-|

PROCEEDINCS

U n ive rs ity Assoc i atio nfor

Emergency Med ical Services

Th i rd An n ual Meet ing

May 23-25, 1973

Hami l ton, Ontar io, Canada-

OFFICERS: PresidentVice-PresidentSecretaryTreasurer

UA/EMS LEADERSHIP

Robert B. Rutherford, M,D.James R, Mackenzie, M,D.Will iam E, Matory, M.D.Ronald L. Krome. M.D.

COUNCILMEN: Peter Canizaro, M.D. Carl Jelenko, III, M.D,AIan Dimick, M.D. George Johnson, M,D.Charles Frey, M.D. Gerald Looney, M,D.

PROGRAM COMMITTEE: Leslie R. Rudoll M.D., ChairmanLocAL ARRANGEMENTS CoMMITTEE: James D. Davidson. M.D.. chairman

James R. Mackenzie, M.ti.Robert L. Ruderman, M,D.

REGIONAL DIRECTORS: Region A - William Sereda, M.D., Alberta, CanadaRegion B - Robert Ruderman, M.D,, Toronto, Ontario, CanadaRegion C - Edmond Monaghan, M,D., Montreal, euebec, CanadaRegion I - Earle Wilkins,M.D., Boston, MassachusettsRegion II-A Gerald Shaftan, M.D., Brooklyn, New yorkRegion II-B Robert Hall, M.D., Syracuse, New YorkRegion III-A William Matory, M.D,, Washington, D,C.Region III-B William DeMuth, M.D., Hershey, pennsylvaniaRegion III-C Les Rudolf, M,D., Charlottesville, VirginiaRegion IV-A George Johnson, M.D., Chapel Hill, North CarolinaRegion IV-B Carl Jelenko, III, M.D., Augusta, GeorgiaRegion V-A William Olsen, M.D., Ann Arbor, MichiganRegion V-B Robert Zollinger, M.D,, Cleveland, OhioRegion V-C Claude Hitchcock, M,D,, Minneapolis, MinnesotaRegion VI-A Peter Canizaro, M.D., Dallas, TexasRegion VI-B Harlan Root, M.D., San Antonio, TexasRegion VII Allen Klippel, M.D,, St. Louis, MissouriRegion VIII Cleve Trimble,M.D., Denver, ColoradoRegion IX Robert Lim, M.D., San Francisco, CaliforniaRegion X Trevor Sandy, M.D., Vancouver, British Columbia, Canada

The UA/EMS expresses its.appreciation to: Ethicon Sutures Limited (Canada), The Upjohn Company, Workmen'sCompensation Board, Province of Ontario, for their gen€rous support.Edited by the Publications Committee: Carl Jelenko, III, M.D., Chairman

Ronald Krome, M.D.John H. Morton, M.D,Cleve Trimble. M.D.

Address for Reprints: ACEP, P,O. Box 1241, East Lansing, Michigan 4gg23(Please enclose $5,00 for cost of printing)

I

TABLE OF CONTENTS

l .The Dr. Robert H. Kennedy Lectureship in Emergency Medical CareFraser Gurd, M.D., AssociateSecretary, Royal College of Physicians and Surgeons of Canada

This lectureship has been established in honor of Robert H. Kennedy, M.D., for the work he hasdone as the pioneer in the field of emergency care throughout North America. Beginning in 1931 as amember of the American College of Surgeons - Committee on Trauma (then known as the Com-mittee on Fractures), he worked actively until his retirement in 1969 at age 81 to improve emergencyhealth care. Dr. Kennedy has truly earned the title "the father of emergency medical care in NorthAmerica." As early as the 1950's he spoke out identifying the emergency department of the hospitalas the weakest link in the emergency medical care chain. After focusing attention on this needed im-provement, he turned his efforts toward upgrading the care given by ambulance personnel. His con-tributions to this field of medicine are too numerous to be adequately treated in the limited spaceavailable here.

Smith and Nephew Ltd. of Lachine, Quebec, recognized the need to support the improvement ofemergency medical care, and has agreed to sponsor this lectureship on an annual basis. TheUA/EMS expresses its gratitude to Smith and Nephew whose contribution wil l help to further thetraining and education of men and women in emergency medical care.

lI. Worksho p I Guidelines for Programs Which Train Full-Time Emergency Physicianr . . . .Section Leaders:

Louis G. Br i t t , M.D.John A. Col l ins, M.D.Norman J. Diamond, M.D.Christine E. Haycock, M.D.Cvr i l T. M. Cameron. M.D.

John T. Sandy, M.D.Will iam Ghent, M.D.B. W. Haynes, M.D.Allen P. Klippel, M.D.Richard M. Peters, M.D.

John H. Morton, M.D.Jonathan Morrison, M.D.Stuart M. Poticha, M.D.Joseph E. Snyder, M.D.Will iam Mitty, M.D.

Health Care Scheme Frank Miller, M.P.P., Parliamentarylll. Emergency Medical Care in a PrepaidAssistant to the Minister of Health

IV. Worksho p ll Guidelines for the Core Training Programs for the Specialty Resident and GeneralPrsctitioner in the Emergency Department

Section Leaders:Thomas J . Tarnay , M.D.John H. Mor ton , M.D.A. C. S t r i ck le r , M.D.Luigi E. Dagnone, M.D.Edmond Monaghan, M.D.

V. PresidentialAddress The Academic Surgeon and the Emergency Department Robert B. Rutherford,M . D .

VI. Nuggets:1) The Pediatric Emergency LYard: Midnight to Six A.M.

Charles Q. McClellan, M.D.' Case-Western Reserve. Cleveland. Ohio2) Incorrect X-ray Interpretation by Emergency Department Personnel

A. C. Strickler, M.D.St. Joseph's Hospital, Hamilton, Ontario

3) Geographic and Temporal Triage of Emergency PatientsC.R.F. Baker, M.D.Emory University, School of Medicine, Atlanta, Georgia

4) Do You Really Know How Much a Visit to Your E.D. Costs?R.F. Wi l l iams, M.D. , M.R. Cammarn, M.D. , R.M. Zol l inger , M.D.Case-Western Reserve, Cleveland, Ohio

5) Transportation ofthe Sick and Injured by HelicopterW. Evans, M.D., R. Ruppert, M.D., R. Orr, M.D.Ohio State, College of Medicine, Columbus, Ohio .

6) A Systems Approach to Emergency Medical ServicesD.R. Boyd, M.D.Department of Public Health, Springfield, Illinois

7) Computer Diagnosis in the Emergency RoomB. Houtchens, M.D., H. Warner, M.D., F. Chang, M.D., F. Moody, M.D.University of Utah, Salt Lake City, Utah

t0

l 3

16

l 8

20

22

25

3l

The Emergency Medical Services Morbidity and Mortality ConferenceF. Platt, M.D., Cleve Trimble, M.D.Denver beneral Hospital, Denver, Colorado 38The Role of the Ombudsman in the Emergency DepartmentWill iam Mitty, M.D., Rev. D. G. Lothrop, Rev. D. S. LothropS t . V i n c e n t ' s , N e w Y o r k , N e w Y o r k . . . . . . . . . . . . . . 3 9The Team Concept in the (Jniversity Affiliated Emergency CenterK. Mattox, M.D., G. Jordan, M.D.Baylor Coilege oflMedicine, Houston, Texas . 4lConcepts in the Emergency Care of Children with Major Injuries: Organization and Stffing ofSpecial FacilitiesJ. Issacs, M.D., D. Gann, M.D., J. White, M.D., J.A. Haller, M.D.J o h n s H o p k i n r , B u l t i r n o r . , M a r y l a n d . . . . . . . . . . . . . . . . . . . . 4 4A Shock Team Approach to ResuscitationPeter Rosen, M.D.University of Chicago, Chicago, Illinois . . . . 40The Use of the Videotape in ldentifying Emergency Department Problems and in the Educationof the Emergency TeamG. Schwartz, M.D., J. Bulette, M.D., A. Palmer, M.D.MedicalColiegeof Pennsylvania, Philadelphia,iennsylvania .... ... 49

VII. "Emergency Medical Services in the USSR . . . A Resident's Evaluation"Larry Reithaus, M.D. and Robert Scribner, M.D.

"In order to meet Proceeding's deadlines, the Editorial Board has authorizedpublication of the manuscript at Page 3l which is unedited. The format and contentsis solely that of the authors".

8)

e)

10)

1 1 )

r2)

l ? \

5l

J- I

DR. ROBERT H. KENNEDY LECTURESHIP IN EMERGENCY MEDICAL CARETHE EDUCATION OF THE GRADUATE PHYSICIAN IN EMERGENCY MEDICAL CARE

Fraser N. Gurd. M.D.

My tit le is the tit le of this conference. A key-note ad-dress, it seems to me, should borrow from the art ofmusic. This I propose to do. My themes wil l be im-pressionistic, wil l repeat themselves with variations, butwi l l prov ide, I hope, basic ideas which we canorchestrate in subsequent discussions. You wil l f indappended a selected l ist of references which have helpedme in the preparation of the paper, which I acknowledgegratelully.

The invitation to address this meeting was a specialhonour and pleasure for me. It has been my privilege tohave known your founders when they were juniormembers of their respective faculties, charged with theadministration of emergency departments, and layingtheir plans for the init ial organization of the Association.For my own part, f ive years of army service in the Se-cond World War, followed by twenty-five years of sur-g ica l pract ice in an academic set t ing, form thereasonable basis for this invitation to be here today. Twoother qualif ications may deserve special mention. One isa l ifelong interest in the scientif ic base supportingcrit ical care medicine, along with some experience in theeducational and administrative aspects.

The second special privilege which I have enjoyed is along friendship with Dr. Robert H. Kennedy. My father,Dr. Fraser B. Gurd, introduced us when I was a studentat McGill. At that t ime both men were active membersof the Committee on Trauma of the American Collegeof Surgeons and were engaged in founding the AmericanAssociation for the Surgery of Trauma. From then unti la year or two ago I talked with Dr. Kennedy two or threetimes a year about our common problems. He never fail-ed to challenge and encourage. In particular, during theyears when I was responsible for the Emergency Depart-ment at the Montreal General Hospital, and Dr.Kennedy was devoting all his energies to the problem ofemcrgency facil i t ies, he was a constant source of ex-cellent advice.

I have decided that this talk should set out upon theroute which emergency medical care has followed in thelifetime of our patron. However, no one would bb moreannoyed than Dr. Kennedy if I stopped there, so Ipropose to forge ahead with some abandon, seeking alogical projection of the course which he has set.

To my mind, Dr. Kennedy would have completed thedesign which was the main consideration of his lateryears had he been able to retire at 90, instead of only atthe age of 80. He brought the conceptual framework fora system for emergency services so close to a completely

integrated form that we must pause a moment to con-sider his accomplishments.

Dr. Kennedy was trained a general surgeon and in theearly 1920's and early 30's he was an innovative operatorin the l ield of cancer surgery, writ ing extensively of hisexperience in cancer of the oropharynx, then a commonand intractable disease. His appointment as SurgicalDirector of the Beekman-Downtown Hosoital in NewYork City turned his attention more towirds trauma.From 1939 to 1952 he was Chairman of the Committeeon Trauma of the American College of Surgeons in-terrupted by service as a Colonel in the Second WorldWar.

The 1950's saw the expansion of what might be termedPhase I activit ies by Dr. Kennedy and his concernedcolleagues in the field of trauma. I am referring to thecontributions which have been made to the care of the in-jured and acutely i l l between the site of an accident andthe threshold of the hospital. So much sti l l needs to beaccomplished in relation to Phase I that we are l iable tounderestimate the forward strides which can be recordedin the past few years. This l ist includes advances in firstaid and vehicle extraction procedures, ambulance per-sonnel and equipment, ambulance ordinances, helicopterevacuat ion, te lecommunicat ion, automobi le safetyfeatures, cardio-pulmonary resuscitation, f ire and explo-sion disaster management. Above all, we have seen thebuild-up of public recognition of the preventable loss ofl ives which could be saved by better work within Phase I.Telephone and radio triage to the location, the growth ofspecial mobile units capable of l i fe support as well asrescue are now part of the accepted real world of PhaseI. I shall spend no more time on this phase, not because Ideem it unimportant, but because I wish to considerother matters in the short t ime available.

Having contributed a normal l i fetime of energy toPhase I promotional activit ies as a public-spirited volun-tary surgeon, and having at the same time conducted atrauma service in New York which was a model for allothers, in 1960 Dr. Kennedy attacked the area ofweakness between Phase I and the inpatient serviceswithin the active treatment hospitals. He became theDirector of the Field Program of the Committee onTrauma of the American College of Surgeons with as p e c i a l c h a r g e t o a s s i s t h o s p i t a l E m e r g e n c yDepartments. The establishment of such facil i t ies hasbeen pursued with such enthusiasm in the past ten yearsthat questions have been raised regarding the desirabilityof their continued proliferation.

It seems to me that we should ask ourselves, as weopen this important meeting, how we might re-examinethe Emergency Department and its requirements forsupporting staff, together with their educational needs,

"The Emergency" came about as an extension of out-patient clinics in many hospitals. It is now not only acommunity convenience, but a matter of local pride forhospitals to have a brightly-l ighted invitation to all com-ers. Thus the Emergency has become a drop-in centrenot only for desperate cit izens with a need for the im-mediate correction of l i fe-threatening injury and il lness,but for the entire spectrum of seekers after care. Thus itcaters to a mixture of clinical problems ranging fromcitizens who simply feel they need to see a doctor to themost hazardous of crises demanding expert managementwithout delay. The burden of the vocal majority who arebetter suited to a definit ive ambulatory treatment centremay constitute a threat to the silent majority of genuinedisaster patients whose futures in truth depend not uponcliches such as smooth entry to a bright and shininghealth care system but upon a guarantee of an instantaccess to active treatment.

I am concerned fundamentally in this talk with thelatter group, the crit ically i l l and injured, the patientswho get well or die depending on the treatment theyreceive, and for whom time is of the essence. Are wetraining men and women adequately for the care of suchpatients? Whatever else we talk about during thismeeting let us not forget that question.

Therefore I make a olea to commence with the crit icalpatients. Gear the syitem to receive them as the toppriority, leaving aside for the moment the largernumbers of non-crit ical patients. Picture a city or aregion where no one is mildly i l l or slightly injured, butwhere every case is a genuine emergency.

What would we do? Surely, we would organize byregions. Surely, we would organize our rescue squads foron-site resuscitation. Surely, we would insist on radiocontact with the rescue personnel, and put at their dis-posal expert and sophisticated advisers who must decideon the immediate action to be taken on the site, the dis-patch ol special support teams, and where to take thepatient.

It is an axiom that the more we refine emergency orcr i t ica l care the more we tend to e l iminate themiddleman. The multiple injury patient belongs in eithera trauma unit, or in a pre-operative intensive care unit,or in the operating room. It has been shown that survivalof l iver injuries is inversely proportional to the time lagbetween injury and laparotomy, which should be lessthan an hour if at all possible.

The patient with the evident myocardial infarctionshould not l ie in an emergency department for an houror two, invit ing cardiac arrest. Ideally he should be in-stantly transported to an indoor monitoring unit whereshock could be detected and defined, placement of anaortic balloon undertaken if indicated and considerationduly given to emergency aortocoronary bypass.

We might not be stretching our projection too far werewe to foresee a time when it wil l be considered morallywrong, in any civil ized community possessing the power

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

One can conceive that when init ial l i fe support is ablyhandled at the site and in the ambulance, and the indoorhospital staff have been alerted, there is little need forany stop-over in the emergency department. In such anideal situation the emergency room would receive suchpatients but not delay immediate admission into thehands of a prepared and forewarned indoor staff. Irealize that at this time the capabil ity to resuscitate andstabil ize is inescapable for any emergency departmentworthy of the name, regardless of the category of thehospi ta l . Therefore we must p lan for i t for theforeseeable future.

Regional categorization of hospitals means litt le un-less the primary decisions which govern casualty collect-ing in Phase I are monitored through some form of com-munication network, so that the init ial tr iage is effectedat the site. I can well appreciate that triage on site todifferent hospitals implies that certain hospitals play cer-tain roles according to a plan based on assigning eachpatient to the hospital which meets his needs. Therefore,we must define the needs in each community, developrational arrangements, and measure their effectiveness.Dil ' ferent areas wil l require differing patterns, indeed forsome a strictly regional approach may not be right at all.

In any breakdown of emergencies we may recognizethree classes of patients. On one end of the scale is theminority of extremely crit ical, whom we have been con-sidering. On the other end is the majority of more or lessambulatory cases in search of medical assistance.Between lies the third group, whose classification withinthe spectrum is unclear init ially. Thus, we may recognizethree primary colours in the spectrum. At the red end arecrit ical emergencies. Far over at the other end arepatients in the blue and violet, even ultraviolet bands, thes u b a c u t e a n d c h r o n i c a n d t h e w o r r i e d s e e k i n greassurance. Between is a large group of problempatients flashing a predominantly amber l ight, call ingfbr caut ion.

The solution to the effective handling of this complexspectrum, and the defining of the educational back-uprequired, is the question before this conference.

The ideal plan for the extremely crit ical, the redpatients, would be a civil ian variant of modern militarypractice, such'as we have already mentioned. Why haithis adaptation not been made on a broader scale, sincerecent war experience has demonstrated the advantagesof virtually instant injection of the patient into an activetreatment centre'?

Those in search of medical assistunce on a non-emergent basis surely require a prtrr,ary medical facil i tydesigned to take care of the init iai needs of the patientand to follow-through in arranging for continuing care interms of further diagnosis and treatment.

In my opinion, the problem group lies in the middle ofthe spectrum, the patients in between the two extremes,whose diagnosis is unknown when they come through thedoor. These are the patients who do not by their obviouscrit ical nature proclaim their need for immediate admis-sion to hospital, but who cannot be discharged without

some study. They constitute the patients under suspicionof potentially disabling injury or less acute but seriousdisease. They demand time and skil l in interviewing, ex-amination, choice of investigation and degree of obser-vation. It is these patients who must be accommodatedin an identif iable emergency facil i ty, who consume thegreater share of space, t ime and professional attentionand who are the source of most of our lapses of judgmentand medico-legal diff icult ies. Who should take care ofthis large and troublesome group, and how should he betrained to do it?

Here again I must return to a further development ofthe concept ol planning for a finite population group orregion. If we would l ist our needs for personnel, studiesmust be conducted which wil l quantitate the call uponemergency resources. Each community or region mustdefine its best approach to a solution. The cit izens mustbe involved from an early stage, and must be persuadedthat it is in their interests to forego certain prerogativesrelated to convenience and local traditions in return forbetter treatment. Above all, the people who wil l beoperating the plan must accept the whole idea, or it wil lnot succeed.

The regional council must have the power to innovate.One physical layout which appeals to me is that whichmay be seen at the McMaster University Medical Cen-tre. The arrangement allows for the immediate diversionof patients suitable for management on an ambulatorybasis to the primary care unit which is adjacent to theemergency room. Cases ol the intermediate or ambergroup can be studied in a well-equipped observationarea, while crit ical red cases can be admitted directly tothe indoor treatment services. The plan in use at theMontreal General Hospital calls for a rough division ofthe patient f low into medical and surgical sections,although stretcher cases of any discipline are placed in alarge acute care area. The medical section handles thenrajor i ty of b lue and some of the amber cases.

The Parkland Hospital in Dallas has an EmergencyDepartment divided into five divisions on a disciplinarybasis, a mammoth fac i l i ty unique in my exper ience.However, as a city, neither Montreal nor Dallas has awell-developed plan of the type which is emerging inHami l t on .

A well-conceived design for any region wil l make gooduse of hospitals in categories better suited to house am-bulatory facil i t ies, thereby providing centres convenientfor the public while sparing hospitals in categories I andII some of the burden of the blue and amber patients.

My purpose in l ingering on these alternative ap-proaches is to bring out the point that different types ofmedical personnel are required to fulf i l l varying rolesdepending on the dominant f low of patients into thedifferent settings. For, in the very act of identifying thetypes of medical persons needed we can reach some con-ceot of our educational obiectives.

The spectrum of, profeisionals to be trained mustmatch the spectrum of patients. The blue patients wil l beserved best by general physicians who may double asfamily doctors. The red, or crit ically i l l or injured,should be in touch with specialist care within minutes of

onset. The educational thrust of a flow diagram for thered patients should be first towards perfecting radio-triage and care on site and in transit through the trainingol the personnel or mobile units. Next, these patientsshould be met at the door of the most appropriatehospital by agents of the indoor specialty services andswept into Phase II for active indoor treatment. I strong-ly lavour providing specialist care for crit ical cases in theemergency department. In particular, red surgicalemergencies should be seen by surgeons from the mo-ment that the ambulance arrives. The care ol majortrauma must be surgical from the beginning of Phase II,and I mean adequately trained surgeons.

The College of Family Physicians of Canada supportsthe education of general practit ioners for emergencywopk. There need be no restrictions on the trainingavailable for general doctors to provide a special form ofexpert care for patients from the blue end of the spec-t rum.

The Royal College ol Physicians and Surgeons ofCanada has recently re-emphasized experience inemergency areas for those in training in specialt ies witha significant content of emergency work.

Therefore, on the face ofit, existing patterns should beable to provide for training personnel of satisfactorycompetence to manage patients lrom the two ends of thespectrum of emergencies. Do not forget that in myreckoning I am including highly-qualif ied rescue-trained non-medical personnel manning the ambulancesand the reception areas. Each regional council must givetop priority to the development and maintenance of suchpeople.

You recognize that I am over-simplifying, but pleasenote that if we assign the milder ambulatory patients tothe specially qualif ied practit ioners, and the red casesentering Phase Il to specialists developed by establishedtraining programs, there sti l l remains a gross hiatus inour framework, namely the question of the type of doc-tor who wil l deal effectively with amber patients, andhow he should be trained. He, or she, may well prove tobe the principal subject of this meeting.

The person whom we seek must be a paragon, whomust evaluate the various and interdisciplinary potpourri of patients who are neither clearly candidates foracute admission to hospital, nor safe for dischargewithout reasonable study. Examples are the cit izens inpain of every type, visceral, skeletal or anxiety-related;patients with fever, suspected fractures, suspectedpoisonings and drug and alcohol abuses; head injuries,chest and abdominal injuries without too drastic init ialmanifestations, suspected suicide attempts and manias.Creative sorting-out and disposition of these peoplecalls for an expertise of a high order, the leader being theemergency physician in charge.

This is the person who requires the special training.He should be no less skil l ful at l i fe-saving proceduresthan are the ambulance attendants or the nurses in thecoronary unit, yet he wil l have a more sophisticatedjudgment. He should possess the social awareness of thegeneral practit ioner, sharing his concern for follow-through. Fall ing as he does between conventional

specialization and the usual forms of primary medicine,he requires not only special knowledge but a range ofclinical competence beyond the usual. He must be a par-ticularly keen observer, quick by nature, emotionallystable yet patient and compassionate.

How can one formulate a schedule for the recruit-ment, education and training of the personnel we need?The anchor point must be the medical school. The facul-ty has l itt le choice but to accept the extra load ofeducating personnel to man the crucial functions in thesystem. A matrix management design, with functionsanalyzed against the disciplines which must participate,should help the school and the regional council to con-struct a basic program for emergency services in theirarea. It seems to me that the approach used byMcMaster University in building up its well-regardedclinical programs for the Hamilton region could be con-sidered for our purposes.

Such a solution would ensure the needed academicbase. It would perhaps save us some ol the wasted mo-tion entailed in seeking answers to unanswerablequestiond (unanswerable up to now at any rate) aboutwhether emergency medicine is a specialty or not. Statuswould come to those who are faithful to the program; inlact, directors of such interdisciplinary programs seemto have outd is tanced chai rmen of convent ionaldepartments on the academic scene.

I am in full agreement with the view that universit iesmay lose their independence by becoming too involved inservice or the workings of society. Nevertheless, the uni-versity is the repository of our resources for bothteaching and research. Its graduate training programs inMedicine are one expression of its new role in educationwhich has been accepted throughout Canada. Its entryinto fields involving small-scale demonstration modelsmay also serve the purposes of both research andteaching. Guidelines are needed for the development oftraining programs, university-related, in order to meetneeds as they are recognized.

The primary objective of this Association is improve-ment in the quality of care of the acutely i l l and injured.The listed means by which this objective is to be pursuedare nine in number. They include data gathering,reseq,rch, administrative planning in cooperation withother authorit ies, guidelines for education, and evalua-tion ol the services as they emerge. The academic valueof service in this field is to be recognized. Keep each ofthese in mind in your discussions.

As we conclude this talk a word would be in order onthe role of the Royal College in the areas of interest ofyour Association and of this conference. The Collegeworks by activating the interplay between the specialtygroups ofthe country and the university medical centres.The catalytic role played by the College is proving mostproductive at the level of residency education in somethirty specialt ies. Up to the present t ime the College hasaccepted that a specialty is characterized by researchand development in depth of a circumscribed area ofbiomedicine not shared by others. Nevertheless, it isquite l ikely that the recent recognition ofwhat are calledareas of special competence may open up a pattern into

which crit ical care and emergency medicine can be in-troduced and given recognition as a special competencewithin a broader specialty framework such as internalmedicine or general surgery.

Canada is probably less homogenous than the UnitedStates. Detailed planning lor medical care and the sup-porting educational establishment is t ied to local needs.Thus each province, and the regions of each province,wil l be found to differ in proportionate requirementsfor the varying classes of trained personnel, includingdoctors, nurses and auxil iaries. Fortunately for Canada,we have a university medical school more or less handyto each district.

Despite the wide variety of needs across the countrythe Fellows of our College seem to feel that commonbasic principles can be adduced to serve as guidelines forthose charged with mobil izing educational resources ineach region.

The College has a new Committee on EmergencyMedical Care which has chosen as its principal objectiveto identify the educational requirements for emergencyand crit ical care medicine and to establish guidelines toassist the universit ies to meet these needs.

As a l l o f us move i n to a new wor ld o f newrelationships with our society we must adapt the patternswhich have served us in the past . This meet ing marks astep in th is adapl ive process.

Litt le that we shall talk about wil l not reflect the in-fluence of Dr. Kennedy, to whom we owe as to fewothers the best features of our present system.

The final chord which I shall strike in key-noting thismeet ing is in a major key. On your behal f I would paytr ibute to th is accornpl ished man, not only muchrespected, but also deeply loved.

The spiritual heritage of Robert H. Kennedy appearsto me, as I survey the scene, to be alive and well.

References

Kennedy, R.H.: A Di lemma in Emergency Department Coverage,Journal o l ' Trauma, 9:821-822, 1969.

Procecdings of the Airlie Conference on Emergency Medical Services,

Comrni t tee on Trauma, American Col lege of Surgeons, and Com-

rnittee on Injuries, American Academy of Orthopaedic Surgeons,

Ch i cago , 1970 .

Guidel ines for Design and Funct ion of a Hospi ta l Emergency Depart-ment. Commit tee on Trauma, American Col lege of Surgeons, Chicago,I 970 .

Fi t ts , Wi l l iam T. , Jr . : Men for the Care of the In jured: A Cr is is Facing

the 70's, Bul let in, American Col lege of Surgeons, December 1970.

Frey, .C.F. , Dimick, A.R., Johnson, G. Jr . : Organiz ing to Improve

Enrergency Services: Birth ofthe University Association for Emergen-cy Medical Services, Journal of Trauma, l0:806-810, 1970.

Hamp ton , O . P . J r . : Ca tego r i za t i on o f Hosp i t a l EmergencyDepartments or Hospi ta ls, Journal of Trauma l0:183-184, 1970.

Categorization of Hospital Emergency Capabilities, American Medical

Associat ion, Chicago, 1970.

Shires, G.T. : Care of the In jured - The Surgeon's Responsibi l i ty ,Bul let in, American Col lege of Surgeons, February, 1973.

A Symposium on I l l inois Plan for Trauma Care; Journal of Traumal3 : Ap r i l , 1973 .

Robertson, H.R.: Heal th Care in Canada: A Commentary, ScienceCounci l of Canada, Special Study No. 29, March 1973.

\

I- :

GUIDELINES FOR PROGRAMS WHICH TRAIN FULL.TIME EMERGENCY PHYSICIANS

DELIBERATION OF WORKSHOP

William F. Mitty, Jr., M.D.

The l0 workshops on "Guidelines for Programs whichTrain Full-tirne Entergency Physicians" were given fivecharges for discussion and possible solutions. These were:

I. Will the full time Emergency Physician have aviable career in the future if other nrethods forproviding health care are developed either withinor without the government.

II. What are the educational requirements fortraining the full time Emergency Physician be hea new graduate or a man or woman embarkingupon a second career in Emergency Medicine.

IIL What type of program can be developed and cana "Basic Prototype" program be set up in view ofthe l 'act that there are now programs both in thecomtnunity hospitals as well as in UniversityCenters.

IV. ts there a need for accrediting these programs andif so by whom - the University - a SpecialtyBoard - or the University Association lbrEmergency Medical Services or other similarinterested groups.

V. Should the Emergency full-t ime Physician begiven academic recognition by the Deans of theschools as well as the Departntental Chairrnen.

To the first charge concerning a future viable career, itwas the consensus of most groups that within the nextdecade or two they will have a viable career. For those whosee fit to depart from the ranks of full-time EmergencyPhysician, it was the opinion of the group that two avenuesare available to them, narrely (a) to pursue u career itrfamily practice, or (b) with further training they couldbecome board certif ied in their chosen specialty. Sorneuncertainty was expressed about the future viabil ity of thisspecialty; and therefore, some participants felt that itwould be safer to continue some sort of outside activit ies intheir chosen previous career. It was felt by most that toinsure viabil ity in the future, the complete full-t irnePhysician wil l not only be caring for patients but mustassume the role of teacher and do some clinical research aswell.

The second charge was the educational requirementsfor the full-time Emergency Physician. Opinions varied asto the exact edueational requiretnents for these Doctors.Most of the participants thought that the Specialist shoulddo the vast majority of teaching while a minority felt tl'ratthe Family Practioner should be charged with the educationof the full-time Emergency Physician. Most of theparticipants thought the teaching should be under the aegisof the University and not at the Comn.runity Hospital sincedepth of personnel for teaching is not available in the

average Cornn.runity Hospital. It was thought that some ofthe educational requirements should be in the field ofhospital administration and some exposure to thernechanism of Systems managements as well as tocommunity problems and to the business aspect of theEmergency Depart nrent .

For the Physician who is seeking a second career as afull{ ime Emergency Physician his retraining should consistof a formal course of didactic lectures fullt ime for a periodof one to two months and then have his training continuedin the Ernergency Department under the usual workingconditions, but he must be supervised constantly unti l hiscoulpetency is attested to by his teacher who should be af q , ' r r l t r r m p n r h c r

It is of paranrount importance that both the newgraduate and the physician seeking a second career as anEmergency Physician should be well motivated to pursuethis type of career and'to avail hiurself of all the facil i t ies ofthe University so that as a flnished graduate all can beproud of him.

The third topic under discussion was what type ofprogram should be developed for the training of thefuli-t inre Physician. This was the only area where there wasnear unanimity of opinion. A11 participants felt that eithertwo or three years of training would be necessarydepending on whether or not the rotating or mixedinternship is sti l l available for the student as his first year ofpost-graduate training. If he takes an internship, thenanother two years should suffice to rnake him a safe andcompetent full-t ime E,mergency Physician; otherwise, hisprogranr should be of three years duration. His rotationshould encompass all the disciplines but only as they relateto the diseases and traunra that they can expect to see itrthe Emergency Department. Prototype progranrs sinti lar tothose now in existence seerned satisfactory to most groupsprovided the teaching is done by board certif ied specialistsin all the discipline and not by the Family Physician. In therotation schedule rnore time should be alloted to thosedisciplines which wil l provide the student more knowledgeof the diseases which he wil l encounter most conluonly

The fourth and fifth charges nanred accreditation andacademic recognition are so interrelated that many groupsdiscussed thern conjointly. A rnarked dichotorny was notedhere. Sonre thought that accreditation wil l eventually corneas lnore University progran$ beconre operational and thefinished product can be better evaluated by the variousaccrediting agencies and therefore do nothing in the nextfew years. Some participants thought accreditation is anabsolute necessity now by examination with no grandfatherclause for the development and growth of the programs as

r

well as to attract the bright, young medical student topursue a career as a full-time Emergency Physician. Thosein the second group thought that at this present momentand time the accrediting body should be the section ofEmergency Medicine of the AMA. Then at a later time theCouncil of Medical Education should be petitioned toreview the program and ultimately attain the status of aspecialty within its own right.

Most participants did not think that either thisorganization or the American College of EmergencyPhysicians should be the accrediting agency. It wasfrequently mentioned that ultimately all residencyprograms will be accredited by the University and not by aSpecialty Board.

All participants agreed that academic recognition isnecessary and important to obtain as it relates to the Dean'sOffice as well as the Departmental Chairman. If thesephysicians are to be on a level with their colleagues inesteem, they absolutely require academic recognition. Mostparticipants felt that the Directors of the EmergencyDepartment should be on the Executive Committee of thehospital with all the rights and privileges of other Directorsin the hospital,

Most participants thought that the Director of theEmergency Department should also be Chairman of theDepartment in a Medical School and sit as coequal with theExecutive Councils.

EMERGENCY MEDICAL CARE IN A PREPAID HEALTH CARE SCHEME

Frank Miller, M.P.P.

Before I talk about Emergency Medical Service as aninsured benefit, I should explain how medical services arefinanced in Ontario. The Provincial Government is involvedin much more than simply paying claims for hospital andmedical services -- the usual concept of a prepaid healthcare plan,

Through its Ministry of Health, the Ontariogovernment has statutory obligations for assuring theavaiiability of adequate preventive, diagnostic andtherapeutic medical services to all its citizens. Capital andoperating costs for a broad spectrum of institutions andhealth agencies, including the whole public hospital system,are funded through a mix of direct services, grants andtransfer payments.

Payment for physician's services is made largely byreimbursement on a fee-for-service basis -- though asignificant number of physicians now receive salaries fromuniversities, hospitals, health units and community clinicsfunded by the Ministry.

Government is committed to financing not only thedelivery of health services, but the educational and trainingprograms necessary to supply adequate numbers ofqualified medical, allied and paramedical personnel to staffthe delivery system.

Inevitably, any publicly funded health delivery systemis prone to abuse, not only by patients and physicians, butby all personnel involved. The smaller the facility that ispermitted autonomy, the greater the degree of parochialismengendered. This is NOT to say that the total system mustbe operated by one giant, central, bureaucratic agency.However, it does mean that government must, on behalf ofall its citizens, ensure that the system provides the righttype of facility or service in the right place.

It also means that each must be operated as efficientlyand economically as possible, keeping in mind that all typesof service must be available to all, even though the highlyspecialized levels of investigation and treatment cannot beestablished in every town or village, or even, in some cases,in every city. One must inevitably equate probable demandfor care with planning the location of facilities for itsprovision.

Assistance in overall planning for such a system has tocome from regional or district councils that cover enougharea and population that most levels of care should logicallybe provided within them. At some point, we mustobviously determine the authority and autonomy suchhealth councils can be expected to assume within the totalsystem.

The establishment and maintenance of standards for

each type of service or facility, we believe, should rest withthe Ministry. Operating efficiency must be among thosestandards.

Over the past few years, there has been a great deal ofdiscussion about the idea of community health centres.While all l0 provinces in Canada, as well as the provincialgovernment, are agreed that this type of facility will assumea significant role in both the planning and the delivery ofhealth care, a great deal of planning and study andevaluation will be needed before we introduce the concepton a wholesale basis.

The Hastings Report, with which I 'm sure most of youare familiar, has many interesting things to tell us, but herewe find endorsation without enough actual statistics toform a sound opinion on how they can fit into our system.

Research is also needed on whether the emergencyroom of today's hospital should become either all or part ofan evolving comrnunity health centre.

There are argurnents, such as capital costs, in favour ofthis approach; there are also arguments against it, like thedanger of the centre becoming sinrply a feeding station forthe hospital.

The Ministry of Health is well aware of thesearguments and the province is going ahead with DistrictHealth Councils and community health centres - both on alimited and experimental basis.

It is our feeling that the Community Health Centrewill tend to be different in one community from the next,and we expect that the district health councils will have alot to say in how the local emergency services are bestco-ordinated into the local plan for health care delivery.

Let us now turn to the question of emergency medicalservice within an insured health program. Provision ofadequate care for the victims of traumatic or medicalemergencies is complicated tremendously by thesuddenness of the need.

Although the definition of an emergency depends onwhether it is made subjectively or objectively, there is nodoubt that an effective health delivery system must becapable of res.ponding to the sudden cry for help, and beprepared to sort out the true emergency victims, whorequire care urgently, from those whose treatment can bedeferred. This process of sorting is well understood by yourgroup. It's a process that begins with receipt of the call andcontinues throughout the prograrn of care.

Emergency medical service, as I understand it, involvesdelivering effective primary care to the casualties as well asdelivering them to appropriate definitive treatment centres.lt may also, I presume, involve care and movement within

the complex of treatment facilities. The care andtransportation of the sick and injured is a significant aspectof emergency medicatr service, one that must be integratedinto a total program.

I believe Ontario is the first jurisdiction of its size toaccept the concept of an integrated system of ambulanceservices and communications, designed to assure all itscitizens availability of quality emergency care andtransportation, as an insured benefit. Since 1968, thegovernment, through its emergency health services, hasbeen evolving just such a system.

I am pleased to find that a demonstration of some ofthe equipment, vehicles and communications is on yourprogram. Evolution of this program has involved emphasison all aspects of the service - personnel, equipment,vehicles, communications, data collection and operationalresearch. It has involved the development andimplementation of standards for all the foregoingcomponents, as well as a new approach to a province-widesystem,

This system envisages the ultimate development ofmutually supporting regionally administered services, linkedtogether b! a network of despatch centres spanning theprovince. These, in turn, are linked with other emergencyagencies, including police and fire services at appropriatepoints. I'm sure you'll learn more of the details of thisambitious program during your conference.

From the patient's viewpoint, and of particularinterest to a group such as yours, education and trainingprograms for personnel involved in the delivery of care aresignificant.

Starting from a point where no training or otherqualifications were required, basic training in thefundamentals of casualty care has now been given to morethan 1600 ambulance workers. Advanced training forexperienced men has been developed that will produce trueparamedical professionals, capable of dealing moreeffectively with a wide range of emergency situations underthe general supervision of physicians such as yourselves.

The curriculum was developed by representatives ofthe Ontario Medical Association, the Ontario HospitalAssocjation and our own Emergency Health ServicesBranch. Hopefully, this course will become a requirementfor all new entrants into the system.

A part-time coune is also to be offered at communitycolleges and contract hospitals to upgrade the basiceducation and patient-care skills of those already workingin services throughout the province who have qualified inour own fundamentals of casualty care courses.

Net capital training and operating costs of thiscomprehensive system in 1973 will cost the taxpayersabout 1% of the provincial health budget. Since our recordsshow that the system transported more than 405,000patients in 1972 and that at least two hundred patientsapparently dead were revived and delivered to hospitalduring the year, such costs do not appear out of line.

I said earlier that an ambulance service system shouldbe integrated with other elements of an emergency medicalservice system. I'm sure you'll agree that the developmentof such a system in a meaningful way is generally less thanadequate. There is little point in providing effective on-siteemergency care and delivery of emergency casualties totreatment centres if the latter are not organized, equippedand staffed effectively to peak capacity for reception of allemergency casualties twenty-four hours a day.

Here, then, we are talking of an effective system,designed to assure availability not only of emergency careand transportation, but of properly equipped, staffedfacilities at which patients can be assured of prompt,competent, definit ive primary care.

I suggest that if we plan such resources on a district orregional basis, much more can be done without significantescalation of costs. Since staff is the prime dollar consumer,perhaps we can do much better for less.

To sum it all up, emergency medical service MUST beprovided in a health care delivery system. There is an urgentneed to organize it as a system of mutually supportingdistricts or regions, and to integrate our emergency care andtransportation service into it.

Trauma has been described as the most neglecteddisease of modern society, I suggest that care of trueemergencies of all types could be improved. I hope you willagree that we recognize the problem, and are attempting todo something about it -- within, if you will, a prepaid healthcare plan.

GUIDELINES

RESIDENT AND

FOR THE CORE TRAINING

GENERAL PRACTITIONER

PROGRAMS FOR THEIN THE EMERGENCY

SPECIALTY

DEPARTMENT

REPORT ON WORKSHOP II

Allen P. Klippel, M.D.

ln considering the guidelines for training physicians inthe Emergency Department of any hospital this workshopfelt the most important requirement was the availabil ity ofan adequate number of patients. In a sense the idea of"turf" was paranrount. Many university hospirals areextremely well staffed, but it is possible that there are notenough patients with emergency problems to prclvide anadequate experience both for the specialty resident and alsofor the resident in emergency medicine. It was consideredthat, should this be a problem, affiliations with otherinstitutions including municipal hospitals should beconsidered.

Some participants expressed the need for adequatesupervision of the house-staff in the emergency department.It is no longer considered proper medical care to leave a

new intern "muddle through" thereby increasing hisexperience to the detriment of the unsuspecting patient.This is true also for the first year resident. Supervision byan attending physician or at least a third year resident isrequi red to meet the guidel ines of the AMA"Calegorizalion of Hospital Emergency Facilities." At thesame time, it is hoped that the non-elnergent patient couidbe treated in an area removed from the emergencydepartment. Some universit ies and affi l iated hospitals havedeveloped ambulatory carc areas where treatment isprovided by residents or attending physicians from theFamily Practice Programs. This policy would help in thetraining of emergency and specialty residents by allowingthem to focus on the emergency problem and not beobliged to provide "service."

THE ACADEMIC SURGEONAND THE EMERGENCYDEPARTMENT

Robert B. Rutherford, M.D.

I asked the program chairman if I couldn't have anopportunity to present to the membership, the results ofa survey which I conducted this year among my surgicalcolleagues who were ED directors. It was a bit too longfor the "nuggets" and somehow it has now turned into a"Presidential Address," but I hope I have not establish-ed a precedent to which my successors are committed.

As you well know, the emergency facilities ofhospitals throughout the United States and Canada arecurrently the scene of great change and unrest. Majorquantitative and qualitative changes in the patient pop-ulations of these emergency "rooms," or departments,have forced equally major adjustments to be made.Many, if not most Emergency Department directors,have become intimately involved with such matters asemergency department design, physician staffing plans,categorization, triage, screening or walk-in clinics,poison control, drug abuse, psychiatric crisis care,emergency communica t ion sys tems, he l i cop terspecifications, ambulance design, and much more. Itmay be legitimately asked, what has all this to do withsurgery and particularly academic surgery since the vastmajority of ED directors in teaching hospitals are stil lsurgeons.

The surgeon's role as an ED director is a legacy of thedays when these facilities functioned almost exclusivelyfor the care of the seriously il l or injured. But now theacademic surgeon, originally drawn into the emergencydepartment out of a natural interest in trauma and othersurgical emergencies, often finds himself being drawnfarther and farther afield from purely surgical interestsor, indeed, from any traditionally recognized academicpursuit. As the demands of the director's position srowwith the size of his emergency departmeni, the suigeonmay frnd that he can no longer do justice to both it andhis dther cl in ical and academic interests. Manyacademic surgeons stil l feel strongly that the emergencydepartment should be "surgical territory" and that ittakes the "surgical approach" to emergency problems toa.ssure effective ED operations. Others, while resentingthe intrusion of minor medical and other ambulatorycare problems on the ED nevertheless feel that publicpressures are i r res is t ib le and tha t emergencydepartments will never be the same again. They aretherefore unwilling to fight to restore or retain the statusquo.

I perceived, from my own personal experiences andfrom conversations with my colleagues, that seriousproblems existed in the relationship between manyacademic surgeons and today's emergency departments,so to shed more light on this matter, I conducted a sur-

vey of all ED directors in the UA/EMS who were listedas surgeons. Forty-six (46) replies were complete enoughfor group analysis, and I hope those of you who are sur-geons will find the results not only interesting but help-ful. Those ofyou who are not surgeons, but have to coex-ist with these lovable comrades, will not only understandthem better but discover, to your surprise, that you dohave much in common, even if it is only commonheadaches.

f ) A profile of your 'oaverage" academic surgeon EDdirector indicates that he is 42, nine years out ofresiden-cy, has held the position four years, and most likely, (i,e.537o) holds the rank of associate or full professor.

2) His major clinical interests are led by trauma andgeneral surgery. Only l3%o listed EMS as their primaryinterest and 40Vo didn't list it at all.

3) Our average surgeon-ED director spends l4 hoursa week physically present in his ED and an extra 8 hoursworking outside the ED in its behalf. This 22-hour totalrepresents 30Vo of effort of the average 70 hour/week.Half their time is spent on administrative work, one-quarter in teaching, 20Vo in direct patient care and only570 in chemical research.

4) More interesting is the fact that 76Vo would notwish to continue as ED director if required to spend atleast 507o of their time physically present in the ED and58% would not wish to continue if their other surgical ac-tivities had to be significantly curtailed to meet in-creasing demands for attention by the ED.

5) lSVo of respondents found no satisfaction with thejob of ED director; another 1870 found little satisfaction;28Vo were moderately satisfied and 36Vo were so satisfiedthey had never thought of quitting.

6) Professional satisfaction was provided to 64Vo ofthe respondees by; first, service to patients and thehospital and teaching experiences, followed by thechallenge of running an important clinical service andpersonal clinical experiences. Clinical research oppor-tunities and increased financial rewards ranked lowest.

7) What were the sources of professional dissatisfac-tion? First ranked was lack of academic recognition forthe EE activities. Administrative impediments to gettingthe job done was a very close second. Close to half (41-5070) listed lack of opportunity for chemical research inthe ED third. Fourth were impediments to developinggood educational programs in the ED and fifth was lackof personal clinical experiences in the ED. A few just feltthey didn't have enough time to devote to the ED.

Further;64Vo found the job frustrating and annoying much

of the time

10

5l7o would step down if a qualif ied faculty memberoffered to take the job

31Vo said they won't stay if their situation doesn'tlmprove

24Vo said they won't stay if major changes in theEMS system do not come soon

l2vo said they would quit right now if there wassome reasonable way out

l3Vo would probably stay on if their ED was givendepartmental status.

Why are they staying on? - For58Vo it is the enjoyment of running an

ical service44Vo are expecting major improvements

active clin-

in the nearfuture, but

40Vo are staying on because they feel an obligationto their departmental chairman, and

29Vo simply lack a qualified replacementIn the face of all this disil lusionment. who do

academic surgeons feel should run the ED's of teachinghospitals? - A surprising 64Vo sti l l felt that a surgeonwas the most appropriate man for the job. Those againstsurgeons as ED directors were also equally dividedamong 3 reasons: (l) surgeons can't spare the time(35Vo), (2) surgical problems are in the decided minorityin today's ED (307o), and, (3) today's ED requires a full-t ime emergency physician. lSVo said, anyone interestedand motivated, l2Vo named a full-t ime emergency physi-cian and only 6%o voted for an internist of GP.

The respondees were asked to l ist and rank thosechanges which would most significantly improve theirlots as ED directors. An effective means of keeping non-emergency, general medical problems out of the EDranked firstl and some who didn't l ist this noted thatthey had already accomplished it. 4lEo desired to en-courage more traumatic and surgical emergencies. Inanswer to another question, 54Vo felt that the educationalvalue of the house staff rotation in their ED wassignificantly diminished by the high percentage of un-instructive, minor medical problems they were requiredto see.

Next in importance came hospital departmental statusor its functional equivalent.

In th is regard,93Vo lelt the ED director should be renresented on

the governing medical body of the hospital orbe always consulted on matters affecting theED

only 64Vo had this representation82% felt the ED director needed to play a major

role in the ED budgetonly 3 l%o had th is involvement - and -

60Vo felt that the ED director should have "hiring

and fir ing" privileges over their nurses andclerks, and

only 20Vo had this authorityIt is not surprising that most felt they needed a bigger

ED (10Ea). 8070 wanted greater faculty support for EDpo l i c i es and p rog rams .

It is interesting to l ist just where these men felt thatsupport of ED pol ic ies and programs was most lack ing.

44Vo incriminated their deans42Vo their clinical faculty36Vo the heads of other (i.e. non-surgical) services,

and27Vo each felt that their hospital administrator and

their house staff let them downonly 1 1Vo felt their surgical chairman was not support-

ive, and9Vo felt their nursing service had let them down

70Vo wanted a better coordinated regional EMSsystem

687o wanted more funds and/or facil i t ies for chem-ical research in the ED, and

4870 desired a separate trauma or acute surgicalservice under their direction. The latter rank-ing higher (ff4) as a primary objective.

Desired improvements included: Increased income.However, in answer to another question, 36Vo akeadyfelt they were receiving a greater income than they wouldhave were they not the ED director. Of these 6070 felt theamount was not an appropriate enough incentive and63Vo of those who received no particular recompense fortheir efforts as ED director felt that some financial in-centive was appropriate.

There is obviously a certain degree'of bias introducedinto a survey such as this, just in the selection and word-ing ol the question. I cannot keep bias out of my inter-pretation and discussion. I don't apologize for this and Iknow the reader wil l draw his own conclusions and selectthose findings which support his own beliefs. I guessthere is a l itt le something in it for everybody.

Hopefully, the deans, administrators and surgicalchairmen and future ED directors who read this wil l notsimply dismiss the entire matter as being nothing morethan a reflection of today's society, where so manyappear to be organizing for greater recognition, a senseof identity, more authority, a greater role in their ownself-determination and better compensation for their ef-forts. Rather, I f leel that there are some importantspecific issues involved here that should not go unheed-ed.

First of all, there is obvious evidence of widespreaddissatislaction among academic surgeons with the posi-tion of ED director. Most spend relatively l i tt le t ime intheir emergency departments and are unwill ing to makea greater commitment of t ime and effort to the job ofdirector unless it is made more attractive to them: ad-ministratively, clinically, and academically. At the mo-ment, many are apparently staying on only because ofthe lack of a qualif ied replacement or out of a feeling ofobligation to their department chairman. On the otherhand, the majority apparently derive some measure ofprofessional satisfaction from the job, feel a surgeon isthe most appropriate faculty member for this positionand would stay on under other than the currently ex-isting circumstances. For many, the main issue appearsto be less one of whether surgeons should be directing theemergency departments of teaching hospitals, but howthe position can be made professionally more satisfyingand attractive to the academic surgeon. Based on theresponses to this survey, several recommendations

11

deserve consideration.Of all the suggested changes which might improve

their lots as emergency department directors, an effec-tive means of diverting non-emergency traffic from theED ranked the highest. It is becoming diff icult to defendthe ED of a teaching hospital as "surgical territory"when neither surgical nor even emergency problems con-stitute a majority of those being treated there. In spite ofsignificant increases in trauma, it is the non-emergent,general medical problems which are overloading ouremergency departments. These facil i t ies, originallydesigned, equipped and staffed to care for the acutely i l land injured, now find themselves inundated with patientswith relatively minor problems, who either have not es-tablished a functional relationship with physicians prac-ticing in the community; f ind it more convenient to usethe emergency department; were unable to reach theirphysician; were sent there by him or simply find theemergency department's conveniently "open door" to bethei r only reasonable point of access to today 's heal thcare del ivery "system" (or "non-system,"

as i t shouldmore appropr iate ly be termed).

None of us wishes to deny these patients appropriatemedical care at reasonable convenience and cost, but thewisdom must be seriously challenged of allowing them tocontinue to clog up emergency care facil i t ies, where theyrnust suffer long treatment delays when forced to com-pete for medical attention with more urgent, higherpr io i ty problems. The use of an ED for the managementof non-urgent , general medical problems ends up being"episodic, ineffective and expensive medical care." Evenil this trend can be reversed by a resurgency ofgeneral orfamily practice, the development of health maintenanceorganizat ions or other improvements in the system,more adequate and accommodating ambulatory carefacil i t ies wil l be needed in most of our hosoitals.However, i l these facil i t ies must share space with thosedevoted to emergency medical care, eveiy effort shouldbe made to have them be adjacent but functionallyseparate, with a good triage or screening operationfronting the entire complex. An equally, if not moreeffective approach, in major population centers at least,would be the establishment of trauma and emergencycare centers in selected teaching hospitals through aprocess of regional planning. This could even result in ashift ing of non-emergent patients to hospitals which arenot adequately equipped, staffed or in some cases, evenmotivated to manage the seriously i l l or injured. Unfor-tunately, reactions to perceived threats to prestige oreconomy may seriously impede acceptance of this ap-proach. However, the development of trauma andEmergincy Care cenlers would not only improveemergency medical care, but prov ide a soundbasis for amajor career interest and professional comrnitment tothis field by academic surgeons and even by faculty fromother academic specialt ies. It would provide the oppor-tunity for clinical experience and research, and providestimulating educational experiences for the house staffand the faculty who supervise and train them. In otherwords, it would establish an appropriate environment fortraining programs for all physicians who wil l be the

future providers of emergency medical care.Fail ing this, the ED should at least be restored to its

original functionl Reducing the number of non-emergency patients by providing alternative ambulatorycare facil i t ies elsewhere in the institution or even in thecommunity and have such facil i t ies stay open onevenings and weekends. Thereby the administrative andnon-educational service requirements of the ED could bereduced to a level which could be manased adeouatelvon a part-t ime basis.

Our survey suggests that few surgeons with seriousacademic aspirations wil l be wil l ing to continue servingas the director of an every expanding ambulatory carefacil i ty whose operation demands an inappropriatelylarge expenditure of his time in proportion to theprofessional satisfaction and academic recognition hereceives in return for his efforts.

While the foregoing may be considered of vital impor-tance to the academic surgeon, such changes alone mayfail to produce a completely satisfying environment forthe academic surgeon in the teaching hospital ED.However, most of the other changes which this surveysuggest are desirable for any ED director regardless ofhis prolessional background or specialty affi l iation. Thissurvey indicated that administrative impediments andthe lack of widespread institutional support for EDprograms and policies are other very major sources offrustration and job dissatisfaction for the ED director.This is expressed in the desire for hospital departmentalstatus or its functional equivalent, for better coverage bysupervisory faculty, for more support from the dean andthose clinical chiefs other than their own departmenthead and for a better opportunity to improve theeducational programs for the house officers and medicalstudents assigned to the emergency department. It isequally clear that although an enlarged ED facil i ty, abetter coordinated regional EMS program, facil i t ies andlunds for clinical research in the ED and increased finan-cial incentives are all l isted as desirable imorovements bv"the

majority of the respondent ED directors (and I 'msure are important objectives) their individual lack doesnot constitute the major source of their job dissatisfac-tion, since a combined total of less than l07o of therespondees listed any one of these as their most desiredimprovement .

I n s u m m a r y , i t w o u l d s e e m t h a t m o r e t h a nmaterialistic incentives wil l be necessary to attract or re-tain qualif ied academic surgeons to serve as directors ofthe emergency departments of teaching hospitals in thefuture. The necessary ingredients appear to include, (l) amore effective functional separation of ambulatory andemergency health care problems within the institution ifnot the community, (2) an opportunity for academicallyrewarding professional experiences, sufficient at least tobalance the administrative and service oblieations of thejob, and (3) the administrative and facultly support -and the authority - to get the job done. Time is of theessence, for the rate of turnover of surgeon-ED directorsin teaching hospitals is already high and for manyacademic surgeons, their hospitals' emergency depart-ment has already become a matter of "f ight" or ..f l ight."

12

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

Charles O.

I. IntroductionReports by Kirkpatrick, Torrens, and Perkoff in-

dicate that urban-based hospital emergency wards fil lseveral functions: (l) treatment of acute medical andsurgical emergencies; (2) provision of surrogate physi-cian care for non-available private physicians in thecommunity; and (3) provision of a family physician rolefor the urban poor. Hilkovitz suggested that universityhospitals emergency facilities attempt to define the ap-propriate philosophies of function of their patientclinentele to avoid compromising the quality of medicalcare. As a part of a broader inquiry into the utilization ofambulatory pediatric health services by several pop-ulations, this inquiry was undertaken and attempted toanswer four questions: (l) Who uses the universityhospital pediatric emergency rooms between midnightand 6 a.m.? (2) To what extend does this populationrepresent "at risk" populations? (3) What life styles con-tribute to the patient's util ization of the pediatricemergency ward during these hours? (4) To what extentdoes this population require emergency medical care?II. Research Setting, Methods and Materials:

The pediatric emergency ward located in a separatelyhoused facility at University Hospitals is reachedthrough the general hospital emergency entrance. Thestaff, consisting of the department of pediatrics, Schoolof Medicine, Case Western Reserve University, housestaff, and full-time pediatric emergency room nursingpersonnel, provides emergency services for all childrenfrom birth to 16 years of age.

All patients registered in the pediatric emergencyward between midnight and 6 a.m. for a six week periodin the spring of l97l were interviewed by the staffpediatric nurse. She explained the research project andpermission was obtained for the participation in thestudy program.

After a consent form was signed, data was collectedon patient identification and demography, medicalhistory, family profile, parent employment, baby sitterand transportation resources. A medical evaluation wascompleted by the house officer, who also was asked toassign a ranking of il lness severity as follows: (1) no dis-ease found, (2) mildly il l, (3) moderately il l, (4) acutelyill, (5) life-threatened illness. The following morningcharts were reviewed by the investigator and house of-ficer so that concurrence was reached on the assisnmentof severity of il lness.III. Results:

During the study data was collectd on 170 patients. 10families refused to participate in the study. It was notpossible for the nurse to register all families during times

McClelland, M.D.

of high patient load. Less than 25 families failed to par-ticipate during this period of time for this reason.

A. Demographic Description of the Population:

Figure l.

Age of Patlents: NumberBir th to s ix months 12Six to twelve months 14One to two years 34Two to five years 50Five to twelve years 43Over twelve years 17

Race of Patlentg:BlackWhi te

Sex of Patlents:Ma leFemale

Geographlc Dlstrlbutlon:G lenv i l l eHoughCentra lMt. PleasantOther

Marltal Status(158 Faml l les) :

Single parentDouble parents

Public Asslstance(158 Faml l les) :

ADC Fami l iesNon-ADC Fami l ies

Y Z

78

64403 11 71 8

1 5 91 1

82/ o

8 11- '

Percent7I

2030251 0

94

E A

46

38231 81 01 1

5248

c l

49

Figure 2.

Place of Blrth Usual Health Regource

Number PercentNumber

OYz o

1 47

3024

4 1

84

1 81 4

Univers i ty Hosp.Metropol i tan

Gen' l Hosp.Mt. Sinai Hosp.St . Luke's Hosp.Other Hospi ta ls :No Data Avai lablePr ivate Physic ianCi ty Heal th Cl in icsNeighborhood Heal th

Center

107 633 2

1 ' l0 0

3 0 1 88 46 3

B. To What Extent does the Midnight to 6 a.m. User

of the Pediatric Emergency Ward Represent "At

Risk" Populations?Teaching of ambulatory pediatrics stresses the need to

ask "Is there anything about this patient's past medicalhistory, present i l lness, family or social structure thatsuggests that the course of this i l lness wil l be at varianceto that of the expected general population?"

Among such potential risk groups are included infants(l) with iow birth weights, (2) without apparent i l lness,

and (3) those previously hospitalized.l. Low Birth Weight Infants:

Of the 87 infants less than 30 months of age, only 8 in-fants were found to have birth weights less than 2'25kilos. These were all classified as mildly i l l .

2. Infants Without Apparent l l lness:The fourteen patients classified as having no apparent

disease, had no differences with regard to percentage ofs ingle pat ients, ADC parents, parent employmentpxt terns. personal t ransportat ion. etc .

3. Previously Hospitalized Patients:

l. Parent Employment Patterns:Figure 4, data on employment pat terns of the parents

are presented. Approximately 5070 of the families defin-ed one or both of the parents as employed, 40% of thefanr i l ies del ined no parenta l employment . In 52% of thefanr i l ies the employed parent worked f rom 7 a.m. to 3p.nr . and l2%o ol the fami l ies f rom 3 p.m. to l l p .m.

2. Siblings and Sitter ResourcesIn Figure f5 are presented the data on sibling patterns

and baby sitter resources.

Figure 5.

Siblings Pattern NumberNo s ib l i ngs 391 -2 s i b l i ngs 78Over 3 s i b l i ngs 39U n k n o w n 1 4

Percent234623I

Figure 3.

Previously Non-HosPitalizedHospitalized Patients PatientsNumber Percent Number Percent

28 53 77 66

25 47 40 34

Family Sitler ResourcesParent or re lat iveNe ighbo rNo s i t tersNot ind icated

Twenty-three percent of the families had singlechilrJren, whtle 23Vo over 3 siblings. Approximately 213used a Darent or relative as a sitter resource and only 570indicated a lack of any s i t ter resource.

3. Transportation ResourcesData on t ransportat ion resources are stated in

F igu re 6 .

Figure 6.

Transportation Resource Number Percent

Personal automobi le 95 56Fr iend /ne ighbo r 42 25

au tomob i l ePub l i c t r anspo r ta t i on 14Po l i ce ambu lance 1Taxi 7Not ind icated 1 ' l

F i l t y - s i x p e r c e n t i n d i c a t e d t h a t t h e p e r s o n a lautomobi le was the sole mode of t ransport to thehosoital: while 25Vo borrowed an automobile. Therenia inder used-some form of publ ic t ransportat ion. InCleveland where hospi ta l ambulances are non-exis tentand police arnbulance services are severely constrained,only one pat ient arr ived by ambulance.D. To What Extent Does this Popurlation Require

Emergency Medical Care?l. Medical Diagnoses Encountered:

Figure 7.

Medical Diagnosis Number

Upper respi ratory in fect ion 37T r a u m a 1 6Ot i t i s Med ia 15As thma 14Acute Gastroenter i t is 14Pharyng i t i s 13Acute Non-Speci f ic Vi ra l 13

Disease

1 1 0 6 5t c v9 5

36 21

Groups1 & 2

Groups3 , 4 , 5

Tota l 53 117

X , - 3 .2 p Va lue l ess t han .10

F i l t y - t h ree (3170 ) pa t i en t s had been p rev ious l yhospi ta l ized; two-th i rds of these at Univers i ty Hospi ta ls .Six ty-s ix percent were for non-surg ical admiss ions. Incontrast to our expectat ions, a lmost hal f o f the previous-ly hospitalized patients were classified as moderately oracute ly i l l . (F igure 3)C. Life Style Patterns of the Patients:

Data were collected on parent employment patterns,presence and number of s ib l ings in the fami ly , avai labi l i -ty of baby s i t ter resources, and t ransportat ion resources.

Figure 4.

Parent Employment Pattern Number Percenl

Father employed regular ly 38 45Mother employed regular ly 27 32Both parents employed 19 23Tota l parents employed 84 49

Fami l ies wi thout parenta lemp loymen t

Parenta l em ployment dataunKnown

Hours ol Parent EmploymentT A M t o 3 P M3 P M t o 1 1 P M1 1 P M t o 7 A MNot indicatedTotal

14o

A 1

9

621 24

221 0 0

70

t o

521 03

1 984

Percent22

II

I8tJ

14

CroupSkin DisordersPneumoni t is /Bronchi t isContagious DiseasesHemoph i l i aSick le Cel l DiseaseNo Disease FoundOtherTotal

NumberNo D isease Found 14Mi ld l y i l l 91Moderate ly i l l 50Acute ly i11 t4Li fe Threatened l l lness 1

References

Lee, S.L. , Solon, J.A. , and Sheps, C.G.; How New pat terns of MedicalCare Af fect the Emergency Uni t , Mod. Hosp. 94:97, 1960.Short l i f fe, 8.C., Hami l ton, T.S. and Noroian, E.H.: The Emergencyl:^"1

"i9_r^h" Changing patterns of Medical iare, New Eng. J."Med'.2 5 8 : 2 0 , 1 9 5 8 .

Skudder, P.A. , McCarrol l . J .R. , and.Wade, p.A. : Hospi ta l EmergencyFaci l i t ies and Services, A Survey. Bul l . Amer. Col l . Surg. 46:44, 1961.We ine rman , E .R . , Ra tne r , R .S . , Rob ins , A . and Lavenha r , M .A . : ya l eSludies. in Ambulatory Medical Care V. Determinants of Use ofHospi ta l Emergency Services, Amer. J. pub. Heal th 56:1037, 1966.Vaughan, H.R. Jr . , and Gamester_, C.E. ; Why pat ients Use Hospi ta lEmergency Departments, Hospi ta ls, J .A.H.A. 40:59, 1966.Reed , J . 1 . , and Reade r , G .G . : euan t i t a t i ve Su rvey o f New yo rkHosp i t a l Emergency Room, I 965 , N . y . S ta te l . n4ed . o l : t : :S . t qOZ .B,rown, B.S. . : Reg_arding the Emergency Room, Let ter to the Edi tor ,New Eng . J . Med . 258 :507 , t 95g .Bergm,an. A.B and Haggerty, R.J. ; The Emergency Cl in ic: A Study ofi ts Role in a Teaching Hospi ta l , Amer. J. Oi-s. Ci i la . rc4j6, 1962.Alpert , J .J. , Kosa, J. , et a l . : The Types of Fami l ies That Use.anEmergency Cl in ic, Med. Care 7:55. l -9b9.Robinson, G.C. and Klonof f , H. : Hospi ta l Emergency Services forChi ldren and Adolescents: A One-yeir Review

"at t ie Vancouver

Gene ra l Hosp i t a l , Canad . Med . Ass . J . 96 :1304 , 1967W i n g e r t , W . A . , F r i e d m a n , D . 8 . , a n d L a r s o n , W . R . : T h eDenographical and Ecological Character is t ics o i a Large UrbanPediatr ic Outpat ient Populat ion and Impl icat ions for Improv- ing Com-mun i t y Ped ia t r i c Ca re . Amer . J . pub . i j ea l t h . 5g :g59 , I 96g .K i r kpa t r i c k , J .R . , and Taubenhaus , L . J . : The Non_Urgen t pa t i en t onthe Enrergency Floor, Med. Care 5i19. 196.1 .Torrens, P.R., and yedvab, D.G., Var iat ions Among EmergencyRoonr Populat ions: A Compar ison of Four Hospi ta ls in New york Ci-t y , Med . Ca re 8 :60 . 1970 .Perkof f , G.T. and Anderson, M.: Relat ionship Between DemographicCharacter is t ics, Pat ient 's Chief Complaint , and Medical Care Dest ina-t r on i n an Emergency Room, Med . Ca re g :309 , 1970 .Hi lkovi tz, G.: V. The Emergency Room in the Teaching Hospi ta l , J .Med . Educ . 4 l : 724 . 1966 .

,* lq l l i ,^ ! F and Wingert , W,A.: parental At t i tudes Associated wi th"Wel l " Chi ld Vis i ts to pediatr ic Emergency Rooms. Ambulatory

Pediatr ic Associat ion Meet ing, 1972, Wa;hinfuon, D.C.K le i nbe rg , W.M, , H i l deb rand t , H .M . , and Hage , M , : The young I n_fant in the Emergency Room: A Mother,s Cry"for Help. ArhbulatoryPediatr ic Associar ion Meer ing, 1970, At lant ic Ci tv. Ni- r .B . c rgn .e r . L . . l nd Ye rby . A .S , : Low Inco rne and Ba r r i e r s t o [ J se o IH c r n n 5 c r v l c e s . N e w E n g . J . M e d . 2 7 g : 5 4 1 . I 9 6 g .Hunsh l r gc r . L ,C . : pe r sona l commun i ca t i on .Solo.n, .1.A. . and Rigg, R.D.: pat terns of Medical Care Among Userso l Hosp i t a l Emergency Un i t s , Med . Ca re I 0 :60 , 19 i2 .Roth, J.A. : Ut i l izat ion of the Hospi ta l Emergency Department,. l .Hea l t h & Soc . Behav . l 2 : 312 . l 9 i l .Nigro, S.A. : A Psychiatr is t ,s Exper iences in General pract icel f osp i t a l En re rgency Room, J .A .M .A .214 :1657 , 1970 .Sa t i n , D .G . and Duh i , F . J . : He lp , l : The Hosp i t a l Emergency Un i t asConrnrunrty Physic ian, Med. Caie l0:24g. 1972.So l ky . C .C . , and Hoeke lman , R .A . : The ped ia t r i c Emergency Depa r t_' ] l . l ! , . Lo9l , lor Recogni t ion of psychosocia l Disabi l i iy , Cl in. 'ped.I 0 : 524 . I 97 I

96q

4zz

1 41

frpatients

54

z

1181

100percent

In f igure #7 are summarized the d iagnoses en-countered in the I 70 pat ients. Two_th i rds of ihe pat ientspresented wi th sorne form of respi ratory d isease. Almostl0% presented wi th some sequelae of i rauma.

.Dur ing the course of the study 5 of I l0 parrents wereadnt i t ted: two wi th croup, one wi th hemoph' i l ia , one wi thasept ic n leningi t is , and one wi th acute masto id i t is .

2. Ordinal Scale of Severity of l l lness:. In F igure #8 are l is ted data on o;d inal scale c lass i f ica_

t ion of 'sever i ty o l pat ient i l lness.

Figure 8.

I

Percenl

85430I

< 1

.Sixty-two _percent of the patients registered betweenmidnight and 6 a.m. were c lass i f ied as e l ther mi ld ly i l lorwell. 9Vo were acutely i l l which is higher than the usualexpenence reported.IV. Summary:

This report presents medical, social, and demo_graphic information on 170 patients registered in thepediatric emergency ward of University i lospitals frommidn igh t t o 6 a .m .

Sixty-two percent of the patients were classified asei ther mi ld ly i l l or wel l .

There.is no significant difference in severity of i l lness,or the above socia l var iables according to ihe t ime o iregistration in the pediatric emergency ,iard. These datasuggest that emergency medical needs are indeed not themaJor determinant of the pediat r ic emergcncy roombetween midnight and 6 a.m. and may reflJct informa_tron, physical and program barr iers that tend to inhib i tmore appropr iate use of the heal th serv ices by urbanpoor.

Based on these data, the development of a l ternat iveinformation services and organizatibn of care services toexpanded hours and cont inu_i ty groups are being propos_ed and evaluated in an effori to facil i tate more ap_propr iate ut i l izat ion of the emergency ward.

INCORRECT X.RAY INTERPRETATION BY EMERGENCY DEPARTMENT PERSONNEL

A. C, Strickler, M.D.

INTRODUCTION

St. Joseph's Hospi ta l , Hami l ton, Ontar io is a 650-bedgeneral hospital having an Emergency Departmentvolunre of 50,000 patient visits in 1972. h is part of thetota l undergraduate and graduate teaching complex thatinc ludes the McMaster Univers i ty Medical Centre andother Hami l ton hospi ta ls . There is , therefore, a largeconsultant and resident staffl. An active Department ofFami ly Medic ine oversees the Emergency Department .

The Department is staffed by 6 full-t ime physicianswho work 40 hours a week on a shi f t basis . Thei r respon-s ib i l i t ies are f i rs t , pat ient care, and second, teaching ofn iedical undergraduates and interns.

The Director 's responsib i l i t ies inc lude adminis t rat ion,teaching, development and research wi th only a smal lcomponent of d i rect pat ient care, usual ly re lated toteaching.

THE PROBLEM:

Radio logis ts are present in the hospi ta l f rom 8:00 a.m.to 5:00 p.m. Therefore, the Emergency physic ian is onhis own lor l5 hours of the day. Whi le the radio logis t ison cal l dur ing th is t ime, t radi t ion and condi t ion ing d ic-tate that he is rare ly cal led.

If the radiologist were called for every case, he wouldremain in hospi ta l v i r tual ly 24 hours a day every day.We see approximately 85 pat ients dur ing those 15 hoursof whom 30 percent require some form of x-ray ex-am ina t i on .

ITS MANAGEMENT:

Some mechanism for communicat ion must be set uo.therefore, to l ink together the pat ient who was mis in-formed the evening or n ight before, and the radio logis t 'si ind ings the morning af ter .

We do th is through the E.D. Director and the pat ient 'slami ly doctor .

Radio logis t

tE, D. Director_---> FamilyDoctor

L - - - - - - - - - - - - + Pa t l en t

This e l iminates the radio logis t 's f rust rat ion of t ry ingto locate the Emergency physician who saw the patientthe night before and now the following morning isasleep, away, or unavai lable for whatever reason.

Al l l inks in the chain are fa i r ly constant . I f the pat ienthas no lamily doctor, then the Director notif ies thepatient directly and arranges for appropriate follow up.

In the event that the Director is away, then the respon-s ib i l i ty of in lorming fa l ls to the Emergency physic ian onduty. Al l o f the fu l l - t ime physic ians who staf f theEmergency Department are aware of the system.

The results of this system are l isted in Tables I and IL

CLASSIF ICATION &

TABLE I

D ISTRIBUTION OF MIS INTERPRETED X-RAYS(False Negatives Only)

1 973Axia l

Skelelon Epiphyseg Ches lAssociated

Les ionslnc identa lF ind ings

Extremit iesD i s l a l l oWrist &Ankle Other Tota l

J A N 6 1 z z 1 A 1 1 1

F E B 6 1 3 I J

M A R 4 4 I

A P R 2 1 1 1 1 1

Tota l 1 7 o 4 z 1 7 2 50

16

TABLE I I

THE SCOPE OF THE PROBLEM,MISINTERPRETED X.RAYS

CONCLUSIONS & IMPLICATIONS:l . None of the misinterpreted x-rays produced

catastrophic results.2. Family doctors or their patients were informed of the

correct x-ray result, generally within l8 hours of thepat ient 's E.D. vis i t .Therefore , the worst effect on the patient was the un-explained cause of his discomfort and whatever in-convenience was involved in carrying out the followup.

3 . These f ind ings wou ld tend to suppor t theRadiologist 's posi t ion that extended inhospitalcoverage is not essential to better patient care,

4. False positives also occurred but only rarely and thesewere not recorded in this study,

5. The well known fact that x-ray interpretation of someanatomical regions is more difficult than others isdocumented. Teaching should be directed to theseareas,

6. If you don't see it, or don't look for it, then you mayvery well miss it.

17

GEOGRAPHIC AND TEMPORAL TRIAGE OF EMERGENCY PATIENTS

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

The number of patients utilizing hospital basedemergency medical services continues to increase,perhaps at a rate even faster than previously suggested.tFrom 1968 to l9'72 the patients treated in the five majoremergency clinics of Grady Memorial Hospital have in-creased from 206,000 to 266,000 per year. It ismeaningless to argue about which of these patients con-stitute real emergencies and which are non-emergent.These patients have placed immediate demands on ourmedical care system by their entrance into the system.To meet these immediate demands of the public more ef-liciently must be the primary goal of emergency medicalservice systems. Rutherford has pointed out that as aresult of uni lateral improvement in eff ic iency inemergency care, more patients are attracted into the im-proved portion of this system.2 No one would seriouslyargue against such improvements in medical care on thisbasis but the secondary increase in patients must be an-ticipated. It may be that those hospitals not seeking toimprove emergency medical services will not continue toattract other patients when the public recognizes thatsuch institutions are providing only limited services.

PRACTICAL SOLUTTONS

Faced with the continually increasing numbers ofpatients in all emergency clinic areas (Table I) GradyMemorial Hospital has sought to triage patientsgeographically and temporally as other hospitals havedone.3 Sorting the patients to different clinic areas ofthehospital is performed by clerical personnel on the basisof easily understood criteria (geographic triage). TheSurgical Emergency Cl inic (SEC) and MedicalEmergency Clinic (MEC) are located on the groundfloor opposite the clerical triage area which is just insidethe hospital emergency entrance. This triage systemworks effectively and it is unusual for patients to requiretransfer to a second emergency service.

Approx imate ly ha l f the pa t ien ts w i thout ap-pointments present themselves between 4 p.m. and mid-night. Arranging for additional treatment areas in clinics

YEAB

1 968'1969

1 9701 9711972

sEc89,08590,88392,41188,17797,959

MEC

64,87865 ,13560,78846,11153,496

normally not in use during these hours and establishingevening clinics to meet specific needs (temporal triage)have diverted large numbers of patients from the ,fivemaJor emergency c l ln lcs - surgery , meo lc lne ,pediatrics, obstetrics, and psychiatry. Probably thosesame factors operating to increase patient loads inhospitals providing efficient emergency care serve toreinforce utilization of these additional clinics.

In 1970 a psychiatric emergency clinic and a separatedrug dependence unit were established removing thesepatients from the medical emergency clinic. Similarly anight medicine general admission clinic (GAC) was es-tablished at this time further diverting patients from theMEC. Currently gynecological emergencies are treatedin the SEC. These patients constitute about ten percentof the daily patient load in that clinic. In 1972 GYNclinic began accepting patients without appointmentsduring the day and in March 1973 a night GYN clinicopened. These ancillary clinics diverted approximately72,000 patients from the major emergency clinic areas in1972 (Table II). These clinics are staffed with permanentnursing service personnel. Faculty, fel lows, andhousestaff physicians are attracted to staff these ad-ditional clinics primarily by financial reward - current-ly at the rate of $10.00 per hour. This competes withcommunity rates between $12 and $18 per hour foremergency room physicians.

CURRENT GOALSIn any particular emergency area increasing numbers

of patients will eventually result in a decrease in efficien-cy. From observations in several emergency centers itappears that no single unit of an emergency clinic is ableto efficiently handle more than approximately 50,000patients per year. This number of patients can be handl-ed efficiently with proper organization as has beendemonstrated at George Washington Universi tyHospital , Freedman's Hospital , and ProvidenceHospital in the District of Columbia. To reduce thenumbers of patients seen in any clinic area to this level is

OB1s,63015,76819,32619,66721,317

PSY TOTAL

206,493206,231

2,182 213,31011.312 211.54711.526 266.537

PED

36,69434,41538,60346,26482,239

TABLE I

GRADY EMERGENCY CLINICSPATIENT VISITS

TABLE II

UNSCHEDULED PATIENTS _ 1972(Non EC Areas)

Started

1972 Med GAC g4,7\z1970 Drug Dependence

Uni t 26.6951970 Med GAC Night 11,9711972 cYN 4,124

72,502

a current working goal in Grady Memorial Hospital,SUMMARY

Geographic triage and

availability can divert significant numbers of patientsfrom over-crowded emergency areas. It is hoped thatfurther utilization of these concepts combined with localand. regional planning can reduce the numbers ofpatients treated in those emergency clinic areas treatingmore than 50,000 patients per yeir.

BIBLIOGRAPHYI. National Research Council, Committee on Trauma and Committee

on Shock. Accidental Death and Disability: The Neglected Diseaseof . Modern ,Society. Washington, D,C.' Nationai Academy ofSciences, 1966.

2, Rutherford, R. B.: problems in Operating an Emergency Room in aUniv-ersily Hospital, University Emerge-ncy Oepariment DirectorsC^onference proceedings. University of iUUirr, Birmingham,t970,

3. Canizaro, P. C.:.ryllllg-ement of the Non_Emergent patrent,Jour_nat oJ I rauma, I l :544-551. 1971.extension of clinic

l 9

DO YOU REALLY KNOW HOW MUCH A VISIT TO YOUR

R. F. Williams, M.D.,M.R. Cammarn, M.D.,

R. M. Zollinger, Jr', M.D.

EMERGENCY WARD COSTS?

In 1970, a serious financial situation became apparentin the Ambulatory Patient Services at University Hospitalswhere an open door emergency ward facility is provided foran urban pbpulation. The combined deficits of the Clinicsand the Emergency Ward consumed all the gifts andendowment income plus the depreciation allowance, andthus the hospital arrived in the "never-never" land of net,net deficit.

Not surprisingly, the physicians directing ambulatoryservices found that the cost figures, as prepared by thehospital's traditional accounting procedures, were of littleassiitance in pinpointing the problems. In particular, thefinancial ledgers were not readily understandable to thephysicians and managerial personnel who were chargedi"iftr ttte responsibiht! for

-lowering ambulatory costs

without turning patients away or lessening . services.Furthermore,

- because of increasing third party

involvement, it has become necessary to present true costsfor all the components: in-patient, out-patient, research,and teachins.

Accordingly the first maneuver was to restructure thecost accounting system into categories which were morecomprehensibla to physicians and which accuratelyrefleited all components of cost for our emergency wardservice. Additionally, a separate business office wasdeveloped for the ambulatory services. This was and is anessential keystone for analyzing and controlling emergencywaro costs.

Seventeen cost centers were identified and dividedinto three categories: (l) Patient Related; (2) SpaceRelated; and (3) Supporting Services. The cost centerswithin each of these three categories are presented in Table1. These figures reflect the cost per patient for 4,560 visitsin Janrnry, 1973 in an emergency ward occupying 7,000square'feet within Univenity Hospitals. These figuresreflect the operational cost of purchasing goods and servicesfrom diverse sources and departments within the hospital'

In brder to make comparisons, these cost centers aretabulated for both the current month and the year'to-dateas shown in Figure 1, a simplified version of our emergencyward accounting ledger. The first column shows the currentmonth's cost; the second column, the budgeted projectionfor 1913; and the third column, last year's cost. It isobviously easy to calculate the cost per visit for each item,as well as the percentage of each item relative to the totalemergency ward cost.

Having once established the various cost centers byfunction, each was then thoroughly investigated as to themethod of allocation and the validity of each allocation.Significant errors were found in the efsting traditionalallocations, and in most instances the erron weredisadvantageous to the ambulatory services. Whereverpossible, we tried to change from estimated, or samplederived percentage apportionment, to actual direct cost. Asan example, housekeeping costs were shifted from an

allocation based on square feet to the actual cost of theman-houn involved. The methods used for determiningthese cost distributions were not unusual; however, theseanalyses did make inequities apparent.

This system has yielded several benefits. The costfigures for operating an emergency ward are more realisticand closer to the actual plant and operating costs.

Frequently these costs are hidden in the operating costs ofthe

^hospiial itself. There is a clear distinction between

emergeniy service costs and hospital costs. Current costsare eisily and quickly identified-, and this capability hasbeen particularly helpful in detecting trends such asincreas-ed. utilization of the laboratory, radiology, andmedications. This sytem enables monitoring theeffectiveness of new programs designed to control risingcosts, the financial eff6cts of personnel re-assignments, andof moving to larger physical quarters.

We - believe that this system of cost analysis is

reproducible and leads to more effective emergency wardad^ministration. Its most important contribution, however,is that it can be readily understood by physicians who haveminimal experience with traditional cost acco-untingmethods but who are now being held accountable for thecost effectiveness of emergency ward care.

Patient RelatedNurses & AidesCler ica lHouse OfficersX-rayLaboratoryEKGBlood BankPharmacy

Space RelatedHousekeepingUt i l i t iesMaintenanceProtective ServiceDepreciation

Supportlng ServlcesMedical RecordsCl in ic Adminis t rat ionCredit & CollectionsSuppl ies

EW costs per patient

17 cost centers within

Table I

v is i t in January, 19733 major categories

$5.801 . 7 04 . 1 02.603.50. 1 0.60.60

1gT0-

$ .go.50.70.50

1 . 2 0-330-

$ .30.20

2.20.70

340

according to

20

Flgure I

University Hospitals ol Cleveland

Tota l E.W. Actual vs. Budget

Month of - & Year-to-Date 1973

Category

Patlent-RelatedNurses & AidesCler ica lHouse OfficersX-RayLaboratoryEKGBlood BankPharmacy

Total

Supporting ServlcesMedical RecordsCl in ic Adminis t rat lonCredi t & Col lect ionsSupp l i es

Total

Space RelaledHousekeepingUt i l i t iesMaintenanceProtective ServiceDepreciation

Total

Tota l Bi l lab le Expense

Number of Bi l lab le Vis i ts

Cost Per Bi l lab le Vis i t

Mr.

Dr . .

Year-to-Date

21

I

TRANSPORTATION OF THE SICK AND INJURED BY HELICOPTER

William E. Evans, M.D.Richard Ruppert, M.D.

R. Orr. M.D.

Since 1967, The Ohio State University and the OhioNational Guard have cooperated in a program ofhelicopter transport of acutely ill and injured patients.Although various helicopters have been used, currentlythe Huey UH-1 H is available. Weighing 9,500lbs., it isextremely mobile and provides ample space for patientcare in higtrt. the helicopter is currently capable ofcarrying two or three litters, Equipment for monitoringand resuscitation are available.

All requests for the Medicopter are funneled throughthe Director of the program to screen cases who mightbenefit from this service. A daily call roster ofvolunteerphysicians is maintained and these men provide medicalcoverage when necessary. In addition, E.M.T. andparamedical personnel are available, Both helicoptercrew chiefs are E.M.T.-trained and are working onParamedic status. During regular duty hours, OhioNational Guard personnel form our flying teams. In off-duty hours, these services are provided by these samepersonnel, again, on a voluntary basis.

Two types of helicopter services are provided. Themost common is hospital-to-hospital transfer of theacutely il l or injured, requiring treatment at the Univer-sity Hospital. The second is emergency highway patrol.On weekends, the helicopter and crew are on alert andactually airborne for most of the daylight hours, respond-ing as requested by conventional ground rescue units.The unit is considered a supplement to existing standardground rescue units, serving primarily in those situationswhere ground transportation cannot meet the needs ofthe specific patient's problems.

A previous report by Roberts, et al.,r outlined the first50 patients transported in our program. In all, ap-proximately 150 patients have been transported byhelicopter to the University and Columbus Children'sHospitals. Experience with 35 patients is reported to in-dicate the types of problems encountered during opera-tion, These patients were seen in November andDecember 1972 and January 1973.

As noted in Figure 1, 20 patients were transported toColumbus Children's Hospital while 15 adults enteredthe University Hospital. There were a total of 19 sur-gical patients, 10 of whom required operations and 16with primary medical problems. Trauma accounted for14 admissions, six from the accident scene with eighttransported from community hospitals.

t . nob"r , r , S. , Bai ley, C. , Vandermade, J.R. , and Marable, S. :Medicopter: An Airborne Intensive Care Unit. Ann Surg, 172:325-33,I 970.

Figure l.

November - December - JanuarY35 patients

M E D I C I N ESURGERYUNDERWENT OPERATIONDEATHS

20 15Chlldren's Unlveralty

1 3 37 1 25 C

c . t

In Table l, data pertaining to the 35 patients is outlin-ed. There were five deaths among the 20 patientstransported to The Children's Hospital with three deathsin the adult group. Seven of the eight deaths occurred inthe hospital-to-hospital group whereas one patientevacuated from the scene of an accident expired onarrival in the emergency room from a crushing chest in-jury.

CASE REPORTR. B. is a 25-year old white male involved in a one car

accident in northern Franklin County (15 miles fromThe Universi ty Hospital) at2:05 p.m., March 10, 1973.The Medicopter was airborne at the time in the highwaysurveilance program. A fire rescue squad reached thescene of the accident at2:09 p.m. The patient was rapid-ly assessed by the fire rescue team and the Medicopterwas notified at 2:12 p.m. of an injury requiring im-mediate pickup and transfer. The Medicopter arrived atthe scene at 2:18 p.m. The Mission Report by the on-board physician E.M.T, and paramedic showed that thepatient was disoriented and combative. He was pale andthe skin was cool and moist. Respirations were shallowand rapid. Pulse was weak and rapid at 120 per minute,Blood pressure was unobtainable. The crew-assessmentsummarization was that of head injury, intra-abdominalinjury and lower extremity fracture. His fracture wassplinted and Ringer's Lactate was started through alarge bore intracath. Oxygen was administered,.he wasrestrained, and spinal immobilization was instituted. Hearrived in the University Hospital Emergency Room at2:25 p.m. During the inbound flight, the emergencyroom was contacted by mobile telephone in order toalert a surgical team. The operating room was prepared.On admission to the University Hospital EmergencyRoom, the patient's blood pressure was I l0/70; pulsewas strong with a rate of I10. He was moved to theoperating room area, x-rays were taken, and explorationwas carried out. He was found to have a ruptured spleen,and splenectomy was done. Traction apparatus was

22

applied for treatment of his femoral shaft fracture. Thepatient made an uneventful postoperative recovery fromh is i n t ra -abdomina l p rocedu re . On the e igh t t lpostoperative day, an intramedullary nail was insertedfor control of his femoral shaft fracture, He was dis-charged on the 20th postoperative day.

COMMENT

Several factors in this specific case point out some ofthe principal advantages of helicopter transfer. First isthe factor of speed of response. Although not the mostimportant factor, it was clearly demonstrated here that

the ability of the helicopter to reach its destination un-impeded by the local traffic conditions is a distinct ad-vantage. Secondly, it provides the delivery of trainedemergency medical personnel to the scene of the accidentso that treatment can proceed during the period oftransport. In this particular instance, the ability toprovide resuscitative efforts may have been of criticalimportance. Thirdly, the ability to communicate directlywith the hospital receiving the patient allows formobilization of the proper medical or surgical teamsdecreasing delay once the patient has reached thehosnital .

columbus chi ldren's Hospi ta l - Medicopter Missions - November, 1972 through January, 1973

Distancofrom

Columbusto pickup Nature of

Pt . Sex Age Pickup Si ts in mi les i l lness/ in j .

0.N. M 4 mo. ER-MI. Vernon, O. 30 subdural hematoma exotreo

M. t \4 . F .B , K . MS.S. IVIJ , B , MO , B , M

S . M , M

B . F , M

B , H , M

90 cot ical contusion90 T-E f is tu la

177 T -E f i s t u l a106 drug ingest ion30 mul t ip le t rauma/fractures

subdural hematoma9O diaphragmat ic evsntrat ton

mi ld prematur i ty30 severe id iopathic rsspiratory expired

drstress syn.-premature90 cyanosis-respiratorydistress med.

heart murmurJ.D. M NB Mariet ta Mem. Hosp. 112 gastroschis is possib le sepsis surgery-

explreoR .D . M 10 y r . Ga l l apo l i s , O . 1OO poss ib l e encepha l i t us med .

8 yr . ER-Portsmouth, ONB L ima , O .

7 mo . I nd ianapo l i s , I nd .12 y r . Ga l l apo l i s , O .8 yr . Mem. Hosp.-

Newark, O.4 da. Portsmouth, O.

NB Mt . Ve rnon , O .

NB L ima Mem. Hosp .

1 1 yr . Barnesvi l le Hosp. 1 1 112 y r . Ga l l apo l i s . O . 106

lv l 73 St . Ri ta 's , O

meo.surgerysurgofymed,surgeryexpiredmed.

m e d ,meo.

med.su rgery

Naturo oftroatmant

1 3 d a .

4 da .3 m o2 m o'I da.4 da.

Length Dischargeof stay Diagnosis

bat tered chi ld syn.cerebral contusion-exp.cerebral contusionT-E f is tu la/ imperforate anusT-E f is tu lapentobarbi ta l ingest ionbrain death/ruptured spleen

J , H , FR,B, IV I

J . H , MC . S , M

F.B. M 7 mo. L ima Mem. Hosp. 90 severe congeni ta l heart d isease med.pneumonra

9 wk. Gal lapol is , O. 106 pneumonia/bronchiol i t isNB Scioto Val . Hosp. 90 L, d iaphragmat ic hernia

J ,C . FR ,W, FA . B , M

R.Z. M 54 yr . West Union, O,

high fever/ rapid rospirat ion med.Reye's Syndrome/pneumonia meo.

med. 1 1 dasurgery 36 da

85 skul l lacerat ionsfractures of spineand manubium med. 8 da

15 head i n j u r y med . 8 da

13 da , L . d iaphragmat ic event ra t ion

1 da . IRDS/prematur i t ysevere hya l ine membrane

9 da . cyanot ic hear t d iseasecong. hear t fa i lu re

4 da . congest ive hear t fa i lu re

7 da , encepha l i tus i ron de f .a n e m i a

7 da . d iabetes ke toac idos is7 da . Reyes Syndrome

bi la te ra l pneumonia17 da . congen i ta l hear t d isease

b i la te ra l pneumoniaL . d iaph. hern ia /ven. hern ia

congest ive hear t fa i lu reprobab le hypop las t ic hear t

congest ive hear t fa i lu ree p i d e r m o l y s i s b u l l o s a 'wrist fractureresp i ra to ry d isease

cya nos is

B.S. M 2 da. Dover Hosp., O 1O7 Congest ive heart fa i lure expired 1 d a

50 da. Toledo Hosp. 141 epidermolysis bul losa med. 36 da8 yr . scene of accident shock/wr is l in jury med. 1 da2 da. Toledo Hosp. 141 congest ive heart fa i lure med. b da

The Ohio Stat€ Univers i ty Hospi ta l - Modicoptor Missions

W . S , F 2 1

T . B , M 1 8

rvl .s . F 50R . G . F 1 7

C .C , F 65t v t .K . F 16

L. tvt.

E , B ,T. tvl.

J , F .J J ,

R , B ,

C . G .

90 ruotured aort ic aneurvsm

hear t a t tacklung d iseasesku l l f rac tu recrush in ju ry -ches tr e n a l f a i l u r e

mul t ip le t raumaruptured sp leen

fx -L . femurface lacera t ions

acute cerv ica l s t ra in

FM

FM

71 C i r c l ev i l l e , O . 25A thens Hosp . , O . 77Union Co. Hosp. 30

1l h ighway acc. Ohic, -25 Ga l l apo l i s , O . 1OG

M 2 5 h i g h w a y 1 5Westerv i l le , O.

M 5 8 h i g h w a y - 3 5Sugargrove. O.

P icker ing ton , O

Athens , O. 77 cerebra l con tus ion

Portsmouth, O. 90 mul t ip le contusionsSt. Ri ta 's L ima, O. 90 vaginal b leeding af ter

C-sect ion/ab. painGalena-auto accident 20 possib le h ip f ractureS. Webster , O. 114 crush in iurv

fx. manubiumhead t rauma & contusion

skul l f racturemed. 4 da, head t rauma

probable seizure disorder2 da , depress ive neuroses7 da . anemia b leed ing

f rom su ture l ine1 d a . m u s c l e p a i n & s p a s m

1 6 d a . d i f f u s e p u l m o n a r y h e m a t o m ad iabetes

surgery 1 da. ruptured aort ic aneurysmexprred cardiac arrestexpired 2 hr . myocardia l infarct ionmed , 10 da . unob ta i nab lemed. 6 da. skul l f ractureexpired in ER t hr . mul t ip le t rauma/crush in jurymed. 27 da. broken pelv is

surgery 20 da. f ractured L. femurcerebral contusion

med. 5 da. acute cerv ical st ra in

SUMMARYThe feasibility of such a project is greatly enhanced by

the availability of a multipurpose helicopter operationsuch as the Ohio National Guard which eliminates in-vestment costs.

In assessing our modest effort of helicopter transportof the sick and injured, it would appear that benefits arederived when the helicopter is used as a supplementalservice to the standard ground ambulance and frre andrescue squads. In the majority ofinstances, these stand-

ard services are quite satisfactory, expecially when well-trained personnel man these vehicles. The helicopterdoes have the advantage of speed under certain cir-cumstances, especially in the situations of congestedtraffic and transfers involving long distances. In addi-tion, the availabil ity of physicians, E.M.T.'s andparamedics make resuscitation during transport possi-ble. The abil ity to assess the patient's problem and tomobil ize needed personnel at the site of delivery has beenan important factor in this program.

24

A SYSTEMS APPROACH TO STATEWIDE EMERGENCYMEDICAL SERVICES

David R. Bovd. M.D.

. Emergency death and disability can no longer bejustifiably classified as an insoluble treatth problem. Medicalexpertis,e and technology are now available whictr can eisity119,.,_.lfi.j,.l,ly .be^ uppltgd ro this previously "rgf..irtneatrn problem. In lact, it is only with the better uti l izationof

, presently available ,erour.es through areawide

rmprementatron that an immediate beneficial improvementcan be effected in a badly organized emergericy healthsystem. In Il l inois, the development of a Stateividjfraumarrogram has shown that through regionalization, expertcare, which was previously avaitible olly in tt . uniuriiivcenters, can now be effectively and efficiently providelHr^":g!:-",

the, state, especially n tne ruiai communlry.ltre success ot'the Trauma program on a statewide basis hasprovided the-gro.undwork forlhe development of a Totaitmergency Medical Service System ln the State ofIl l inoic.4,l U

^ ^In.a spgcial message on health care, Governor RichardB. Ogjlvie discussed the future developrnent of some 40specialized centers for the care of th6 critically iniuredpatient

lo bg- designated throughout the srate.l j ' f l .,elrauma Lare Flan was to be the first component of a TotalEmergency Medical Service .System2,

'which i, U.i.,g

developed on a controlled and systemaiic implementatiofisched ule.

A controlled systems approach to the problems of anemergency medicai service is the most practical andsensible, and will yield the most return. The Iliinois TraumaLare yrogram has been developed in stages by: defining aspecific problem, "Th. Critically I"uiur.a patien?'ideveloping a plan based on established priricipies of clinicaimanagemenr; .a.nd implement ing th is p lan in a systemat icma1nel Dy,uttt lzlng and augmenting existing care facil i t ies,proresslonai talent, and techilologic resources within a giverrcommunitl,. The Illinois Trauma_ program is continuSuslyrnonitored by a specially_designed infolrmational system fo'raccldental i1jury.t,),6 Because of the statewide systemsdevelopment oi a trauma care network, a healthy andpractical implementation enyironment has developed whereproblems have been approached on an empirical basis and*:9t.d

as ongoing events by the entire health community.-l ne successtul implementation of the Il l inois TraumaProgranl is now leading the way for a similar regionalizationo l a l l ca tego , i es o fe lne rgcnc l ' hea l rh ca re .

Status of the Trauma ProgXram

The Il l inois Trauma Progrrrin pla,t lrrs i,ecn previouslyreported in The Journal o.f |iuttrtr^t.I r-he trauma careplogram has to date been implentented in almost every partof the state with the establishrnent of 2I Local.-eishtAreawide, nine Regional and two special Resional Centi.rs.From each trauma center there has been a reo-rganization ofthe communiti.wide patient distribution Ind referralpatterns, the init iation of trauma care education andtraining efforts for ali professionals and allied emersencvpersonnel, implernentation of a urliform and disciflined

communications system, a reorientation and upgrading ofthe transport_ation capability, and an ongoing 6valuaiionproces.s for all patients treated within the sfstem.

All trauma centers are staffed by a new healthprofessional , the Trauma Coordinator . l l t r r .professionals are military-trained medical personnel withmany years of casualty experience. Theie new healthglperts" are employed by the Illinois Division of EmergencyMedical Services and Highway Safety, and are locat"ed ittrauma centers to assist in the various administrative andmanagerial aspects of the Trauma program. TraumaCoordinators are responsible for the ongoin-g collection ofdata fbr the Trauma Regrstry. They have aTso establishedth., basic training course' for imbulance emergencytechnicians. At present, Illinois has the largest numder ofl a l i g n a l l y r e g i s t e r e d E m e r g e n - c y M e d i c a l'Iechnicians-Ambulance

(EMT-Ak). Working with hospitalme di cal chiefs of staff, trauma Jurgeons,

^and

administrators, the Trauma Coordinators are" developingimproved liaisons with the community and ambulancelrescue, and law enforcement personnel. These professionalshave been instrumental in developing thi StatewideProgram at the community level, and hav6 made sisnificantcontributions to the care of -the critically inj-ured byiynlovlng th^e organization of the Illinoii EmergencyMedical Care Svstem.

Special educational programs for trauma eare, e.g.,surgical grand rounds, symposiums, and conferences f6iphysicians, surgeons, and medical students, nurses, andambulance attendants (EMT-A's) are being offered at thetrauma centers across the state. The Trauma NurseIntensive Training Course is providing postgraduate'trainingat the Regional Centers for-nurses across"the state. Thes6nurses have returned to their commur.rities to provideimproved patient care to the accident victims ai theirhospitals. It is these educational efforts that willcontinually improve the quality of trauma ano emergencymedical care in every part of Illinois.

^^ The newiy expanding total emergency medical careetlort is extending these educational efforts to includemore.centers providing the training of EMT-A,s and mobileIeaclltng vans tor ntore remote rural communities. Thetrauma -nurse program is expanding to include all otherareas ol emergency and critical care medicine. There hasbeen the establishment of two residency programs foremergency physicians, and 20 stipends for-Triuria Crit icalCare and Emergency Medical Services Fellows have beenprovided to various communities and university hospitals tosupport, young. professionais in their pursuit of'specialknowledge jn.their respective clinicai f ieids. Moreovei, theDivision of Emergenry Medicat Services and HighwaySalety have trained 1.2 mill ion Il l inois cit izens in medic;lself-help to date.

Program Evaluat ionIn the first year of operation (July 1971 through June

25

lg72), 12,000 patients were admitted-to 20 Traumairnijir with an overall mortality of 2'0%.1 The anticipatednumber of patients to be treated in this system in thesecond year is over 30,000 patients, as more trauma centerscome into it.

An evaluation of the hlghway deaths in a l5'countyarea of central Illinois has shown significant results.o Allhishwav or vehicular-related deaths of calendar yeat 7971an-d of ihe first 6 months of 1972 in Region III-A of Illinoiswere studied. Region III-A, an l8-county a-rea in ceutralIllinois, was chosen for this study because of the initiationof the Statewide Regionaiization Program in this area. Itrthe well-defined cential I 5 -county portion of this area, fourtrauma centers were designated between July 1 andDecember 1 ,1971 .

The patient distribution of all vehicular'related deathsin this

^area has been studied for the effects of

resionalization of patient care for the critically injured. Thespicial emphasis oi this report is the effect of the changingcharacter of patient redistribution and the time constantssurrounding these changes. There are 290 patient deaths inthis study.-Information for evaluation was obtained fromthe hospital and emergency records, autopsy reports,records from the Illinois Highway Department, State PoliceDepartment, Department of Vital Records, and countycotoner reports.

-These patient records were investigated in

detail. Special emphasis was piaced on vital statistics andepidemiologic

- in format ion ( i lc luding t ime and

trinsportation factors when availabie), status of the patienton admission, t ime and type of operation, area of ir.rjurY,organ involvement, and major contributing cause of death.Af patient information was entered into a computerjzedinfoimational system, the Trauma Registry, which utilizesdirect entry and retrieval through remote video terminals.

A highway fatality study was chosen to establishbaseline data for future evaluations. One major problem inevaluating this new program is that of obtaining baseline^information. The study- period includes the first year ofoperation, July 1971 through June 1972, and the 6-monthp6riod just prior to this. Corolers' reports, state policeiecords, and autopsies from the pre'program (control)period" Januarv to June 1971 , were analyzed to provide theLaseline data oi this study. This information, along with thehospital and emergency patient records from theestabtshed trauma centers, was utilized. Three cases in thisstudv. in which conclusive evidence with regard to themeciranism of injury (vehicte) could not be determined, arenot included in ihii report. Several terms are used in thisstudy relating to time/death factors' An accident victimwho was killed instantaneously or died within minutes atthe accident scene if defined as "Death at Accident"(DAAC). "DOA" refers to a victim who was consideredalive during transportation but died before arrival at ahospital emergency room and was pronounced dead onarrival. All other pitients deaths in this study occurred afterhospital admission.

Mortality EvaluationPatient Redistribution. Evaluation of the Trauma

Program has shown several positive findings in the first yearof operation. The 290 deaths studied were divided intothree groups: (1) the pre-program period from January 1 toJune 30, 1971; (2) the program implementation period forJuly I to December 31,1911; and (3) the first 6 months offull operation between January 1 to June 30, 1972. Theprogram was implemented at hospital trauma centers in this

area, in Springfield in July l97I,In Litchfield and Lincolnin August 1911, and in Jacksonvil le in December 1971.This phase development necessitated a commitment bythese

- communities for the designation of the hospital

trauma centers. Because no trauma center had beendesignated in the far western three-county area, the datareported here refer only to the central l5-county area ofReeion II-A.-

There has been a definite change in patient flow inRegton III-A. A general disarray of patient tratlsportationafter critical injury in the III'A Region was noted duringthe control (pre-program) period. During the programimplementation period, it was evident that there was anori-entation of the critically injured patients to the LocalTrauma Centers at Jacksonvilie and Lincoln, withsecondary transfers to the Regional Center in Springfield.In the Springfield area, particularly, there was a strikingchange in pafient distribution. This trend has been furthersubstantiated in the third period from January to June1972. ln this period, 15% of all nonsurviving accidentvictims taken to Springfield went to the Regional TraumaCenter. The number of patients directed toward traumacenters increased 60% during the two periods ofimplementation and fuii operation. The number of dyingpaiients going to the nontrauma centers decreased 20% forthe same period.

Highway Mortality Rate. The Department of Statisticsof the National Safety Council has reported a decline of 8%in highway fatalities for the State of Illinois for the first 6months of 1972 as compared with the same period of 1971.An increase in highway accidents (8Vo) and persons injured(9%) was also reported for this period over the entire state.During this same period, the 15 counties in Region III'Ahave experienced an increase in accidents (27%), a:r increasein persons sustaining injury (l6V), and a decrease inhighway deaths (15%). Of particular significance is thesteady decline in the percentage of deaths per personinjured -- a decrease ftom 2.8% to 2.1% for the studyperiod. Although the accident reporting rate to the IllinoisDepartment of Transportation is up 23% for the first 6months of 1972, this does not affect the percentage ofpersons dying in Region III-A after accidental injury, whichis reported here (Figure 1).

Time of Death. During the implementation and fulloperation periods of the trauma system, there has been asignificant change in patient survival times. In conjunctionwith an overall decrease in the number of vehicular deaths,the total number of victims who die at the accident scene(DAAC) has dropped fron 42 during the first period to 26in the third period, a decrease of 38%. The number of Deadon Arrival at Hospital (DOA) and the number of patientsliving beyond admission to the designated center haveincreased. Of those admitted to a traullu center, thenumber of those dying within the first hour has decreasedfrom 44.4% to 32.1%, with more patients l iving longer inthe hospital while in a better treatment environment(Figure 2).

Gross Anatomic Involvement. An evaluation of thetype and magnitude of injury to these dying patients hasbeen undertaken. The gross anatomic part, including thecentral nervous system (CNS), face chest, abdomen,extremities, and those with multiple (undefined) injurieshave been cross-indexed to the recorded time of death. Sofar there have been no significant changes in the types ormagnitude of injuries sustained in these dying patie,nts-These data indicate that CNS and chest iniuries are involved

26

It

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

The beneficial effects of improved patient survivai, inspite of increased ac_cident una in1u.y rates, have beenaccomplished by the development of a irospitai network oitrauma centers. The reported improvern'ents in patientredistribution and length- of patieni survival are secbndaryeffects of this effort to.designate one strategic hospitaiiieach area for the special cari of the accideiit nctim. Theprogram activities for the first year have been directedalmost entirely toward the hospiial phase of the accidentcare systen. The apparent improvernerrt in thetransportatio^n phase can only be attributed to ar.r indirectsecondarv ellect,

Systems lmplementation by Model Building

The suCcess of the Trauma prograrn can be measured ir.rterms of local health-planning, regionaiizatiou of care, and,more recently, the development of a uniformcommunications systenl upgrading the transportatroncapability, and establishmeii of

-lay and professional

educational progrsms. These sub-system components havebeen sequentially integrated into the trauma system overthe past year, and will be evaluated for their effettiveness inthe very near future.

^ Tlr. Trauma Program has identified the terms Regional,Areawide, and Local for trauma ceuters (Figure 3). 'Thesedefinit ions are now being broadened in scope"to inciude theentire community. The levc.l of clinical care capabil ity,communications and trausportation ,eso urcei, arideducational po-tential are now laking on a comniunity andareawide significance for all other categories of ernergencymedical care. The development of i Regonal t iealtirSystern has been an ex^citing proposition, a.,id its benefitshave been anticipated for some time. The State of I l l inoishas embarked on a Regionalization program for the Care ofthe.,Crit ically Injured Patient, and is" r.row developing asimilar.prograitr on a wider spectrum for all emergellcymedical care. Program development and overall resulti wli lrequlre adequate monitoring and documentation withsupportive evidence. On-line data acquisit ion and analysisusing the Regstry approach are esseniial for the succesi ofsuch€_ program, and are now being developed.

The basic trauma sys^tem is now funciioning as a modellor,9th91. categories, of emergency medical- care, e.g.,Cardiac (Figure 4), _Pediatri cs, Poisoning, Drug Into icatio"n,lnd Psychiatry. By expanding the prinliples of theStatewide*-Trauma System, a Total Emergency MedicalSystem (EMS) is now being established for

-all the citizens

of I l l inois. Categorization of all emergency departments isnow mandarory by l l l ino is law (p.A. ZO- lS5S;. and must bedone ln concert with areawide EMS planning. Allcalegorization_proposals must be approved 6y the l l inoisprptor] ot Emergency Medical Servlces and HighwaySatety by Jar.ruary 1913 and implemented by July"1975.L aregonzat lon und areawide p lanning are beingaccomplishejl by local planning agencie"s and newliestab lished Emergen cy Medi cal Servi ce

-Co un ciis. Be cause oi

the Trauma Program, many communities in the state havealreaoy_ galned a great measure of sophistication incomprehensive areawide planning and implementation.

Technical implemeniation of the cornmunications andtransportation,subsystems has become achievable, now thatan areawide planning mechanism is working. Education ofnealtn personnel is an ongoing program throughout thestatewide system. These educationai programs 1re being

developed in conjunction with community colleges anduniversit ies across the state.

, - fledigal ernergencies other than trauma are being addedatong reglonal designs in a time_phase sequence. Additionalcrnlcat regtstnes are being developed to evaluate theprogress in each category. In Il l inois an unstructuredp.rogram for pediatric enrergerrcies arrd ptl ison corrtrolaheady exists, ald is being phased info the traumaemergency medical services network. Clinical cardiac andcr i t ica l care programs wi l i be in tegrated in to the Tota l EMSrysrem ato l lg wi th thei r coro l lary t ra in ing and educat iongo_gl-.*: Psychiatric.emergency iare in Illinois is currentlyIraglnented, scrttered, and nonregionalized. Considerablit ime wil l be necessary_ for the planning with tt.Department of Mental Health for impiovej' .,rl.rg.n.yservices in most of the geographic areas oi I l l inois.

The initial results of tle Trauma program are verysatisfactory_: a iA% decrease in death irom hlghway?:.i.d?tj, throughoLrr the srate and 15.4% in the {egoil jt-A;Y lhis regional approach to accident care can decriaserne. tugn death rate now being experieirced across thenation. The change in patient distribution, as well as thetrnre_ta.ctors^in patie^nt deaths in this study, point to theDenerlclal eltects ot a controlled systems n]odificatior.rapproach. The. ntajor emphasis in the trauma system hasbeen the establishment of an interrelating hospital (traumacenter) network. The secondary, benefi"ts eained'in thetransportation of the crit ically i l l include the-redirection ofpatient llow and a change in the time constants for the timeoldel rh af ter a fate l in iurv.. Approxirnately 6Ci% bf all heart attack ractirru die of

therr major s).ntptonts within the first hour.9 Death usuallyoccurs outside the hospital and without professionilassrstants in attendance. The hospital corouary care unlt(CCU) has reduced the in-hospifal death iate for hear.tattacl<s by 20% through arrhythmia detection andtreatnrent.v Much of this highiy specialized care is given bywell-trained nurses. The total impict of the hospitai CCU islirnited. by the fact thar the nrijority of patients do notrerch rhe hospiral alive. It is rhe interit of the Ii l inois Totaltnrergency Medicd Care System to improve coronary andcrit ical care medicine in remote community hospit; ls ttestablishing Ourlying Criticat Care Units fbCCU). il1#reltote lrospital intensive care units will be lii*ed toadvanced Regionrl Centers for expert on_line medicalcollsultation.z

Overland Crit ical Care Vans (OCCV), a regionally basedmobile intensive care ambuiance will facilitat"e tne ,i.li;;;tof sophisticated critical care_ during the prehospital anii{:t!-C:O!lu, periods. The Overland Crii i iat iare Van(OCCV) (F igure 4) is a mobi le , rnul r ip le-purpose intensivecare unit that wil l uti l ize the special nreOicat t i ient availableat each Regional Center to provide optimal intensrve criticalcare for a large geographic area ol responsibil i l ;2

These vans wil l be based at the i legional ind Areawide9:n, .p, i , lg wi l l prov ide the u l t i r f ia te in specia l izedPlensiye

(l ite-support). care for patients while they areDelng transported to advanced facil i t ies where specializeddefinitive care is available. OCCV,s will provide anextension of the Intensive Care Unit (ICtf iritical areacapability of Regional and Areawid. horpituls to othermstitutions. In the OCCV, patients wil l reieive continuedard many times enhanced critical care during transfer. Thethreat of loss of continuity of patient .*. Of.ing necessarytransfers will not occur. Uniform resuscitation equlpment,fluids, drugs, ventilators, and critical laboratory aids will be

tt

21

installed in these vans. They will have an operational rangeof approdmately 50 miles. Beyond a radius of 50 miles,helicopters and fixed wing aircraft are being employed. ̂

T[e core staff for these vans consists of certifiedemergency medical technicians. The technicians receive, inaddition to the nationally prescribed 82-hour course' a4-hour seminar which emphasizes management of the vanequipment , resusci tat ion (mechanics and drugad-ministration), and therapy of cardiopulmonaryinsufficiency. Training is continuous, and special coursesfeature pediatric and coronary care. The EMS technicalstaff is augmented when necessary by specially trainedrespiratory therapists, nurses, and physicians. Theseprofessionals will be used to satisfy the specific needs ofinv individual patient being transfened. When transferinvolves a high-riik or premature infant, special nurses andphysicians from the Regional High Risk Center willaccompany tne van,

A-critical care van should have the capability ofcarrying two patients of any age or size. There must beenough floor area and head room so that the attendants canadminister critical care readily to both patients. Thepractice of critical care necessitates a smooth ride. As thevan system has the same capability as any special care unit,a hijh rate of speed is not only unnecessary but alsoundesirable.

It is the aim of the Illinois statewide effort todemonstrate an emergency health delivery system withgood care at the scene of the accident, during primary-andiecondary transport, and at the special care units whichmeet the specific needs of any critically ill or injuredpatient.-

A trauma system, as impiemented in Illinois, can standalone, or be an integral part of a total emergency medicaiservices system. Each component of a trauma system can beindepend-ent or be integrated in varying degrees with thecomponents of a critical care system' The cofiImolldenominators of these systems are: (1) regionalization ofplanning and care; (2) communications and transportation;ind (3t education at all levels of the society. The efficacyof each program component must be objectively measuredon a continuous basis.

Discussion

It has been anticipated for some time that improvedtrauma and emergencymedical care could be obtained by abetter organizational approach to this pro-blem.

In Il'linois, the d6velopment of a Statewide TraumaProgram has shown that regionalization of expert care,which was previously available only in the universitycenters. can now be effectively and efficiently deliveredthroughout the state, especialiy in the rural community.The iiitlal success of the Trauma Program on a statewidebasis has provided the groundwork for the.developmentofa Total E'mergen.y Medical Service (EMS) System in theSrate of I l l inois.

The system for trauma care is being developed byintegrating the following essential components: hospital( t rJuma- center) categor izat ion; communicat ions;iransportation; training and education of bothlrofessionalsand ihe public; and program evaluation. The essentialsubsystemi must be integrated into a comprehensivepa.kag. which supports improved patient care and furthersdevelopment of regional designs. Some cotitroversy exists asto which is the most important subsystem. The Iiiinoistrauma care approach has not attempted to establish a

priori which subsystem will eventually be considered themost important. Instead, an arbitrary decision was made toproceed initially along the line of categorization ofb-rtg.n.y care facilitiei for the critically inJured patient.

In each major community and strategic geographicdistrict the local Health Planning authority was asked toselect the one hospital best suited for the care of theseriously injured. In addition to this initial designation of -atrauma'-cenier, all hospitals, professional and allied healthpersonnel, and community leaden have started the task ofintegrating other subsystems into a comprehensive traumacare system by developing areawide Emergency ServiceCouncils. It is anticipated that every hospital will haveself-categorized its capability for all aspects of emergencymedical care by July 1 , 1973 .

Calegorization is only the first of the necessary steps toa true regional EMS system. The goal of this approach mustbe the continual upgrading of trauma ar.rd emergencymedical capability in communities with substandardresources. This approach will produce other benefitsincluding better cost effectiveuess and improved resourceutilization in those communities which are unnecessarilyduplicating their efforts, monies, and medical manpower.

The second highest priority in the Illinois TraumaSystem is the development of a comprehensive, uniform,simple, practi cal, and w orkable communications- capability.Thii wili by necessity be pluralistic, and will include simpletwo-way ridio voici:, teiephone patch, dedicated phonelines, and in some instances microwave capabilities. Themost important aspect of a communications subsystem isthat it compliments the medical needs of the entire- system.It must lnilude central dispatch and controi of mobileelements of the system. A medical tesource guidancesystem is being developed for patient care advice'interpretation of bioelectricai data' and triage at-the sceneof th-e accident and during transportation to a designatedtreatment facility. Necessaiy engineering can be effectivelyadapted to serve medical requirements as they areidentif ied.

Solutions to the problem of providing upgradedambulance services musi be stylized to meet the specificneeds and capitalize on the existing resources of eachcommunity. In Il l inois, each Trauma. Coordinator isworking with local govemments, municipalities, arid privateambulairce operators to develop workable answers to whatin many communities were considered "insoluble"

problems. By identifying existing medical resources iniommunity hospitals, colleges, industries, and even prisons,and by assisting in federal grant appiications, the TraumaCoordinator lias beeu instrumental in introducingambulalces of nationally accepted design criteria for thefirst time to many rural ateas. Previously, many of thesecommunities had no real comprehension of an acceptableambulance. In addition to improving primary ambuianceresponse capability, Illinois is developing a secondarytransportation system which includes helicopters, fixedwing airplanes, and mobile intensive care vans.*The-lasting

benefits of medical program depend on thequality of thJmedical personnel providing those essentialetnerg-ency services. The Illinois Program has placed a majorempliasis on the training of emergencyirealth and traumacare workers at all levels, including: the Emergency MedicalTechnician-Ambuiance (EMT-A) and the advanced EMT-A;the trauma nurse and her educator, the Trauma NurseCoordinator; and a new administrative professional, theTrauma-EMS Coordinator. Educational programs for

28

em€rgency physicians, Trauma and Critical Care Fellows,and trauma surgeons arc also being developed aspostgrad.uate. training programs. young- traumatologists,well-equi_pped_and trained in the team approach to accildentcare, will further the apparent progresi

-that is now being

realized in this field.Evaluation at all levels of the system is necessary.

![nois Qs pionee,rejl in this area with tfie deveiopment of a

Irauma^Registry.l Data are now available which documentsome of the results of change in patient distribution anddemonstrate the need for sp-ecialty Uu.f.up-u, well as theallocation of criticai care manpow6r. Thesd studies are alsopointing the way to better cost and clinical effectrveness intrauma care. These evaluation programs are being extendedto measure_public awareness-and accessibil i ty to entryroutes into the trauma-EMS system in times of need.

In order to init iate a total system approach to traumaand.emergency medical care, a simple, piu'.ti.u1, controlledim?,lemen"tatiol. pl?n. was -developea. ny O.fining it,p:91:T tor criticalty injured.patienrs,, and by categoiizingnospltal emergency capabilities for this group, significanlprogress has been realized. One enthusiasri; ir idividual.?gency, or association will not solve this massive problem.It will require a consortium ofall interested health agenciesworking together rather than in competiiion.

-These

participants will need to realize that individual efforts mustbe consistent with the overall pro$am.

Figure 2.

T IME DEATH INDICES(Region A(15 Cotrnt ies)

IOO%-1z

G

3 Aov"

E.a

0

(J

Figure l.

HIGHWAY DEATH RATE(Region I f A( l5 Count ies)

ttttt'

G--------- ----at t" t t t '

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

Tofol Deofhs, AZ 96 70ftriod, Jon.alune, l97l July-Dec., l97l Jon_June, 1972

The time of death: Dead at accident (DAAC ),Dead on arrival at hospital (DOA), and thosedying after admission to trauma centers.Shown is the deuease in DAAC from 5l.2Voto 37.t%o, while the DOA and aftir admissiondeaths correspondingly increase,

Figure 3.

Spec io lCoreCente rs

A graphic conceptuqlization of the areawidecategorization of hospitqls in the TraumaProgram. Small "Local"

and medium-sized" Areawide" Trauma Centers selectivelv refer

patients to the larger Regional Cenier.Patients with unique problems leave the basiccatchment area to Special Trauma TreatmentCenters.

o

Ec

o

- l lb_r r - ,

, -aa t ' - - - - -

_ r_- - -_ - '

-autt'

e'- ,---. Tolot occidenls

ffi font persons injuled

Tolol Deolhs' 82 96 70Per iod, Jon.-June, 197 | July_Dec, l97l Jon._June, 1972

Highway accidents, injuries, ond mortalityNote the increase in the number of accidents(auto) and injuries (individuat) during rhestudy period. The percentage of patientsd_eaths per individuals injured (pC beaths/Injured) has decreqsed from 2.8Vo to 2.1%in this study period.

29

Summary

The following is a list of prograrn goals which arebeing implemented in the State of I l l inois' Total EmergencyMedical Service System.

. Goal I. To provide accessibil i ty and emergencymedical service to every cil izen of I l l inois in order thai thevmay receive benefits of emergency and crit ical car-emedicine.

Goal II. To develop a comprehensive energency andcritical care _ system which will fully utilize existingresources while stimulating the development of new carecapabil it ies where these are insufficieni or totally lacklng.

Goal III. To develop practical and workable solutionsto the _ ̂ emergency medical service problem uti l izingaccepted forms of health care application.

Goal IV. To plan and develop all phases of theprogram uti l izing community and areawide planning.

Goal V. To evaluate and monitor programscontinuously in order to determine all critical factors toprovide for ongoing modifications and analysis.

Figure 4.

Pre Hospitolt rmo.nann. en 'o

A graphic conceptualization of the developingCardiac Care System. Multiple hospitals ineach local, areawide, and regional communitywill be involved with primary emergency cqr-diac care. Outlying Crit ical Care tJnits(OCCLI's) and Overland Critical Care Vqns(OCCV's), as well as prehospital emergencycare programs, are being developed. Asemergency coronary care improves, includingacute open-heart surgery, a referral systemwill be implemented as shown.

Goal VI. To develop a total system that will befinancially and administiatively self-supporting withoutcontinued subsidization from external sources or relianceon a state or federal bureaucracy.

Fortunately for the State of Illinois, a vast amount ofe xperience in problem identification and systemsremodeling in the area of emergency medical service hasbeen gained. With the successfui development of theStatewide Trauma Care Program, specific

- problems and

their solutions have been identified and tested. By using thepositive and negative feedback approach, the entire healthcommunity of the state has gained a considerabie degree ofsophistication in the area of emergency care systemsdevelopment . Because of the statewide systemsdevelopment of a trauma care network, there has been theemergence of a healthy and practical implementationenvironment where problems approached on an empiricalbasis have been studied as on going events by the entirehealth community.It is the effort over the past 2 years thatis enabling lllinois to step forward to a total systemsapproach to emergency and critical care medicine on astatewide basis. Emergency medical care is no longer aneglected disease in Il l inois.

References

L Boyd, D.R.: Computer ized t rauma registry (edi tor ia l ) . J . Traumal l : 449 -450 .1971 .

2. Boyd, D.R.: A tota l emergency medical serv ice system for I l l inois:a preview. I l l . Med. J. 142:486-488, 1972.

3 . Boyd , D .R . , Dunea , M .M . , and F lashne r , B .A , : The I l l i no i s p l anf or a statewide systemof t rauma centers.J. Trauma13:24-31,1973.

4. Boyd, D.R. and Flashner, B.A.: The Critically Injured Patient -Concept and the Illinois Statewide Plan for Trauma Centers.Spr ingf ie ld, I l l . , Department of Publ ic Heal th pr inters, 1971.

5 . Boyd , D .R . , Lowe , R . J . , Bake r , R . J . , and Nyhus , L .M . : T raumaregistry: new computer method for mul t i factor ia l evaluat ion of amajor heal th problem. J.A.M.A. 223:422-428, 19'73

6. Boyd, D.R., Lowe, R.J. , and Flashner, B.A. : A contro l led systemsapproach to statewide emergency medical services implementation.President ia l -e lect paper presented at the American Publ ic Heal thAssociat ion meet ing November 14, 1972.

7. Boyd, D.R., Mains, K.D., and Flashner, B.A. : Status report :I l l inois statewide t rauma care system. I l l . Med. J. 14l :56-62, 1972.

8. Boyd, D.R., Rappaport , D.M., Marbarger, J.P. , Baker, R.J. , andNyhus, L.M.: A computer ized t rauma registry: a method for com-prehensive invest igat ion ofa major heal th problem. Proceedings ofSan Diego Biomedical Symposium, Feb., 1971, pp. 209-218.

9. Con, R.D.: The prehospi ta l care of medical emergencies.Proceedings of Maryland Nat ional Conference of EmergencyHea l t h Se rv i ces ,Dec .2 , 1971 . U .S . Depa r tmen to f Hea l t h , Educa -t ion, and Welfare, 1912, p. 11 .

10. Flashner, B.A. and Boyd, D.R.: The cr i t ical ly in jured pat ient : aplan for the organizat ion of a statewide system of t rauma faci l i t ies.I l l . Med. J. 139:256-265. l9 '11.

l l . Ma ins , K .D . , Boyd , D .R . , and F lashne r , B .A . : A new hea l t hp ro fess i ona l : t he t r auma coo rd ina to r . l l l . Med . J . 142 :158 -160 ,1972.

12. Nat ional Academy of Sciences, Nat ional Research Counci l Com-mit tee on Trauma and Commit tee on Shock: Accidental Death andDisabi l i ty : The Neglected Disease of Modern Society.Wash ing ton , NAS-NRC, 1966 .

13. Ogi lv ie, R.B. : Specia l message on heal th care. Spr ingf ie ld, I l l . ,State of l l l inois Pr int ing Off ice, 1971.

30

t -

STUDY OF THE EFFECTIVENESS OF COMPUTERIZED MEDICAL SYSTEMSREVIEW AND DISEASE DIAGNOSIS IN THE EMERGBNCY ROOM SETTING

Bruce Houtchens, M.D.

INTRODUCTION

In the summer of 1972, a study of the effectiveness ofcomputerized medical systems review and diseasediagnosis, in the emergency room setting, was conductedat the University of Utah Medical Center.

The emergency room setting has not previously, to ourknowledge, been the site of attempts at computerizeddiagnosis. However, in several respects, it offers an idealsetting for evaluating such attempts, both for accuracyand usefulness. In contrast to a hospital admissionsscreening clinic, most non-trauma cases of acute oremergency room medicine present with unknown or self"guessed-at" problems, and many require immediateconsideration of differential diagnoses before an ap-propriate disposition can be made.

In the E.R. setting, physicians have not t ime to takethorough histories; and at all hours and under all cir-cumstances, cannot consistently take into account allfacts potentially at their disposal. A computer can beeffective in this environment if i t ( 1) gathers informationin minimum time and with minimum interference withemergency room routine; (2) organizes information forpresentation in concise, logical printout; (3) minimizesboth false negative (missed) diagnoses and false positivediagnoses (which, in engineering jargon, constitute"noise") .

OBJECTIVES AND PATIENT SELECTION

Initial objectives of the study were three: (1) to seehow well the comouter could do "asainst the housestaff '

in evaluating previously undiagnoied problems; (2) toobtain housestafl reaction regarding usefulness of havingthe computer printout as an aid in reaching a diagnosisand making a disposition; (3) to find out what sorts ofadditional problems and information could be elicitedfrom an emergency room patient population by fairlythorough and systematic questioning. This last objectivewas expected to raise some interesting questions; as mostof this sort of information probably currently goes un-disclosed in the emergency room setting, thus obviatingthe need for decisions.

Patients selected for computerized history taking weresimply those who presented with an init ial complaintwhich appeared would necessitate consideration of adifferential diagnosis before a disposition could be made.A common complaint of this nature is abdominal pain;hence much of this study focused on that problem in par-ticular. Obviously excluded were the very young, thevery old, those too seriously i l l to give a history, andtrauma victims.

THE PROGRAM AND THE HARDWARE

The basic logic of the computer program used in thisstudy consists of a sequential Bayesean approach,modified by various l ists of l inked questions.t The heartof the Bayes decision-making data bank is a probabil itymatr ix table, consis t ing of 292 quest ions by 132 d iseases.To each position in the matrix table (Figure l) is assign-ed a number: the probabil ity that a patient having thedisease listed on that row would answer "yes" to thequest ion l is ted in that co lumn.For each question answered "yes," the following equa-t ion is so lved:

oej( p n o r )

to ,

p ^where

' u i (on the le f t ) is the probabi l i ty of the pat ienthaving d isease i a l ier g iv ing a "yes" answer to quest ion j

P ^(and u i on the r ight is that probabi l i ty pr ior to answer-ing quest ion j ) ; and PQi is the probabi l i ty that a pat ient

l ) iwi l l answer "yes" to quest ion j , g iven that he has d iseasei ; and the denonr inator represents normal izat ion over a l ld i seases.

In each of l0 body systems ( ie , G-1, G-U, etc. ) thereare sets of 5 questions designated as "key." A sample setol' such questions, for the G-l system, follows:

Do you have diff iculty swallowingHave you recently had pain in the abdomen or groinHave you recentlv been bothered by nausea or

vomit ingAre bowel movements even dark b lack color , or wi th

red bloodHave you recently been having diarrhea

Befbre beginning the history, the patient is asked toselect that area which he feels is bothering him most; sothat the first set of key questions with which he ispresented wil l hopefully contain his chief complaint.When "yes" answers to key questions are obtained, ad-d i t ional quest ions are brought up ( in groups of about 5 ata time) according to several considerations.

The f i rs t considerat ion in select ing those nextquestions are the l ists of l inked questions. If a patientresponds "yes" regarding pain in the abdomen, then

t o ,Di

ns---t

L too

Po

Dr.

3t

Figure 1: Sample portion of probabll lty matrlx table (abdomlnal pain l inked questions)

PepticUlcerDisease

5

on

5

20

AcuteGastro-enterltls

1 0

40

1 0

1 5

20

Hlatal Ghole- pan-Hernla cystitls creatitis

Do you get pain which ismade-worse by lying flat

Does bending or s toopingbr ing on your pain ormake i t worse

ls your pain made worse bvfood or dr ink

ls your pain re l ieved ormade bet ter by food, mi lk ,antac ids

Does your abdomen hurrmore when you move a-round or cough

Do you have pain made bet-ter or worse by a bowelmovement

Do you have abdominalpain which goes awayaf ter vomit ing

1 5

1 0

20

'10

70

70

50

1 5

50

1 020

(before a calculation is made regarding the probabil ityof particular G-I or G-U disorders) sets of questionshaving to do with when it occurs, its location, its nature,and what makes it better or worse wil l be presented.(The "what makes it better or worse" questions for ab_dominal pain appear in the leftmost column of Figure l,above.)

The next consideration'in selecting additional ques_tions is that of maximizing probabil i iy ratios. It is thisconcept which permits moving to diagnosis relativelyquickly, avoiding the time consuming nJed to follow ouilong branching arrangements inherenl in binary decision(Boolean lo.gic) programs. It also offers the abil ity toquickly get back on the right l ine of questioning, despitean erroneous answer early in the history.

.Sequences of questions are presented unti l either theprobabil ity for a disease reaches at least 90Vo, or oneruns out of questions that are ,.worth" asking. Then thene;(t set of key questions is brought up.

The probabil ity ratio concept functions asfollows: When all l inked questions have been ask_ed, disease probabil it ies are calculated and the twomost probable diagnoses are selected. For each ofthese diseases a new question to be asked isselected, which maximizes the rat io of theprobabil ity of a patient having that disease giving a"yes" answer, compared to the average proUabit_ity of a "yes" answer in the general population. Toattempt to distinguish between the two diseases.three additional questions are selected which max_imize the ratio of the probabil ity of a ..yes" answerfor one- disease, to the probibil i ty bf a ,.yes"answer for the other. For instance, ior the case ofabdominal pain, reference to Figure I shows thatto attempt to distinguish between peptic ulcer and

A disease is considered ,.diagnosed" (and issuggested on the printout) when probabil ityreaches 90Vo. lt is considered that thire are nomore questions worth asking in a system when themaximum ratio of probabil ity of a .,yes" answer toa question for the most l ikely disease, to a ,,yes,'answer for the next most l ikely disease, is less than|.2 for all (yet unasked) questions. In this event,the most l ikely disease wil l be suggested anyway,provided that the sum of the probabil it ies of t ieIwo most l ikely diseases exceeds 0.5. If theprobabil ity of the second most l ikely disease ex_ceeds 0.2, i t wi l l a lso be suggested.

Whenever a new set of key questions is ..brought

up," all disease probabil it ies are reset to nomiialvalues so that additional diseases can later bediagnosed "independently." (Note, however, thatprevious positive answers are o.remembered"

bythe machine; and all subsequent calculations arebased on a/ / prev ious answers.)The essential hardware items present in the emergen_

cy room were a computer terminal with a large cathoderay tube screen; a high-speed printer; and an extensiontelephone and data l ink unit. Each of these items fit con_veniently on a separate shelf of a small castor-wheeledsupply cart, and each (non-trauma) room in the E.R.had an extension telephone wall-jack receptacle. Thus apatient could work on the computer histoiy in his roomwhile waiting to be seen by a doctor (or whiie waiting forlabf x- ray resul ts . etc . ) .

To connect the power cords, dial the data-link

cholecystit is, good questionspain made worse by food orpain relieved or made betterac ids."

5

to ask are "Is yourdrink" and "Is yourby food, milk, ant-

32

telephone number (to make connection to the centralcomputer), "enter" the patient into the system, and ex_pfain the moves to the patient, all took about l - l lzminutes. After making the first couple of moves, mostpatlents never required further assistance-they wereleft alone with the terminal until the history was com-pleted. Median time required to complete the history in

the emergency room study was l l minutes.A printed copy of the diagnostic suggestions, under

each of which were listed those positive risponses whichcontributed to those diagnoses; and a l ist of otherpositive responses in the systems review (organized ac-cording to appropriate system); was obiained im-mediately following completion of the history.

THE PATIENT ALSO1 CONSTITUTIONAL2 SKIN3 EENT4 NECK AND NODES5 BREASTS6 HEART7 LUNG8 G- l

RESULTSIn evaluating the data, it is convenient to make the

following definitions: A "primary diagnosis" is definedto be one which could be an explanation for the patientrschief complaint on presentation in the emergency room.A "secondary diagnosis" is taken to be on! which ex-plains some condition other than directly related to thechief complaint. A "true" diagnosis is taken to be oneconfirmed in one or more of the following ways: (l)..In-disputable" clinical impression by more than onedoctorat the completion of E.R. evaluation (copies of eachE.R. sheet were attached to the computer printout and

7 /18/72

HAS HAD DIARRHEA RECENTLY9 G-U

1O M-SGETS LOW BACK PAIN

11 ENDOCRINE12 NEURO13 PSYCH

PATIENT COMPLETED HISTORY IN 6 MINUTES

Flgure 2: Sample prlntout

SELF ADMINISTERED PATIENT HISTORY

SMITH SADIE 6006860HISTORY SUGGESTS

CHOLECYSTITIS-__BECAUSE THE PATIENT

HAS PAIN AGGRAVATED BY FOOD OR DRINKIS AWAKENED AT NIGHT BY PAINEXPERIENCES PAIN WHICH IS SHARP AND STABBINGHAS RECENTLY BEEN BOTHERED BY NAUSEA OR VOMITINGEXPERIENCES ATTACKS OF CRAMPY ABDOMINAL PAINHAS HAD STEADY CONTINUOUS ABDOMINAL PAINHAS HAD RIGHT UPPPER QUADRANT ABDOMINAL PAINEXPERIENCES PAIN FOLLOWED BY NAUSEA OR VOMITINGHAS HAD ABDOMINAL PAIN OF GREATER THAN 30 MINUTES DURATIONHAS HAD SEVERAL OTHER EPISODES OF SIMILAR ABDOMINAL PAIN

CARDIAC FAILURE___BECAUSE, IN ADDITION, THE PATIENT

IS OFTEN SHORT OF BREATHIS SHORT OF BREATH LYING DOWN BUT NOT SITTING UPHAS DIFFICULTY BREATHING AFTER FLIGHT OF STAIRSHAS HAD HIGH BLOOD PRESSURE

SYSTEM REVIEW

kept on file); (2) convincing evidence by later inpatientor outpatient studies (ulcer on UGI x-ray, M.I. by ECGand blood chemistries, etc.), which, when done, werefollowed-up for each patient in the study; or (3) evolvedclinical impression after one or more follow-up out-patient clinic visits (chart review several weeks laier). A"false'o_ diagnosis is one disproved in those same ways."Signal-to-noise ratio" is number of correct (primary orsecondary) diagnoses: number of incorrect (primary orsecondary) diagnoses.

The data are presented in several tables, for furtherdiscussion.

33

TABLE A: Break-down of primary dlagnoses accordingto appropriate system ol chief complaint

system forwh ich ch ie l

compla in t wagg iven

Const i tu t ional(ma in l y f l u )

EENT 21c-R 30G-l and 92

abdomina l pa in

numborof numberof Percentpatienls lor patlents lor accuracy

whom cottect whom PrimarYprimary dlag- dlagnoslt wa8

noaia was mlssed bYmade by compuler

computer

7 3 7110= 70To

G-UM-SEndocr ineNeuroPsychTotal

2450

1 5l c

209

1 21/22 = 96Vo15 30/45 = 67Vo16 92/108 = 85Vo

4 24/28 = 86Vo0 5/5 = 100Va1 O/1 = 0Vo3 '15/18 = 83Vo2 15/17 = 88Vo

45 209/254 = 82Va

254 patients constituted the study. Overall -accuracylor primary diagnoses was 82Va' Accuracy of primary

diagnoses 'for

108 patients presenting with abdominalpain or G- l d is turbance was 85%.

TABLE B: Break-down of all dlagnoees lor all patlents, accordlng to sgont maklngdlagnoals

lruo fallo truo lalse noprlmary prlmary lecondary secondary dlagnosls

dlagnoatr dlagnotlr dlagnolls dlagnotls

4 2 0 2

agent maklng dlagno!l!

computer , a l l involvedhousestaff , and susPectedby patient

computer , and a l l involved 163housestaff

computer , but missed bY 35at least one of involvedhousestaff

housestaf f , but missed 37by computer

known to pat ient , andmade by comPuter , butneglected by in i t ia l house-

1 6 9 1 1

165 219* 226 1

22

58

staff physician

Total, all agentsTota l , computer

277 ***

240

2031 8 1

226226

1 31 2

294288. .

* 104 o l which are psychiat r ic d iagnoses** 184 when computer-only psychiat r ic d iagnoses are excluded

*"* There are more totat primiry diagnoses than patients, as some patients had morethan a s ingle pr imary d iagnosis - for instance, chest wal l pain and anxiety

An overall primary diagnosis accuracy of 82Vo wasconsidered moie than acceptable at this stage ofdevelop-ment. But that accuracy level was not without its price topay in "noise." For ofien, when a correct diagnosis wasiniae ty the computer, one or more incorrect diagnoseswere also made. For primary diagnoses in general (TableB) , the "s igna l - to -no ise 'n ra t io i s seen to be240:l8l = 1.3. For the abdominal pain problem in par-ticular (Table C) the ratio is 1.2. Consideration of this

ratio is important in accessing accuracy; for, after all,the more diugnot.t listed, the greater the- pr.obabilitythat the "tru;" one will be included on the list (thuseliminating "false negatives"); yet the lesser the abilityto distinguish which one to pick from the list'

It shoild be noted that Ttble B permits determiningan "overall" "signal-to-noise" ratio. The false primarydiagnosis columi contains a number of cases where nocoriect primary computer diagnosis was made' Another

34

. Note: occasional ly more than one pr imary d iagnosiswas bonsidered correct

Overal l s ignal - to-noise rat io for th is group is92:(49 + 28; = 1.2, which is essentially the same as forthe general pat ient populat ion. Excluding those pat ientsnot correctly diagnosed by the computer, signal-to-noiseratio for successful diagnoses is92:49 = 1.9. This signifi-cant improvement probably represents effect of ex-c luding poor h is tor ians and " tota l ly posi t ive, , systemsreview patients, where diagnosis is always more diff icult.Such exclus ion, however, is unfa i r in analys is of appl ica-tion of the method to the general population;

-and a

signal - to-noise rat io of about 1.3 for pr imarv d iasnosesis probably a realistic f igure at this stage bt O"-u"top-ment .

TABLE D: Further break-down of pailents presenilngwith chief complalnt ol abdomlnal paln or G-ld i s tu rbance ; acco rd lng to app rop r l a tesystem of correct llnal prlmary dlagnoole

way to look at noise factor would be to first catesorizeall cases without a correct primary computer diagnosisas simply erroneous; and then define as noise only thosefalse diagnoses which occur on printouts which c/so con-tain true diagnoses. Such analysis is done below,specifically for the G-I/abdominal pain case.

TABLE C: Noise factor analysis for patlents presentlngwith chief complalnt of G-l dlsturbanceand/ot abdominal paln

92 patienls tor 1 6 pailents lorwhom coarect whom coarecl

prtmary compuler prlmary compuleldiagnoele made dlagnorl! nol made

number of t ruepr imary d iagnoses 92 + * 0number o faddi t ional fa lsepr imary d iagnoses 49 28

It should also be pointed out that, as long as this ratioremains greater than 1.0, a relatively low signal-to-noiseratio is not necessarily such a bad thing. It prevents"l 'alse negatives." This ratio can be adjusted rather free-ly by changing the percent probabil ity required fordiagnosis; but better to accept an erroneous diagnosisalong with each correct diagnosis, than to set diagnosticcriteria so strictly that neither diagnosis gets printed-out.

It is important to recognize that "system for whichchief cornplaint was given" (Table A) does not alwaysimply system in which final diagnosis was made. Notethat for the abdominal pain/G-I disturbance case (TableD), 108 X 56 = 52 pat ients, or 52/108 = 48Vo ofpersonss.o presenting turned out to have other than primary G-Io lsgase.

For abdominal pain, the fraction of t ime the computerout-diagnosed at least some member of the housestaff(14/ f 08 = 13Vo) was essent ia l ly the same as that f rac-tion of t ime the computer failed to make the diagnosis( l6 i 108 = l5Vo). This assumes more s isn i f icance whenit is.recognized that the housestaif had the advantageof physical examinat ion.

l7 o l ' these pat ients ( l6Vo) came to surgery wi th in 24hours o l 'admiss ion ( f rom the E.R.) to the hospi ta l . Mosto1 ' these were lbr appendic i t is ; o ther reasons were acutecholecyst i t is , renal s tone, pelv ic in f lammatory d iseasewi th suspic ion of tubal pregnancy, and intest inalobstruct ion. In only one of these cases was the comDuterd iagnosis proved incorrect (ovar ian cyst instead ofappend i c i t i s ) .

In several o l ' these immediate surs ica l cases thec o m p u t e r h a d o u t - d i a g n o s e d i t l e a s t o n ehousesta l '1 'n tember: In one case, the in tern,gynecology res ident , and chief surg ical res ident a l ld iagnosed appendic i t is ; the computer d iagnosis ofP. l .D. was proven at surgery. In another case as e n i o r s u r g i c a l r e s i d e n t d i a g n o s e d a c u t echolecyst i t is ; computer d iagnosis of appendic i t iswas proven at surgery. In another (dramat ic) case,the in tern had d iagnosed ur inary t ract in fect ion,and Lhe patient was in the process of being dis-charged when intercepted by the senior surgicalresident; at surgery, compute diagnosis of acutecholecyst i t is (gangrenous gal l b ladder) was proven.

I t should be noted that in the abdominal oaingroup, the computer d id very wel l (as wel l aJ thehousestafl in f act) in discriminating pelvic inflam-matory disease (seen frequently in the E.R.) fromother problems, par t icu lar ly appendic i t is . Ear lysuggestion of this diagnosis is helpful in preventingthese patients from coming to immediate surgery.In evaluating secondary diagnoses, two interesting -

and somewhat unexpected - facts appeared.The iirst of these was the disappointing inabil ity to

pick-up meaningl'ul organic i l lness unrelated to the ihiefcompla int . When computer-only psychiat r ic d iagnoseswere excluded, the overall signal-to-noise ratio forsecondary organic diagnoses is 184:226 = 0.8 (Table B).This represents just too much chaff to sift through, ingeneral , to make most secondary p ick-up worthwhi le . I tconf irms conclusions from other (non-computer) studies

35

gastro- in test inal 50geni ta l 21

unnary 5non G- | -G-U , 1medical

Ey8temto numbetofwhlch correct patlents torfinal primaay whom coarecl

d iagno8ls pr tmary dtag-belong8 noslawaa

made bycomputel

number ol number ofpatl6nl! for patlent3 for

whom prlmary whom cottecldlagnollr wa! prlmary dlag-

mlered by nollr wa!computer mllred by al

loalt one otInvolyed

houlertaft, butmado by thecomputet

6 6

3 6

1 2

1

1

4

psych iatric

no d iagnosis(et io logyunknown)

Total

1 1

4

92 t o 1 4

that the y ie ld in general populat ion screening foron),thing is very low when there is not a spebil ic com-plaint. There were a very lew notable gems - such ascornputer secondary d iagnosis of hyperparathyro id ismon a pat ient wi th known ulcer d isease; whose acute renalstone was the primary computer diagnosis, and the onlydiagnosis made by the housestaf f - that s igni f icant lya l tered the pat ient 's management. However (Table B) ,58/ I 84 = about one- th i rd of correct computer secon-dary organic diagnoses were already known to thepat ients; and "uncover ing" most of the remain ing two-th i rds o l these secondary organic d iagnoses made nodiif 'erence whatsoever in patient management.

PSYCHIATRIC ASPECTS

The second fact relating to secondary diagnoses has todo wi th the surpr is ing capabi l i ty of the machine to e l ic i tsynrptoms of emot ional s t ress and psychiat r ic problems.An a lmost shockingly heavy inc idence of secondary psy-chiat r ic d iagnoses - most ly anxiety and depresston -

occu r red . The re we re 109 seconda ry psych ia t r i cd iagnoses: only 4 of these were formal ly noted byhousesta l ' { 'or f reely admit ted by the pat ient . Thus exceptf 'or computer "p ick-up," the ex is tence of these s i tuat ionsa s " s e c o n d a r y p r o b l e m s " i n c l u d i n g s e v e r a ldepressions severe enough to admit being suicidal -would have almost always gone unrecognized to theenrergency room housestaf f dur ing evaluat ion of the"pr imary" problenr . This is despi te the fact that even thebr ie l 'est in terv iew wi th many emergency room v is i torsol len reveals thei r emot ional s t ress s i tuat ion to be muchnrore destruct ive to thei r l i fe , in a. long- term or overal lsense, than thei r "pr imary" problem for which theypresented.

This capabil ity is formidable in the primary diagnosisarea, as well. Ten percent of all patients presenting withstrictly organic chief complaints turned out to havestr ic t ly psychiat r ic pr imary d iagnoses [Table A: 241-(254 - 17 ) :0 .11 . A l l bu t two o l t hese were co r rec t l yd iagnosed by the computer . ln the abdominal paincategory a lone, l l% of pat ients received a st r ic t ly psy-ch ia t r i c p r imary d iagnos i s (Tab le D : 12 l l 08 = 0 . l l ) ; a l lbut one of which the computer correct ly p icked up. Ear lyc lues to these problems - hence avoidance of cost ly andt ime consuming (somet imes harassing and r isky) G-Iwork-ups - are of obvious benef i t .

I t was observed that a number of pat ients wi thpr imary psychiat r ic compla ints - and who were severe-ly depressed, bel l igerent , or even a lmost catatonic -

seemed more wi l l ing to operate the computer terminalthan to ta lk to a doctor or nurse. A number of pat ientswere wi l l ing to d ivu lge to the computer in format ionregarding drug use, family or sexual problems, troublewith police, or severe depression and suicidal thoughts- while they (purposefully or not) withheld this same in-formation from the doctor or nurse. Among other possi-ble explanations, these responses may have to do withanonymity the computer affords; or may reflect arelatively more concerned interest or "appropriateness,"

and non-condemning manner the computer pro jects,compared to a physician, in the hustle-bustle of the

energency room scene. The machine probes the psy-chiat r ic real rn wi th the same thoroughness, apparent in-terest , and lack of judgment or embarrassment , wi thwhich i t quer ies the G- l t ract .

HOUSESTAFF AND PATIENT RESPONSE

Housestaff ' reaction to the study was favorable. Therelat ive ly shor t t i rne requi red to complete the com-puter ized interv iew and re lat ive pat ient independence inoperat ing the terminal meant min imal in ter ference wi themergency room rout ine. The avai labi l i ty of a computerd iagnosis pr in tout was thought to be reassur ing in mostcases; as the house of f lcer commit ted h imsel f to adiagnosis on the E.R. sheet . In many cases the pr intoutsuggested a prev iously not thought-of d iagnosis. (Thenunrber o l ' t inres the computer is recorded as having"out-d iagnosed" the housestaf f in th is s tudy may actual -ly be on the low side; since lrequently the house officerknew the computer inrpression before he commit tedh i r r se l l - t o a d iagnos i s . )

Pat ient acceptance was excel lent . Most people s implyaccepted i t as an in tegrated par t of thei r evaluat ion, andwent about i t in a business- l ike fashion. When pat ientslbund the procedure remarkable, i t was a lmost a lwaysI ' ronr the standpoint o l being a lavorable "extra."

SUMMARY AND CONCLUSIONS

Many non-trauma cases of acute or emergency roommedicine require immediate consideration of differentialdiagnoses before reaching disposition. In this setting,physicians have not t ime to take thorough histories, andat all hours and under all circumstances, cannot con-sistently take into account all facts potentially at theirdisposal. A computer can be effective in this environ-ment, as a clinical tool and a teaching device, if i t (1)gathers information in minimum time and with minimalinterference with E.R. routine; (2) organizes informationfor presentat ion in concise, log ical pr in tout ; (3)minimizes both false negative ("missed") and falseposi t ive, ( "noise") d iagnoses.

In this study, a computer program employing a se-quential Bayesean logic system was used to interview254 E.R. patients. Median time to complete historieswas I I minutes. Overall accuracy for primary (related tochief complaint) diagnosis was 82Vo, with an overallsignal-to-noise (!rue, to false primary diagnosis) ratio oft . 3 .

Accuracy of primary diagnosis for 108 patientspresenting with chief complaint of abdominal pain or G-I disturbance was 857o, with signal-to-noise ratio 1.2,48Vo of these patients turned out to have other thanprimary G-l disease. Sixteen percent camc to immediatesurgery; the computer had made a correct diagnosis onall but one of these. The fraction of t ime the computerout-diagnosed some member of the housestaff on thesecases was essentially the same as the fraction of t imethe computer was out-diagnosed by the housestaff. Thislast observation is even more significant when house-staff advantage of a physical examination in reaching adiagnosis is taken into account.

Abil ity of computer history to pick up otherwise un-suspected secondary organic disease was disappointing.

36

dary psychiatric problems and emotional stressurprisingly good, and this area offers great promise

further applications.

Housestaff and patient reaction was quite favorable.In general, the machine was felt to be uleful both as aclinical tool and as a teachins device.

REFERENCES

L Warner, Homer R., Rutherford, Barry D., and Bruce Houtchens.*A Sequen t i a l Ba lesean App roach t o H i s to r y Tak ing andDiagnosis," Conlputers and Biontedical Research S, ZSO_ZAZ, SlZ.

37

THE EMERGENCY MEDICAL SERVICES

MORBIDITY AND MORTALITY CONFERENCE

Frederic W. Platt, M.D., F.A.C.Pand Cleve Trimble, M,D.

The teaching and audit demands of an Emergency

Department may be partially satisfied by regular con-

lerinces which irit ici l ly assess patient morbidity and

mortality. Over the past three years we have varied our

weekly iessions in an attempt to develop- a format

w h i c h i s a p p r o p r i a t e l y a n a l y t i c a l , i n f o r m a t i v e ,

educational, fast-moving, and encouraglng oI group par-

ticioation. The result of this endeavor has prompted the

following description of method.Departmental activities ate analyzed from Sunday to

Sunday with the agenda (Table) prepared o-n Monday,

distributed on TueJday, and the formal conference held

on Thursday. This allows those house officers with casepresentat ions an opportuni ty to prepare succinct

r e v i e w s , t o g a t h e i a p p r o p r i a t e l a b o r a t o r y a n d

radiographic results, and to followup on patient out-

comes .Statistical data are clerically-maintained on a daily

basis and these tabulations for 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 uti l ized in a formula

which provides a coefficient of Departmental proficien-

cy .Every death en route to or within the Department is

describ-ed immediately by the responsible resident on a

detailed form which analyzes ambulance and field ac-

tivit ies as well as resuscitational methodology. These

clinical features are then evaluated in l ight 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 identif ied areas of problem or interest'

Eisht to ten cases are then selected for their teaching

rnJrit. Th.t. usually focus on errors and include topics

which are both mundane and sophisticated. These dis-

cussions are presented in a staccato fashion rather than

as exhaustive dissertations. Every effort is made to

stimulate controversy, with "experts" of divergent

ooinions invited. A collection of such vignettes over a

on. y.ut period has comprised a text on the salient

features of EmergencY Medicine.2These 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 emphasis is continually placed upon the value of

error anaiysis, no one feels threatened when the l imelight

comes hij way. The staff participants purposely open

themselves to crit icism and seek a peer identif icationrather than an authoritarian stance in relationship to the

other participants, which include Emergency Medical

Technicians, nurses, medical students, interns, residents,

policemen, social service workers, et cetera. It has also

b".n uppur.nt that a circular and non-structured seating

arrang^ement has stimulated individuals to involve

themselves. An attendance often exceeding 65 has

suggested accePtance.

References

L Turner, W., Johnson, R. , Plat t , F. , and Tr imble, C : Four Hour

Sumnrar ies. Proc. LIA I EMS, 2:30-31' 19"12.

2. Plat t . F. ' . Case Srudies in Entergencl ' Medic ine Li t t le Brown and

Co . . Bos ton , l n P ress .

38

I

Table

ETIERGENCY DEPARTIIENTl l o r t a l i t y a D d [ t o r ' b i d i t - y C o n f e ! e n c e8 A I I T h u r s d a y \ t a y L t ' L r t '

I . S t a t i s t i c s ( M a Y ? - 1 3 , 1 9 7 3 ) I

A l f r e d N e l s o n 4 lE v e r e t t B a r n h i l l 2 9Donald frbb6 55Thoi l ras Wright 30B e l e t t a J e n k i n s 2 2

U n i t IP a t i e n t s i 4 6 7O v e r 4 H o u r s : 6LWBSI 7Adi l iss ions I 39

h . o f i c i e n c y C o e f f t c i € n t : 0 . 8 ?

u-4!It uni! -I l I ro!?r334 803 1604

2 3 4 3 39 2 2 3 8

8 6 2 6 1 5 r

I 1 - 3 ? - 4 8 S a r c o l d o s i a S a n f o r d

I g - 2 7 - 6 9 E l e c t r o c u t i o n M u n k r e E

44-64-19 Court Fi t Robertson4 6 - 0 0 - 0 2 G S w K l e i n1 4 - 8 0 - 3 8 G s l { K l e i n

4 5 - 9 4 - 6 3 C a f e C o l o n u Y K l e i n m a nI 1 - 3 ? - I 4 H y a t e r i a l l a n n e r y1 7 - 5 2 - 3 7 h y c h o t l c S c o t t45-97-33 Impaled Moncy46-00-47 Alm Glanzer44-98-99 Gonococcal Phdyngit is Schsu'tz45_98_?3 Coma BoaI4I-47-98 Dlslocated lFng I lDger Flanrery

C a s e P r e s e n t a t i o n s i

R o b e r t S c h a l k 7 3

C e c e l i a t l a s c a r e n e s 1 3

k n a t l e l a n d e r 6 9

P a t t i C o l e m a n 1 3

C h a r l e s t l y l a n 5 1

o i l i R i n t a l a 1 9

Roy WoodE 70

D e a n w l l l i a m 6 5

Sample agenda f rom weekly M & M Conference.

F -

THE ROLE OF THE OMBUDSMAN IN THE EMERGENCY DEPARTMENT

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 NewYork City Emergency Department treated 46,488patients in the year 1912. The community boards arevery active and sophisticated in regard to consumers'rights. They are extremely concerned about the deliveryof qual i ty heal th care and make thei r demands wel lknown to the hospital authorit ies. To serve the com-muni ty , the hospi ta l Adminis t rat ion appointed two Om-budsmen for the Emergency Department. According toWebster 's Dict ionary, an Ombudsman is , "A govern-ment official appointed to receive and investigate com-pla ints made by indiv iduals against abuses or capr ic iousacts of publ ic of f ic ia ls . " Thei r hours are f rom 4:00 P.M.to Midnight , which are the busiest hours in the Emergen-cy Department .

The ro le of the Ombudsman or Pat ient 's Represen-tative is now becoming more accepted in many hospitalsthroughout the country. Thei r new ro le is now recogniz-ed by virtue of the lact that there is a section ol theAmerican Hospital Association called, "Society ofPat ient 's Representat ive of the Amer ican Hospi ta lAssociat ion."

The pr imary ro le of the Ombudsman in the Emergen-cy Department is to identify patient care problems andto expedite the flow of patients in an orderly manner.The goal of the Ombudsman is to humanize the pat ient 'sEmergency Department experience. They act as thepatient's friend from the time of his admission unti l hisdischarge or hospitalization. They are the l iaison officerbetween patients, the professional staffs and the clericalpersonnel working in the Emergency Department. TheOmbudsman must have the power to get th ings done i f adefect in patient care exists.

A major problem present in most active EmergencyDepartments is the prolonged delays of patients beingseen, treated and disposition determined. A major factorior the prolonged delays of patients in St. Vincent'sHospital and f4edical Center of New York is theminimal physical space available in the EmergencyDepartment for the care of these patients.

The Ombudsmen aid in the alleviation of the over-crowded conditions by the following means:

l. They see that all visitors wait in the designatedvis i tors lounge.

2. They keep the patient's families informed as tothe progress of the individual patient's work-up, thuspreventing the relatives and friends from visit ing thetreatment rooms to inquire as to the patient's condition.

3. When the house officer has made a tentative

diagnosis, the Ombudsman escor ts the doctor out to thewai t ing room to meet the fami ly and expla in what is tohappen next with the patient, thus alleviating congestionin t he t rea tmen t a reas .

4. They notify both the house and nursing staffs ofany i ncoming ca tas t rophes .

5. Another important ro le of the Ombudsman is themanagement of the press and police officials. It iscustomary in the c i ty of New York that when a pol ice of -f icer is shot in the l ine of duty that the Mayor and Pol iceCommissioner v is i t h im in the Emergency Departmento l the hospi ta l in which the of f icer has been taken,creat ing havoc due' to the news and te lev is ion mediadescending upon the hospi ta l . The Ombudsman sees to i tthat the Mayor and other h igh c i ty of f ic ia ls are handledin the manner commensurate wi th thei r posi t ion in theconmrunl ty .

A major concern of the Ombudsman is to change theat t i tudes o l a l l Emergency Room personnel towardspeople as patients, since the Emergency Department isconstantly inundated with the same patients being re-admit ted because of drug overdose and a lcohol ism. Theyassist the professional and non-professional staffs in un-derstanding the needs of these unfortunate people andhave them treated with kindness and compassion as wellas medical expertise.

When the Ombudsmen were first appointed by theAdminis t rat ion of the hospi ta l , many problems becameimmediately apparent particularly between them and thehouse and nursing stafls. The professional staffs believedthat they were placed there to act for the Administrationand d id not t rust them. This was due to a lack of com-municat ion and knowledge as to the in ter- re lat ionshipbetween the Ombudsmen, patients, and the medical andnursing stalfs. This lack of trust was at f irst compoundedby the lact that the Ombudsmen wore as identif ication abadge on their lapels inscribed "Administration" on it.The house and nursing stafls immediately thought thatth is meant thei r ro le was not to see that the needs of thepatients were properly cared for, but that the medicaland nursing stafls did their work in a more proficientnranner. Also, the pat ients, unaware what the connota-tion on their badge meant, resented a stranger coming upand asking them quest ions concerning thei r heal th needs.The matter was promptly settled when it was suggestedto both the Administration and the Ombudsmen thattheir name badge read "Patient's Representative ." Sincethis changeover all of the groups now know the true roleof the Ombudsmen and all of the previous conflicts

3g

between them have ceased and now all work in harmonytrying to improve pat ient care.

Other ways in which some of the problems were solvedwere by inviting the Ombudsmen to attend the monthlyEmergency Department Advisory Committee meetingswhere pertinent problems of the Emergency Departmentare discussed by the directors of the various departmentsand key nursing and administrative personnel. They alsoattend the monthly Orientation Seminars for theEmergency Department's house staff. To circumvent theproblems with the Nursing Staff that had occurred, theOmbudsmen now make rounds with the nurses at thechange of nursing shifts so that they are appraised oftheproblems present in the Emergency Department at thetime their tour of duty starts. It is of interest that withinthree months the nurses now seek out the Ombudsmento relate to them problems concerning patient care andare most cooperative rather than by-passing them asthey were doing at the start of the program.

The Ombudsmen render a written monthlv reoort to

the Deputy Executive Director of the hospital.At St. Vincent's Hospital we are concerned especially

in our Emergency Department with treating the patient'stotal needs. We thus instruct both the nursing and housestaff that whatever they do for a patient as part of theirregular duties, there's something extra you can add: Abig dose of patience and understanding. There is aspecial.medicine our patients need that only you can dis-pense . . . understanding. Understanding what it 's like tobe worried. Understanding what it 's like to be confused.Understanding what it 's like to be afraid. People whostudy human behavior tell us that these are the emotionsmost patients bring to the hospital,

In conclusion, since the Ombudsmen were first ap-pointed by the hospital's Administration, the entire at-mosphere in the Emergency Department has changedbecause both the nursing and house staffs understandcompletely that patients are concerned and worried peo-ple in need of expert medical care rendered in a com-passionate manner.

THE TEAM CONCEPT IN THE UNIVERSITY AFFILIATED

EMERGENCY CENTER

Kenneth L. Mattox, M.D.George L. Jordan, Jr., M.D.

A team concept has been initiated at Ben TaubGeneral Hospital Emergency Center to provide goodcare for the patient and a worthwhile educational ex-perience for the house officer. Early identification ofthepatient's problem is provided by initial triage, afterwhich the patient becomes the responsibility of a coor-dinated functioning team which consists of physicians,nurses, and clerks with support from orderlies as needed,Since this program has been in effect, patient flow, divi-sion of responsibility, and identification of developingproblem areas have markedly improved.

Teaching rounds with alternate teams allows theremaining teams to continue normal activity. Hospitaladministration, nursing service, consulting services,^andhouse staff have enthusiastically supported this system.

The problem of the adequate provision of emergencymedical care has been an area of concern, not only tothose involved, but also to the general publis.t,z,r Atien-tion has been focused on epidemiology, ,'u legislation,aeducation, 6,7,8 ambulance systems,a communication0 andcategorization.r0 Medical and surgical techniques tomanage urgent il lness have been widely described. Thepresent challenge then is to devise systems which op-timize the available care.

Depending on one's perspective, the term "EmergencyPhysician" stimulates various images.lr The full timecontractual emergency physician in a rural 100 bedhospital is faced with an entirely different set oforganizational problems than that of Director ofEmergency Medical Services of a university affiliated1000 bed city/county hospital,

The university-affil iated emergency center must bedesigned to serve all of the functions of the medicalschool, including patient care. A system must be devisedto accomplish the goals of prompt, efficient patient carein a setting which provides a good educational ex-perience. These emergency departments are frequentlypublicly financed, and are also under the close scrutinyof the press. Categorization of Emergency Departmentswithin a large city encourages community cooperation.In a rural hospital, categorization of the emergencydepartment merely identifies the scope of servicesavailable.

Replacement of interns and residents in the universityemergsncy center with certified physicians allows formore rapid, and perhaps, better medical care. However,this maneuver may not only be financially untenable inthe busy city/county hospital, but may also preclude the

house officer from developing clinical judgement in theemergency setting. However, a system which emphasizesstaff supervision is desirable.

The chaos and pathos of city/county hospitals at mid-century are well remembered.5,12'r3 Jnterns worked longhours in "the pit" on charity patients under the theorythat patients getting free care could not be chooserswhen it came to physician selection. They became vic-tims of a "catch as catch can" system frequently devoidof empathy.'3 House staff would designate one room as a"tank" for alcoholics and drug abusers. Patients withvague complaints rnight wait several hours before anadequate evaluation disclosed a hypertensive crises, abasal skull fracture, or that the unconscious "drunk"

had d iabet ic coma.Systems to expedite patient f low are ovolving.r'r,tr,ts,to

Specialized areas within a hospital (or even specializedhospi ta ls) for d i f ferent emergencies may be onesolution;r{ but, the more the specialization, the moresophisticated the patient (and/or ambulance emergencymedical technicians) must be in discriminating thenature of his i l lness. The introduction of a triage nu-rse atthe registration area is gaining popularity.a'1,r,1? Theapplication of both specialty areas and nurse/physiciantriaging may eliminate congestion at the emergencydepartment entrance and even identify the patient'surgent medical problem; however, without a continuedsystems approach, confusion may develop in the secon-dary areas. Standards of design and function have beensuggested by the American College of Surgeons Com-mit tee on Trauma.18

Specifically, all have seen such logistic problems in theuniversity affiliated emergency center as a) overcrowding,b) long waits, c) inequitable dispersion of work load, d)diff icult teaching environment and e) poor coordinationbetween nurses and physicians. We, therefore, soughtto devise -an internal operations system which wouldencompass the following parameters:

a. Allow for earlier identif ication of i l lness.b. Provide orderly, rapid, and equitable patient care.c. Develop judgement among house staff.d. Assure control of patient records.e. Provide programmed teaching uti l izing the un-

programmed sporadic work load.The Harris County Hospital District, associated with

Baylor College of Medicine, is municipally f inanced, andprovides care for an estimated 400,000 people. Theemergency care is provided in five areas which allow, for

41

the most part, self-triage by the patient. These includeneighborhood clinics for treatment of minor problems, aseparate institution for obstetrical emergencies, thetreatment of non-traumatic pediatric problems in thepediatric clinic, and an acute medical clinic. The fiftharea is designated as the emergency center, in which alltraumatic lesions, acute surgical problems, and seriousmedical problems are managed.

The 10,314 square foot center has two shock rooms,eight specialty examination/treatment rooms, two uti l i-ty examinat ion rooms, a 14 bed hold ing area, a 32 bedobservation ward, and two radiographic examinationrooms. It is staffed with three second year residents (twosurgical and one medical), four interns, four studentsand a stafl physician director. Fifteen per cent of theaverage daily census of 200, arrive by ambulance.

Anatomy and Mechanics of Teams

Analys is of dai ly pat ient loads and nurs ing serv iceassignment sheets provided a guide for the constructionol ind iv idual teams. The nurs ing superv isor , the medicalresident and the surgical resident assume the supervisoryroles and are responsible lor subordinate activity. Allpatient dispositions are reviewed by the residents whoare responsible to the chief resident (medical and/or sur-gical) as well as to the director of emergency medicalservices (Fig. l). Patient records are subject to audit, andall emergency center deaths are presented in conference.

Each team is composed of an intern, a registerednurse, a ward c lerk, a nurs ing assis tant and a student(Fig. 2) . Each team has i ts own char t rack, and handlesi ts own char ts . The pat ient 's arm bracelet is marked wi thteam identif ication. The patient's movements throughthe emergency center are indicated on his chart.

Ambulatory patients with emergency problems oracute mani festat ions of chronic condi t ions are in i t ia l lytriaged at the registration desk. The chart is given to theteam nurse; team assignment being done on a rotat ionbasis by the regis t rat ion c lerks.

Ut i l iz ing her natura l and t ra ined inst incts of empathy,protector of patient charts, team leader and guardian ofthe physician, the nurse becomes the logical init iator ofin ternal pat ient movement. She is s imul taneously awareol l ) team physic ian work load, 2) avai lable examinat ionareas and 3) urgency of patient problems. Furthermore,because res idents and interns rotate, she is both asusta in ing and stabi l iz ing force. Pat ients are seen by theteam members, appropr iate tests ordered, and the char tgoes to the team rack. As x-ray and laboratory data areavailable, the ward clerk presents these to the intern whomakes a disposition after consultation with the resident.I f a t any t ime the in tern or nurse becomes aware that thepat ient 's condi t ion is urgent or that he might needhospi ta l izat ion, the res ident is summoned and d isposi -t i on i s made .

Pat ients arr iv ing by ambulance are checked by theteam physician. Only one team directs their attention tothe non-ambulatory pat ient 's care; a l lowing other teamsto continue their work undisturbed. Should severalurgent cases arr ive s imul taneously, the teams are ready-made into assigned uni ts . The shock rooms and card iac

rooms contain only those tearn members working withthe pat ient .

Consultations, referrals for admission, etc. are ac-complished on separate forms. The patient record staysin the team chart rack or with a team member. Frequentchart reviews help the intern to assess the status ofpatients awaiting disposition.

Peer and Chart Review

Team physicians, residents, consultants and theemergency medical service director have ready access tothe chart rack. Time/effectiveness evaluations on eachpatient and team are routine and unannounced. Recordanalysis includes consideration of team function. Super-visory personnel can ascertain at a glance which team ismoving patients slowly and institute the appropriatesteps to improve e l f ic iency.

Educational Techniques

Our program is based upon the concept that educationin emergency care is best provided in an atmospherewhich allows those participating to observe and par-ticipate in treatment. Thus, the emergency center is notgeographically divided into areas, so that a patient witha surgical problem may be adjacent to one with amedical problem. Each intern sees the spectrum ofemergency problems and gains insight into prompt care,regardless of his primary career orientation.

In addition the concept of both medical and surgicalsupervision allows for a broader clinical experience thancan occur in an emergency center with a high degree ofspecialty space designation. The working relationship es-tablished between the surgical and medical residentsserves to provide cross-ferti l ization as well as mutualrespect for individual competence.

Surgical and medical services make teaching rounds,as well as unannounced appearances in the emergencycenter for the purpose of conducting rounds with oneteam. The unannounced rounds take approximately l5minutes and are designed to not affect patient careamong teams not making rounds.

Nursing Service Participation

For the non-shock room emergency patient, the teamnurse in i t ia tes the pat ient 's evaluat ion and care. She con-tacts the physician on her team as new patients arriveand d i rects h im to thei r locat ion. At any g iven t ime, theteam has approximately 6-8 patients under their direc-tion, and an average ol 2 new patients are seen eachnou r .

The nursing service has found that this systemprovides (l) division of responsibil i ty, (2) equitable dis-persion of the work load, (3) identif iable l ines of com-munication, and (4) early identif ication of patientswhose disposition is prolonged.

Transfer of Responsibil i ty

Residents are on a rotating 24 hour shift, interns areon a rotat ing l2 hour shi f t , and the nurses adhere to theclassic 8 hour shi f t . Team nurses make end-of-shi f trounds only on thei r team pat ients at 7:00 a.m., 3:00p.m., and l1:00 p.m. wi th the oncoming nurses. The

42

charge nurse makes end-of-shift rounds on all natients inthe center with the new charge hurse. Medical and sur-gical residents accompany the charge nurse on fullemergency rounds while the interns make rounds withtheir nurses only. As the interns change shifts, usually at7:00 a.m. and 7:00 p.m., they again make formalrounds with their team nurse and the oncoming intern.The changing residents make full rounds together dailyat 8:00 a.m.

Adjunctive Systems

This team concept easily dovetails with the newdesigns for the provision of emergency care, Undercurrent evaluation are area dispersion of patients, an in-novative packaged record system, expansion ofthe floorspace and house staff assigned as wel l as moresophisticated triage. None of these, in theory, appears toadversely affect or be affected by the team concept.Summary

Advances in ambulance systems, telemetry, triage, ad-ministration and treatment methods have been widelvcirculated. Problems of internal operation prompted uito adapt a division of responsibility and reorientation ofthe classic approach to a city/county university affiliatedemergency center. This team concept allows for im-proved patient care, provides unique educational oppor-tunities and stimulates a competitive esprit de coips.

Referencesl . Fit ts, W.T.: Men for the Care of the Injured: A Crisis Facing the

70's. Bulletin, American College of Surgeons, December, igZO,p p . 9 - 1 8 .

2. Shires, G.T.:Care of the Injured -The Surgeon's Responsibility.Bulletin, American College of Surgeons,5S:7-21, February, 1973.

3. Hampton, O.P.: The Committee on Trauma of the AmericanCollege of Surgeons, 1922-1972. Bulletin, American College ofSurgeons, 57:7-13, June, 1972.

4. Proceedings of the Airlie Conference on Emergency Medical Ser-vices, Committee on Trauma, American College of Surgeons, andCommittee on Injuries, American Academy of OrthopedicSurgeons: Chicago, 1969.

5. Walt, A.J. and Krome, R.L.: Of Wicked Stepmothers, UglySisters, and Academic Cinderellas. Journal of Trauma ll:554-557, t97 | .

6. Rittenbury, Max: Training of Emergency Department personnel:Goals and Levels. Proceedings of the University Association forEmergency Medical Services, Washington, D.C., May l2-13,1972, pp. l-5.

7. Mackenzie, R.: Training of Emergency Department personnel:Techniques. Proceedings of the University Association forEmergency Medical Services, Washington, D.C., May l2-13,1972, pp . l0 -13 .

8. Mitty, W.F., Nealon, T.F.: An Educational program in anEmergency Department. Proceedings of the University Associa-tion for Emergency Medical Services, Washington, D.C., May12-t3, 1972, pp. 3l-36.

9. U.St Department of Health, Education, and Welfare: EmergencyMedica l Serv ices Communica t ions Sys tems, Roct<v i t te ,Maryland, August, 1972.

0. Recommendations of the American Medical Associat ionConference on the Guidelines for the Cateeorization of HosoitalEmergency Capabil i t ies, Chicago, lg7 l .

Figure 1

Director of Emergency Medical Serv ice

Nurs ing Superv isor

Surgical Resident

Medical Resident

T e a m A I I T e a m B | | T e a m C

Flgure 2

l l .

t 2 .

1 3 .

t4 .

1 5 .

Dailey, R.H.: A Metaphor: "Who is the Emergency physician?,'Proceedings of the University Association for EmergencyMedical Services, Washington, D.C., May lZ-13, 1972, pp. 25-26.The Emergency Room and the Outpatient Clinics. Rejident andStaff Physician, pp. 94-106, January, 1970.The Great Emergency Game. Medical Llt'orld News, pp. 35-42,March 5 , 1971.Canizaro, P.C.: Management of the Non-emergent Patient. TheJournal of Trauma l l :544-51, 1971.Turner, W., Johnson, R., Platt, F., Trimble, C.: Four Hour Sum-maries. Proceedings of the University Association for EmergencyMedical Services, Washington, D.C., May 12-13, 1972, pp. 36-37.Platt, F.W,, Turner, W., Johnson, R., Trimble, C.: EmergencyTriage by Nurses. Proceedings of the University Association forEmergency Medical Services, Washington, D.C., May l2-13,1972, pp . 30-31 .Rudolf, L.E.: The Non-emergent Patient in the EmergencyRoom. ?Ffte Journal of Trauma l, l :552-53, 1971.Guidelines for Design and Function of A Hospital EmergencyDepartment. American College of Surgeons, Chicago, 1970.

1 6 .

1 7 .

1 8 .

43

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

, 1 ff i: ii ; ::: |ii X : ? ;, f,7 T,!!.',,";:: i{:,* ;

A number of major concepts must be heeded in orderto^^organize and staff emergency medical services in anefficient and humane- manner. At least flfteen such

:fl l"Ti.:"'TiJ,.,o',nli,!5"f,?ry,,J;[i*,'f .lt]'.H#*tifl,,:,.,:llti jt] 9::le'.9,for . emergen.y -.ai iur ;.r;. ii):::yj:i,_" :mergencles rall inro lwo basic categories:accloenrs 1or trauma)_and acute i i lnesses (obstetrical laborts an, ex.ception). (3) children are differeni because of theirsmall dimensions, immature r€sponses to trauma, andprecious emotional reserves, and s^hould be separated'fromadults as emergency patients. (+) Ff,Vri.i.ns providineemergency medical services should be

"broadly 'UurrJ-l imedical and sursical training una .upuUitiii-ri, i... primaryphysician care s[outd not b? ;;;gi;i;;; :,medical,,,

butappropriate for the. .patient _ iopulation. (5) Nu;;

ilSFlf':ti1:,itstl':i!:1, j;l,ln"'lffia'i$f.T#:*physician and nurse. (6) Intensive ,*r

-irrrt19, generaloperating.. faciiities, and a biood bank ur. n...rruru

d3:.;il, q,i:J :t#fr : 1:. !:r. ffi1 l. 1', ;. Tff [],]. [H:lMedical Services should have its ;; ;;;. diagnosticfacilities for X-rays and simple tests. f"Uorutory results ofother. types shoutd ue rapidty ;;.il.bl;.-i;i si!.irj,iyconsultants and teams TTr b.. lrovideilon r;;ay dh.i10iThe Emergency Medical Servic6r,h;;ld huuJ-urrono_ou,departmental status in the plan of hospital organization.(11) rhere should be a. deffi;a-Chi;i-;i E;;6;;;;Medical Services..(12) There ;h;"lJ Url-air.to, of anyseparate units such as adult or children's emergenc)/ rooms,lruy*u celle.rl, etc. with a sizable .rnrrr. ii? Oti..to. oisuch a unit ideallv should.be full_time. (t3) A ,"riOrn.Vtraining program should u.. o-u.iop.J'i; ;;;;r"ry medicatservic-es. (14) A regional communication, iiunrportation,and dispatch plan ii optimar to .ootoinuil iniiuicuoi .ur.gng mass disaster handling. notf,

-u.-Urtun.r, andhelic.opters equipped wirtr i 'ppropiiur.-'.oirnunicarion

capablities are reqiired ror a modern transportation service.(15) Ambutance^ and h.li;;p;;' ;.rr""i.i 'rrr"uld haveadvanced training and continuing education -a pru&i., infirst aid and reslscitative technilu* l".i"Jirg'lntravenoustherapy as well as cardiopulmonary methodology.-_. -, At the present tim6 only u few taige ciii& unO severalli:::

.::{.1.:s in,the u{Je{ States frave acknowledged

il'ff "r:":i:oti..?il,lrrn'^o tded the pro per organizati"on'

servicei.p*hqi,;.1;';,1,"J#Tlt:ff ,;:l'ir"'t:{.,il'.riixprogress which has been made at The fofrns Uopf<insHospital. in the l ight of these concepts.

Episodic and chronic patientjhave been channelled toa new (Walk-In) primary iare Clinic for ;duiis, and to a

separate Harriet Lane Home Clinic for children. Thechildren's facilities are housed in a new

-Edward A. park

building, w_hich has a Comprehensive ChilJ Care Ctinii onone floor, the Walk-In Harri6t Lane Home primary Care andSpecialty Clinics on another_floor, and tfr. nrn.rgrn.y!.?r,1,:._:

or a,sep,arate floor. The ROutt nmeigency service,wnlch was attending 105,000 parients a year,-has now been11d,19.?9'�,o about 75,000'a yea'r. r";;;b;; may prove robe lower.

The Children's Emergency Service has a section foraccidents_(Children's Trauma

-Center) and a section for

ilrl.l::r, Primary physician care is renderedLy pediatricians

tn oo^tn sectlons, including suturing of lacerati,ons and init ialcare for multiple major injuries.

"

The new Johna Hopkins School of Health Services hasmatriculated its first class of fifty students, of which iix,T::9, I l!l".ry m edical .orprrnin'ur. i" tr;fi ng as surgical(nearth) assistants. The Trauma Course for th6 Schojl ofHealth.Services is taught in the Childr.nl, Tiurrnu Center.Ieglqgc.nu.rse practitioners are now at work in the parkrJultolng ln the non-emergency sections.

The Pediatric Intensive-Care Unit has 14 beds underthe .supervision of a pediatric anesthesiologist who alsoconducts. a_ training -ourse for nursing ind technicalpersonnel. In the same area there is a p-ediatric SurgicaiRecovery Room and a special section ior Children,sNeurosurgical Intensive carb. The ourruit lntensive careca.pacity in The Johns Hopkins Hospital is 42 beds foradults and children. There'are utro ,?,fuiui. Surgicai andMedical Intensive Care Units for adults.

'

^ lttq General Operating Rooms are near the IntensiveCare Units and Blood Ban[ and huue un udiucent 25 bedRecovery Room. There is a pediatric Surgi.luf Division of,^h^.^,l1g.t.* Dep.artment wirh a pediatric Sirgicaf Resideni,As$stant Residents and Interns rotate frori the GeneraiSurgical and Pediatric Services. ttrere are- also General andlneglatjV Surgical Resident staffs roiating- ttrrougtr ilieAdult Emergency Service.

A Poison Control Center operates as a part of theChildren's Emergency Service. fn.iupy

-foi overdose isavailable in borh itre aAutt und child;;;i;r;;.

, ,. .9org, diagnostic. facil i t ies (radiology and smallmqlviouat laboratories) are present in both the Adult and:^1lq]:n's lm:rgelc{ Services. The Emergency Laboraroryt"o:^tlr

:l!ir: hospital is locared in the par-k Building on thl

trmergency iloor. Consultants from all the special-ties areassigned and available promptly to the Childrefi s and aaulltmergency Services.

"^,_,1 new, position as Chief of Emergency Medical

)ervlces has been designated and appointment made. TheCh ild re.n t Emergen cy 5e rvi ce tr as a fi,it _tim. -tjiir.t

or.lne rlrst step in a Residency Training program in

Emergency Medical Services began July l,1973,with a fullyear appointment of an Assistant Resident in the Children'sTrauma Center.

Intimate cooperation between the University ofMaryland the The Johns Hopkins Schools of Medicin'e hasproduced a coordinated plan(under the Baltimore RegionalPlanning Council (BRPC) for individual and massemergency services in the greater Baltimore area. This planhas provisions for enlargement to a state-wide program. TheUniversity of Maryland- Trauma Center and The

-Baltimore

City Hospitals Burn Unit and Neonatal Intensive Care Unitare coordinated with The Johns Hopkins Children's TraumaCenter and Adult Emergency Service under this plan. Thehospitals of greater Baltimore have been categorized by theBRPC according to capabilities for handling of emergencypatients.

Communications and (ambulance and helicopter)transportation systems and policies have been extensivelyreviewed under the auspices of the BRPC. Plans have been

made for coordination under grants-in-aid from bothfederal and state sources, with technical consultation fromThe Johns Hopkins Laboratory of Applied Physics.

Educational programs have been underway fortraining of ambulance and helicopter personnel inresuscitative technics under the auspices of the AmericanCollege of Surgeons (Regional), the various Baltimorehospitals and Baltimore Fire Department, and The JohnsHopkins School of Health Services. Disaster drills have beeninsfigated on a city-wide basis and carried through forconstructive improvement and practical experience in allfacets of emergency medical service.

The concepts presented here are not all inclusive, notentirely applicable to every locality, but are guidelineswhich have served The Johns Hopkins Medical Institutionsin implementing their responsibililies for providing effectiveregional emergency medical services. They are presented assuch in order to encourage other institutions and regions inthe developmental stages of their systerns.

45

SHOCK TEAM APPROACH TO

Peter Rosen. M.D.

RESUSCITATION

To anyone who has had responsibility for manage-ment of a busy Emergency Department, it is clear thatdecision-making and response to the acute emergencyare different from that wtrich is conventionallylearned.2,3,6,8

One must react rather than act, and usually on little,or no information. He must also make an instantaneousdecision about the level of physiologic derangement.System rather than organ patfioptrysiology is oflmport-ance in this setting. The proper question is: ..Whaf life-threats need to be dealt with?"' not ,,what is thediagnosis?" Only after stabilization is achieved is it thenappropriate to ask questions leading to a specific label.

After studying our resuscitative techniques, and con-cluding that we were failing in our initial appioach, weevolved a shock-team. Similar techniques are usedelsewhere, but we felt it might be profitable to share ourexperiences.2'3'8

As presently staffed, the shock team consists of oneresident, one intern, one nurse, and one emergencytechnician.'A daily staff assignment, and when the shiftchanges, it is team captain's responsibility to know whothe new nurse, intern, etc., are. Selection of the teamcaptain varies depending on the situation, for trauma,the Surgical resident; for cardiac arrest, the Medicalresident. Either resident is able to manage either team.

The team captain functions as the overseer, If hebecomes involved in a specific chore, (e.g., intubation orinsertion of a chest tube) the overseer duties aredelegated to another team member. He must beaggressive in his control of the resuscitation, Majortrauma and cardiac arrest invariably produce a wealthof on-lookers. These must be removed from the area ifresuscltation is to occur smoothly. The team captainmust control the environment. For the team to functionas a unit, as it must, a strong team captain and ex-perience are necessary. The trauma team is summonedby ringing a bell throughout the Emergency Depart-ment. A full resuscitation is carried out before anydiagnostic procedures are begun.

Each member of the team has specific duties relatingto our trauma protocol (see figure l). This is a con-tinuing process, as by the time we have one group train-ed, we rotate and start a new group of physicians.

Step l: Getting the Patient to the Shock Room andSummoning the Team.

This is no trivial problem. Ambulance drivers arefrequently more concerned with retrieval of theirstretchers than the welfare of their patients. On morethan one occasion, they have announced a ',dead onarrival" in a patient who was fully resuscitable.

The technicians who perform our initial triage usuallybecome aware of the case first. They, therefore, are theones to push the trauma bell and to assist the ambulancepersonnel.

Step 2: The Patient's Airway.We all know how important the airway is, but action

requires practice.6 We have made videotapes ofresuscitations and it is amazing how long the airway isneglected. It is now standing order to apply nasal can-nula and full volume O, flow immediately. We accept therisk of the emphysematous patient. Our trauma captainsare prepared to breathe for the patient. By this time theteam is on the scene and under control of the captain.

The following steps are parallel:Step 3: Undress the Patient.Patients should be completely undressed cutting

clothes if necessary. Patients have been. thrown intoprofound shock by sitting up or standing to removeclothes. Once nude, the patient should be covered forwarmth and modesty, Severely injured patients are stillvery aware of their surroundings.

Step 4: Obtain Blood Pressure and Pulse.These are obtained by the nurse who reports them

loudly to the captain.Step 5: Start a CVP line.aThis is done in the right arm by the intern, who im:

mediately measures the CVP and reports to the captain.During these steps, the captain is managing tlie air-

wayr he is ready to intervene immediately withmechanical assistance for respiration and subsequent in-tubation if necessary.s If the cup line is not obtained, thetrauma captain immediately will make a decision on theinsertion of an internal jugular or subclavian line.

Should he opt for these, the intern becomes the teamcaptain until the procedure is finished. Simultaneously,the nurse andlor technician start a second conventionlllarge-bore I.V. in the left arm, If more lines are needed.they can be added.t'e

The only alteration is for the cardiac arrest team,when the initial determination of absent pulse and comawould have produced a closed chest massage, as well asthe airway management.6

At this point in the resuscitation, the captain canpause and assess extent of injury. He can delegate this,or quickly perform the examination himself.

He will make a decision about the necessity for Foleycatheterization, nasogastric intubation, thoracostomy,paracentesis, or peri-cardiocentesis.2,s'5'8 By now, bloodwill also have been drawn for type and cross match, andif the situation warrants, type-specific but unmatchedblood can be started. We prefer not to use O (-) blood.

At this time, the patient should have responded toresuscitation. Pericardial tamponade may be considered,and pericardiocentesis performed.2,3

By now too, the specialty teams have been notifiedand the operating room made ready, surgery can be per-formed in the Emergency Department, when necessary.Injuries that survive long enough to reach the Emergen-cy Department can usually reach the operating room, so

46

that it is rare for surgery to be necessary.The remainder of our protocol is included for infor-

. Figure I TRAUMA(l) Disrobe completely, also immediate blood pressure

and pulse. If status of spine not known, cut clothingaway.

(2) Airway(a) Oral airway.(b) Ambu bag.(c) O' - open wide.(d) Endotracheal equipment at direction of Trauma

Captain.l . laryngoscope2. E T tubes3. Procaine 2Vo,3 cc. for transtracheal injection4. Succinyl choline, 40 mg. at discretion of

Trauma Captain(3) I .V . ' s

(a) Lactate ringers only.(b) #14 intracath for CVP.

#14 intracath.(c) Subclavian line at request of Trauma Captain.

(4) Open wounds to be bandaged at direction of TraumaCaptain.

(5) Fractures to be splinted at direction of Trauma Cap-tain.

(6) Consultations, x-rays, EKG, and laboratory at dis-cretion of Trauma Captain. No diagnostic X-rays orEKG until patient's condition is well stabilized!!!

(7) Tetanus Toxoid, Vz cc. lM - all patients.(a) On minor trauma, no toxoid if booster within l2

months.

Figure 2

mation. We have seen many deaths ensue from efforts todiagnose, when active intervention was needed.

PATIENTS(b) On major trauma, all patients to receive booster.

Human antitetanus antitoxin, 500 u. IM if nogood history of prior tetanus immunization.

(8) For all penetrating thoracic and abdominal trauma,antibiotics to be started as follows:

Thoracic: 1,000,000 u. Penicill in I.V. pint bottle,and 250,000 each following bottle; Vz gramStreptomycin IM.If Penicillin allergy, Lincocin 4 cc. I.V.Abdominql: I gm. Kanamycin, first I.V. bottleand 250 mg. each following bottle, but no morethan 2 gm. to be given in Emergency Room.Give 4 cc. Lincocin LV. in first bottle.

For all patients in shock, i.e., blood pressure lessthan 100/60, pulse greater than 100 and clinical signsol diaphoresis, cold clammy skin, weak pulse pressure,and apathy to surroundings.( l ) Foley catheter,(2) Chest tube 138 Fr. inserted in R,, L., or both 5th in-

tercostal spaces in anterior axillary line at discretionof Trauma Capti in,

(3) N-G tube at discretion of Trauma Captain.(4) Type and cross match 6 units of whole blood.(5) Stat CBC, electrolytes, and blood gases.(6) One Amp NaHCO3, LV. push - additional at dis-

cretion of Trauma Caotain.(7) Abdominal paracenteiis at discretion of Trauma

Cantain.

l. Observe trauma orotocol2. If patient indicat-es shock at any time, or if obvious

peritoneal penetration (EG bowel of omentumevisceration or signs of peritonitis) all these patientsmust be explored in the operating room. If patientfinancially ineligible, admission must be mandatory.

3. The remaining stab wounds will be handled asfollows:

In the Emergency Room the wound will beprepped and ster i le ly draped. Under localanesthesia the stab wound will be enlarsed and ex-plored.

Figure 3

ABDOMINAL STAB WOUND PROTOCOL

DIAGNOSTIC PARACENTESIS PROTOCOL

a) If the fascia is penetrated the procedure will beterminated, the wound packed open, and thepatient explored in the operating room. Admis-sion will be mandatory if the patient is finan-cially ineligible.

b) If there is no fascial penetration, the wound willbe closed primarily and if no other indicationfor admission, the patient will be discharged.

4. Tetanus prophylaxis will be carried out. (see TetanusProtocol)

5. Under no circumstances is the stab wound to beprobed.

Abdominal trauma (any injury below a l ine drawnthrough the nipples).A. Gunshot wound - mandatory exploration.B. Stab wounds

l. Peritoneal signs - exploration2. No per i toneal s igns:

Explore wound locallya) penetration of fascia - explore in

Operating Room.b) no penetration - observe or discharge.

C. Blunt t raumal. Conscious patient with no abdominal signs -

observe or discharge.2. Conscious patient with abdominal signs - ex-

plore or observe, (if questionable bruise of ab-dominal wal l ) .

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

4. Comatose or inebr iated pat ients wi th noperitoneal signs or equivocal signs:

Abdominal paracentesisa) peritoneal dialysis catheter inserted in

midline below umbilicus. I l iter lac_tated Ringer,s RUN in (500 cc. inchildren) I liter, then RUN out.

b) if return grossly bloody, explore inOperat ing Room.

c) if fluid-clear or pink, then do following:RBC, WBC, Amvlase.

d) if RBC > 100,00b/mmr _ explore inOperat ing Room.if RBC < 100,000/mmr _ observe(repeat paracentesis if indicated).

e ) i f W B COperating Room.

fl if Amylase ) l00y/l00ml, explore in_ Operat ing Room.

All_ patients who underfo_ paracentesis with dialysiscatheter are admitted for-obs-ervation, if paracentesis isnegative.

Summary:

. A team approach for the stabilization of life_threa.tenlng pathophysiology is recommended. Oncestabllrzatlon has been achieved, more conventionaldiagnosis and therapy can be introduced.

ReferencesL Baxter , C.R., Canizaro, p.C., Carr ico, C.J. , and Shires, G.T. :

Fluid Resuscitation of Hemorrhagic Shock. postgrad. Med.,48:95-99, Sepr. , 1970.

2. Beal l , A.C., Br icker, D. f . , Crawford, H.W., and DeBakey, M.E.:Surgical Management of penetrating Thoracic Trauma. Dis. ofthe Chest ,49:568-577, June. 1966.

3. Beal l , A.C., Dierhr ich, E.B. , Crawford, H.W., Cooley, D.A. , andDeBakey, M.E.: Surgical Management of penetrat ing CaiAiaclnjuries. Am J Surg, 112:6g6_691, Nov., 1966.

4. Cohn, J.N. : Central Venous pressure as a Guide to Volume Ex_pansron. Ann lntern Med, yol 66:12g3. 1967.

5 C: l ] ' . . . J .A. . and Lloyd. J.W.: pracr ical points in the Treatmenror Lnest fnJurres. Anesthesia. yol . 22:J92, 1967.

6. Gi ls ton, A. , and Resnekov,_L-: Cardiorespiratory Resusci tat ion,1971. F.A. Davis & Co., phi ladelphia.

7. Haddad, G.H., p izz i , W.F. , F le isc imann, 8.p. , and Moynahan,J.M.:

.Abdominal Signs and Sinograms as Dependable Cr i ter iafor Selective Management of Stab

-Wounds of the Abdomen. ,4nn

Surg, 172:6t-67, July, 1970.8. McNamara, J.J. , Messersmith, J.K. , Dunn, R.A. , Molot , M.D.,

and Stremple, J.F. : Thoracic In jur ies in iomtai Casual t ies inVietnam. Ann Thoracic Surg, 10:399_401, Nov., 1970.

9. Moyer, C.A. , and Butcher, H.R.: Burns, Shot[ and plasmaVolume Regulat ion, 1967. C.V. Mosby, Si . Louis,

10. Perry, J.F. , DeMeules, J.8. , and f ioot , H.O.: Diagnost icPer i toneal Lavage in Blunt Abdominal Trauma. Surg,6yn, &Obst, 13l:742-744, Oct., 1970.

48

USE OF THE VIDEOTAPE INEMERGENCY MEDICINE

George R. Schwartz, M.D.

. The portable videotape is a relatively new technicaldevelopment in medicini, much of its use being il;;t_chiatry.z'0 Professionally prepared programs have beenemployed with some sucCess', tr and iti use to improveteaching techniques has been described.r,12

--*l::: presenting our use of videorape in emergency

medrclne general considerations and cautions shou-ld b!mentioned_ The potential for the constructive use ofvloeorape ln emergency medical education is largely un-tlpp.a. One must remember that it is a tool, un-A ii, ,f_ficacy must be demonstrated before it is'adopted forwidespread use. Ryan and Budner found that live casepresentations in neurology were less effective than theirvideotape presentations,-in terms of subsiquent reten_tion. There is this caution: the television-monitor can_not and should not replace the skilled clinical teacherbecause he does much'more than si.pt/-impurt facts.The teacher provides the students stimuiaiion, the excite_ment of l llbj"g!, the logic behind it, and un identifica_tron moctel tor his students. A television image cannotdo this.

The emergency physician specializes in the immediate,r:.^:9:lrlon.und,response to. altered path ophysiology andln systems rnvolved in the initial care of lhi emergencypatient. The key words here are immediate recognition,response, and systems.

The physician spends many years in an educationalsystem which serves not_only to provide needed facts, butalso to provide logical thought p.orrrr", unO int.nriti.iooservatlonal capacities. Nowhere in medicine are thesecnaractenstlcs needed more than in emergency medi-cine.

In the first videotape segment we observe a child inrespiratory distress. After watching this patient studentsand clinicians are asked to list theii oUr"iuuiionr. As thecamera focuses in, the tachypnea, the intercostal retrac_tions, the abdominal rejpirationr, it "- suprasternalIlrj,llt i:

the flaring. of th-e alae nasae, the prolongeJexplratory phase, the hunched over shoulders,-increaiedcarotid pulsation, are all seen clearly. the siuAents areasked,to go through a logical thoughiprocess to arrive at:..l l.,l l gl"g"osis. Questions about hisrory and physicalexamlnatlon may be asked._ Objective evaluation of the effects of such exercises isdifficult. When shown additional videotad the follow_ing week, the students were able to detect more abnor_mal findings. The twenty-four medical students andP:.1..",1 glu,guut:, physicilns "*po*a io it i, prog.urnnave rhe teetrng that they are looking more cioseiy at

their patients. With the videotape we are attempting toimprove observation,

The next element is the response of the staff to thepatient. In emergency medicine, this often is a teamresponse. Videotape review enables the team to reviewthelr own actions, and better understand the patient,spathophysiology. The function of the team membersmay be analyzed and discussed.

Tapes may be used with medical students, and as thecase evolves, it may be stopped and the medicalr.esponse, altered physiology and leam interaction can bediscussed at lensih.-

The third key-is systems study. The response to a dis_aster or disaster exercises can be videotajed in order tohelp future planning. The videotap" rniy be used torecord the activities of .the emerg'ency room, patientflow, problems with waiting .oorr] etc. This ."n b" uneffective lever for changc.

Some of our studeits did a documentary of theemergency.facility at the Medical College of penn_sytvanla. I nls was shown before the emergency roomcommittee and the medical director. Somitimes, themirror of reality is painful.

There are many other situations which can be filmed,and we,have videotaped some unusual or rare problems.I ne vldeotapg may be u-sed for program description forpotential applicants or foundatibn lrants.

Although objective tests of pir"n." of learningenhancement, increased observational capacities, aniimproved decision making have not yet been done, thesubjective responses have been uniformly favorabie. Ibelieve such use should.be_encouraged ani comparativetesting employed to see if the subjeciive responses can beborne out.Summary - The videotape may be effectively used inEmergency Medicine. particulai uses include:. 1.. Enhancing observational capacities of emergency

physicians and teaching on undergiaduate and postE;;;:uate level.

2. Evaluation of the Emergency response in lifethreatening 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 y D e p a r r m e n rprob.lems. Quantitative evaluatio-n of'the benefits inmedical education is necessary.References

l. Perlberg, Arye et al.: Microteaching and Videotape Recordings: ANew Approach to Improving Teiching, J. Med. Ed. 47:4i_SO,t972.

2. Chodoff, Paul: Supervision of psychotherapy with Videotape: pros

49

and Cons, Amer. J. Psychiat. 128:819-823, 1972.3. Cline, David W.: Video Tape Documentation of Behavioral

Change in Children, Amer. J. Orthopsychiat. 42:40-4'1,1972.4. Ryan, James H., Budner, Stanley: The Impact of Television: An

Evaluation of the Use of Videotapes in Psychiatric Training,Amer. J. Psychiat. 126:1397-1403, 1970.

5. Suess, James F.: Self-Confrontation of Videotaped Psychotherapyas a Teaching Device for Psychiatric Students, J. Med. Ed.45:271-282, 1970.

6. Wilmer, Harry A.: Television as Participant Recorder, Amer. J.Psychiat. 124: | | 57 -l 163, 1968.

7. Sigafoos, Thomas, Jordan, Judith: Staff development via

Videotape, J.A.H,A, 46: 40-42, 1972.Bronson, Nathaniel R.: Videotape in Ophthalmic Surgery, Amer.J. Ophthalmolo gy. 7 l :544-548, 1970,There's Something for Everybody - And it's all on Videotape,Mod . Hosp . l l 9 : 88 -89 , 1972 .Peltier, Leonard: Television videotape recording: An adjunct inteaching emergency medical care, Surg. 66:233-236,1969.Jamron, Kenneth S., Nailen, R.L.: Homemade videotapes trainstaff and help patients understand hospital procedures, Mod.Hosp . 117 :87 -88 , 1971 .Crandall, G.M.: Videotape Keeps the Training up to Date, Holdsthe Cost Down, Mod. Hosp. l l7 :85-87, 1971.

9 .

1 0 .

l l

t2.

50

EMERGENCY MEDICAL SERVICES IN THE USSR

A RESIDENT'S EVALUATION

Robert Scribner, M.D.Larrv Reithaus. M.D.

The Soviet Emergency Medical Services was foundedin 1919, not long after the Revolution. The purpose ofthe Emergency Medical System, the Russian name forwhich is Skoraya Meditsinkaya Pomosch, was toprovide emergency medical care to a large urban and amassive rural population - a population scattered overthe greatest single land mass in the world. From thisgigantic task of providing medical care over eight and ahall million square miles, the fundamental concept ofSoviet Emergency Medical Care evolved: That is, sendthe doctor to the oatient rather than the oatient to thedoctor. This has been the central them-e and it hasremained at the core of the system.

The administrative structure is highly centralized. Atthe summit is the Ministry of Health in the SovietUnion. Within this ministry, there are administratorswho specifically govern the Skoraya. They officiatethrough their counterparts and a Ministry of Health ineach republic. In turn, there are rural and city Divisionsofl Health, which administrate health care at the locallevel. The Skoraya of a given region is governed directlyby such a division of health, but close control is main-tained from the top on down. For example, the healthcare budget comes from the Ministry of Health of theSoviet Union, but the Ministry of Health of eachrepublic governs how much it spends on its yearly healthcare allocation on the Skoraya. This will vary fromregion to region.

In addition, the types of ambulances are decided uponby the Ministry of Health of the USSR, but the numbeiof ambulances assigned for a given area is determined byeach rural or city division, depending upon their localneeds. Thus, whilg financial and governmental cen-tralization is maintained, a great deal of local freedom isexercised in the utilization of funds, equipment and man-power.

The young medical student graduates at age 22. If heor she - for 50Vo of the graduates are women - desiresto be a Skoraya doctor, he begins with a six monthcourse in emergency training. Upon completion of hiscourse, he becomes a Skoraya Generalist. From then on,he learns as he works. He must know basic medical andsurgical differential diagnosis. As a young SkorayaGeneralist, he spends three to four months per year on aspecialty brigade. There are six such brigades: Car-diology, Trauma and Shock Resuscitation, Toxicology,etc. In addition, there is a separate psychiatric brigadestaffed by psychiatrists. Skoraya Generalists ultimately

gain expertise in the specialty brigade of his choice.Skoraya Generalists wil l work three or four months

per year riding the ambulances and the remainder of thetime, wil l work in a specialty ward in one of theemergency hospitals. In Moscow, there are five suchhospitals. The major one being the SklifosovskyInstitute, a 600 bed hospital and institute for scientif icresearch into the problems of emergency care.

The Skoraya specialist continues to learn and super-specialize as he works. He wil l participate in particularcourses, educational activit ies, that deal with his special-ty. He wil l attend various emergency medical serviceconferences throughout the Soviet Union. He wil l befinancially supported for these meetings by his localSkoraya. On the average, he wil l work l2 hours and beoff 36 hours. A good deal of his l2 hours on call wil l bespent watching television, reading, or just chatting, buthe is always ready for immediate call. He wil l probablybe a Skoraya Doctor his entire l ife.

Skoraya physicians are outnumbered four to one bymiddle-level medical workers in the Soviet EMS Ser-vice. Two-thirds of these are feldshers. The feldsher isunique to Russia. They are highly trained nurses, belowthe level of a doctor. The name is derived from the fieldof surgeons of the l Tth century Swedish and German ar-mies. The idea was imported into Russia by Peter theGreat and feldshers were, for a long time, solely respon-sible for medical care throughout the rural reaches ofRussia. As the number of Soviet physicians has in-creased, now 650 thousand, (greater than the UnitedStates, Great Britain and France combined), thefeldsher's role has decreased and may soon disappearaltogether.

Skoraya is designed to treat the accident victim andthe acute ly i l l . As an emergency system, i t adheres to theprimary tenet of reducing the time lrom the primaryonset of the i l lness to the del ivery of t reatment . I tsmodus operandi, however, is to apply l ife saving, l i fe-supporting measures at the scene and during transporta-t ion rather than merely t ransport ing pat ients to thehospi ta l as rapid ly as possib le. To do th is , i t is essent ia lto take the doctor and the treatment to the patient. Inthe Moscow Skoraya which wil l serve as an example ofthe urban system, there are 200 ambulances in service inthe daytine and 100 at night. One ambulance serves ap-proximately 35,000 people.

Ambulances are ol two types. First, there is the l ineambulance which is similar to the American Chevy van.

5l

It contains a stretcher, splints and an anesthesia machineus ing n i t r ous ox ide , a resp i ra to r , i n t ravenousresuscitative materials and basiC emergency medicines.It is staffed by a doctor and one oi t*o feldshers.Secondly, there is a specialty ambulance which is essen_tially an ER on wheels. It contains all the equipment int h e l i n e a m b u l a n c e , p l u s a n E K G m a c h i n e , adefibri l lator cardiac massage apparatus, tracheostomyand thoracotomy sets, and poiJon antidotes. On theseambulances, are a feldsher and two doctors, one _ abrigade specialist.

The Moscow Skoraya consists of a central telephonedispatch and 22 regional aid stations. Each station isresponsib.le for a particu_lar geographical area of the city.Central dispatch is in direcl telephone and radio com_munication with each of these stations and with theirambulances. It also communicates with other medicalpo.ints, factories, stores, transportation systems such assubway stations, etc. There is a single radio band for theSkoraya all over the Soviet Union.

. Central dispatch is manned by dispatchers who areeither (eldshers or doctors. Their iunction is comparableto that. of the persons manning the switchboard^ at theambulance communication center in New york City.They are trained in telephone recognition of the natuieand severity of an i l lness. They havJat their disposal, anup-to-date accounting of the bed situation at everyemergency hospital in the city. They can thus direitdelivery of a patient to the appropriate hospital in theclty.

.. During.on_e of my nights on call at the First CityHospital in_ Moscow, there was no surgery being per'_formed and we had a number of youig doctori andmedical students sitt ing around idie. T[ere being nolibrary.zrnd certainly no pub in the hospital, we cil ledC-entral Dispatch and asked them to send us some casesof possible acute appendicit is. Within two hours, we hadIOUr Cases.

On the other hand, when we called Central Disoatchand told them we were backed up with operative iases,we received no more surgical cases for t lat night.

-Let us now examine a typical emergency situation. Apatient sustains a _myocardial infarct-ion in a park. Apasserby goes to the nearest telephone. All puLlic paytelephones have a^push button for emergencyialls. Thisoovrates the need lor a two kopek coin. It is about 2( notl0p. Next to this button are initructions: Dial0l for f ire,02 for police, and 03 for medical help. This is standardthroughout the Soviet Union. Our pai.lrby dials 03 andit goes directly to the Central station of the Skorayasystem of that city. Central Dispatch receives the cil lwithin one minute and calls th-e nearest aid station.Within three minutes a specialty ambulance is dispatch-ed with a specialist from the cardiology brigade onboard. If the specialty ambulance is not al-the sLtion, itcan be contacted directly by radio. Within six to tenminutes of the original call, the patient is resuscitated atthe scene, and taken to the nearest emergency hospital.The ambulance or Central Dispatch cun ilro call aheadto the receiving hospital so that all is prepared for thepatient's arrival. Transportation through tire city is less

diflicult than in the United States. Traffic is less for onething. Emergency traffic lanes exist. And there are traf-fic policemen who man the major intersections 24 hoursa day.

We have a good deal to learn from the Soviet Unionconcerning rapid and efficient delivery of emergencymedical care. Emergency Medicine has-been a soeiialtvin the Soviet Union for over 50 years. In keeping wititthe entire political structure, ceniralization and verticaldispersal of administrative authority predominate. TheSoviet System stresses physician'specialization. TheEmergency Medical Service is an esiablished and life-long. .career special ty. I t also engenders super_specialization. So that, for example, a physi^cianbecomes not only a pediatrician but a speiialist inemergency pediatrics. The Soviet system, thui in a sense.reverses our own. The Soviet becomes an emergencygeneralist first, then casts off into trauma, n"urjogy,pediatrics, etc.

In summary, I would .like to suggest the followingemergency care characteristics of the Soviet emergencysystem, that warrant consideration for impiovingemergency care in our own countries.

First, centralization of administration and funds., Secondly, lifelong career specialization for emergency

physicians.Third, central izat ion of communicat ions with

geographically distributed aid stations and hospitaltreatment centers.

, Fourth, the widespread use of the emergency room onwheels.

Finally, adherence to the concept that the doctor goesto the patient rather than the patient going to the docior.

In the Soviet Union, the cry .,call a dictor" has notbeen replaced by the cry, ..call an ambulance."

Dr. Reithaus: I'd just like to point out that theSkoraya has a very important central role. The overallorganization of health care and its delivery bears an in_teresting relationship to the specialty institutes of bothmedicine and surgery. Specialty institutes of the Soviet.Unign are organized on a far more highly centralizedlevel than comparable institutions in thJwest. There areseparate institutes in many of the surgical and medicalsub-specialties, on a regional, republic-wide and an All_Union level. For example, I spent three months workingat the All-Union Institute of

-Clinical and ExperimentaT

Oncology but there were regional centers as well whichhandled most of the straightforward cancer cases, Thus,in Moscow, Leningrad, and other major cities one findsrnstrtutes ol- cardiovascular. surgery, pulmonary surgery,orthopedic and reconstructive surgery, G.I. suigeryi aiaeven surgery for acute arterio-emboiism.

As already mentioned, care for acute trauma is ac_complished in the Skoraya hospitals. Specially trainedemergency care physicians as described by Dr. Scribnerare assigned to the ambulance and they are capable ofd-iagnosing and directly admitting the acute pro6lems tothe appropriate surgical hospital or other lppropriatespecialty.ho.spital. Thus there is a direct and'efficientlylinked relationship between the emergency care systemand the specialty institutes.

52

ients.that the Skoraya has picked up for suspectedocardial infarction. In addition, of the patienfs that

rgu.ired resuscitation, approximately 20(io reportedlyurvlved ancl went on to convalescence. In the USSR

re are about 27.6 physicians per 10,000 population. In;or metropolitan centers, the figure goes even higher.

In Kiev, for.example, there are 43.4 physicians peil0,-!p0 population, for providing direct patient care. In theUnited States, as of December 31, i970. there were l7physicians per 10,000 delivering direct patient care.

couple of other figures which I would like to Question: Do you have any idea of their professionaland financial remuneration?

Dr. Scribner: The Skoraya doctor, as most middle_trained doctors, receives about a hundred to a hundredand ten rubles a month. This is about l l0 to l l5 dol larsa month which is about $120 in Canadian monev. If thevare interested in research, they can go direcily to anacademic career -- a whole separate topic of theeducational system in the Soviet Union. They are vervpragmatic. If they train people to practice

-medicine,

that's all they practice. They'll work on a standard shifijust like an engineer will work in a factory. In fact. thevmake the same salary as most factory workers,

'

jes University Association for Emergency Medical Services uAbMs Post Office Box 1241 East Lansing, Michigan 48823

Additional copies of this publication available for five dollars each .