff developmentvia

Videotape, J.A.H,A, 46: 40-42, 1972.

Bronson, Nathaniel R.: Videotape in Ophthalmic Surgery, Amer.

J . O p h t h a l m o l og y . 7 l : 5 4 4 - 5 4 8 ,1 9 7 0 , 9 . There's Something for Everybody - And it's all on Videotape, M o d . H o s p . l l 9 : 8 8 - 8 9 ,1 9 7 2 .

1 0 .Peltier, Leonard: Television videotape recording: An adjunct in teaching emergency medical care, Surg. 66:233-236,1969. l l Jamron, Kenneth S., Nailen, R.L.: Homemade videotapestrain staff and help patients understand hospital procedures, Mod. H o s p . 1 1 7 : 8 7 - 8 81, 9 7 1 . t2. Crandall, G.M.: Videotape Keeps the Training up to Date, Holds the Cost Down, Mod. Hosp. ll7:85-87, 1971.

50

EMERGENCYMEDICAL SERVICESIN THE USSR A RESIDENT'SEVALUATION

RobertScribner,M.D. Larrv Reithaus.M.D.

The SovietEmergencyMedicalServiceswasfounded in 1919,not long after the Revolution.The purposeof the Emergency MedicalSystem,the Russiannamefor which is Skoraya MeditsinkayaPomosch,was to provideemergency medicalcareto a largeurbanand a massive over rural population- a populationscattered the greatestsingleland massin the world. From this gigantic task of providingmedicalcareovereightanda hall million squaremiles,the fundamentalconceptof SovietEmergency MedicalCareevolved:That is, send thedoctorto the oatientratherthan the oatientto the doctor.This has been the centralthem-eand it has remained at the core of the system.

At Theadministrative structureis highlycentralized. the summit is the Ministry of Health in the Soviet Union.Within this ministry,there are administrators who specificallygovern the Skoraya.They officiate throughtheir counterparts and a Ministry of Healthin eachrepublic.In turn, therearerural andcity Divisions ofl Health,which administratehealth care at the local level.The Skorayaof a givenregionis governeddirectly by sucha divisionof health,but closecontrolis maintainedfrom the top on down. For example,the health carebudgetcomesfrom the Ministry of Healthof the SovietUnion, but the Ministry of Health of each governshow muchit spends republic on its yearlyhealth careallocationon the Skoraya.This will vary from regionto region. upon In addition,thetypesof ambulances aredecided by theMinistryof Healthof the USSR,but thenumbei by of ambulances assigned for a givenareais determined eachrural or city division,depending upon their local needs.Thus, whilg financial and governmentalcentralization is maintained, a greatdealof localfreedomis exercised in theutilizationof funds,equipment andmanpower.

Theyoungmedicalstudentgraduates at age22. If he or she- for 50Vo of the graduates arewomen- desires to be a Skorayadoctor, he beginswith a six month coursein emergency training.Upon completionof his hebecomes course, a SkorayaGeneralist.

Fromthenon, helearnsas he works.He mustknowbasicmedicaland surgicaldifferentialdiagnosis.As a young Skoraya he spendsthreeto four monthsperyearon a Generalist, specialtybrigade.There are six such brigades:CarToxicology, diology,Traumaand ShockResuscitation, psychiatricbrigade etc.In addition,thereis a separate staffedby psychiatrists.SkorayaGeneralistsultimately

5l

gain expertisein the specialtybrigade of his choice.

Skoraya Generalistswill work three or four months per year riding the ambulancesand the remainderof the time, will work in a specialty ward in one of the emergencyhospitals. In Moscow, there are five such hospitals. The major one being the Sklifosovsky Institute, a 600 bed hospital and institute for scientific researchinto the problems of emergencycare.

The Skoraya specialistcontinuesto learn and superspecializeas he works. He will participatein particular courses,educationalactivities,that deal with his specialty. He will attend various emergencymedical service conferencesthroughout the Soviet Union. He will be financially supported for these meetings by his local Skoraya. On the average,he will work l2 hours and be off 36 hours. A good deal of his l2 hours on call will be spent watching television,reading, or just chatting, but he is always ready for immediatecall. He will probably be a Skoraya Doctor his entire life.

Skoraya physiciansare outnumberedfour to one by middle-levelmedical workers in the Soviet EMS Service. Two-thirds of these are feldshers.The feldsheris unique to Russia.They are highly trained nurses,below the level of a doctor. The name is derivedfrom the field of surgeonsof the l Tth century Swedishand German armies. The idea was imported into Russia by Peter the Great and feldsherswere, for a long time, solelyresponsible for medical care throughout the rural reachesof Russia. As the number of Soviet physicianshas increased,now 650 thousand, (greater than the United States, Great Britain and France combined), the feldsher'srole has decreasedand may soon disappear altogether.

Skoraya is designedto treat the accidentvictim and t h e a c u t e l yi l l . A s a n e m e r g e n c ys y s t e m i,t a d h e r e st o t h e primary tenet of reducing the time lrom the primary o n s e t o f t h e i l l n e s st o t h e d e l i v e r y o f t r e a t m e n t .I t s modus operandi, however,is to apply life saving, lifesupportingmeasuresat the sceneand during transportat i o n r a t h e r t h a n m e r e l y t r a n s p o r t i n gp a t i e n t s t o t h e h o s p i t a la s r a p i d l y a s p o s s i b l eT. o d o t h i s , i t i s e s s e n t i a l to take the doctor and the treatment to the patient. In the Moscow Skoraya which will serveas an exampleof the urban system,there are 200 ambulancesin servicein the daytine and 100at night. One ambulanceservesapp r o x i m a t e l y3 5 , 0 0 0p e o p l e .

Ambulancesare ol two types. First, there is the line ambulancewhich is similar to the American Chevy van.

It containsa stretcher,splintsand an anesthesiamachine using nitrous oxide, a respirator, intravenous resuscitativematerials and basiCemergencymedicines.

It is staffed by a doctor and one oi t*o feldshers.

Secondly,there is a specialtyambulancewhich is essen_ tially an ER on wheels.It containsall the equipmentin the line ambulance,plus an EKG machine, a defibrillator cardiac massageapparatus,tracheostomy and thoracotomy sets, and poiJon antidotes.On these ambulances,are a feldsher and two doctors, one _ a brigade specialist.

The Moscow Skoraya consistsof a central telephone dispatch and 22 regional aid stations. Each station is responsib.le for a particu_lar geographicalareaof the city.

Central dispatch is in direcl telephoneand radio com_ munication with each of these stations and with their ambulances.It also communicateswith other medical po.ints,factories,stores,transportationsystemssuch as subwaystations,etc. There is a singleradio band for the Skoraya all over the Soviet Union.

Central dispatch is manned by dispatcherswho are . either (eldshersor doctors.Their iunction is comparable to that. of the personsmanning the switchboard^ at the ambulance communication center in New york City.

They are trained in telephonerecognitionof the natuie and severityof an illness.They havJat their disposal,an up-to-date accounting of the bed situation at every emergency hospital in the city. They can thus direit deliveryof a patient to the appropriate hospital in the clty.

During.on_eof my nights on call at the First City ..

Hospital in_Moscow, there was no surgery being per'_ formed and we had a number of youig doctori and medical students sitting around idie. T[ere being no library.zrndcertainly no pub in the hospital, we cilled C-entralDispatch and asked them to sendus some cases of possibleacute appendicitis.Within two hours,we had IOUrCases.

On the other hand, when we called Central Disoatch and told them we were backed up with operativeiases, we receivedno more surgical casesfor tlat night.

-Let us now examine a typical emergencysituation.A patient sustainsa _myocardialinfarct-ionin a park. A passerbygoes to the nearesttelephone.All puLlic pay telephoneshavea^pushbutton for emergencyialls.This oovratesthe needlor a two kopek coin. It is about 2( not l0p. Next to this button are initructions: Dial0l for fire, 02 for police, and 03 for medical help. This is standard throughoutthe Soviet Union. Our pai.lrby dials 03 and it goes directly to the Central station of the Skoraya system of that city. Central Dispatch receivesthe cill within one minute and calls th-e nearest aid station.

Within three minutes a specialtyambulanceis dispatched with a specialist from the cardiology brigade on board. If the specialtyambulanceis not al-the sLtion, it can be contacted directly by radio. Within six to ten minutesof the original call, the patient is resuscitatedat the scene,and taken to the nearestemergencyhospital.

The ambulanceor Central Dispatch cun ilro call ahead to the receivinghospital so that all is preparedfor the patient'sarrival. Transportationthrough tire city is less

52

diflicultthanin the UnitedStates.Trafficis lessfor one thing.Emergency traffic lanesexist.And therearetraffic policemen who manthe majorintersections 24 hours a day.

We havea gooddealto learnfrom the SovietUnion concerningrapid and efficient delivery of emergency medicalcare.Emergency Medicinehas-been a soeiialtv in the SovietUnion for over50 years.In keepingwitit the entirepoliticalstructure,ceniralization and vertical dispersalof administrative authoritypredominate.

The Soviet Systemstressesphysician'specialization.

The EmergencyMedical Serviceis an esiablishedand lifelong. .career specialty. It also engenderssuper_ specialization.So that, for example, a physi^cian becomesnot only a pediatricianbut a speiialistin emergency pediatrics.

TheSovietsystem,thui in a sense. reverses our own. The Sovietbecomesan emergency generalistfirst, then castsoff into trauma,n"urjogy, pediatrics, etc.

In summary,I would .like to suggestthe following emergency carecharacteristics of the Sovietemergency system, that warrant considerationfor impioving emergency carein our own countries.

First, centralization of administration and funds.

Secondly, lifelong career specialization for emergency , physicians.

Third, centralizationof communicationswith geographicallydistributedaid stationsand hospital treatmentcenters.

Fourth,the widespread useof theemergency roomon , wheels.

Finally,adherence to the conceptthat the doctorgoes to thepatientratherthanthepatientgoingto thedocior.

In the SovietUnion,the cry .,calla dictor" hasnot beenreplacedby the cry, ..callan ambulance."

Dr. Reithaus:I'd just like to point out that the Skorayahas a very importantcentralrole.The overall organization of healthcareand its deliverybearsan in_ terestingrelationship to the specialtyinstitutesof both medicineand surgery.Specialtyinstitutesof the Soviet .Unign are organizedon a far more highly centralized levelthancomparable institutions in thJwest.Thereare separate institutesin many of the surgicaland medical sub-specialties, on a regional,republic-wide and an All_ Unionlevel.For example,I spent threemonthsworking -Clinical at the All-Union Instituteof and ExperimentaT Oncologybut therewereregionalcentersas well which handledmostof the straightforward cancercases, Thus, in Moscow,Leningrad,and othermajorcitiesonefinds rnstrtutesol-cardiovascular. surgery,pulmonarysurgery, orthopedicand reconstructive surgery,G.I. suigeryi aia evensurgeryfor acutearterio-emboiism.

As alreadymentioned,care for acutetraumais ac_ complished in the Skorayahospitals.Speciallytrained emergency carephysiciansas describedby Dr. Scribner are assignedto the ambulanceand they are capableof d-iagnosing anddirectlyadmittingthe acutepro6lemsto the appropriatesurgicalhospitalor otherlppropriate specialty.ho.spital.

Thus thereis a direct and'efficiently linked relationship betweenthe emergency caresystem and the specialtyinstitutes.

coupleof other figureswhich I would like to

ients.thatthe Skorayahas pickedup for suspected ocardialinfarction.In addition,of the patienfsthat rgu.iredresuscitation,approximately20(ioreportedly urvlvedanclwent on to convalescence.

In the USSR reareabout27.6physicians per 10,000 population.

In centers, ;or metropolitan the figuregoesevenhigher.

In Kiev,for.example, thereare 43.4physicians peil0,population, for providing patient direct care.

In the !p0 UnitedStates,as of December31, i970. therewerel7 physicians per 10,000deliveringdirectpatientcare.

Question:Do you haveany ideaof their professional and financialremuneration?

Dr. Scribner:The Skorayadoctor,as most middle_ traineddoctors,receives abouta hundredto a hundred andten rublesa month.Thisis aboutll0 to ll5 dollars a monthwhichis about$120in Canadian monev.If thev are interestedin research,they can go direcily to an academiccareer -- a whole separatetopic of the educational systemin the SovietUnion. They are verv -medicine, pragmatic.If they train peopleto practice that'sall theypractice.They'llwork on a standardshifi just like an engineer will work in a factory.In fact.thev ' makethe samesalaryas most factoryworkers,

jes

uAbMs

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