Tuesday, September 22, 2009

Rarely do I encounter a statement from a professional organization that I agree with en total. The following myth-busting memo from the American College of Emergency Physicians (of which I am a resident member) is one I can put my support behind. President Obama mentioned emergency medicine in his joint session, but in doing so added fuel to the fire that emergency care is at the root of our current crisis. It is not. Take a few minutes to read this well crafted letter.

An Open Letter from America's Emergency Physicians

As the physicians on the front lines of emergency care, we see the tragic problems of a failing health care system. We care for people who are ravaged by untreated disease; help worried mothers on weekends with sick children, unable to access a system that's open 9 to 5, weekdays only; and treat the victims of heart attack, stroke and injuries whose very lives depend on our care.

The role of emergency medicine has been badly misrepresented during the health care reform debate. The American College of Emergency Physicians supports comprehensive reform, including universal coverage. But it is vitally important that reform legislation not be based on erroneous perceptions, but instead address the critical problems harming emergency patients. It is time to debunk the myths, focus on the real problems and outline solutions to ensure that health care reform will protect and enhance everyone's access to quality, timely emergency care.

Myth: Emergency medical care is expensive and inefficient. Reducing emergency care will "bend the cost curve" on our nation's rising health care costs.
Fact: The 120 million annual visits made to emergency departments account for only 3% of all health care spending. In addition, emergency departments are equipped with state-of- the-art diagnostic equipment and highly trained physicians who can draw on many hospital resources quickly, providing coordinated, efficient patient care. The fixed costs of being open 24/7 are high, but the variable costs for seeing patients in the emergency department are the same as anywhere else care is provided.

Myth: Emergency departments are crowded with patients seeking non-urgent care.
Fact: Only 12.1% of emergency patients have non-urgent conditions that could wait 2 to 24 hours for medical care, according to the Centers for Disease Control and Prevention (CDC). While this percentage may be slightly higher in some hospitals, the reality is that crowded conditions and longer wait times are primarily caused by patients being "boarded," or forced to stay in the emergency department - often on gurneys lining the hallways - long after they have been seen and admitted to the hospital.

Myth: Your local emergency department will always be there when you need it.
Fact: Hundreds of emergency departments have closed nationwide because of an overburdened emergency care system. Those remaining must accommodate an average increase of 3 million more patient visits each year. Every 60 seconds emergency care is delayed when an ambulance is diverted to a distant hospital because a nearer one is unable to accept more patients. In addition, 75% of emergency department directors report significant problems getting needed on-call specialists, such as neurosurgeons and orthopedists, to provide vital on-call services to emergency patients.

Myth: The need for emergency care will decrease when health care reform is enacted.
Fact: With a growing and aging population, our role in providing care to the sick and injured any time day or night, and our front line responsibility in responding to natural and man-made disasters, will be in even greater demand in the future. Since enacting its universal health care legislation, Massachusetts has experienced an increase in emergency department patients. Emergency medicine is an essential community service that is vitally important to our nation's health care system.

To help ensure our country has a strong emergency care system, the American College of Emergency Physicians supports comprehensive health care reform that includes:

  • Every person in America must have meaningful and affordable health insurance coverage provided through a combination of employer and individually mandated insurance. It should be means-tested, allowing those in need to receive coverage or financial support to buy insurance. A combination of private sector and governmental solutions may be needed to achieve universal coverage. America is experiencing a dramatically rising tide of uninsured and underinsured patients. Emergency physicians are the only doctors in the country required by federal law to treat all patients regardless of their ability to pay. It is a responsibility we embrace proudly, but many emergency departments and physician groups are closing under the burden of uncompensated care.
  • Health care costs must be reduced. Significant medical liability reform is needed to eliminate unnecessary, expensive tests known as "defensive medicine." Liability reform can also help increase the availability of critically needed on-call specialists. Widespread adoption of electronic health records could substantially cut costs and improve patient care if there were complete integration of data between the emergency department and other medical settings. Administrative and overhead costs must be reduced.
  • Quality and patient safety must be improved by eliminating the practice of "boarding" admitted patients in emergency department hallways until they are transferred to an in-patient hospital bed. This can be achieved by establishing quality standards that define how quickly admitted patients are moved to their appropriate care settings, with such information reported and available to the public.
  • A national surge capacity plan must be developed and resources provided to prepare our nation's hospital emergency departments for public health crises such as the H1N1 pandemic, a terrorist attack or other catastrophes.

With so much at stake, America can no longer ignore the crisis in its emergency medical care system or make health reform decisions based on myths. Go to www.acep.org/realities for information on protecting your access to quality, timely emergency care.

We must act now.

Nick Jouriles, MD, FACEP
American College of Emergency Physicians

Thursday, September 17, 2009

This Crazy Town

Everything's connected.

Earlier this month, I spent a week in the back of ambulances learning about pre-hospital medical care. As part of that, I was on the scene at two rather large fires in the city of New Haven. The first was well-reported by the New Haven Independent. I helped take care of guys that had been battling the blaze for hours. We monitored heart rates and blood pressure, gave oxygen, and transported guys with vital signs out of range to local hospitals just to be checked out. The second fire I was present for occurred early one morning and happened to be across the street from a neighborhood where both one of my senior residents and one of my professors live. The former took this photograph of me looking happy about the smoking building in the background. Really, I was just happy to be outside of the back of the ambulance cab...

The very next call that day was for a person who was feeling like she might hurt herself. She had a history of feeling suicidal and had been hospitalized before, so we took her to Yale, where she would presumably be connected with a psychiatrist who could help her. Hopefully it would not be the self-proclaimed "Savior of Death," who was arrested a few days ago about 2 blocks from my home. Evidently, a well-respected psychiatry resident was involved in an altercation in a local bar and found to have an unlicensed firearm on his person. Any person who is charged in the care of others who makes threatening gestures suggesting danger to those individuals or others in the public may be arrested and be searched without a warrant. A subsequent search of this individual's home revealed a stockpile of firearms and ammunition. He lived about a block from me. The instigating incident goes to show that everyone can be affected by alcohol or mental illness - even physicians.

The arrest was made at the same time that the news conference announcing the discovery of Annie Le, the unfortunate victim who has put Yale on the front page of the nation's newspapers and other news sources. The continued media presence around the police headquarters in New Haven has provided additional unlikely casualties in this story. No fewer than two people from the television news industry have presented to the Yale-New Haven Hospital for carbon monoxide poisoning. I treated a cameraman who was thinking slowly and just wanted to go to sleep. It's the time of year that we ER docs need to think more about that colorless, odorless gas that causes more people to wake up dead than any other poison. (Check your heaters for leaks and please don't burn kerosene or gasoline inside!) The cameraman (and his friend, a union representative) asked me what I knew about the occupational dangers of CO. I know that no significant studies have shown ambulance drivers (who often leave the rigs' engines running in closed spaces) to be at risk, but that smokers and firefighters tend to be chronically exposed and sometimes need to be monitored as such.

Which reminded me of the ambulance ride-alongs I did earlier this month.

Friday, September 4, 2009

Fireman Doctor

Have you ever wondered how a 9-1-1 call translates into a trip to the local emergency department? What determines if the fire department shows up, or a private company like AMR?

When I'm not in the ED, I live in New Haven. When residents of this city (and most others in Connecticut) call 9-1-1 for a medical emergency, there are a number of steps between the call and an ambulance showing up. I've been riding around on ambulances this week, so have learned a bit about the system. This knowledge will help me in the ED, but could also be interesting to you, the random reader of this site.

Step 1: The call. You'll speak with an operator who tries to gather as much info as possible from you. Generally the info they need is your address and what happened. If bad things are happening, this is when to say it. "I stubbed my toe" is not bad. "My dad collapsed and hasn't woken up yet" is bad. This is where the 9-1-1 charge on your phone bill goes.

Step 2: The relay. Medical calls get routed to a dispatch system that tells the fire department and the ambulance service of the problem. If the ambulance service is integrated into the municipal department, this dispatcher will send the nearest paramedic to the scene, with the nearest ambulance to follow. Sometimes the nearest medic is at a fire station with an engine. That's why a fire truck may show up for a heart attack.

Step 3: Ambulance Dispatch. In many locations, the fire department only responds to the call for help. Those medics do not transport sick patients to the hospital. A second dispatch occurs to tell the ambulance where to go and how fast. (Lights & Sirens?) The ambulance tells both dispatches where it is headed so everyone is on the same page.

Step 4: The Scene. Most of the time, the FD is already there by the time the ambulance arrives and tells the transporting medic the story. A story in the Washington Post this week draws attention to this new role of firefighters in America's urban centers. Most of the time, in CT, the fire department goes to the next call while the ambulance continues care. The medic gives a call to the emergency department preferred by the patient about 5-10 minutes out, and before you know it, the patient is rolling through the ambulance bay doors.

All along the way, critical information is repeated, either in person, on the radio or in print. The patient hand-off between the medics and the hospital team may be the first of many during the hospital stay. What I typically forget from my view in the ER is that a complicated game of telephone was acted out even before anyone saw the patient.

Thursday, September 3, 2009

Swan Song

My last post over at the WebMD-sponsored medical student blog, The Differential went up on September 1. My thank-you to readers marks the end of my first honest attempt to tailor my writing for a general audience. But don't worry: I'm hooked! Look for other ways for me to participate in written media over the coming months and years. I'll keep you updated. I cannot stop writing about my journey. Here's a rough account of something that occurred tonight.

Barreling up State St. in the back of an ambulance at 50 mph, I was reminded this evening there is much to observe, experience and transcribe about medicine in an emergency setting. This week, I'm participating in "ride-alongs" with paramedic ambulance teams; I'm learning a lot about pre-hospital care that will help me in the ED. While en route to a code-100 (or presumed cardiac arrest), I was reviewing how I would do my initial assessment at the scene and what my likely first interventions would be. Bouncing around the captain's chair in the back of the cab, I noticed with a shiver the music on the radio up front: "December" by Collective Soul. It turned out the soul we were about to collect had found its way to another place, or soon would. We found the patient warm but lifeless. She would not notice the view of a world being left behind from the windows on the back of the truck. She probably wouldn't even notice her ribs cracking as I compressed her chest to pump blood through her body. Her work on this planet was finished even as ours had just begun. At the behest of her family, we applied all of Western medicine's best known methods of restoration. Mrs. Lazarus traveled from home to the Yale Emergency Department, all the while being maintained in an intermediate stage between life and death. There would be no miracle this evening, however. The accompanying family member was invited into the code room shortly before the attending pronounced death. But by then, we were responding to another call. Someone in West Haven was vomiting blood.