UAUNIVERSITY

SECONDANNUAL MEETING: MAYWASHINGTON, D. C.

ASSOCIATION FOR EMERGENCY MEDICAL SERVICES

EMS

PROCEEDINGS

72-13, 1,972

CONTENTS

I Training of Emergency Department Personnel

A. Goals and Levels . . . Max Rittenbury

I I I Nuggets '72

"Four Hour Summaries" - Wi l l iamTurner '

IV Organizational Business

A. Executive Committee Minutes'

B. Of f icers, 7977: l '972 ' ̂ " '

C. Committees, L971-797 Z " " " " '

D. Of f icers, l972-7973

1 .

1B. Curriculum Charles FreY

e i; i.; i ;es rames *fl: l ::"- ' ' ' ' ;;; i ;; R;;;.......::..:::.:D. Workshop Summary on I ra tn tng I ta

II Legislation Related to Emergency Medical Services

A. Congressman Paul G' Rogers (D-Fla) '

i i . r t r r . Ft "a iewis - NHST-A-DOT : " " ' * r^ ' . 'c^ i i " ; " ' . . . . . . . . . . . .u. lvlr . rreq LEwr' - n,.air sadler[ ' . 'Workrhop Summary - Leg is la t ton o t

13

17 .18.21.

L C ,

49,

,58.

H

I

n "Who is the Emergency Physic ian" - Robert Dai ley '' '

U" lu. t t i ,y of Souihern Cal i f orn ia

B. ,,The Transmission. of Closed Circuit Television Emergency Laboratory Data,, by - Joseph B.

VanderVeer ,Jr . " "awrr i i " *S.F l " tche. , i j ^ i ' . , , i .vof -oregoni ' , r .J i . " iSchool � � � � � � � � � � � � � � � � � � � � � �

C' , ,TheFo l l ow .UpNurse inanEmergencyRoomSet t i ng , , . she ldonJacobson ,Be r t randM.Be l l ,a n d W i l m a K e I I y ; A l b " r t E i n s t e i n c o l l e g e o f M e d i c i n e . . . . . . . . , . . 2 7

D. "Emergency TriaS^e by N,urses" --Frederic W' Platt ' Will iam Turner' Roger Johnson and Cleve

Trimbie; Dlnver General HosPital

E . , ,AnEduca t i ona lP rog ram inanEmergencyDepar tmen t , , -W i l l i amF.M i t t y , J r . , andThomasF. Nealon; st. Vincen-t's Hospital urla rutJitTi6;;;;; i N"* York

" " ' �31'

Roger Johnson, Fred Platt and Cleve Trimble'" " ' 3 6

Denver General HosPital

G. "Emergency Services - A Section of a Department - Jesse H' M-eredith' and Richard T'

Myers; The Bowma" a;r';:il"rcr vr;.rlr".iiw"tt rorest Universitv " ' " " " "38'

, ,Emergency Room Records, , - David B. Pi lcher , Univers i ty of Vermont School of Medic ine . . . . . ' . 39,

"The PhYsician's Role in Emergency Department Nurse Education George T. Anast ,

Chicago, I l l inois "

The presentations of this meeting have been published with the

the Division of r*""' i" ' ' ' ; ; Fi;; l ih "5t'u.itt ' '

Public Health service;

ucation and Welfare"iJtt ' ' Carl Ueienko' III ' ' M'D' Department of

of Georgia, Augusta, Georgia 30902'

assistance of a grant from

Defartment of Health' Ed-

Surgery, Medical College

TRAINING oF EMERGENCY DEPARTMENT PERSoNNEL:

GOALS AND LEVELS

MAX S. RITTENBURY, M.D.

PROFESSOR OF SURGERYMEDICAL UNIVERSITY OF SOUTH CAROLINA

My charge as one of the keynote speak-ers is to stimulate thought f or laier discussion

by you, not to pro,,tal^ ut"*t"' tftft"tln i hop" it i: ' 1",citi*ute

t{ 'offer'-suggestions' My

remarks will concern the goals of this organi,utio,' relative to training, in university and

aff il itated hospitals, "tn.'*p|rro""ut

that ,.*. in emergency togT:, units" or departments'

Each of you may pi.t';.;;.;;;; .i ;r;t;;lt; for tlie laiter' Unfortunatelv' statistics upon

the ef fective performance of emergency'...^ O?i:onnel are imperfect and sc-anty' and there-

fore, most of my ,;;;r";;r. u'. u"..J ;.;-^,h; ideas of *u.,v p..rons interested in this

pr.if.*, my own pr"iJit"t, and a few professional journals'

First, what is the goal of this organization relative to training? This' in its simplest form'

is as follows, ,.to afJord the appropriate training to appropriate emergency room personnel"'

This is a tremendour *"i*r''."';. fi'a;iii;i*fii'^tit',-'t of ihese'few ti^plt-*311i .^.Second, where are the emergen.y tu.i i i t i .r ' i tt tthlth the persons we train wil l labor? Only

3ITo of our populaiio.r t i,r. i i a city, '^in"- "*ui"der l iving either in suburbs or small com-

muni t ies surrounding the c i t ies, or i t ' ' ^ " " " i^- " " " t ' Therefore ' most of our populat ion are

not in the large metropolitan- areas inu, have large emergency d1nar1me1-t1. available with

full-staffing patterns. Thlrein l ies one ;i '";; '^"io'"ptoUt""i ' ' i t ' who to train to serve this

69% of ou, poprrlJo.r. it," overall statistics, ho*et'e' ' meutt' "othing when -we consider our

individual states. Michigan has over Zn6'i.tptt"i ' *itn- "*ttg"tty 'oJ^'. or departments while

South Carolina has just over -+0,^ 1nd I am not certain

"if i i ff .,f these sirould have the

emergency rooms ; " ' ; ; r ,g ; ;d. .b . ly 'z^ J^ 'o" ' hospi ta ls in South Carol ina have suf f ic ient

emergency patients';h.td; u phyri. iun .""tf i-p"lt iUly be efficiently uti l ized full-t ime' Four

of these have residency traininS programs with emergency room coverage' - one has emergency

room physicians working full-t ime, "^;^';*;"ha,re u"cull"^tytit^ for t l ie hospital staff (1)' I

mention these only to l l lustrate tn.t, ]-,"i i t i" irv, '-tnt tt"f f i ;; ttttd' u" variable' and I hope

that my remarks *i l l ;";^;; i^.n" ru., th;; ' ;[;;; is no singre u.'"r*.r, the easv one, to this probrem'

And, third, *h; ;;; the different .ut"go.iu, of p"ison.,el needed to staff the emergency

room or department, what are- th.i, .";"; i;; i t ""a'*n"'" tutt they probably function best?

we have different categories of p"rro.,l""i";; ' ;;;r;"r, u^d I wil l discuss three: the Emergency

i' i .;t-";, the Profession'al Nurse' and the Physician's Assistant'

EMERGENCY PHYSICIAN

A n e w t y p e o f p r a c t i c i n g p h y s i c i a n h a s a p p e a r e d , ' t h e p h y s i c i a n w h o . d e s i r e s t o w o r k f u l l _time in an emergency department and ;h., i ' ' ^o*'dt*uiJ-it 'g i^ptoved training in order to

fulf i l l his practice othguiio.,r. Th. A^;;iJ^"" i"1ftg" of Emeigenry Physicians is a vigorous

and growing organization requesting two dif f erent types of training curricula: the f irst a

ref resher course for physicians in ,"""."f

-;;;;; i ." .n""gl"g to thii type

, of practice' and

the second a graduated residency pr.;;;; that adequatell i t iains the new phvsicians to enter

into this type of career pattern. r"t . ^^'.rrr. i.,rtu 'r.r

in.r.-- p.o-g.u*' .hut" been partially

developed by this and othei interested gr*p', but this .it ".,t real"ly pertinent to my subject'

The physiciu., ir- t ' i ' '"- *ost highl, ' .,1't i l5, ' ui ' ' i ' po"*iv th" besi irained person we have

to serve in an emergency department. Ao*.,r.., I must quickly add that he may be greatly

over-trained to serve in this area unless ih.r" ir ' a large ttu^bti of emergency or sick patients

requiring care. Til ^;;

; i ;" u ..tutiu.ty";p;;t;t;- i l ttn"J tf provide- medical care in the

emergency a.puri*.,, u..urrr. four or f ive of . these physicians, giving complete

24-hour coverage, presently require U.i*.., i^gaOpOO -u"a $50'OOO each yearly' Various schemes

for payment have '*ol,r"d,

vaiying f;;; ' i" l i i ime full-pav tv the hospital .to fee-for-service'

and both schemes require a significant emergency 'oo^ Oltltttt load to justify the cost' Most

of our hospitals ,e" 1es, than LbO P"ii;"i; pJt a"V in the emersencY room' but we well assume

that f igure is a 'break-even" point under p iesent concepts ' -Hoi t " " i ' look ' c losely at th is f igure

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and it means that the average patient must, therefore, pay $11 1 to the physician or to thehiring hospital (based upon a rough assumption of a basic salary of $40,000 each for 5 physicians,a 75Vo fringe benefit allowance, 157o overhead for collection by the hospital or physician'spractice group, and a collection rate of Tovo). This fee is for the physician only and is inaddition to the other emergency department charges, etc.

I believe it is appropriate here, just f rom the standpoint of medical care costs, to consideran alternate system. Approximately ZOVo of these patients are some type of major or minoremergency, and one to four percent, in most areas, are i l l enough to require hospitalization.The eighty or so patients in this group who do not need immedicate care might well be handledby trained non-physician personnel, and at a much lower cost. In our own Emergency Roomone-half of these patients are saf ely referred out without drug or appliance treatment orreferral to another physician. The estimated l1%o that do need some type of treatmentfor a minor emergency could also probably be handled by a trained Physician's Assistant.Unfortunately, we do not have objective data to compare the relative performance efficiencyin this area of physicians and physician's assistants (2).

I feel that we must give caref ul consideration to both the economics of emergency careand also the uti l ization of the total number of available physicians' t ime. In this day of thirdparty payment for medical care, l ike it or not, we must be aware that excessively expensivemethods of care wil l not be tolerated by the third party dispensers of funds.

Other aspects of the needs for the Emergency Physician are also being carefully scrutinized.Is an Emergency Physician needed for triage? Is an Emergency Physician needed for admini-strative duties in the emergency room? Is an Emergency Physician needed f or the develop-ment of community medical services? The answer may be yes or no, according to the com-munity situation. But other physicians, nurses, or hospital administrators are also perfectlycapable of carrying out these functions. Even surgeons have become deeply involved in com-munity care plans. Therefore; although the Emergency Physician may function in these otherimportant capacities, this f act alone may not be justif ication for their presence in a givencommunity emergency room or department.

What are the relationships of the Emergency Physician within the medical community?Can they do certain surgical or other procedures that are usually taken care of by thespecialt ies? Will these specialt ies accept, in return for the immediate care available to mustpatients, their init ial treatment of the diseases or injuries that have historically come to be with-in each narrow specialty range? The usual fee for service charged for emergency care in-cludes follow-up, and wil l the Emergency Physician charge a lesser fee because they do notsee patients in follow-up? Will this affect all fee schedules under third-party payment schemes?

And the last question I wish to ask is probably the most important. Will a physician behuppy in this career pattern for 40 years? The follow-up care of our patients is primarilyinstructive, and we all l ike the expressions of appreciation f rom a gratif ied patient. Willthe lack of this f ollow-up, plus the need to refer the more complicated patients to otherphysicians, afford sufficient professional satisfaction to the Emergency Physician? I canf ind no data relevant to this question.

I have asked these questions, not because I am antagonistic, but because they are amongthe legitimate ones that must be answered by each community and region bef ore a de-cision can be made concerning the need for us to train large numbers of physicians topractice only in an emergency department. It is obvious that some areas wil l need and canbest uti l ize the Emergency Physician, especially those communities with large numbers ofemergency department patient visits, and the universit ies and other teaching programs mustrespond to this need. However, it is not obvious that the Emergency Physician is needed forall communities and that specific residency training programs must be set up by all medicalteaching programs.

THE NURSE

The first consideration of the role of the Emergency Room Nurse is whether or not hertraditional role is adequate. What should the Emergency Room Nurse be capable of doing?Should she perform endotracheal intubation? Subclavian venous punctures? CPR? AdministerIV medications that are potentially lethal? Have the freedom to give emergency drugs priorto or without the direct order of a physician? All of these questions are pertinent due to

the rapidly expanding health care needs in this area. In many highly structured hospitalswith adequate resident and intern staff s, the nurses do not do these tasks, but in smallhospitals without readily available physician coverage most of them have been and are doingthese procedures.

Many physicians f eel that the nurses' roles should be greatly extended, especially inthe intensive nursing care units, and I include the emergency area under this category. How-ever, as usual with physicians, we may often fail to ask the nurse if she wants to assumean increased technical and therapeutic role. The more established nursing associations havenot yet aggressively responded to this need in a visible manner although they say they wishto develop their own expanded role in patient care, but often not under the direction of thephysician (3). This is a logical expression of their desire to extend the role of their profession,but the response of the nurses in many hospitals to the courses that have been offered tothem by the physicians (and the formation of EDNA) all indicate that these aggressive anddedicated nurses do desire a direct expansion of their role in the emergency care area, areanxious to do it now, and are very receptive to post-graduate training from the physicians (4).

We frequently ask if the nurse is capable of functioning independently. This is not reallya very pract ica l quest ion. I say th is because over two-th i rds of the nurses in the lastof our courses in Emergency Nursing def initely had to f unction independently because ofthe lack of physician availabil ity in these small community hospitals in which they l ivedand worked. Their average emergency room load was ten to twelve patients per day, of alltypes. Therefore, in the communities of this size the nurse must be given the training tof unction independently, and in many instances therapeutically, in the emergency room.

The nursing profession seems somewhat ambiguous in responding to the role of the physiciansassis tant . The Amer ican Nurs ing Associat ion of f ic ia l ly s tates that th is is not an appropr iaterole f or the registered nurse. But at the same time, and as I have recently been toldby the deans of two nurs ing schools, they f eel that the nurse pract i t ioner must come f or-ward as a member of the health care team. In one of the proposed curricula for thisnew type of nurse, the student wil l need a 4 year Bachelor of Science Nursing degree, a1 year internship, and 2 years in a Master's Degree Program. A total of 7 yearst Withthe l imi ted ro le of a person who has been t ra ined for 7 years, why not ut i l ize the M. D.curriculum and have a fully qualif ied physician within the same length of t ime?

I t is obvious to me that the nurse can mainta in her t radi t ional ro le of dedicat ion to herpatient and also improve the range of her services. Our problem is both to seek the meanswhereby this can be done, and to help those now beginning to formulate the necessary guide-

l ines (5) .

PHYSICIAN'S ASSISTANT

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"The Physic ian 's Assis tant is a sk i l led personto prov ide pat ient serv ices under the superv is ionis responsib le f or the per formance of that ass is tant" (6) .

Presently there are several categories of Physician's Assistant, beginningprogram, and extending up to the two and four or f ive year college levelThirty or forty of these training programs wil l be functioning within the next year.

Medicine is now grappling with the problem of where and how best to uti l ize these per-sonnel, and we must help decide both how to give them the necessary skil ls, and whatskil ls are needed. This is crit ical when we realize that we must use those persons in theemergency departments and in other areas of emergency medical services.

The Physicians Assistant, at whatever level of training, working in a large metropolitanemergency department under the direct supervision of the appropriate physician, of fers noinsurmountable problems. These can be ef fective at all levels of training, and, with in-creasing uti l ization, can widen the scope of the physicians' abil it ies. Studies of the ef fective-ness of the least trained of the Physicians Assistant, the Medex, has shown a 30% to 40%increase in the number of patients that a physician can see in his office. This probably wouldalso apply in the emergency department (7, 8).

The problems, however, ar ise when we d iscuss the status of the Physic ian 's Assis tant whofunctions without the direct physical and continuing supervision f rom the physician. Legal,ethical, and moral questions arise with this type of function. The American Medical Association

qua l i f ied by academic and prac t ica l t ra in ing

and direct ion of a l icensed phvsician who

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has def ined the role of these persons and agrees that they can f unction if the physiciantakes "responsibil i ty and direction." The V. A. has issured guidelines for the uti l izationof dif ferent categories of Physician's Assistants, "f unctioning as the direct representative ofthe physician". Their directive outl ines a wide range of procedures that this person may doin the V. A. Hospitals, including the writ ing of orders that must be countersigned by a physicianwithin 24 hours (9). This is, historically, the last prerogative of physicians to f all.

Is it legal for a non-physician to diagnose and treat? Eleven states, and probably moreby now, have passed legislation allowing the delegation of patient care f unctions. It hasbeen stated by the director of one very successf ul Physician's Assistant Program that in hisstate legislation wil l not be necessary for them to practice because the law can also bechanged by "usual and customary procedure", and there are now sufficient numbers in hisstate to make thier performance "usual and customary". However, not all of his co-profes-sionals in that state agree with this intepretation.

What can the Physicians Assistant do? It varies according to his training. At the presenttime there is a prof usion of speciality training courses that are available so that he maybe a surgical assistaht, an internal medicine assistant, a primary care physicians assistant,a pediatric assistant, etc. Despite the recent categorization of these programs, I feel thatthe universit ies should exert leadership and develop a standard level of basic training, withlater specialization if desired by additional training. The level of training, based upon pre-vious experience, must be def ined in order to adequately uti l ize these persons. It is ref reshingihat a larger number of the corpsmen now being released f rom the armed services are in-terested in continuing a career in the para-medical f ield. A danger, however, is that theClass A Physicians Assistant, with four years of college-level training, may well become dis-satisf ied with his role unless adequatley stimulated.

The well-trained Physicians Assistant can probably take care of TOV, to Sovo of the patientsseeking health care delivery. This immediately suggest both a direct role for patient carein the large emergency room, and an "independent-duty" type role in the smaller communityhospitals with lesser numbers of emergency patients. The salaries range from 10 to 15 thou-sand dollars per year and this is a signif icant decrease in the cost of health care delivery inan emergency room. I strongly urge that careful consideration be given to this in your delib-erations upon whom and how to choose the person you need to train.

SUMMARY

I hope that I have been able to bring out some of the predominent features concerningeach type of person who staf f s an emergency department. I believe that each universityshould survey the medical area served to determine the emergency health care personnelneeds prior to beginning a preconceived curriculum f or training one of more of thesepersonnel categories. In addition to the objective date needed (the numbers of patients need-i^g emergency care, the f acil i t ies available, and the coverage patterns already establishedin the communities) subjective data should be obtained concerning the attitude of thephysicians and cit izens of these areas relative to emergency medical services. The methodsof f inancing that are available in the communities should be evaluated, and only af ter thisinf ormation has been evaluated by the university, should a decision be made to determinewhat type or types of persons should be trained to f unction in that particular region orarea. I believe that it is obvious that each state or geographical region wil l f ind a somewhatdif ferent answer.

I am, theref ore, pleading f or a logical look at the needs, a close evaluation of the desiresand capabil it ies of the categories of personnel, and an objective determination of the levelof care obtainable and needed in your regions. Then, and only then can you begin the nextstep, the formulation of appropriate curricula and programs. Plan on these bases and not,as has happened so often in the past, upon the availabil ity of the Federal dollar.

1. South Carolina State Committee on Trauma, American College of Surgeons, Survey of EmergencyRooms and Facil it ie s, 197 2 revision.

2. Elsom, K. O. , et a l . , Physic ians ' Use of Ob. lect ive Data in Cl in ica l Diagnoses. JAMA 2o7: 109,7967.

3 .O f f i c i a l l ySpeak ing . .ThePhys i c i an ' sAss i s tan ts 'RN 'pp '57 'Oc lobe tL9To '

4. The New E. R. Nursing - Is It for You? RN' pp'37' Novembet'l '970'

5. Secretary's Committee to Study Extended Roles for Nurses, Extending the Scope of Nursing

Pract ice. IAMA 22O: '1 '23L, 197 2 '

6. Todd, M. D. and Foy, D. F. Current Status of the Physician's Assistant and Related Issues'

IAMA 22o:7774,1972.

7. smith, R. A., Anderson, J. R., and okimoto, J. T. Increasing Physician Productivity and the

Hospitalization Ci',ur".t"ristics of p.u.ti."t Uting Mede><"- A Progress Report' Northwest

Med.7o: 7o7,197'1.

8. Can Doctor's Aides Solve the Manpower Crisis? Med. World News, 25' (January)197O'

9. VA Issues Hospital Guidelines for Physician's Assistants, U' S' Medicine' (May) L97L'

EMERGENCY HEATTH SERVICESEDUCATION OF THE MEDICAL STUDENT

CHARLES F. FREY, M'D,, F.A.C.S'

FROM THE SECTION OF GENERAL SURGERY

UNIVERSITY OF MICHIGAN MEDICAL CENTERANN ARBOR, MICHIGAN

SCOPE OF THE PROBLEM:

Accidents and acute illness have been called the neglected diseases of modern society'

The scope u^d ,.rutrirJ ;-i ih; problem of acute illness 1nd injury are known to members

of the University erro.iution for f*"rgJ;.y -ftf.ailut

Services. ioduy, in the United States'

accidents are the f.uaing -

l",rr. of a"ut"n - "p to ?8e,

gg '. Mvocardial inf arction kills 400'000

annually. Deaths "rt-'n?tpr ?; ;;h;;;'" .!"i.7utu"t iniuries in rural than urban areas'

There are inadequacies "'r communicati* -tvt*iot,

ambulances, ambulance tq:iP-T:lt:-"1t1;

i"g - "f ambulanie ;;;;".i- ;e lack of toordination between transPortation systems ancr

hospitals capable of providing- care to ;i. ;"ly ill and injured' The financial toll from

disabling and t"tnui ir,;,rries -alone

ur. .,to'*ous 'and

estimated to approach Z'l' billion an-

nually by the Nuti*ui''JJ;y a;;l.li. V"t, only $ '50 per patient is spent in research related

to the injured puai.ni, ;ht1;' $iZO/patient'it--tpt"t on the cancer patient' Even deaths from

accidents seem to exciie little attentibn. Whut it the cost of a human life worth in our system

of priorities? Appare-Jv,--i-i J""i1, i, f;;;-; accident, it does not prick the conscience of

American society. p;it.i.i; l"i" r*a"".r tfntrv concerned about the 4s,oo0 killed in Viet

Nam over the last 10 yearq have mounted no -proiest

marches or appeared on -national television

about the 45o,oo0 killed from rnotor u"i'ti.t"-"i.idents alone. It is'estimated that 250'000 could

have been salvaged by better puckagiif in their cars or 9o,ooo salvaged by an improved

emergency medical care system'Unlike some diseases whose symptoms we can describe, but, are without cures, the rem-

edies which will improve the care .f ;i; ;;t;il ttl Tq injured are -unknown and could be

purchased u, u r"ul'5,11il[ oit."'",,,.".,"T;. fi"-pt*".ial for rulrug. of lives lost unnecessarilv

in the United States has been estima."itty- ilfi' Fi;;it.v' pitttior of the Emersencv Medical

Services Division of H. S. M. H. A. to be z2,5OO of the fiOpOO tilltd f'o^ "acciients

and

35,ooo of the 4oo,ooo dying from *y-o.urdiuf infarition. The costs of improving hospital emergency

medical services systems to annually salvage 55,500 persons now dying f rom acute illness

and injury has been estimated by Henry Iiuntley, 1 to be 2 billion dollars ot 27/z%o of the

t q'o

present B0 bil l ion dollar health budget.

IMPROVEMENTS NEEDED IN THE EMERGENCY HEALTH SERVICE SYSTEM:

In order to increase. patient salvage consideration should be given to the use of air andland transport in regional planning' of emergency r;;; i..r. vlhicle design should includeadequate space fol and the -equipm*ent

necessJry io, intravenous fluid th;;"py, endotrachealintubation, relief of tension pneumothorax, cardiai monitoring and defibri l lation.' Communicationcapabil ity between hospital and ambulance and between" hospitals ;h;;i; be d.;; i;;;.Emergency medical technicians need to be .trained u.,d gi,r..r medico-legal protection to per-form intravenous fluid- therapy, endotracheal l.,t.rbutio.,, ?ardiac -."it". i"g ?a d.fib.i l lation.

Educational programs for medical students, residents anJ postgruduut. ff;yJ.iu", should bedeveloped' State-wide planning, of an emergency medical service system is necessary to co-9rd.ln1te the components u.td avoid duplication of expensive hospital and transportationfac i l i t ies.

THE MEDICAL SCHOOL AND ITS RELATIONSHIP TO EDUCATIONAL PROGRAMSFOR MEDICAL STUDENTS IN THE CARE OF THE ACUTELY ILL AND INJURED:

The medicat schools of the United states have been no different from the rest of AmericanSociety in their neglect of problems associated with the care of the ucutJy i l l and injuredpatient' Until 10 years ago, most medical schools had no programs in emergency medicalcare or of fered "1ly f irsi aid programs more appropriate ; 6o, scouts and housewives.

Historically, much of the stimulus and interesi i l developing ..,o." .o^prehensive ed-ucational programs . in. emergency medicine for medical students" *"r

^ g."*ra.a by indivi-duals associated wi th.d isaste i p lanning, . the_MEND lM.ar .ut Educat ion r i , Nut lo. ,u l Defense)or professional organizations such as the Committee

'on Trauma of the American College ofSurgeons or the Amer ican Heart Associat ion. The ef for ts of these i "a i " tauui r -and associat ionswere aug.mented - by ,h9 following concomitant social and technologicai-.t ung., which ac-celerated through the 1960's. :

1' The potential for salvage among .the acutely i l l and injured was constantly beingincreased by improvement in methods of ..rur.itutio.., resuscitation equipment,transportation, communication and hospital care.

? Plrysicians and - government become concerned with the delivery of health care.Funds were shifted from basic research to impro,ru th. a.tl*.y- ir "n""rin

servicesincluding emergency health services.3' Medical students and physicians- have long recognized that their individual mini-strations to patients do not have the .otnpuibl" i irpact of public Health measures,such as clean water and air, or a small po*, o. pol' io vaccine in reducing mortalityfrom disease or injury.4' In contrast, medical students and. -physicians have only recently recognizedthey could not improve emergency health iu." u, t"Jr"iar"irl ""L'rr ' in., becameinvolved with national, state ind

-local government with regard t" "^lri""ce ordi-nances, regulation, I icensing, personnel t iaining and certif ic"tr.", .."..g!i.y ,".ri..,funding, etc.

The effect of the ,social changes and - technological advances enumerated was to alterthe perception of medical studentl and physicia;; ' ;;"rJi"g their roles and responsibil i t ies

iltl;uol:ttt'n and created a favorable .ii^ut. ro, .,r?.i.utu", .t u.,g", t., tl* latter purt oi

while the climate for curricular change was f avorable in medical schools f or introductionof new educational programs during the 1960's, emergency medicine p;;;;;"r; had to com_pete with non-emergency programs of high priority.other practical problems have hl.tdered. rapid proliferation of educational programs insome medical schools. Programs for medical studenis in the care of the acutely i l l and in-

iured have to compete.for-faculty and funding ;ith-th;e-^for emergency medical technicians,postgraduate courses for physicians and .,uir.r, M"ai.ul so.i.ty programs in emergencymedicine, internship ""L i.: idllcy programs in emergency medicine, and physician assistantsin emergency medicine' (Table I.) Most of th" faculty tI provide this compler uiruy of educational

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programs in emergency medicine are members of the Departments of Surgery, Medicine and

i'ediatrics, whose iirst-allegiance is a commitment to the programs of their own Departments.

Furthermore, participation ln programs outside one's own department r,nay not be encouraged

or ..*u.d.i by the department. In f act, this may even be resented by the Departmental

Chairman who may be having diff iculty staff ing his own departmental programs.

The wide ranging demands f or educational programs in emerg€ncy medicine are reason

enough to justif! f-ormation of an Emergency Department within both the hospital and the

medi ia lschoolwi t i rs tatusequivalent totheDepartmentofMedic ineandSurgery�Among the array of educational programs in emerge_ncy medicjne directed at emergency

medical technicians, nurses, postgraduate physicians, house staf f and medical students,

those for medical students pariiculir ly freshmen, deserve to be given in my opinion, a high

priority by Universit ies. Educational programs f or f reshmen medical students in emergency

medicine will provide these f uture phyriciu.,s with a f rame of reference and basic set of

principles ..guidi.,g the delivery of emergency health services which will make their later

experiences and training more meaningful. The very ,presence of programs on emergency

*.di. in. in the f reshmen curriculum gives the medical student a more realistic perspective

regarding the relative importance of acute i l lness and injury in our society with respect to

otf,". d["ur"r. If we hope to continue to improve the delivery of emergency health care in

the United States, we shbuld start with the freshmen medical student. The dynamism of our

society and the rate of technologic change is so great that present medical students have the

opporiunity and most l ikely wil l be tomorrow's policy makers, spokesman and teachers in

this new field of emergency medicine.

The status of emergency medicine in medical school curriculum is improving but uneven.

Existing medical school educational programs in the care of the acutely ill and .injur,ed le-prur..ri a diverse hodge podge of programs as recorded in the Stephenson report. (Table II.) The

majority of the educalional programs in emergency medicine are electives, or clerkships- usuallysponsoied by the Surgery Department. The clerkships in emergency medicine are of ten un-

supervised by senior rtuff . For the most part, these programs sti l l represent the ef f orts of

interested individuals who have recognized the need for educational programs in emergency

medicine rather than a f irm institutional curriculum commitment by the medical school.

On the other hand, it is gratifying to those of us in the University Association for Emergency

Medical Services to f ind some medical schools have educational programs in emergency

medicine which include didactic content def ining the patterns of i l lness and injury, the

physiologic and metabolic response to injury, the emergency medical care system uld the

economic- and emotional sequlae of injury, coordinated with a supervised emergency depart-

ment clerkship. The f aculty of these medical schools recog4ize the emergency depart-

ment represents a vast, previously untapped source of clinical teaching material.In the absence of

- published criteria for educational programs in emergency medicine _for

medical students, the University Association for Emergency Medical Services hopes to defineguidelines, and objectives of educational programs in emergency medicine appropriate for

medical students and useful to medical school curriculum planners.

The medical student should be provided with an understanding of :

1. The scope and nature of the problems ofof the present system of care.2. The pathophysiology and treatment ofcardial inf arction, pulmonary and renaldrug abuse, the unconscious patient.3. Those techniques, essential f or the init ial resuscitation ofinjured patient through actual practice and implementation.

the acutely ill and

4. The emergency response system, its components, and organization, and the neces-

sity for statewide and areawide planning of emergency health services.5. The need for emotional and physical rehabil itation and the effect of workmen'scompensation on the temporarily and permanently disabled victims of injury.6. The role of hospitalization, income and property insurance in protecting groupsof individuals against the costs of catastrophic i l lness and injury.7. An analysis of the mounting social and polit ical pressures to reduce the cost ofinjury and il lness through various National Health Insurance formats.

acute i l lness and injury and the inadequacies

acute injury, shock burns, fractures, myo-insuf f iciency, poisonings, emotional i l lness,

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Adequate resources exist in most medical centers to implement educational programs inemergency medicine for medical students. These resources include a multidisciplinary faculty,professional societies, contacts with government agencies at the federal, state and local levelin emergency services, highway saf ety and regional medical programs, comprehensive healthplanning, the emergency department, intensive care and coronary care units and their staf f ,cardiac arrest teams, anesthesia and the community ambulance services. (Table III.)

Specif ic programs and curricula wil l vary with the individual medical school, but canof ten be structured around existing programs or expertise, e. g. in disaster preparedness,highway safety, clerkships in the emergency department, coronary care or intensive care units.Elective programs should also be available to the medical student in emergency healthservices systems, and the pathophysiology of trauma. (Table IV.)

The curricula in emergency medicine as implemented in medical schools should be ad-justed and integrated to the student's level of understanding. The f irst year curricula shouldbe devoted to didactic material defining the patterns of acute injury and il lness, the emergencymedical care system, the economic and emotional sequlae of injury and il lness. This didacticmaterial should be supplemented by practice on the manniken in cardiopulmonary resusci-tation and movement of the patient with spine injury. Material on the metabolic and physiologicresponse to injury and principles of definit ive treatment should best be reserved for the secondyear or late in the first year of medical school. At the University of Michigan we have giventhis material late in the first year and have been careful that the anatomy and physiology ofa particular body area such as the heart have preceded our presentation and practice incardiopulmonary resuscitation. Supervised clerkships in emergency medicine and electiveswould be appropr iate to the 3rd and 4th years of medical school .

SUMMARY

Educational programs f or medical students in emergency health services are recommended.These programs should include an overview of the problems of acute i l lness and injuryin our society dur ing the f reshman year of medical school . The students can be in t roducedto the pathophysiology, diagnosis and treatment of acute i l lness and injury during thelater par t of the f reshman or ear ly in the sophomore year of medical school . Didact icpresentation should be supplemented by actual practice in the init ial resuscitation of theacutely i l l and injured patient and well supervised clerkships in emergency medicine.

REFERENCES:

1. Hunt ley, H. C. : Presentat ion at the Department of Emergency Heal th Serv ices Meet ing inBethesda Maryland December 2, 797 7.

2. Stephenson, H. E. : Bul le t in of Amer ican Col lege of Surgeons 56:9-77, 1977.

TABLE I

EDUCATIONAL PROCRAMS IN EMERGENCY MEDICINECOMPETING FOR FUNDS AND FACULTY

EMERGENCY MEDICAL TECHNICIANS

POSTCRADUATE COURSES FOR PHYSICIANS AND NURSES

MEDICAL SOCIETY MEETINGS AND PROGRAMS

CLERKSHIPS FOR MEDICAL STUDENTS

RESIDENCY PROCRAMS IN EMERGENCY MEDICINE

RESIDENCY PROGRAMS IN SURGERY, MEDICINE AND PEDIATRICS

6

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TABLE II

PRESENT STATE OF EDUCATIONAL PROGRAMS IN EMERGENCY MEDICINE

ron io.ooo uNITED sTATES MEDICAL STUDENTS

33 SCHOOLSELECTIVE DIDACTIC COURSE

11 1ST YEAR

, ,ND YEAR

2 3RD YEAR

N 4TH YEAR

1s 2 OR MORE YEARS

10* REQUIRED COURSES

*PERSONALCOMMUNICATIONWITHHUGHSTEPHENSoN

TABLE II I

RESOURCES FOR EMERGENCY MEDICINE PROGRAMS

PROFESSIONAL SOCIETIESMULTI-DISCIPLINARY FACULTYGOVERNMENT:

FEDERAL - H. S. M. A., D. O. T. AND 98 OTHER AGENCIES

STATE - OFFI.i Oi COT"TPREHENSIVE PLANNINC _OFFI.E OP UICHWAY SAFETY PLANNING

REGIONAL MEDICAL PROGRAMSETT/�TNTITTICY HEALTH SERVICES COUNC ILS

STATE HEALTH DEPARTMENTLOCAL - EMEiT-GiNCY HEETTH SERVICES COUNCIL

HEALTH DEPARTMENT

THE HOSPITAL EMERGENCY DEPARTMENT

iNilNswr AND coRoNARY cARE uNIrCARDIAC ARREST TEAMSANESTHESIAAMBULANCE SERVICES

TABLE IV

EMERGENCY MEDICINEPROGRAMS FOR MEDICAL STUDENTS

DIDACTIC INSTRUCTION

TRAINING PROCRAMS

DISASTER MEDICINE

CLERKSHIPS IN EMERCENCY DEPARTMENT

CLERKSHIPS IN CORONARY AND INTENSIVE CARE UNITS

ELECTIVES - EMERCENCY HEALTH SERVICES SYSTEMPATHOPHYSIOLOGY OF TRAUMA

TRAININC OF EMERGENCY DEPARTMENT PERSONNEL - TECHNIQUES

r h. s..o.,dPi",iill'rXul?",,"* . r .r,.Univers i ty Associat ion f or Emergency-M"dlcul Serv ices

May 12th-13 th, 7922, Washington, D. C.

JAMES R . MACKENZIE , M .D .

, The. prev ious speakers (us an rnt roduct ion to the workshops that fo l low) have d iscussedthe philosophy of educating Emergency. Department p"rrorrn"l. They hu,r. '

.o.r..ntrated onwho, why and what should Le taug"ht. ' i-his talk *i l l tt ierefore concentrate upon the techniquesthat could be used to translate eJucational philosophy and. objectives i.,to' l i tuut emergencymedical care programs- In order to l imit the ,.op. of ih. tulk, i wil l discu* o,.rly those tech-niques used to teach emergency medical care to medical students at McMaster Universitysince they are now considered- part

9f the Emergency Department pu.ror,.r. l. However,techniques which are used in their training can u.rJ ur. being applied to the training ofphysicians, nurses and . emergency medical technicians 1.utt"a Senior Ambulance Attendantsin Ontario) in graduate and continuing education programs in the Emergency Department.The first major objective of the Emergency l i ledical Care gtelt ive n.ogr; ut McMaster isto encourage the students

.to . be responsible for their own education i.r .*".g"rrcy medicalcare' We have therefore asked the siudents under the guidance of the edrlulio., committeeto develop .an appropriate curriculum. Th"y have lde,it lf ied the .o;rr. ;; j ..r i,r.r, the re-sources needed, and the techniques used to teach the objectives. Each class has' changedthe objectives, course content or method of teaching, ac-cording to th.i l. ",ruluution of theeffectiveness of the course as their legacy to the class" that ,rr...".d, them. They even preparemany of the educational resources ruch us rl lde-tape shows used in the elective.Another method which encourages self education is to ask the student to solve hypotheticalproblems b-ased upon real l i fe emergency medical care situations. Each problem covers oneo]'.

T?tt of

, the co.u-rse objectives and by solving the problem, the rtuaJ"i-u"aerstands theobJective The problem also contains objectives

- which wil l relate the .-"r*"^.u medical

l 0

r-care program to the rest of the M. D. pfogram. For example, . a problem concerning the

emergency management of chest trauma *ight' also - contain an objective concerning the re-

i;t";;hi; oi bf"ood -;"r;r

io ..gio.tul. venti iation of the lungs, a respiratorv unit learning

objective. Thus, by :; i; i"g the "problem

the student learns about emergency medical care

"r'-*.ff as the ,"lutlo.rshif of .ai" in that setting to the other aspects of the patient care

provided outside of the conf ines of the Emergency Department'

The problem ".,"y -;;-

;"l"ua UV the sfudent uio.t" o, in conjunction with -a multidisciplinary

tutorial group, i. u. "u

;;;"; co-pored of ambulance attendants, nurses, Emergency Depart-

^."i pniri. iu.,, u.rd str. idents. The group is -usually lead, by a "non-expert". tutor, i ' e' by a

person skil led in gt;;--;a;.uiior, ".ather

than knowledgeable in the subject matter being

[i;;;;;"i.-^ih.rr, tni group acts as its own expert advis6rs in the problem at hand' If the

g..rp fr stymied bV ih" problem then. it can tuin to advice f rom the "exPert" tutor' i ' e' one

i.rr.d in the subject matter being discussed'

The interdisciplinary tutorial setting accomplishes two other educational objectives of ,the

emergency medical care plogram. First, it generates mutual respect between the student

and other members of the .*u.g..t.y' m"dlul care team, "tp"i iully the . nurse and the

emergency medical i".h.ri. iu.,. It i ! nJp.J that this respect wii l be remembered when the

student becomes th.";h;ri; iu.,. S".ondfp if ' t" mixed tutorial setting provides a subtle medium

for teaching .o.. Uiotigi*i ""a -psychosocial,

legal and epidemiological concepts of emergency

medical .ur"io the gradua"te physician and all ied health personnel.

The second objective of the program i; i; .";;;;age the student to evaluate his own attitudes'

acquisit ion of skil ls u.rJ .o.r..ptu"al knowledge; and"to evaluate the effectiveness of the course'

Conceptual knowledge is tested by the ;; i i i l ' "f in9 student to "problem solve" as described

above. Skil ls and uititrrd., are best tested on the f ir ing l ine in the Emergency Department'

Thus, we have installed a television and tape recorder in the major resuscitation room'

When a major "*;;; arrives, the student can tape his performl,":. u"1 that of his team

and then, l ike the f"ootbalt coach on Monday morning,..can replay "the match" at his leisure

and pick out his flaws in his own p.rfo.*u.,.. u, *1ll as those- of the team' A variation of

this evaluation technique is to have the tutorial group observe one of their membels "per-

forming" with a p";[; i through u o.,"-*uy wind]ow next to the treatment room' The per-

forman"ce is then crit icized in group"discussion af ter the patient has lef t '

Finally, of course, the student -and the casualty officer (one of whose duties is to educate

the medical ,t.rd..ri) - i ir..rrr", all cases that the student treats in the Emergency pep.art-

ment, thereby .r; l""ai";-ih; ,ttd..t ir- (and the casulty officer's) performance and their

"Uifit i to relate clinical problems to basic scientif ic phenomenon'

The acquisit ion of Emergency Department skil ls is needed by the student so that he can

treat patients in ih" e *Jrg"n.y- Department. We believe that taking care of the patient

rather than oUr.ruing ;;;;"" l lse tieating the patien^t,. spurs. the student into applying the

problems identif ied i i the patient to his k"nowled^ge of baiic biological concepts. It also pre-

oares him to be comfortable in treating the emergeicy patient when he is a graduate physician'

The skil ls that we teach are as follows:

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1. Recognition of the priority of the emerSency. This can be taught to the student in

at least two waYs, for instance:

a) by programing patients. to _simulate emergency medical care problems, i ' e' teaching

actors to arrrve in the Emergency De-partment with acute medical, surgical or

prv.t oro.iul dlr."r". -i;.

.*uripl.," we have, programed a girl to f ake uncon-

,.i,orrr.t.r, due to hypoglycemia, head trauma, overdose' and

b) by working in the Emergency Department under the direct supervision of a phys-'

iclan responsible for the students'

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2. Diagnosis of the emergency under emergency conditions. This skil l is best taughtby clinical exposure in the Emergency Department although the use of the pro-gramed patient can supplement the clinical situation.Audiovisual aides such as movies, slide-tape shows or T. V. tapes which demon-strate history taking, physical diagnosis or diagnostic procedures in the EmergencyDepartment are also of benefit in teaching skil ls. The American College of Surgeonshas a series of movies which i l lustrate these points as they apply to the traumapatients. The American Heart Association and American Academy of OrthopaedicSurgeons and others have the same type of f i lms related to subjects in their specialty.

3. Treat minor conditions with expertise - the course on how to manage lacerationsis the most popular part of the elective. The student is f irst taught how to scrub,gown and glove himself and then to prepare and drape the patient. He is thentaught how to tie knots and to debride and sew representative wounds made inpigs' feet (obtained f rom the local butcher). Finally, he acts as f irst assistant toone of the plastic surgeons who allows the student to sew up several simple woundson Iive people. Only after this, is the student allowed to suture wounds on patientsin the Emergency Department. He is also taught how to take blood and startintravenous fluids by the nurses on the I. V. team; and to take arterial blood bvthe Intensive Care Unit Resident.

4. Resuscitate l ife threatening problems until help arrives.

a) The student f irst learns the anatomy and physiology of the cardiopul-monary system before applying his knowledge to the arrest situation.He then practices ventilation and endotracheal intubation and airwayclearance and cardiac massage and def ibri l lation on the appropriateplastic models.

b) Next, the student learns airway management and endotracheal intubationin the operating room on anaesthetized patients.

c) Finally, the student accompanies the in-hospital cardiac arrest team oni ts resusci tat ion cal ls .

Only then is the student considered ready to resuscitate patients on his own in the EmergencyDepartment.

The third major objective of the elective is to constantly remind the student that as aphysician, he is only one person in the Emergency Department team and that successfulemergency medical care depends upon how effectively he can use the team. He is also taughtthat the Emergency Department team stands with one foot into the community and in.other into the hospital and theref ore he must learn how rhe Emergency Department re-Iates to the other emergency medical care facil i t ies, both in the community and the hospital.He learns these facts by being taught by and working with members of the team both inthe community and the hospital.

Thus, part one of the Emergency Medical Care Elective is taught by the ambulanceattendants in conjunction with clinicians and basic scientists. The student rides as an am-bulance attendant during the course and writes his First Aid Certif icate at the completionof the course. He is then qualif ied to ride ambulance as first attendant on his own and caneven earn money for this work.

In part two of the elective, he is taught that the skil ls used by the emergency physician inhis work by those who are the most skil led and in the appropriate specialized unit. Thesepeople have been mentioned above, e. g. plastic surgeons, anaesthetists, casualty of f icers, etc.

- ln part three of the elective, taken during the last year of medical school, the student ap-plies his knowledge of emergency medical care as a clerk in the Emergency Department.He acts in place of, or on, an equal footing with the intern. He, in turn, uses his knowledgeand skil l to teach others in the tutorial setting and the circle begins again.

In summary, I have used the Emergency Medical Care Elective for medical students atMcMaster University as one model for developing techniques used for training emergencydepartment personnel. The objectives of the program have been identif ied and some oF themethods used to teach the objectives described. The course is given in three parts - the

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principles of f irst aid are taught in their f irst year by ambulance attendants tbgether with

clinical personnel and basic scientists. The appiication" of biological, epidemiological, legal,

economical and clinical skil ls to "me.ge.,cy .n.di.ul .utt is taughl - in. the second part' - The

student applies his skil ls to the emeigency department patient and their problems to basic

,.i.*if i . ^frinciples.

in"- ,nita part oI t lte elective is taken as a clerkship in emergency

medical care under the direct supervision of an em€rgency department physician who is re-

,p""riff" f.r the students' education and care given by the stu.dent to his patients'

It is my .hull..rgu io" V." p""pfe in- the "*o.kshop

to improve on the philosophy of education

f or emergency a.p"ri^'""i p"rson.t"l . and to develop immaginative, but appropriate tech-

niques to meet th. ^^;hll;;"pi..u1

and educational objectives of the program's need to train

Emergency DePartment Personnel.

REPORT OF WORKSHOP

H.D. ROOT, M.D.

THE UNIVERSITY OF TEXAS MEDICAL SCHOOL AT SAN ANTONIO

The summary opinions of the morning workshops may be expressed under the following items:

1. An rnventory of the teaching activit ies in the Emergenry Roo.ms of" the institutions

represented iho*, the .o.n*o^ pattern of haphazard teaching f or the medical

students, fo.- ihu interns u.td r"rid"nts, with *u.i of the teaching for the students

being done by the house staf f assigned. to the. Emergency Room', This perpetuates

inadequate teaching. Experience is ga-ined through trial and error' In one institution

there was a full-t ime E. R. teachei and the experience for the students was much

more orderly ^;i ih

a;".hi.rg ,by. a planned program. In most institutions Emergency

Medical Care was a stepcnlid of the ^i1ot- clinical rotations, with considerable

var iat ions.

2. There was a strong feeling that there should be a separate Emergency Medicine

Departmerit ut lerst" in tnJ notfit"l and wherever pottiblt in the. medical school

provid ing fu l l academic .urrk "q, r i , ra lent . to . that , o f the major c l in ica l departments '

The faculty-Io. -ru.h

a department should be chosen on the basis of training' in-

terest, and teaching abil ity u-rrd- .ot necessarily restricted to those with surgical

training ;".k;;;e. i" inir way, an .orderly -programmed.. teaching curriculum

could b. -;;;;;;A

and delivered ib medical siudents as well as house staff ' It

would also enhance patient cale and selve to eliminate or at least solve early

the administrative problems that arise between clinical departments in the Emer-

gency Room.

If separate or supplemental funding sources. could be found for the Emergency

Medical p"pu.,*""f ,n"" the other clinical departmental chairmen and the Deans

might be more wil l ing to forfeit some amount of t ime in the curriculum as long

as it was not costing u ̂ ujo, sum of money f rom the current budget.

3. The Emergency Medical Department should be organized so. that the faculty has

input into'the' medical schooi lurriculum and not be dependent upon disinterested

clinical departmental chairmen. The curriculum should consist of teaching programs

for rt"d"i;- -ir;;;.

staff , and also paramedical people' The .E' M' Department

would serve an important l iaison function with the- community for the general

problems of emergency medical care'

1 3

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rain

4. There is needed a position paper regarding the education of medical studentsin emergency medicine. A l iaison committee f rom the UA/EMS to medicalschools, possibly through the AAMC, was suggested.

5. The medical students in most institutions are now demanding early training inemergency medical care. They feel f rustrated in not having some knowledge andabil ity to manage common emergency problems. Because they are labeled byneighbors as "doctor" f rom the f irst day they begin medical school they are of -ten looked to for handling emergency problems and feel grossly inadequate.It was found that rarely do any students have full-t ime assignments in the Emer-gency Room and the most common pattern was that of a fourth year electivewhich was popular in most schools. There was a definite consensus that studentsshould get training in Emergency Medical Care throughout all f our years of theirmedical school training. It was suggested that an advanced f irst aid course couldbe taught to freshmen students early in the year and then in addition curriculuminput covering such items as epidemiology, sociologic impact and implication ofcosts f or emergency medical problems should be included. Cardiopulmonary re-suscitation and time f or practice with plastic mannequins should be provided inthe f irst year. In addition, a f irst year elective in the Emergency Room for ob-servation only was suggested with other possible electives such as operation roomtime or intensive care unit rounds to provide for continuity in their observationof patients they may have seen in the Emergency Room.

For the second year it was suggested that in the blocks of t ime f or SystemsPathology that Emergency Medicine should have it 's input into each of the systemssince trauma and emergency problems do bear upon all organ systems. It wassuggested that injury and drug ef fects should be established as pathologic enti-t ie s .

There was an area of agreement that Emergency Room could be usedas an excellent clinical resource f or teaching of physical diagnosis to the sopho-mores. Such techniques as video taping and replay of resuscitative efforts in theEmergency Room might provide vivid demonstrations for the students.

For the third year emphasis on Emergency Medicine should be put in each ofthe major clinical rotations. There was division of opinion as to whether thereshould be separate blocks of t ime f or f ull-t ime Emergency Room participationoutside of the major clinical rotations. This could be especially helpful since lessand less Ambulatory Care Medicine is now being taught in the major clinicaldepartments. Students could get good experience in routine out-patient medicinein this manner.

For the f ourth year Emergency Room electives in all disciplines should be madeavailable including f ull-t ime emergency medical care rotations in the EmergencyRoom under the guidance and training of a f ull-t ime Emergency Medicine De-par tment Director .

6. There was a strong feeling of definit ion of the boundaries and end-product desiredfor each group to be taught in the Emergency Room. A suggested curriculum out-Iine f or the medical students as well as the house staff and paramedical per-sonnel would be most helpf ul.

7. The final area of consensus was that there was a definite need for evaluating theteaching of Emergency Medical Care to medical students. There should be selectedquestions put on state or national boards to evaluate the knowledge of the studentsabout the management of emergency medical problems. Another suggestion ofdef ining end-point and deciding on adequacy of teaching was the functional test-ing of the students by taping resuscitative ef f orts on video tape and replaying itand grading the students on their activit ies.

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