}TEETING OF I]NIVERSITY EMERGENCYDEPARTT"TEM DIRECTORS

MARCH 6, 7.970

UI{IVERSITY OF AI,ABA},IA IN BIRMINGITAI"IBIRMINGHAI\T, ALABAMA

NOTE: The presentat ions of thls meeting have been transcr ibedand dlstr lbuted with the assletance of the Divis lon ofEarergency Health Services, PubJ-ic Health Service, Depart-nrent of Health, Educat lon, and Welfare.

PROCEEDINGS

MarcLh 6. 1970

BIRMINGHAM, ALASAMA

6,itg uf T$irmingfturn, $,luhunra

O F F I C E O F T H E M A Y O R

March 5, L97O

TT's NTCtr To HAVE YOU IN BIRMINGHAM

are indeed proud to have you with us for lt alLows us to show youand growing Birmingham.

I know that your lnterest ls ln the f ieLd of Emergency Servlce Departments.We are fortunate to have some of the flnest emergency factLities found anlnuhere.Blrnlnghan ls lndeed proud of, the people who have devoted themseLves to the per-fec t lon o f these fac i l i t i es .

Wtrlle you are lrith us, please feel at horne and take tl.me to see the beautyand recreat lon spots of our ci ty. I regret that I wi l l not be abl-e to join youwhi le you are wlth us. I have two conferences to attend ln Washington, D. C.

EnJoy yourself and'plan to return to Birmlnghaur soon after the conpletlonof your conference.

Se lbe ls ,

GGSJr: ss

G E O R G E G . S E I B E L S , J R .M A Y O R

Wethe new

ncereLy,

George

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,t{i'4 119j,\ . / . t J l - .

tle Untrsersity of-.{/abana tn Btrntnghamf

March 2, L970

?art ic i .pants tn the Meeting of universi ty Emergency DepartmentD i rec tors

J . F . Vo lker

TO:

FROM:

r regret that a pr ior engagement prevents me from extending a per-sonal welcome to you. es a untversi ty administrator and a concernedcit izen, r have been very much aware ihat there are a number of verycr i t t caL areas r .n_our p resent sys tem o f heat th care de l i very . Th is ieespectal . ly t rue of the emergency departments.

l {e at the unrverstty of Alabama in Bi.rmingham feel honored thatthe prob lems assoc ia ted w i . th th is aspec t o f med ica l ' care are the sub-Ject of a meeting on our campus. I fopefui l .y, the deriberat ione wirr beprof i table to aIL concerned and wi lL- Lead lo " "ont i .nuous communtca_t ion be tween aL l in te res ted par t ies .

1 1

AGENDA

Meet ing of universi ty Emergency Department DirectorsFr i day, March 6 ,

'1970Room l l2 (Ground F ' loor ) , Lyons-Har r ison Research Bu i ld ingun ivers i ty o f A labama Med ica l cen ter , B i rmingham, A labama

Morni ng Sessi ,on

7:30 Reg is t ra t ion and D is t r ibu t ion o f Emergency Depar tmentProcedures

8:30 Wel coming Remarks . . .Dr . E . C. Oventon , B i rmi nghamCi ty Counci lman - Chai rman,Commi t tee on Educat ion , Hea l thn

and l, le' lf are

8:40 l^lel coming Remarks . . .J o h n W . K i r k l i n , M . D . , P r o f e s s o rand Chairman, Department of Surgery,Un j versi ty of A'labama

8:50 Introductory CommentsA l a n R . D i m i c k , M . D . , A s s i s t a n tProfessor of SurgenyUnivers i ty o f A labama

9:00 "Movement of the Acutely I ' r ' r or In jured pat ient to theEmergency Department . . .

C h a r l e s F . F r e y , M . D . ,Un ivers i ty o f M ich igan

9: '15 "Reg iona l P lann ing o f Emergency Med ica l serv ices"J a m e s R . M a c k e n z i e , M . D .McMaster Un ivers i tyHami l ton , 0n tar io , Canada

9:40 D iscuss ion o f Ph i ' losophy , Goa ls and 0b jec t ives o f 0 rgan iza t ion ;P l a n s f o r 1 9 7 0 F a l l M e e t i n g

l0 :45 Descr ip t ion_of Emergency Depar tment , Un ivers i ty Hosp i ta l ,and Tours of Emergency Department and Related Faci l i t ies

A l a n R . D i m i c k , M . D .

NOON LUNCH

l

i l i

Afternoon Session

2 : 0 0

3 : 4 5

Workshops:

Presentat i onChai rmen

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*Movement of the Acutely I l l or In juredPatient to the Emergency Department

*The Emergency Department

*Regional Planning of Emergency MedicalServi ces

of Summaries of Workshops by Workshop

1v

MOVn{ENT OF THE ACUTELY tLL

T: THE EMERGENCY DEPARTMENT

OR INJUPJD PATIENTC h a r l e s F . F r e y , M . D .

Those of us responsible for invl t lng you here to Alabana cannot help

but be impressed and grat i f ied at your presence. The spontaneous outpouring

of interest expressed by your appearance here at thi-s meeting is in rny opinion

not a reflection of the drawLng power of famous names as rire are too youthful

for that, or Alabama ln the spr ingt ime, though i t is beaut i ful , but a universal

recognlt lon of the urgent need by al l of us here to improve emergency medical

s.ervices throughout the United States.

I hope that by the end of today we wlLl know something about our exist-

lng emergency uredical services in the Unlted States, what can be done to

improve emergency medical servlces, what our organizat ion can do to help

achieve those lmprovements, and how can we structure and f inance our organiza-

tion to 1-mpJ-enent the goals of our menrbershlp.

Through the keynote speeches this mornLng I bel ieve we can def ine the

Emergency Medlcal Servlces Systern. Our workshops have a far rnore di f f icul t

task. Through your act ive part ic ipat lon they must develop the goals of our

organlzat lon, and recommend an organizat ional and f lnanclal structure which

wi l l implement these goals.

I wish to take thls opportunity to thank our hard working secrega.ry,

Jim Mackenzie, along with the regional repregentat ives, the founders and our

host, Alan Dlmick, for maklng this meetlng possible.

To date we have received 62 emergency medical service gummaries. These

have been compi led, reproduced, and are included in the mater ial you received

at the t ine of registrat ion. Much of the reproduct ion has been done with the

cooperat ion of the Emergency Health Services Divis ion of the publ ic Health

servlce, whose representat ive, Mr. wal- ter Hughes, is with us today. The

I

assembled emergency medlcal services summarles represent, I bel ieve, a

valuable resource. This knowledge of what other universi . t ies have done to

resolve certain problems rnay help us avoid much trial and error in our own

ine t i tu t lons .

I,fith us today are a nurnber of men who, through combinations of j.ntelli-

gence' energy and determlnat lon, have dist . lnguished themselves in the f ie ld of

surgery. [,Ie are happy that they cared enough about the problems of emergency

medLcal services to Joln us today.

' In the preparat ion for the workshops thle afternoon you have recelved

an out l ine descrlbing the emergency medlcal gervtces system. I t is my respon-

siblLi ty to descr ibe emergency rnedical services which consists of two phases

that must be lntegrated into a unif ied system by regional planning. Phase I

lncludes the movement of the pat lenL from the scene of accl-dent or t l lness to

the eurergency oepartmeut of a maJor medi.c.al center. Phase l .L incl .udes the

movement of the pat ient f rom the emergency department of fhe ma.jor mect i{- ja l cenLer

to i ts operat, lng sul te or coronary care un. i . t .

Couponents of an emergen.cy rneclical care system u.nder Phase I include:

1) Survel l lance - that le the Ldent i f lcat lon of the sf" te of accident or the

acene of l l lnees. 2) TransportatLon and equlpment. 3) Communlcat lons. 4)

Training of the rescue worker. Components of an emergency nedicaL care system

under Phase I I , which Dr. Rutherford wi l l d iscuss, include the avai labi l l ty

of the fol lowlng aroqnd the cl-ock in the emergency department and hospital :

1) Physiclans, surglcal and medical special ists. . 2) X-ray technicians and

rad io logy equ lpment . 3 ) B lood bank personne l . 4 ) Opera t ing room s ta f f . 5 )

Coronary care unit . 6) Shock and/or intensive care unit .

Breakdown of any link ln the chain of care ln Phase I or Phase II results

in increased mortal i ty of the pat lent. In the United States today there are

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dlf ferences Ln the avai labi l i ty of emergency medical services. 0f ten they

are least avai lable in the areas where they are needed the most, that is in

the rural areas of this country. Deaths from motor vechl le accidents are

hlgher in rural thgn urban areas. Seventy percent of al l deaths from motor

vehLcle accidents occur ln towns with a populat lon of less than 2r500, accord*v

lng to the Nat lonal Research CounciL. Deaths from al l types of accidents

and acute ill-ness such as myocardial lnfarctions are higher in rural- than urban

areaa. Wal lerts Cal l fornla study also demonstrated the geographic di f ferences2 /

ln the qual i ty of emergency medical services in Cal i forni t . He found deaths

from motor vehlcl-e accldents were l -7.0/ l -00r000 in urban count ies of Cal i fornia,

46 .8 /100,000 in ru raL count les o f Ca l i fo rn ia , and 85 .5 /100,000 in mounra in

count les of Cal i fornla. Deaths from non-transport accldents fol lowed a simi lar

but less pronounced pattern. Deaths in urban count ies of Cal i fornia from non*

t ranspor t acc idents were 17 .9 /100,000, in ro ra l count ies 27 .3 /LOO,0O0, and ln

mountatn counries 48.7 /L00,000.

We made a study of deaths from accldents ln our own countv - and I

recornrnend this to anyone who has not done so - in order to a.ffrr" the extent

and nature of any def ic iencies that exlst ln Phase I or phase I I of theirzl

emergency nedical services system. We found during a six-year experience

fron l-962 to L967 in Washtenaw County, which has a populat ion of 225,000 in

a land area of 720 square ml les n there were 450 deathe from motor vehicle

acc idents ' 235 deaths f rom'o ther types o f acc idents , 166 deaths f rom eu lc lde ,

and' 27 deaths from homicide durlng thle six year period. We Judged the potent lal

for salvage in the 159 pat lents on whom we had autopsy data to be 18 percent.

Death was caused by airway obstruct, ion, hemorrhage, and unrel ieved tension

pneumothorax in the 29 pat ients ln whom there was potent ial for salvage. Of

the 28 deaths only two occurred after hospital arr ival or dur ing phase I of

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.l

the emergency nedical services system. In order to salvage t .he other 26

pat ients ' l t would have been necessary to inplenent airway control including

endotracheal intubat ion, intravenous f luid therapy, and rel ief of tension

pneumothorax at the scene of the accident or in transi t to the hospital in

order to reduce the mortal i ty of those inJured.

There are two maJor teachlng hospitals in Washtenaw County. I arn

certain that the mlninal loss of l l fe after hospital arr ival is a ref lect ion

of h igh Leve l hosp i ta l care . Dr . Ruther fo rd w i l l , I rm sure , ment ion tha t

there are some areas in the country where many needl-ess deathe occur after

hospltal arr ival . In Von l . Iaggonerts study, 606 soldiers were injured whi lea

on leave and t ,reated ln civ l l ian hospltals. Accordlng to the author, one-

sixth of them died frorn inadequate hospital care. Al1 had survived more than

two hours after hospltal arr lval .

In surmarYr rI€ surveyed Phase I and Phase II of our emergency medlcal

services system. Phase rr , hospital care, was adequate. we were coping

sat isfactor i l -y wlth the inJuries del ivered to us. Phase I , the movement of

the acutely lnJured pat ient, needed improvement.

Most urgentr we fel t , was the need for rescue workers trained in

endotracheal- lntubat ion, lntravenous fLuld therapy, cardlopulmonary reguscita-

t ion, and cardiac monitor lng. Provislon for such t .rainlng ls not. present ly

avai lable. Hopeful l -y, community colJ-egee and hospLtals wi l l " develpp one- to

two-year prograns whlch wi l l provide lnetruct ion ln the most sophist icated

techniques of resuscltat ion.

As a corol- lary, the rescue vehlcles servicing emergency cal ls should

be equipped wlth al l - the tools, space and personnel necessary to perform

resuscitat lon. Further, the emergency rnedical technician in the modern rescue

vehicles should have avai lable instant communicat ion with his hospitalrs

emergency department through a th/o-way radio in order to receive instruction

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and help ln carrying out resuscitat ion at the scene of the accident and in

transl t to the hospital . The use of the heLicopter as a means of t ransport

faci l l tates regional planning of emergency nedical services. pat ients

del ivered to hospitals where special ists, blood bank faci l i t ies and other

essent ials of pat ient care are not avai lable can then be brought rapidly to

a maJor medical center for def ini t ive* care.

what benefits nay we expect to gain frora irnproving phase r of

emergency nedical servlces? I t has been est imated we can ant lc ipate a

reduct lon ln mortal i ty f rom myocardial lnfarct lon of 10 percent and in the

mortal i ty f rom accldents of f rom 10 to 20 pereent. These est lmates are based

on the studi-es of pantr idgerS slesouris and Mores . i l ,n"cisserrZ ana8 /

Heidelbert studies, as wer-r. as our own washtenaw county study.

r should emphaslze that unlike most of those dying from cancer and

heart dlsease, accident vlct lms are most often in the 15-30 age group. salvage

ln this younger age group has greater meanlng in terms of l i fe expecrancy

and the value of labor to be ant lc ipated by society from the indivldualfs

cont inued act lv i ty.

Improved energency medical services can also be expected to reduce the

costs to the community and lndivldual-s of the disabi l i ty resul- t ing from inJury.

cos ts o f hosp i taL iza t ion fo r parap leg ics a lone are Judged to be $250,000 to

$500,000 over a l0-ro 2O-year period.

we must emphasize to the conmunlty, its leaders and spokesmen the need

for f inancial support of Phase r of emergency medical services by tax or subsidy.

Emergency nedical services is as much a publ lc ut i t i ty as the pol ice of f i re

department.

My charge then to the workshops and their chalrmen is whar

as indlvlduals ' emergency department dlrectors, and as members of

can

th i s

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we do

l

organlzation to lmprove the meane and methods of

equipnent, the comunlcatlon between hospltals and

the trainlng of a highly sklLled emergency nedical-

transport , the qual l ty of

the rescue vehicLe, and

technician.

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PROBLEMS IN OPEMTING AN EI4ERGENCY ROOMIN A UNIVERSITY HOSPITAL

Rober t B . Ruther fo rd , M.D. , Depar tment o f Surgery , JohnsHopklns Medical School, Bal-timore, Maryland

As part of thls panel on the del lvery of emergency medlcal services,

I have been assigned the task of discusslng those problems involving the

operat ion of the mergency room i- tsel f . However, rather than attemptint to

touch al l the basis, I have elected to concentrate on three exemplary problens

or issues which are not wel l covered in the l i terature on thls subject, but

which wlIl- nevertheless brlng out many of the aspects of emergency room

admlnLstrat ion, organlzat lon and staff ing, pat lent care and teaehing which

w111 be the focue of dlscueslon in this afternoonts workshops.

The flrst problen is one which I have labell-ed "The Emergency Room

Populat lon Explosionrt . Because of a number of major changes in the patt ,ern

of deLivery of cornmunity health care, emergency rooms all over the country

today are being lnundat,ed by a ver i table t ldal wave of pat ients, and part icular ly

pat lents present ing themseJ-ves with general pract ice or non-emergent problems.

Although they were speclf lcat ly designed and organlzed to deaL with emergent

or at least urgent medical problems, the emergency rooms of most major metro-

pol i tan medical centers and, to a lesser extent, suburban and county hospitals,

have also been obl iged to provlde servlces formerly rendered by off lee vis i ts

or house calLs by physiciane pract ic ing in the coumunity.

By and large, surgical and rnedlcal emergencies continued to receive

reasonably Prompt and adequate treatment, but l t ls the pat ients with the

relat, lvely minor or non-urgent. probLems, who by necessity have to wait the

longest t ime for the least t . reatmentr who are the unsat isf ied customers. These

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pat lents cl-og up emergency room operat ions and the constant pressure on the

emergency room staff to keep up wlth this 1og Jarn of pat lents is not only

responsible for t reatment errors (mainly those of omlssion) but leads to

hurr led, impersonal care which, comblned with long wait ing t imes, creates a

degree of f r ict ion between pat ient and staff which not infrequent ly erupts

into unpleasant lncldents. As a result , the overworked emergency room 1s

frustrated to f ind i tsel f at the same t ime one of the hospitaLfs major head-

aches and the target of publ lc anger.

The explanat ion for thls rernarkable upsurge in emergency room ut i l iza-

t lon can be analyzed ln terms of four naJor components: the pat ient, , the

physiclan, the inst i tut lon, and external- forces. The pat ient-related causes

are out l ined in sl lde r . Most of t ,hese are sel f-explanatory and have been

brought out by the coggeshal l and other publ ic hear. th studies.

The physician-reLated causes are al-so famil iar to most of us. These

are out l ined ln Sl lde I I . Less than 15 percent of todayts medical school

graduates enter general pract ice, a eonplete reversal- of the rat lo which

existed at the beginning of thls century, and more than 15 percent who have

graduated ln the last 20 years have returned for special ty training. This,

coupled with populat ion increases, has reduced the number of general pract i t ioners

for a given populat lon to approximately one-third of what i t was three decades

ago' Even the overal l proport lon of physiclans in pr ivate pract ice has dropped

from 86 percent to 63 percent over the last three decades. The rast of the

causes l isted in Table rr appl ies more to the use of suburban or county hospitals.

The pr lvate physictan is increasingly using the hospital emergency room rather

than his own off ice faci l i t ies for the treatment of these problems.

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The inst i tut ion-related causes are l lsted in sl ide I I I . probably the

most inportant of the factors mentj.oned here ls the convenience of the emer*

Sency roomts t topen doors' open hourst ' pol icy. This, along with the decreasing

avai labl l i ty of pr imary care physicians, part lcular ly in the inner ci ty, are

probably the two most important factors in this overar l t rend.

The ' rexternal forces" contr lbut ing to thLs populat lon explosion are

I- lsted on Sl lde IV. The nost important of these, of course, are the var ious

private or state-run third party programs. On the next three sl ldes, I have

offered some stat ist ics to give a perspect lve of the dimensions of this

probleur as i t exlsts ln thls country today, as wel l as l ts ef fect on the com-

nunlty and hospital in which I work. Sl ide V summarlzes the nat lonal s iruat ion.

The annual rate of emergency room visits has increased anywhere from 6 to 9

percent Per year over the l -ast decade, depending on the stat ist lcs one uses.

In the report quoted here, the annual- rate of emergency room visi ts increased

by 1-6 miLl lon (+I75%) from 1954 to 1964, bur rhe f lgure menrioned in rhe

Coggeshal-l- report for the same period was an Lncrease from 16 mil-l-ion to 53

mll l ion in nlne years' or annual lncrease rate of 9 percent per year. Regard-

less of whlch of these statLst ics ls the most accurate, they both indicate that

this rate of increase has not been a gradual one. For exampl.e, in the former

rePort the two years fron 1952-L964 showed a greated combined j-ncrease than for

the total of the preceding f ive years. Furthermore, these increases are out

of proport ion to those seen for in-pat ient adnlssLons and out-pat ient v is i ts

during the 1960fs. Ftnal ly, this ls apparent ly a cont lnuing trend wlth the

current predicted rate of i .ncrease being ln the neighborhood of 10 percent per

year. Sl ide VI ref lects the way in which thls has affected a typical Eastern

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I

metropol is ' namely greater metropol i tan Balt imore, whosb populat ion of two

mil l lon and 24 emergency room faci l i t ies were surveyed in November, 1968.

The survey showed that the annual number of emergency room visits had almost

doubled in eight years. I lowever, the prorated f igure is only two*thirds greater

over the same t ime interval , indicat ing that part of this r ise is due to

populat ion increases. Final ly, i t shows that the ut i l izat ion of emergency

rooms ' and part icular ly their use for non-emergent medical problems, decrea6es

centr i . fugal ly. The Balt imore City f lgure can be seen to be almost two and one-

half t ines the nat lonal average, with the Balt imore County f igure running 20

percent below the nat ional average, and the out ly lng count ies being less than

one-half to one-third.

Sl ide VII out l lnes the character ist ics of the emergency room populat ion

exploslon as i t af fected the Johns Hopkins Hospital in 1968. There was a L75

percent increase ln the annual- number of emergency room visits in the 15 years

slnce the current emergency room faci l l t ies f l rst opened in 1953. However,

the rate of increase averaged Just over 3 percent per year for the f i rst 10

years, but ln the last f ive years of that per iod, i t averaged almost l -5 percent

Per year increase. The figures taken from the census tract irnrnediately around

the Johns Hopklns HospLtal showed an emergency room utilization which was

two and one-half times the greater Baltiurore average and four times the United

States average for the same year. Thls survey showed that up to 65 percent of

our emergency room visLts were for non-urgent problerns, al though only 40-45

percent could be readl ly ldent i f ied as being non-urgent without examlnat ion.

In addit ion, 20 percent of al l our non-urgent vis i ts turned out to be sel f-

generated' that i .s, return vis i ts or check-ups. At the t ime of this study,

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the average "wait ing t lme'r for an emergency room visi t r{ras 2.8 hours. This

includes waiting plus treatment tlme or "tirne in the systemfr. Ilowever, there

Idas a skewed distr ibut ion, so that many of the pat ients actuaLly dld wait

2-3 hours to be seen. The walkout rate had r isen from between 2-3 percent

and was even higher on days when our emergency room census was in the neighbor-

hood of 400 pat ients per day. Our surveys also showed that about one-third of

out Pat ients received X-ray studies whlch amounted to about 30 percent of the

total hospital X-ray load. This has become one of the major bott lenecks to

pati-ent flow. The survey also showed that the evening shift recelved an equal

number of pat ients as the day shi f t between them account ing for 84 percent of

the totaL. Final ly, ln the last 10 years four pr lvate hospltals in the East

Central sector of the clry had relocated in the suburbs, and durlng the same

time the number of general- pract l tLonerb lef t in this area had dropped to 20

wlth an average age of 64.

Since lt was obvlous that approxlrnately one-half of this increased

emergency room t,raf f ic more properl-y beonged in an out-pat ient faci l i ty rather

than ln our emergency room, we al-so surveyed our out-pat ient c l ln ic operat ions.

The highl ights of these f lndings are l - isted ln Sltde VII I . They conf irmed our

suspiclon that over the years our emergency room had gradually become the step-

chl ld of an out-pat lent department whose hours of operat ion, appointment quotas,

and staffing had hardly been adJusted at al-l to accormodate the lncreasi.ng

number of pat ients seeking aLtent ion there. At the t i rne of our survey, the

average wait for an elect i -ve appointment to this group of 48 cl in ics was 27 days.

Fi f ty Percent of the pat ients scheduled did not keep thelr appointments and

many of them could be easl ly traced back to the doors of our emergency room.

Thus, at a t ime of a great ly increaeed demand, our out-pat ient c l in ics were

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ineff ic ient ly seeing only about one-half of the number of pat ients that were

scheduled. The mechanism for screening and steering was i"neffect ive, rout ine

fol low-up care of cormon chronic diseases was not provided for, there was no

mechanizm for handl ing prescr ipt ion ref i l ls for chronic problens (the pat ients

were told usual ly Just to come to the emergency room when their prescr ipt ion

ran out), the cl in lcs l^Iere organized along the l ines of special ty interests

wlth l i t t le provision betng made for the care of common "garden varletyt l

nedical problems.

About Ehe only nice thing that came out of al l these stat ist ics was

that they provlded us with obJective evidence with which to convince the adrnin-

j-strat ion of the hospital and medlcal school of the ser ious dimensions of the

emergency room problem and eventuall-y enabl-ed us to obtain a high priority

commltment of the lnst l tut ionts resources to i t solut ion. When faced with

this problem, l t is lmportant to get this done as early as possible to al low

time for admlnlstrat ive inert ia and appropriate f iscal- plannlng. I t is also

important at the outset to obtain a statement and formal approval- of the basic

poJ-ic les that wi l l govern the lnst i tut ionrs attempts to resolve this cr is is.

That ls, the lnst i tut lon must be made to formal ly come to gr ips with what i t

thinks are i-ts responsibiLitles for providing eornmunlty health care. In many

academic centers, one wi l l encounter strong sent iments Lo preserve t .he inst i tut ion

aa an academically-oriented referral- center, deal-ing malnly with the problems

of speclal lnterest or complexl ty. I t w111 be said that a universi ty hospital

should not be obl iged to provlde cornnuni. ty health care in i ts broadest sense,

and there wi l l be warnings that such a pract ice wi l l only serve to di lute the

experience of those in traintng and discourage top ranking applicants in the

future. Whi le these are very understandable sent iments, and ones which should

not be l ight ly dlsmissed, they do not faee up to the real l ty of the changing

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medical scene nor help solve the pract ical problern of Just who wi l l t reat the

masses seeking medical care on the hospitalrs doorstep. often the real i zat ion

that in this age of the dlsappearing ward pat ient, that a very large proport ion

of the ward admisslons enter vla the emergency room, wi l l make any efforts to

discourage this source of c l in l-cal t ralning mater i-ar seem inappropriate.

I laving dealt with these important prel ininar ies, one can then f inal ly

begin to come to gr ips with pract lcal solut ions to the problem. For your

interest, r have out l ined some of the basic measures which we have recent lv

inst i tuted at our lnst i tut ion to combat our emergency room overroad. overload

can occur not only from too great an input but to bott l -enecks within the system

and the faclLl t ies to which the output is directed. Most of the measures which

we inst i tuted were simply pract ical stop-gap measures, severar of which were

suggested to us by our emergency room and out-pat ient department operat ionar

surveys' They were pr lmarl ly lntended to rel ieve the immediate pressure and

gain t lme and eLbow room for more effect ive and long-range planning. (s l ide rx).

one of the f i rst measures undertaken vf,as the inst i tut ion of a tr iage system

operated during the peak l-2 hours of each day by experienced medical assl-stant

residents who were given aLmost open out-pat ient department appointnent

pr iv l leges' I t soon became apparent that those pat ients who real ly didn,t

belong in our emergency roon fel l lnto two basic categories. one group had

non-urgent probJ-ems which woul-d Justify dlagnostlc work-up and treatment in an

out-pat lent c l in le, but the other had minor, general pract ice-type problems,

exempli f ied by the acute sel f- l l rni ted i l lnesses (viral i .nfect ions, upper

resp i ra to ry in fec t ions , gas t roenter i t i s , e tc . ) wh lch wou ld no t Jus t i f y ou t_

pat ient referral but which needed slmple, expedient, on-the-spot treatment.

For this reason' we recent ly bul l t a smalL dispensary-type operat ion next to

I

- L 4 -

one corner of our emergency room to handle this sort of t raf f ic for 15-18

hours a day. I t is belng run by experienced paid physicians. Since 20 percent

of our return vis i ts had been self-generated, we have requested that these be

restr icted t ,o cases of def ini te teaching value to the house off icer who

orlginal ly saw them. Final- ly, we have diverted the prescr lpt ion ref i1l t raf f ic

directJ-y back to the out-pat lent c l- in ic from whlch i t or iginated.

To operate an effective t,riage system, one has to have somewhere to

tr iage Pat lents to. This attenpt to shl f t a maJor part of our out-pat ient

traf f ic f rom the emergency room back to the out-pat ient c l in ic, along with

evidence produced by our survey, resulted in several- practical- changes in out-

pat ient oPerat ions which are suxnmarlzed in Sl ide X. Agaln, these are for the

most part short- term measures, but they have resulted in a slgni f icant improve-

ment ln operatlonal efficlency and allowed the out-patient department to buy

t ime for a complete reorganizat lon and expansion.

Adjuetments luere made in emergency room staff ing which had also lagged

behlnd the i is ing pat lent Load (sl lde xr) . Al l - rhe staff coverages, but

part icular ly that of the nurslng service, r , rere revlewed and revlsed according

to the Patt ,erns of pat lent loadlng estabLished by our aurvey rather than the

tradit ional three nursing shi f ts. The nursing staff is being rel ieved of some

of i ts adminlstrat lve responeibl l l t ies and the auxl l lary nursLng personnel and

techniciansr reeponsiblLi t les and tralnlng are belng expanded and upgraded.

Some of the most notlceabl-e improvements in emergency room operations

came from fairly simpJ-e efficl-ency measures, particul-arly lmprovements in the

equipment ut l l - izat lon and staff ing of our X-ray facl l i ty which is located r ight

in the mlddle of the emergency room (Sl ide XII) . Even the instal l -at ion of a

9O-second X-omat developer brought about a noticeable irnprovement in patient

- 1 5 -

flow through the system. lfe wtll soon have both X-ray rooms completely

equipped for muLttpurpose use l{l-th two rapid deveLoper X-omats and now have

more genior technlclan coverager as well as an l8-hour a day coverage by a

resldent radiologist and a f i lm cl-erk. Another maJor source of delay in

movlng Patients through the emergency room system has been the waiting time

for the results of laboratory studies. Inst l tut ing a system for gett lng the

specimens to the laboratory quickly, get,ting the l-aboratory to agree to handle

al l emergency room requests on a t tsTATrrbasis, and gett ing the results back as

quickly as posslble, makes a tremendous di f ferenee ln terms of t ime the pat lents

spend in the system. Other measures lnvolved central- izat ion of storage,

ster l l - lzat ion and dlstr ibut lon of emergency room suppl les, improved avatr labi l - i ty

of medical records, reduct ion of the amount of red tape and trsgsgrr work by the

physiclans, have aLl had a signlficant impact. Even a sirnple measure like

inunediately issuing al l - pat ients ldentt f icat ion pJ.ates to go with their htrstor les,

so that al l laboratory and X-ray requests can be stamped rather than f i l led

out by hand, ie a tremendous t lme-saver. Final ly, to keep on top of our progress

we have cont lnued to run a weekLy stat ist ical survey on our pat ient load with

breakdown accordlng t ,o disposit ion, along wlth other vi tal- stat ist ics such as

wait ing t lmes, wal.kout rates' etc. We perlodical ly run a spot check on the

emergency room treatment records whlch brings out otherwise unrecognlzable

problems. rn terms of operat lonal- ef feciency, I think the hour or so spent at

our weekly emergency room conrmittee meetlng hae been a most effect,lve and

pract ical means of coordlnat lng and sustaining this overal l ef fort .

The inpact of these measures has been signi f icant in a number of regards.

The annual emergency room census at our hospltal has gradual ly r isen from 43,000

in l -953 to 58 ,000 ln 1963, then to l lS rooo in 1968 ar wh ich t ime rhese measurea

- 1 6 -

were inst l tuted (sl ide xrrr) . The 1969 f igure, however, shows a drop to

1021000. The waiting times have lessened and the waLkout rates have decreased.

Ilowever, our current statistlcs suggest that we have only tenporariJ-y stemmed

this t lde. Even so' we have galned a br lef respite that hae alLowed us Lo

proceed with long-range plans for reorganization and expansion since lt is

inpossible to make major structural changes ln an overcrowded emergency room.

However' I think it shouLd be sald ln support of the value of regi.onal planning,

that unilateraL attempts to improve the efficiency of emergency room oprations,

such as these, r8y be sel- f-defeat ing l f the rest of the hospitals in the com-

nnunity don,rt aLso change, slnce one wlLl siurply draw more and more patients to

the lnProved facillty as the word spreads around the communfty. our current

long-term plan ie for a staged maJor expanslon into adJacent emergency room-

ambuLatory care facilities with separate entrances--one for the true "anbulance-

type" emergency and the other a walk-ln door for the ambulatory i11. The triage

function and an expanded dlspensary operatlon wil.l- be shifted to the anbulatory

care facLllty, thus allowing us to return the emergency roon to Lts originally

lntended purpose.

The second issue I have chosen to discuss ls the role of the academician

in the emergency room. The job of emergency room chief ls usually delegated

to an anbitlous young member of the Department of Surgery. The acaclemi.c life

ls euppoeed to offer a balanced exletence of reeearch, teaching, cl ln ical and

adninistrat ive act lv l t ies that wi l l keep the academician on the crest of the

advanclng wave of his chosen special-ty. With thls aeslgnment he is apt to flnd

himsel- f thrashing about 1n the undertow of admlnlstrat ive responslbi l l t les. In

most maJor teaching centers, emergency room patients are understandably the

"property" of the house staff , and so there may be l i t t le personal c l in ical

out let here for a young faculty member, part icular ly a surgeon. Also, with t .he

- L 7 *

crowded envl.rons of most universlty hospital emergency rooms, there is usually

neither space nor t lme for sophist lcated invest igat ive studies. Furthermore,

i t ls even di f f icul t to organize and carry out an effect ive teaching program

in such a hect lc environment. The house staff can hardly afford to ignore the

pressing task of keeping up wlth the lat ient load long enough to get together

for decent rounds.

Thls does not mean that the emergency room chief ls left with nothing

to do. As you w111 see by the Job descript lon of an emergency department head

whlch is out l ined below (Sl ide XIV), there is plenty do to. However, a number

of obvious quest lons ar ise out of this predicament. Can an emergency room chief

accompli-sh these tasks wlthout an auth;r i tat ive base such as that of a depart-

mental status, without top rate adminlstrat ive support , without control of the

emergency roorn budget, and wlthout a nursing and auxlliary staff directl-y

responsibLe to hln rather than the nursing hierachy, just to name a few of the

essent lals? Secondly, Ls thls not a fuLL-t i rne job, or how can i t be effect ively

accomprlshed by only 20-40 percent of ef fort? Thirdly, just what are the

academic rewards for these efforts and how do they stack up against other

academLc pursuits which const i tute the more tradl t ional ly accepted credent ials

for advancement? Ftnal-ly, how can the academician enlarge and improve his

research, teaching and personal c l- in lcal act iv i t ies ln the sett ing of an over-

crowded emergency room? I donft Lhtnk there are any simple answers to these

quest ions or a number of others I could have posed, but they obvlously deserve

more than the passing attent ion I have given them. The obvious courae would be

to develop an effective mechanl.sm for divertlng the non-emergency problems to

ambulatory care or other health care faci l i t ies, thus reetor ing the emergency

room to its originally designed function, and then develop the emergency room

- 1 8 -

into a reglonal t rauma resuscitat j -on center and run i t . aa an integrated

pat ient care' t raining, and research program with departmental or div is ional

status. However, this br ings up a number of other problems, not the least of

which are; where to f lnd the funds for such a venture in these t imes of t ight

money, and the Just i f icat ion of t raumatology as st i l l another surgical special ty,

neither of whlch we have time to go into further this morning.

The f inaL problern I wanted to broach is that of the apparent conf l ict

between teaching and patlent care whlch may develop in the emergency rooms of

universi ty hospltale. Unfortunately, this si tuat ion may generate two opposing

camps. On one extreme there are those who say that teaching should only be

carr ied on in an atmosPhere of excel lent pat ient care where the pat ient comes

f irst . They point out that the more experienced physician can care for the

pat ient better, quicker, and by avoiding unnecessary disgnost ic studj-es, cheaper

than the house staff . They polnt out that most pat ients are nov/ covered by thlrd

Party programs and have a r ight to this type of care, and f inaLly they cal im that

learnlng by assistJ.ng an experlenced physician pract ic ing exceLlent pat ient eare

is an acceptable form of t ralning or at least preferable to unsupervised house

staff pract ice. On the other slde are those who polnt out that a signi f icant

degree of responsibi l l ty for decision maklng and personal execut lon of t reatment

is essent ial to a good tralning program, part i -cular ly for a surgeon. SecondJ-y,

that apprent ice-type trainlng hTent out wlth the FLexner report , and that thls

approach provides the least stimul-us for lnnovation and improving upon the

pract iees of oners teachers. I t can also be pointed out that. physicians paid

primari ly for pat ient service' or at least the type we are l iable to accept in

emergency room pract ice contract, are not l ikely to make the best teachers.

Final lyn whi le thls approach may produce inrnediate improvements in pat ient care,

i t nay eventual ly reduce the cal iber of c l in ic ians treat ing future generat ions.

- 1 9 -

Of couree, as usual, the truth liee eomewhere between thege two over-

stated extremes and one has to work out the best posslble compromise wlthin

the ground rules of the part lcular lnstl tut lon in whlch he functlons. However,

I thlnk l t ls part lcularly t lnely to polnt out thls growlng confl ict, because

there are bound to be increasing preesures brought to bear by the Lay public

through governmentaL agenciee for euch meaeures for lurproving the qual-lty of

Patlent care. These preseures are understandable, and Lt ie pretty obvlous

that we can not ethlcally contlnue nuch farther ln the faee of this trend wlth-

out modlfying the way teachlng le conducted in many unlverslty hospltal emer-

gency room8. 8o that 8E valuable aB an energency room experlence ie to an lntern,

lt must be admltted that Letting an lntern by the prlmary care phyelcian for all

patlente entering the emergency room oystem ie going to resuLt ln elower, more

expenelve and probably lees than ldeal patlent care. It is aleo true that lf

one were to try to meet this lncreaeLng emergeney room patlent load prlmarlly

wlth lnterns, they wlll eoon have to apend an lnordlnate part of thelr lntern-

ehtp ln the eruergency roon. Rlght noro, for exempLe, Lf we had to increase our

lntern coverage in our emergency room t,here would be eome spendlng five months

of thelr Lnternshlp there. At the noment our lnterne spend one-thlrd of thelr

t,lme, and the resldente one-eLxth of thelr tlme tn the emergency room and a good

deal. of the tlme expended by the renainder lnvoLveE the Ln-patLent servlces to

which thoee patlents are adnLtted. ThuE the ttme epent ln carlng for petlents

w{th trawra and other problane admitted through the emergeflcy room ls already

htay out, of proport lon to th6t spent {n electlve, general and speclalty surgery.

Rather than take our lnterns out of the energency roon, we are plannlng to

lncreaee the proport lon of eagtetant restdenta on rotatlon there ln the early

part of the yedr, ellowlng lnterns to graduelly take on tncreaslng reeponElbllltteE

- 2 0 -

wlth each addit ional rotat ion. We have also assigned one senior resident to

the emergency room, instituted an lnproved system of teaching rounds, and an

honest morbldlty-mortality conference and provided for more frequent consulta-

t ion with the faculty. A11 these have resulted in a general upgrading of the

cal-iber of both patient care and teachlng in the emergency room. Whether

there w111 eventual ly be a place for salar ied surgeons to work alongside the

house staff in our emergency room ls hard to predlct with certainty, but I

think that thls and other measures which may be offered in the name of improving

the quality of patlent care must be carefull-y consldered in regard to the irnpact

on our training programs. It worlld seem that, excel-Lence ln patlent care and

in student and house staff teaching do not need to be mutual ly exclusive

obJect ives and should at alL costs be prevented from conf l ict ing with each

other Ln the emergency rooms of teaching hospJ.tals.

- 2 L -

l .

2 .

SI.INE I

CAUSES OT THN EMERGUNCY ROOM ''POPUI.ATION HffIOSION!'

THE PATIENT

GENERAL POPUIATION INCREASES - 1.5 - 2,Q % PERANNUIvI

INCREASING DISTRIBUTION AT AGE EffREMES (MORE TRAUtr\4A,CHRONIC DISEA,SE)

INCREASING URBANEATION , ESPECIALTY WITH LOWERSOCIOECONOMIC LEVET.q

TNoREASTNG MOTTLmY - MOVE FREQUENTLY WITHOTIT ESTAB-LISHING NE'\M LMD

INCREASED D(PECTATION OF ADVANCED TECHNIQUES AI{DFACITUIES OF I\4ODERN HOSPIIAIS

i z z -

3 .

4 .

5 .

g"LIDfi: II

CAUSES OF THE EMERGENCY ROOM "POPUI.ATION E(PLOSION''

THE PITYSICIAN

I. DECREASING NUMBER.S OF GENENAL PRACTI9NERS

2. PRIVATE P}IYSICIANS IOINING THE ''PLIGHT TO THE SUBIJRBS''

3. INCREASING TJMTTATTONS ON NONSCHEDUIED OFFICE VISITS

4, INCREASING SPECIATIZATION \MITH DTSENGAGEME{T OF PHYSICIAN. FROM ''PRIMARY MEDICAL CAF,E''

5. INCREASING PROPORTION OF MEDICAL PROFESSION INSTITUTION-BASED

6. INCREASING PRIVATE PIIYSIOI,AN USE OF ETvIERGENCY ROOIvIFACILITIES RATHER TTIAN OFFICE

- ? 3 -

SLIS'E III

CAUSES OT THE EMERGENCY ROOM ''POPUI.ATION S(PIOSION"

THE INSTITUTION

1. AVAIIABITITT OF COMPLD( AND COSTLY DIAGNOETIC A\IDTHERAPEUTIC EQUIPMENT OSUBATED BY SKILI,FD PER,SONNEL

2. PUBLIC IN4AGE AS REPOSITORY OT I\4ODERN MEDICAL MIR.A,CLES

3. COIWENIENCE OF EMERGENCY ROOM "OPEN DOORS, OPENHOURS '' POLICY

4. ACCESSABITITY TO CONCM{TRATED CORE-CITY POPUI,ATION

5. PRIVATE HOSPTTALS REIOCATING IN SUBURBS

- 2 4 -

I .

2 .

3 .

4 .

SI"ID.E IV

CAUSES OF THE EMERGENCY ROOM "POPUI.ATION FXPLOSION"

D(TERNAI FORCES

INCREASING COVERAGE BY PRIVATE OR GOVERNMENT THIRDPARTY PROGRAMS

THIRD PARIY COVERAGE T'OR SERVICFS PERTORMED IN HOSPITATBUT NOT IN OFFICE

INCREASING TENDSNCY FOR SCHOOI.S AND INDUSTRY TO RETERTO HOSPITAT

LESS PI{YEICIAN CONTROL OF AMBUIANCE SERVICES . NOSCREENING, OBLIGATORY TRANSFQRATION TO HOSPITAL

- 2 5 -

1 .

2 .

3 ,

4 .

gtIDE V

DIMENSIONS OF EI\4ERGENCY ROOM '.POPUIATION EXPLosIoN''(NATIONAL)

ANNUAT RATE OF EIVIERGENCY RQOM VISMS INCREASED BY 16MrLrroN (+ 175%) FROM 1954 TO 1964

ACCEI.ERATING RATE OF INCREA$E . 1962 - 1964 INCREA,SE >PRECEDING FIVE YEAR,S

DISPROPORTIONATE INCREASES . ADMISSIONS *8/O, OPD VISIT$+I8%, EMERGENCY ROOM VISrIS +79% (PER 1OOO POPUI.ATIONDURING 1960's

CONTINUING If;EhID - INCREASE IN OPD-ER VISITS TOUR TIMESGREATER THAN INPATIENT ADMISSIONS DURING 1950*1962,PREDICTED EIGix[T TIIvIES GREATER T]IAN BY LgTZ.

- 2 6 -

S.IIDA VI

DIh,IEN$IONS OF EMERGENCY ROOM "PO-PULATION EXPLOSION"(GRF.ATER BALTIMORE - NOVEMBER, I968)

I, ANNUAL ER VISITS ROSE FROI\4 356, 272 IN 1960

z. ANNUAL ER vIsITs RosE rRoM tgz ro gz;/LoCIo

TO 659 , 072 IN 1968

POPUIATION FROMr960 TO 1968

3. NR UUTEATION AI{DCENTRIFUGALTY

PHRCENT NONURGENT VISUS DECREASED

BALro.crry SArTqt .9q.. ApTACEIII Co..,,s.ANNUAL ER vrsrrg / tooo popur,ATroN .*-.ff fiI- B4-rg0

PERCANT NONURGENT VISITS 57 43 3I-41

S.LIDE] VII

CHARACTERISTICS OF ER POPUIATION EXPLOSION0oHNS HOPKTNS HOSPITAL - 1968)

I . A N N U A L E R V I S M S R O S E F R O M 4 3 , O O O I N 1 9 5 3 T O 1 1 8 , O O O I N I 9 6 8

2. AI{NUAI ER VISITS,/IOOO POPUI.ATION = 867, BALTIMORE AVERAGE =326, U.S. AVERAGE = 216

3. 65% OF ER VISMS NONURGENT (20% QF THESE SELT GENERATED)

4. AVERAGE WAITING TIME 2.8 HOURS (STTWED DISTRIBI-ITION)

5. WALKOUTS ROSE TO > 2%

6. 33% RECEIVED X RAYS (29% OT HOSPITAL EIEAD)

7. DAYAND EVENING SHIFTS RECEIVED EQUAL LOADS (42% FECH)

8. ONLY 20 G.P.'s IN EASITERN CENTRAT BATTIMORE (AVERAGE AGE 64)

9. FOUR PRIVATE HOSPITALS RELOCATED IN BALTIMORE COUNTY INIA^ST DECADE

- 2 8 -

EriIgFr vrrr

F EAT UFGS ;,l,?fd,?i ""JJffi

'3ffi-ff#R I B UT IN G

I. AVERAGE WAIT TOR EIEqTIVE CLINIC APPOINTMI$IT - 27 DA1F

2. INEFFICIENCY FROM HIGH,,$'NO-BHOW RATES (ca. 50%)

3. INNFFECTIVE SCRAENING N{D STFARING

4. ROUTINE FOLIOW-UP CARE OF' COMfuION C}IRONIC DISEASESDISCOURAGED

5. NO MECHANISI\� T.OR HANDTING PRES0RIPTIoN R,EFILLS FoRCHRONIC PROBTEMS

MUI"TIPIE SPECIAITY BTIT NO GENERAT MEDICAT CTINIC

PROBLEM PATIENTS DUMPED ON EMERGENCY ROOM W}IANCTINIC CLOSED

6 .

7 .

- 2 9 _

$LID,fr Ix

MEASURES TO COMmT ER OVERTOAD 0HH '67 - '69)

A. ER PATIENT INPUT

1. TRIAGE - RUN BY D(PERIENCED RESIDENTS WITH OPEN OPDAPPOINTMENT PRIVITEGES

2. ADIACENT OPaN-HOURS Ip.$S Ht\I8ilmf OPERATION - RuN BYPAID FACUTTY

3. RffiTRICT ER RETURN VISITS TO THOSI OT TEACHING VALUE

4. RtrUSE NONURGENT PRE$CRIFTION REFItt REQUESTS BY OPDCIINIC PATIENTS

- 3 0 -

SIID-U X

MEASURES TO COMBAT ER OVERLOAD (JHH '67 - '69)

B. CHANGES IN OPD OPM,ATIONS

I. ESTABLISH GENERAL MEDICAT CTINIC TO HANDLE COMMONMEDICAL PROBLEMS

2. INCREASE STAFF COVERAGE OF OPD CTINICS

3. INCREASE CTINIC APPOINTIVIENT QUoTAs, REDUCE BAOKIOG,OVERSCHEDULE: NO SHOW RATE

4. IDENTITY "HoMa ctINIcs" FoR pRIrvIARy CARE oF PATIENTSWITH CHRONIC PROBLEMS

5. STAGGERED APPOINTMENT SCHEDULE SYSTEM

6. D(PEDIENT MICHANISM TOR R"EFILLING PRESCRIPTIONSIN HOME CTINICS

- 3 L -

gtUDN XI

MEA,SURES TO COMBAT ER OVERTOAD (IHH '67 _ '69)

C. STAFFING

1. INCRNASED COVERAGE BY FACULIY, ADMINISTRATION AAIDNURSING AI{D SENIOR HOUSE STAFF

REVISE STAFF COVERAGE ACCORDING TO PATIENT INPIN PATTERNS

RETIEVE NURSING OT ADMINISTRATIVD RES PONSIBITITIES

UPGRADE TRAINING A}ilD RESPONSIBIIMIES OF AUXILARYMEDICAL PERSONNET

MORE AVAIT'ARI"E AI{D RESPON$IVE SPECIALTY CONSULTATION

INCREASED SUPPORT FOR DSALING WITH DISPOSITION PROBLEMS(SOCIAL SERVICE, AI.COHOLIC COUNSETINGi DRUG ABUSEPROGRAM, ETC.)

2 .

3 .

4 .

5 .

6 .

- 3 2 -

s,'uDat xfi

MEASURES TO COMBAT ER OVFRLOAD (IHH '67 * '69)

D. EFFICIENCY MEASURES IN ER

r. IARGER AND I\4ORE EFTICIENT X RAY AI{P TABORATORY SUPPORT

2. CENTRATXZATION Of ST&nAcE, STERITIZATION AND DISTREU-TION OT ER SUPPI,IES

IIVIPROVED AVAII.ABITIIY OT MEDICAT R6$MM[DS

REDUCf, P}TY]SICIAN ''SCUT WORK"

5. IfuTMEDIATE ISSUING Of PATIENT IDENTITICATION PLATES

6. UTILIZATION REVIEWT coNTlNuous srATIsrIcAt suRVEyWEIKIY ER COMMTTTEE MEETINGMEDICAT RECORDS SPOT CHECK

3 .

4 .

- 3 3 -

PAT IENT-VISlTS/ YEAR ( in thousonds)

TU-{ooo

$(.tlooo

o z-omE €Fil TN! - r - t t

o 'r,z* ( -

F Er J

g a| - r | - r* ox,: :u; x( - ) z'Tl

1 5 : ro o? a'�n 't

f i i li a rCoUI

..pooo

O

o()

c)()

ru

8I,IDB] XIV

]OB DESCRIPTION OF ER DEPARTMENT HEAD

r . OVERSEE DAY-TO.DAY ADMINISTRATIVE OPERATIONS OF ER

2. RESPONSIBIIIW FOR QUALIIY OF MEDICAL CARE BY ALt SPECI'I\TTIES

3. RESPONSIBITITY FOR AIVNUAL BUDGET AND ALt FISCAL OPIRATIONS

4. COORDINATE INTERDEPARTMANTAT AI{D SERVICE ACTIVITIES

5. DEVEIOP EFFECTIVE TEACHING PROGRAMS FOR HOUSE STATTAND STUDTNTS

6. DEVILOP AND COORDINATE TRAINING PROGRAIYIS FOR AUXILARYMNDICAL PERSONNEL

7. DEVEIOP AND COORDINATT INSTNUTION'S DISASTIR PI,ANS

8. LEADER.SHIP ROLE IN RSGIONAT PLANNING FOR DETIVERY OF EMER-GENCY MEDICAL SRVICES

9. REPRESENT THE ER ON INSTITIITION'S GOVERNING COMMITTEES

IO. DEVEIOP AND PROMOTE IMMEDIATE AND I,ONG-RANGE IMPROVE-MENTS IN ER FACITITIES

- 3 5 -

REGIONAL PLANNING OF EMERGENCY MEDICAL SERVICES

James R. Mackenzie, M.D., McMaster Universi ty,HarnLJ.ton, OntarLo, Canada

I would l ike to preface remarks on regional lzat ion by stat lng that

they reflect ny or^tn personal views rather than a summary of the sparse

literature on the subJect. These views on regionaL emergency services have

been fornuLated while observlng the early development of the Regional Medical

Program ln Vermont; the effectLveness of the reglonal emergency medical- care

of both civ l l lan and ni l i tary casualt les in rr l r t corps in Vietnam; and f inal ly,

the development of a province*wlde pl-an for emergency cormnunlcatlons and

transportat ion systems Ln Ontar lo, Canada. Interpretat ion of data concernlng

gover'nment representatlon on emergency health care counclls is based upon the

recomuendatlone made by the CanadLan Government Task Force reportg on the Cosg

of HeaLth Services in Canada.

Plannlng of energency medicaL care has developed out of the growlng

need to provide a pJ.anned ' progresslve step-by-step approach to the care of the

emergency vtctim - starting ar the acene of the emergency and ending in

definltlve care in the hoepltal. Regl.onal pJ.anning of emergency medlcal care,

on the other hand, l -s an attempt to provlde a pLanned, progressive approach to

the care of al l emergency vlct iurs ln a spectf led area, for the least cost and

with nlnLnal dupl icat ion of personneL and faci . l i tLes. I t is the purpose of

this taLk to def ine what I thlnk const l tutes a region; how i t dl f fers from a

distrlct; who should govern the decLslons concernlng emergency medical care in

the re8lon; the role of the untversi t ies in regional emergency care, and f lnal ly,

the responstblllties of a governing body involved in regional pLanning.

- 3 6 -

A region, as l t appl ies to emergency medical care, is def ined f i ret of

al l by patrerns of medical pract lces. Pol i t ical boundaries such as ci ty l in l te,

countyr or state l ines shouLd not be the sole constraint upon the size of the

region. Reglons presently evolving tn this manner are found in Ontario and

South CaroLina. In contrast to the pol l t ieal constraLnte pJ-aced upon these

reglons, patterns of pract lce tend to develop Ln relat j -on to transportat ion and

conmunlcatLon routes and the availablllty of a maJor medlcal referral center.

As a result , nedical practLce t ,ransgresses pol- i t ical boundaries as they do in

Kansas City ' St. Louls-East St, . Louis, and lnternattonal l -y, the Quebec-Vermont

border, where the doctors hold l lcenses to pract ice in both Quebec and Vermont.

The regional medlcal programs have recognized the constralnt placed upon their

programs by etate Lines and have def ined the boundaries of their regi-ons at a

rocal level accordlng to recognlzed patterns of medlcal pract lces.

Sec'ondl-y, the reglon ehould have a maJor medLcal- referral center (and.

by center l t could be a hospLtal or group of hospltals) capable of providlng

aJ-J- categories of care for the emergency vtctfuns be they adul-t or child, male

or femaLe. This center muet be connected to aLl dlstr ict or community hospiLals

in the reglon by efflclent transportatlon and communl-catlon systems. I would

Ilke to dLgress for a moment and contrast the functLon of the community hospital

with the regional- referral center. The dlstr ict hospital provides services for

the comtunlty which is defined as an area of about 30-60 mlnutes radius from

the hospital- measured by the speed of the avaf labl"e transportat ion system. The

Emergency Department in these hospitale should be abl-e to provide all- of the

servi-ces needed to keep a pat lent al ive unt i l t ransferred to the reglonal

hospital . In addlt lon, i t must provide most of the ordlnary def ini t tve treat-

ment services demanded by the comnunity surrounding the hospital.

- 3 7 -

Thirdly ' the region should possess a maJor medlcal center where

nedlcal and paramedical personnel needed for the progressive care of the

emergency vlctlm can be educated. The tralning of medlcal students and

resldente Ln emergency care demands that this center be related or attached

to a medlcal school- . I f reeidente and medical students are not invol-ved, .

then the staff of this center does not necessari ly have to be part of a

universl ty faeutr- ty. I lowever, the staff of this maJor hospital must be

prepared to educate the paranedlcal. personnel needed for the reglon, and to

continuously update the skll-Ie of the doctors del-lvering emergency care.

Lastly, a region must be able to inltlate and evaLuate techniques

reLated to both the dellvery and cost effectivenees of emergency health care

within the region. The varLous reglonal ambulance and communlcation systems

proposed for Ontarlo and severaL Unlted States centers are exceLlent examples

of thls funct lon of a reglon.

In sunrmary, the boundarles of a region are determtned by the pattern

of medicaL pract ice and referraL and by i ts obLigat ions to uredical educat ion

and research which ls dLrected towards better and more effect,ive emergency

care del-ivery. The dletrlct boundarLes on the other hand are defined by the

community which resides wlthfn a 30-60 mlnute tine radlus of the comnuni-ty

hospltaJ..

Regional- energency care dernands a reglonaL body composed of all

interested rnedical and non-medlcaL groups if lt is to nake effective and viabLe

decisLons. A1-1 of the hearL-related profeselons, euch as medlcal- and para-

medical associat ionsr as weLl ae hospital adminietrat lon, nuet have a volce on

the council. The Latter group hae not been very active in the regional medical

program and thls ls one of the reasons for the sLow progress made by thls pro-

gram ln some regions. Government at all- leveLs, ineurance and prlvate welfare

- 3 8 -

I

agencies' and industry who supply a great deal of the finance for medical

care must be represented on the councLl. Other non-medlcal emergency groups

can contr lbute' such as the pol lce, f i re and legal departments. Final ly,

the consurner, the cl t izen, the trade unionlst , the pensioner, those who

uLt lnately use the system, uust have a strong voice on the counci l .

Vihat part does the unlverslty play in regional- emergency medical

plannlng? Flrst of aLl", the university must represent the voice of education

and research, as weLl as servlce upon the counci l . Far more important ly,

the unlverslty representative wlth his academl.c baakground should be the

vielonary who suppJ.les the conceptual ideas for reglonal development. It is

ny bellef that the ideae euppj-fed and energy spent by the university

emergency department dlrector in the development and organlzatl-on of energency

health care systems ls as much an academic pursuit as shock reeearch. The

unLverslty nust recognize the academic nature of the time spent by their

representatlve to the regional counclL if he Ls to be accepted by the other

nembers as a vital part of the emergency counctL power structure.

Three Large groups have been ldentified as interested in emergency

health care: government and the cltizeng who elect them, the medLcal professlon

and their nedicaL school- counterperts, and flnaLly, the hoepltal conml"ssions

with thelr pararnedical personneL. Each of these powerful groups at present

pursues h18 interest in the gtrory of lsolated splendor. The pat ient rrho is the

obJect of thelr interest is lef t in the niddle barel-y touched by the circ le of

lnfluence of the powerfuJ-, seJ-f-centered groups. rt would seem to me an

obJect lve of thls society to fuse these groups together, blendlng and dlrect lng

thelr ef forts on the pat ientrs behalf . In the center of this blend would be

the pat lent, bathing in t ,he pure white splendor of uneelf lsh group cooperat ion.

- 3 9 -

Members of thls association, lt is your Job in the workshops and in

our aucceedtng neetLngs to develop pract lcal methods for:

(1) Defining a region Ln your own area of lnfluence.

(2) Conetructlng effectlve governlng councils for the dellvery of

emergency heaLth eare ln your region. Many people in this

audLence have experlence in thls fteLd. Get to know thenn and

do not hesi tate to rdr l te, cal_l_ or vls i t thern.

(3) Deftnlng the responelbilitlee of regional emergency health care

counci ls in the f le lds of:

a. Evaluatlon nethode related to transportati-on and communlcation

systemsr and emergency departnent and hoepltal standards.

b. Declslon and action reLated to dupLlcation of emergency

ser:vlces and poor deLivery of energency servlces by hospital.s.

c. Educatlon of phyelciane and health-related profeeelonaLs in

the deLiverlng of energency care.

d. Evaluat lon of coet effect lveness of emergency care wlthin the

reglon.

r belleve that thls organlzatLon hae the human reaources to eorve the

problens preeented. I{e are youthful, knowl.edgeable and dedlcated. hte muet

not preach to othera on how to do the Job, but rat,her we must use the resources

and lnfluence of thie group to go hone and do the Job oursel_ves.

- 4 0 -

PHITOSOPHY, coAl,s,PIAI{S

OBJECTIVES OFFALL MEETING,

THISL970

ORGANIZATIONANDFOR

Diecuss ion Leader : Char les F . Frey , M.D.

Thls uorningts Progr{m has been ln preparat ion for thls afternoonrs

workshops. rn additlon to deflning the component parts of an Emergency

Medlcal- Servlces System, and some of the problems associated with Lt which

we hope the three prevlous talks have done, we want to ldentify some of the

goale that this menbershiP may want to entertaln. r t ," , rp to the nenbershLp

durlng theee workshops to feed this information back to us after they have

come to thelr own concl'ustons. At the end of the workshops there will be a

flve-rnLnute summary by each trorkshop chalrman. These sumnarieg wirr be trans-

crlbed and sent to the workshop chairnen for edltLng and then returned for

dletr lbut lon to you. Thus todayrs ent ire program wiLl be sent to the member-

ship eo that you wl l r- have a ful l report , rncluding thls morning,s meetlngs

as well as the workshop eumnarieg. r now calL your att,entton to the materlal

l lsted under goars that l tas Juet dlstr lbuted to you. The quest ion ar isee,

why this organization? trlhat makes lt unlque? How do we Justlfy its existence?

The organizers of thls rneetlng feel strongly that the nembers of this orga nrza-

t lon ehould be the lndlvlduals dlrect ly responsible Ln their own rocal i t les

for the provtsion of emergency medical servlces and reglonal planning. This is

not an organtzatlon ln whlch eone indivlduals who have been away fron aetual

part lc ipat ion in emergency nedLcal services for z0 or 30 years are golng to be

ln charge' we want the peopl.e who are actual-Ly doing the Job 1n thelr own

hospitals and communlties. lrlth this type of membership, any information

garnered here or at future meetings wouLd have irmrediate and practlcal applicatlon

- 4 r -

ln each membert own hospitar- and conununity. I^r i th our menbership, we

have a mechanism of feedback to the communi. ty which supersedes anythtng

any other organizat ion has deveLoped. I . Ie also feLt that we wanted to assist

the Univers i ty physicians in establ ishing an academic basis for his

efforts in the Emergency Departuent and regionat_ pr.anning of Emergency

Medica l serv ices ' Th ts has been ment ioned ear l ie r by bo th Dr . MacKenz ie

and Dr, Rutherford. I {e ar-eo feLt that in the past the peopr.e who are

ac tuar ly p rov ld ing servLces , tha t i s , the d i rec to rs o f Emergency Depar tments ,

have not had a spokesman nat ionaLl-y to present their points of v iew

about regional pLanning and Emergency Medical services. There are un-

fortunateLy too many peopLe on the var ious advisory comnit tees at the

nat ionar leveL have been away from actual part lc ipat ion in emergency medical

services for a long period of t i . t rE. And yet they are makrng nat ional

pol icy regardtng emergency medLcal services. These lrere some of the

consi.derat ions the organizers of this meeti .ng fel_t were important and

required the devel.opment of thts organtzatton.

Now, about the spec i f i c goa ls - - one o f them a lLuded to ear l ie r - - the

colLat ion of the Emergency Medical service pLans from the var ious depart-

ments . r th i .nk these p lans w i lL p rove a va luabLe asset to aL l o f us .

Any member now can turn to these plans and f ind information which wiLl be

heLpful ' ln his ovrn emergency department pLanning. He also has the recourse

now of picking up the phone or wri . t i .ng to someone who can herp him in a

part icular area. HopefulLy, he wont t have to repeat the mistakes that someone

e lse has a l ready made.

our organizat ion can also provfde a group of consuLtants for def ining

the probLems ln any EI"IS system as weLl as expLoring soLut lons to these

prob lems ' Thusr our o rgan iza t ion can ac t as a fo rum not on ly fo r the co l lec t ton

of data and development of sol .ut ions to the probreme of emergency rned{cal.

serv ices to ass is t ind iv iduaL members , bu t aLso can th rough the co l lec t i ve

- 4 2 :

ef fo r ts o f a l l 0ur members ac t to in f luence na t iona l , reg ionar and

academi.c optnions on matters rerated to Emergency Medicar_ services.

rn the handouts you received today, a number of possible areas of

in te res t a re l " i s ted . These need to be d iscussed in the a f te rnoon work-

shops' we need a mandate from the membership as to those areas in which

you wou ld l i ke us to take cor rec t ive group ac t ion . For exampre : shou ld

th is o rgan iza t ion a t tempt to i .n fLuence leg is la t ion re ra ted to Emergency

Medical care? should this organizat ion recomrnend the universi ty take

a rore in the regionar. pranning of emergency medicar services? shourd

th{s organizat ion make recoranendat i .ons to the universi ty regarding

the status of the Emergency Department physician in academic medicine?

should this organizat ion part lc ipate in the educat i .on of and development

of t raining progrmls of emergency care for paramedicaL personnel, medicaL

s tudents , house s ta f f , and graduate phys ic ians? What shou ld th is o rganLza_

t ion do to educate the pubr ic regard i .ng the need fo r f inanc ia r . suppor r

o f emergency rned icaL serv ices? shouLd the organ iza t ion he lp es tab l i sh

standards for emergency department faciLi t i .es? what should be the re-

Lat lonship of our organizat ion to other groups organtzed to improve

emergency medical" services? Should our organizat ion reconunend standards

for the communicat ions and transportat ion systems involved in the care of

the acu te ly tL t o r in ju red? we need feedback f rom our membersh ip about

thes matters. rn the workshops you wiLL need to tel . l us rvhat methods

our o rgan iza t ion shouLd use tn the lmp lementa t ion o f the goaLe cor lec t l ve ly

agreed upon by our membership. I . le slrould also coneider how we &re gotng to

f inanciaLLy support the act iv i t les and obj ect ives of our organLzaf lon inthose mat te rs requ i r ing co l r .ec t rve ac t ion . Thus , r^ re a re ask ing you tochar t the course o f th is o rgan iza t ion . Le t rs rev iew the ques t ionna i re youhave received today. PLease cornplete and return i t af ter aLL the workshops l

l- 4 3 -

have been compLeted. we need your help in naming our organizat ion. we

have worked with key words r ike Emergency Medical services, Regional

P lann ing , Un ivers i ty , e tc . , to see i f we couLd come up w i th some ca tchy

term. The one pr in ted on the ques t ionna i re i s names: fo r the Nat iona l

Associat ion of MedicaL Emergency Services. I , le have aLso considered BARF,

SPERM, Fln' lEs, etc. None of them seem perfect and we certainLy \^rant your

thoughts and recommendations.

Regard ing the t im ing o f annua l meet ings and the poss ib i l i t y o f

assoc ia t ion w i th o ther na t iona l g roups , there are a number o f cons idera t ions

tha t r th ink can be d iscussed in the workshop groups . perhaps i t wou l_d

be unwise for us ini t ia lLy to associate with any group unt i l we have a

cons t i tu t ion and s la te o f o f f i cers , and a be t te r unders tand ing o f our

membersh ips des i res . There are th ree poss ib i l . i t i es regard ing the t im ing

of our annua l meet ing tha t the founders cons idered. ( l ) A meet ing pr io r

to or fol l -owing the Associat ion of Academic Surgery meeting in November

L970. (2) Bet l^teen the Associat ion for Trauma and the American col. lege of

Surgeons meeting. (3) Before or after the Comrnit tee on Trauma meeting

of the Amer ican Co lLege o f Surgeons. The t im ingr a t leas t fo r th is year ts

meetingr couLd be one day pr i-or to the Associat ion for Academic Surgery

meet ing . The advantages o f th is par t i cu ta r t ime wou ld be tha t i t wou ld

permit a reduct ion in expense to anybody attending both meetings . I4any ot

our membersh ips , most o f whom are young, a r .e a lso members o f the Assoc{a t lon

for Academic surgeons. Because the Assoc ia t ion fo r Academic Surgery meeEing

fo l lows the Amer ican co l lege t rEet ing i t w iLL permi t the execut ive conrn i t tee

and the cons t i tu t ion conrn i t tee the oppor tun i ty to meet and so lve some o f the i r

problems at the American coLl.ege meeting pr ior to our November meeting.

rn preparaLion for the Fal l meet ing, we would Like to have your thoughts

regarding subjects and programs. hle feLt our organLzaELon should not engage

- 4 4 -

in the presentat ion of scient i f ic papers on the patho-physi:or.ogy and

treatment of in jury. we fel t our meetings should be devoted to those

matters organizat ional and administrat ive related to improving thedeLivery of emergency medicaL service, The format of future meetings

shouLd be cons idered. Do you pre fer the workshops, paner_s , fo rmar ta rks

or other vehicLes of communicat i .on? our regionar representat ives had

the respons ib i l i t y o f con tac t ing aLL o f you end f rom the tu rn ou t i r

would appear they have done an excel lent job. However, Iou may wish toexpand or contract some of these regions. your forder contains a

L i "s t o f the reg ions and the s ta tes inc luded in those reg ions . The

individuaL who out l ined the geographic boundries of these regions, r^ras

a fo re igner to the un i ted s ta tes . some cur ious th ings d id happen. Las tnight we discovered that somehow the state of Nebraska had not been

incLuded in any o f the reg ions . Th is d id cause us some cons terna t ion .

To meet the fu tu re needs o f our o rgan iza t ion , the group wh ich had

pLanned th is meet ing feL t i t bes t to recru i t a b roadLy-based organ iza t iona l

caucus cons is t ing o f the found ing fa thers , the reg iona l representa t ives

and a few add i - t ionar - representa t ives o f spec ia r ta ren t to per fo rm the

fo l low ing taeks by the Fa lL meet ing ; tha t i s , to deve lop a cons t i tu t ion ,

to develop a faLL prcgram, to recommend a slate of of f icers. The member-

ship of the organizatLonal caucus rncrudes your act ing chairman, the

ac t ing secre tary , J im MacKenz le , Rober t Ruther fo rd , the hos t fo r th lsmeeting, ALan Dimick, Ray rdathews, George Johnson, Lesr ie Rudolf , Bi i l .s tahL, Max R i t tenbury , car te r Nance, Herber t Hechtman, Andy Hreno, AdorphYates , Ear r . w i l k ins , B i l r sosman, l t ra r lan Root , pe te can izaro , cu thber towens, Bob L ium, Rorand Fo lse , car l Jer .enko r r r , and w i l l " iam oLsen. Th isgroup can develop a sound const i tut ion for this organizat ion and recommend

- 4 s -

an outstanding slate of of f icers to run i t . i r le could have some discussion

at th is po in t . Perhaps some o f the o ther ind iv iduaLs respons ibLe fo r

your being here might l^tant to make some cornments. Jim, do you or Bob have

any addit ional mater ial that should be covered?

DR. I ' IACKENZTE: There are just two or three things. One is that we

have set out a l ist of the members by a]-phabet ical- order, and also i"n the

forrn of regions, the state or the province to which you beLong to; the

universi ty and the hospital- in which you had wri t ten your emergency

department descr ipt ion from. Now, I am sure that with the mass of in6or-

mation that was coming in to me and then having to be passed on to other

people in such a short t ime that some n€rmes and addresses are \rrong, and

that some people are put under the wrong region, the wrong hospital , or

something l ike that. That is the reason why you have been given these

mimeographed l i s ts so tha t you can @rrec t them. rn add i t ion to tha t ,

we have put a new information sheet quest ionnai-re onto the direccory

that ! ' re would l ike you to complete so that we could have some more correct

in fo rmat ion about yourse l f and about the area , the ac t iv i t ies o f the

emergency department Ehat you are associated with -- your Universi ty. And

I wou ld apprec ia te i t i f the peop le tha t a re here wou ld f i l -L ou t those

new information sheets and Leave them at the registrat ion desk. I think

t h a t r s a L L .

DR. FREY: Bob, did you have any comments?

DR. RUTHERFORD: Just one thing I wanted to mention in terms of our

a f f i l i a t ion or assoc ia t ion be ing in the same pLace as another g roup. r

juet wanted to make a couple of addit ional points which r think might

be important in the f inal decision which has to be obviously up to the

membership, In regard to the Associat ion for Academi.c Surgery, this organLza-

t ion doesn ' t have a spec i f i c ro le in our a rea , bu t I th i .nk i t doee prov ide

us w i th a mechan ism fo r v is i t ing in a na tuxaL way the var ious un ivers i ty' 4 6 '

hosp i taLs . We couLd have an on-s i te v is i t every year and no t ge t invo lved

in the san Franc isco , ch icago, New york , A t lan t ic c i t y c i rcu i t - - no t tha t

I mind the San Francisco - and which would involve maybe an extra expense

of the s ide t r ip be tween the meet ings to v is i t p laces where we dec ide to

have our meeting. rn addit ion, r thinle the leadership of this group

and some of the best talents in this organizat ion are going to be in-

creasingl-y involved in committee meetings and counci l meet ings, biology

cLubs ' e tc . , and aL l - o f these th ings , We are us ing the Amer ican Co1- lege

of Surgeons as a place to get together and we might not have an opportunity

to have th is sor t o f ta len t in our mids t when we need i t most . so r

just wanted to add a l i t t le more information as to t ,he reason r,re seem to

be Leaning toward this one choice, but again, we certainly want to have

everybodyt s comments on this.

DR. Yot l I \ tANs, Kansas ci ty: r real ize the founders here have been

pr tmar i .Ly surgeons as r am. Never theLess , most o f the pa t ien ts tha t

come into our emergency rooms are not surgical probLems. I am concerned

tha t we Lean too much ln the d i rec t ion o f surgery to the exc lus ion o f

in te rnaL med ic ine or ped ia t r i cs , e tc .

DR. FREY: I think this is an important issue that you harze brought

up and our thoughts are that the individual in which we are interested is

the emergency department director, be he an internist , pedLatr lctan or

surgeon. on the o ther hand, i f there is a re la t ionsh ip such as a co-

cha i rmansh ip w i th the surgeon or i f the surgeon p lays a secondary roLe, r

dont t see any reason a t a l l tha t the emergency depar tment d i rec to r and

the surgeon couLdn ' t a t tend th is meet ing . rn o ther words , there is no

reason at al l that there couLdrf t be more than one individual f rom a part icular

ins t i tu t ion coming to th is meet ing . We dont t have any in ten t to exc lude

anybody who is in any l , r tay responsibLe for providlng emergency medLcal service6.

- 4 7 -

DR' MACKENZTE: Therers one other i tem. From the information sheets

from aLL of the regi.onar d, i rectors, ar.most ar l of the peopre that were

contacted seemed to be surgeons. Now there l rere some, the Universi ty

of verrpnt is one, that have an internist as the Director of their

emergency department. There are anesthet ists who are Directors of

emergency departuents and r think there are some pediatr ic ians. These

peopre have al l been invi ted to this part icular meeting and any other

meetings that we have, but there is no doubt about i t that over 99 - 95

percent of the peopr.e who are emergency department Directors.

DR. J.T. sANDy, vancouver, Br i t ish columbia: r wouLd just l ike to put

i 'n a pLea for representat ion of some of the ! i lestern part of canada on this

const i tut ional ' organizat ion. r think there is a big chunk of the country

there tha t werve k tnd o f fo rgo t ten about .

DR. FREy: r th ink tha t has been taken care o f , hasnr t i t J im? Th is

I i tas one of the areas that we wanted to further explore in the workshops

Part icularLy i f there was addit lonaL regionaL representat ion thar l ras

requlred. Any further conunents? I think Dr. DimLck should have the f1oor.

He wiLl expLain the tour of the emergency department and how he is going

to intergrate Lunch somehow into this scheduLe that he has devised.

- 4 8 -

EI"ERGENCY }GDICAL SERVICES coI"ftIITTEE . BIBII"IING}IAM. AL$BAMA

The EMS committee was formed in 1967 by a resoLut ion of the ci tycounci l . r t performs in an advisory capacity to the ci ty counci l ,but has no legaL authori ty.

The commlttee is composed of representat ives from the fol_lowingagenci.es: American col lege of surgeons; county MedicaL society;Red cross; c iv iL Defense; Regional. HospltaL counci l ; county i ieai t t ,Department; Bar Associat ion; pol ice Department; Fire Depariment;Board of Educat ion; ldotor ist Associat ion; Ambulance Associat ion,Cormrunity Services Councll_.

ldeet ings are monthLy throughout the year at Gity Hatt . standi.ngcommittees i .ncLude: conmun{cat ions; Transportat ion; EmergencyFac i l i t ies ; Educat ion .

This comrnit tee has been responsibl-e for: (L) The revision ofBtrmtnghamrs ambulance ordinance in February 196g; (2) organi_zi .nga df.saster plan for the Birmingham Airport ; (3) implementat lon ofa radio network between the locaL hospitals and between ambuLancesand hospital emergency departments; (4) sponsoring training coursesfor a*ulance and rescue personneL

ALan R. Di.nick, I ' t .D., CoordinatorEmergency l , Iedical Services Comnit tee

- 4 9 -

I. Def ine the probl_ems

II . Ourl ine the Solut lons

I1 I . Cons ider

I{orkshop I

Workehop II

I' lorkshop III

WORKSHOP OUTLINE.

Movement of the acutery i r l and/or lnJured pat ient to theEmergency Department.SurveillanceTraneportComnunicatlonTralnlng reacue workers

Emergency DepartmentPhysiclan staff ingSpeclal i ty staff lng

fvaflapfUry of radlology equlpnent and sraffAvai labi l i ry of operart ; ; ,oo*" and staffAvatLabllity of blood anl blood bank personneLDlvereion of_non_emergent medlcal r"d' ;;;;ical iLtnessfrom the Energency DepartmentDlf ferent patterne "".r , , t th ci tyr county, and pr lvatehoepltals

PJ.anning of Emergency Medlcal ServicesEmergency Health Counci le _ loca1, regional_, and stateCoordlnation of ambuLance servtceeGrading of emergency departmentgPostgraduate tralnrng- oi phyelclans in resuscitat lon_ reehniques and ,eihods'oi hoepdtaf t ransi" ,Community educatlon and publ_ic relationsAnbuLance ordlnancescoununlty fundtng and the f inanclal just l f leat l0n of, Frnergency Medleal Servl.cesStaffing and pJ.annlng

1 .2 .

what our organlzat lonrs rol"e should be in -

Deflnlng and cormrunicatlng thle lnformation to the public.Helplng out membershtp inlff"r"rrt improvemente in emergency

H:t;:lrffilti$"ind ieglonat ptanntns ar rhe local, "r"tl,

- 5 0 -

!g!4T4AEIITS Or. WORKSHOPS BY WORKSHOP CHAIRMEN

- Seat t ler Washtngton

Itts hard to contract the many workshop comments into f ive.minutes. This

is one of the rnost enthusiastic meetings I have attended in a long time. I think

this is becauee everybody came for a set purpose.

At the f irst of thie workehop we spent the t ime discussing an organization

of the type that has been euggoated, and. it wae the coneeneus of the group tbat it

was defi.nitely inilicated but that the organizati.onaL etr;cture would best be set-

t led by a caucus committee. I refer primari ly to the off icers, bylaws and exact

format. However, congiderable discussion was given toward. what type of rneet-

ing might be beet, and I think there was general agreernent that i t should be a

struchrred, but informal meeting in the sense that symposia such as were pre-

gented today would al low individuale to come and discuss mutual problems. It

wae also fel.t that it should not be just a time when we come year after year to

rehash our outn pereonal ineti tut ionre problems, but ehould be one that was well

thought out ahead of time and had a specific planned program with topics designed

ahead of t ime which would al low the member's to come with some forethought and

possibly with even some presentatione. The group was definitely againet having

scientif ic segsions in the senae of papers related to trauma or shock as we have

in gorne of our other meetings, but possibly having diecussions relating more to

medical care delivery and the adrninistration of ernergency eerviceg, much as

have been outlined in the rneeting today. It wae felt by the group that this could

- 5 1 -

I

be an irnportant organization for gathering data referable to the emergency de-

lnrtments of universities and that some type of opinion poll or data gathering

source shoul 'd be init iated very soon so we can bring together some of this infor-

mation and then possibly sorne type of ongoing data gathering gervice should be

available which would enhance a more uniform approach to medical care in manv

of the universit iest sett ings.

As far as the site of the meeting, i t was felt strongly by the group that this

should be at a different university center each year, because one of the high-

l ights of this present meeting was being able to visit the ernergency department

here in Birmingham. It wae felt that this did not have to be tacked onto another

meeting and probably would be better not tacked onto another meeting since it

was felt that most members could f inance a eeparate meeting. A separate meet-

ing wouLd al low some variabil i ty and also would el iminate the problems assoc-

iated with di lut ion by another meeting. It wae fett that the results of this meet-

ing and other meetings should be pnrbl ished and distr ibuted. one of the problerns

that was touched uPon is how do you prevent an organization such as this from

being another academic stepping stone or just another place where one comes to

present his papere. It wae felt that much of thig might be eolved by having

anonyrrrous reports, by stressing group action, by using the symposium as a form

of presenting ideas, and by publishing detai led data of the meetings. The re-

mainder of this workshop was spent discussing some of the aspects of medical

care delivery and organization of emergency rooms, the basic problem being one

of the segregation of the non-acute, walk-in patient from the emer gency patrenta.

- 5 2 -

I

Each hospital setting had a different solution to the problem, and I think we can

surnmarize that we are not going to find any single method which will be applic-

able to any hospital. I t wae stressed that most of our group were surgeons, most

were administratively responsible for the emergency department, most spent

only a srnall portion of their tirne each day achrally working in tJre emergency

deparf,ment, so whether we like it or not, many of us were Snrrely and eimply

administratprs of tJr'e ernergency departmeat. This merely cornporrnds what we need

to know about the emerg€n cy departrnent, means that we have to be better in-

formed and have to have sound opinions so that we can cliecuss with the adminis-

trators, and our medical col leagues how the organizatiorurl structure should be.

A number of other i tems concerning individual problems of reEidency training were

touched upon and it was decided that these are i tems which should be discuesed

in greater detai l in some of qtrr fuhrre meetings, and in structuring the meetings

we should pick out epecif ic pointe that could be discussed in great detai l concern-

ing teaching, concerning the rel,at ionship with other hospitals, and a number of other

i tems.

I- 5 3 -

S_UMHARY BY DR._b/lLLlAM STAHL: - New york Clry, New york

I can echo the fact that the workshop was enthusiast ic . Everyone

had someth ing to day. I hope they a l l fe l t that they had a chance to

pa r t i c i pa te .

The a t ten t ton o f a l l was d i rec ted toward p rob lems tha t were ve ry bas i c ,

a n d w e d i d n r t t € l k v e r y m u c h a b o u t t h e s o c i e t y i t s e l f . I n g e n e r a l , w e f e l t

t hs t t he soc ie t y was va luab le and : cou ld he lp by p rov id ing a conce r ted e f fo r t

to improve sorne of the problems that we a l l have. We addressed ourselves

main ly torard the problem of s taf f ing in the emergency depar tment .

l ' /e began by say ing that we a l I had the same problems ment ioned by Bob

Ruther ford, o f pat ients coming in that wsre not emergent but who never theless

should be seen. l t was agrecd upon at the outset that one of t te major causes

o f t h i s p ressu re o f pa t i en ts i n t he emergency depar tmen t i s de f i c i ency i n hea l th

ca re de l i ve ry on an ongo ing a rnbu la to ry bas i s i n many pa r t s o f t he coun t r y . A l -

t h o u g h t h i s p r o b l e m l s n o t w i t h i n o u r s p e c i f i c a r e a , i t i s a m a j o r f a c t o r w h i c h

bears on the problems that we see in the emergency depar tment . perhaps th is

a s s o c l e t l o n s h o u l d d i r e c t i t s e f f o r t s t o t h i s a r e a a l s o .

There were d i f ferences of op in ions ss to how to t ra in a person to take care

o f emergency pa t i en ts . l t was fe l t t ha t cove rage a t t he a t tend ing l eve l shou ld

be present in the emergency depar tment at a l l t imes. Such covsrage should be

in as much b read th and dep th as poss ib le under the c i r cums tances . t / he the r t h i s

a t tend ing shou ld be a super spec ia l i s t , as one o f members sugges ted , t ra ined

q u i t e h i g h l y i n a n u m b e r o f d l s c i p l i n e s , o r w h e t h e r h e s h o u l d b e w h a t m i g h t b eg r l

c a l I a f a m i l y p h y s i c i a n o r " p r i m a r y p h y s i c i a n r t t r a i n e d t o a c e r t a i n l e v e l i n

- 5 4 -

a l l d i s c i p l i n e s a n d r e l y i n g o n s p e c i a l t y b a c k u p , w a s n o t d e c i d e d . T h e r e

a re d i f f e rence o f op in ion . The re was a fee l i ng tha t t he re shou ld be a

res idency i n emergency med lc t rp , 6 t ra in ing p rog ram to t ra in peop le to

funct ion in a career in ernergency depar tment medic ine. The teaching va lue

of the emerg€ncy depar tment exper ience as the f i rs t pat ient contact for a

med ica l s tuden t was s t ressed . I n the hosp i ta l o f one o f t he peop le p resen t ,

the second year s tudent was exposed to h is f i rs t pat ient in thb emergency

d e p a r t m e n t . l t w a s f e l t t h a t t h i s w a s v a l u a b l e t r a i n i n g o n t h r o u g h t h e

res idency l sve l .

The other aspect o f pbt ient care in the emergency depar tment depends

on adequa te func t i on ing o f a good hosp i ta l . l t was fe l t t ha t a ho ld ing ward

was a very impor tant par t o f ercrgency depar t rnent funct ion. Where these are

in ope ra t i on they were we l l used and were though t t o p rov ide a v i t a l f unc t i on .

The impor tance o f an adequa te i n tens i ve ca re fa t l l i t y i n t he hosp i ta l was

s t ressed i n o rde r t o p rov ide a su i tab le l oca le fo r t he pa t i en t once the acu te

resuscl ta t ion were accornpl ished. The ideal ized funct ion of the emergency

depar tmen t i s no t t o g i ve l ong - te rm h igh l ove l nu rs ing ca re , bu t t o resusc i -

t a te and move the pa t i en t t o a de f i n i t l , f , e ca re a rea as soon as poss ib le . A I I

i n a l l , t h e d i s c u s s i o n w a s s c t i v e a n d I t h i n h c o u l d h a v e c o n t i n u e d o n w e l l

i n to the l a te hou rs .

- 5 5 -

- Dallasr Texas

We qlso hqd o very enfhusiostic group. The first portion of fhe meeting wos

spent discusing requirements for membership, ond I bring this up only to rep6rt the vofe os

recorded. One individuol did remqrk ofbr survcying thle rqthcr lmprcrrlvc group thot he

wos not sure he wonfed to ioin any orgonizolion thot would hove him os o m6mb€r. The

only foct everyone ogreed on regording membership wos &hot the individuols involved

should, in foct, be direcfors of their respective emergency deportments. Regording the

question obout university versus non-university off i l iof ion, only three individuols rhought

itshould be str ict ly l imifed to ful l-t ime university foculty. The moiority thought thot

membership should include port-t ime cl inicol or ful l- t ime foculty i f the port iculor individuql

is the direcfor of the emergency room.

All members ogreed thot this group should form o seporote orgonizotion

connected with one of the moior meetings in t ime only; thot is, coincident with o port iculor

meeting, but seporote in orgonizotionol structure. Regording the content of subsequent

meetings, it wos felt by o moiority of the members thot formol presentotions be held to o

minimum with emphosis on workshops ond ponel discussions. In porticulor, presentqtions

nof relevqnt to emergoncy room cone, orgonizotion, tronsporfofion, etc. should be ovoided.

The group then discussed problems reloting to emergency room focilities which

should be included os topics of discussion in lofer meetings. Of immediote importonce, os

mentioned in the fwo previous groups, is treotment of the non-emergent potienf , This is of

porficulor importonce in emergency rooms thot hondle very lorge potient loods, The

solution seems to revolve oround developing on efficient trioge system os Dr. Dimick hos

done here in Birminghom. An ideol trioge sysfem would sort out those potients who could

sofely be referred to ouf-potient clinics or privoie physicions ond frioge those potients who

- 56 --.

' .

need immediqte core bqck to the oppropriote portion of the emergency room. A question

wos then roised regording fhe bosic function of the emergency room which I think has

olreody been onsweted for us. There is no doubt thqt the emergency room hos token the

plcce of doctor's offices, ot leqst for colls ofter 5 p.r., but I think it is somsthing wo qrr

nof going to be oble to ovoid. There wos cr concensus of opinion thot the besf woy to

hondle this port iculor problem is development of on eff icient tr ioge system.

Anofher point not previously discussed involved whether oll hospitols

within o given community should be equiped to hondle ol l fypes of emergencies. The group

ogreed thot oll hospitols with on emergency rrcom, regordless of the size, should be oble to

toke core of the immediote problems ond orronge for tronsportotion to o more complete

foci l i ty. l t is probobly unreolist ic to hove o Closs A emergency room in every community

hospitol however, qnd the solution is going to revolve oround development of integroted

regionol foci l i t ies" Relevont to this discussion, i t wqs olso pointed out thot mony exisf ing .,

emergency deportments could be mqde much more efficient with reorgonizotion of existing

foci l i t ies ot o minimol expense.

Another point which wss discussed deserves considerqtion by this group. One

individuol in the workshop does nof yef hove, but is in the process of setting up on emergency

deportment. He proposed thof this orgonizotion have on odvisory committee thqf on individuol

could contoct in this regord.

Thonk you.

- 5 7 -

SUMMARY BY DR. CAR! JELENKO - Augusta. Gporsia

Our group dld not addrees l teeLf to some of the problems of the

ralson dretre of the society, except to conclude rather overwhelmingly that

there ls a rol-e that thls soclety can serve for the group and for the

indlvidual. I t spent considerable port lon of i ts very vlgorous and pro-

ductlve tine dlscuesing certaln probLems, beglnntng with the rol-e - the

precise roLe - of the lmergency room director, and l t was the consensus of

the group that this lndlvldual needed to have hls role deflned and delimited;

he probabJ.y ought to be a departnent chairnan; that perheps he ought not be

such an lndlvidualr at least of an academie status, as a chlef of a service,

such as the professor and chairman of a department of surgery, but thaL his

department ought to be separate and diet ince. I t wae fel t that ln thls way

he would have conslderabJ"y more Latltude in moving patients ln and out of his

service, and that wae coneldered by the group to be a maJor problem. The

group devotee approximately 30 to L00 percent of lts time, depending upon the

nenbershlp querled, to the emergency room and the bulk of the lndividual-s,

as we have heard before, spend the most of their t lme in adminlstrat ive dut lee.

The guest lon, then, came aa to what sort of ataff ing pattern needed to be

consldered wlth regard to glvlng care to the slck and inJured, and some quest ion

was discussed regardlng screenlng out non-emergency patients and triaging,

and lt wae the consensus that perhape we are doing the lriage businees all wrong,

that perhaps we ought to adJere to the def lni t lon of t r iagerwhich says that

the more experienced individual does it, and that perhape our emergency rooma

ought to be staffed wlth a mfnlmum, at Lea8t in the surglcal area, of a second-

year reeldent, and that the nore experlenced lndivldual- ought to be doing the

select ing of pat lents to go ln the back.

- 5 8 -

These were the naJor areas that the guoup covered and it was the

consensus that thls organizat lon could, by i ts interchange and by group

act lon, serve a useful funct lon for each of i ts individuar mernbers.

- 5 9 -

SUMIfARY BY DR. ADOLPH YATES: - Pittsburgh, pa.

The hour and a half passed fast. I have never seen Less disagreement

anpngst a group of doctors, and part icularLy surgeons, than we had in our

workshop. t{hiLe we touched on some specif ic problems regarding the emergency

room' we certainly did not nor intend that we shouLd come up with specif ic

solut ions. We covered the f i .e ld quite widely, and I wiLl just note some

Points that I think l re got out of our session, one thing we did not touch

on l tas a name for thi .s group. I t didnr t dawn on us unt i l we f inished that

for a sizable group f . ike thts we may not know what we are caLLed, but we

kno^r vhat \de are. There dtd not seem to be any purpose or ident i . ty problem.

The f i rst polnt that arose I think l ras an Lmportant one. I t reLated to the

uniqueness of this group. ! , le are start i .ng from a di f ferent leveL of

cosmunicat i -on, t rai .nlng and servlc,e than the naJori ty of doctors respon-

sibLe for emergency rooms ln the Untted States. We are start ing from a

unlversi ty leveL. Our probLems are not backup or special ty services; our

probleurs are not those of staff ing the emergency room, but rather the Level

o f t re ln ing o f tha t s ta f f . The prob lems are d i . f fe ren t tn maJor c i ty hosp i t *Ls

without untversi ty aff iL lat tons. The naJor medical and surgical groups

lnvolved in the diesemination of emergency roomr phiLosophy and standards

have aimed their broadside pretty much at hospitaLs in general ; they seem

to have o f ten missed the un ivers i ty hosp i ta l , in par t i cuLar . In some se t t lngs

we shoul-d put not one but two residents fulL t ime in the emergency servl-ce,

We must deaL wi. th probl-ems of f inancing for what the medicaL school keeps

caLl ing deftci t spending in the emergency department. These are problems

that nobody has touched upon in nat ional group€. Whtle the major trauma

vlct im at the universi ty hospitaL may be at t imes t tovertreatedtt (many t imes

one of the jobs of an emergency room director wi l l be to try to crear the area

- 6 0 -

of aLl the excess heLp) the non-universi ty hospitals tend to steer that

type of pat ient f ,o the universi ty hospitaL. The reverse, unfortunatery

is sometirea true, and"that-J*6, the universi ty hospttar ls not always

doing a good job with the non-acute. rn soue large cttLes we are tosing

our publ ic image with many of people that present themselves to the

emergency room. we are not doing what the pat ient considers to be a

good Job w l th the non-acute pa t ien t , par tLy because o f in te res t o f the

people that are running the ernergency room, but also part l_y because of

the publ ic. Thts is where the community hospitaLs are often dotng a

better Job' Another potnt that came up--rhe speakers this morntng talked

about Phase r, the t ime before the pat lent casn to the hospitaL, and

Phase rr , the part in the hospltar emergency room , but we thought that

perhaps a maJor concern ehoul.d be calLed 'phase rrrr ' , what do you do

after they are f in ished treatment. Many peopLe waLk out of an emergency

room and don't know when they are supposcd to come back to have a cast

removed; ' they donrt know when or whom they are supposed to see to have

the i r su tures ou t ; and L f they are to see someone, i t rs generar . l y some-

body that had no part in thelr tni t ia l- care. Tte se are problems that we

think need to be discussed, and we think ,phase rrr ' , is an important

aspect of emergency room care. we feLt as far as this organlzat ion was

concerned, one of the maJor effecte of the workshop to our group rra6 the

rearizat ion that there $tere stgnif icant problenrs that need soLvt i lon and

which we had not even broached, There is a need for such an organi zat1on

as th is ' we fe l t tha t fu tu re meet ings shou ld no t be excLus iveLy sc ien t i f i c

sessions, as the previous speakers have al .ready said, but we thought i t should

be dlrectLy related to grassroots management and det ivery care methodsand probl 'ems. we thought that specif ic topics to be discussed at future

- 6 L -

meetings should be narrowed dswn to a

of us are tnterested in alX. phaees that

attending some of the other workshope

In sumary, aLL ln our group fel t that

def lnt teLy a must.

I tmited f ie ld, because so many

we may feel we have lost out by not

ln which tre may be equal ly lntereeted.

conttnulng such a soctety was

- 6 2 -

SUMMARY BY DR. MN( RITTENBURY: - Charl-esron, South Carolina

Our workshop was concerned with a different phase, and we hrere

asked to discuss the problems associated wi.th regional planning for

emergency nedical services. I thtnk that everyone tn the workehop

reaLized the need for planning at severaL LeveLs, i .e. nat i .onal and

state level-s. The guideLines, rul-es, etc. could the.n be coordi .nated and

used at a locaL leveL at pLanni.ng. Everyone feLt that the goaLs of better

ut iLizat ion of the avat labLe services should be attained.

I t was suggested that the cr i ter ia establtshed for accreditat ion

of hospital .s and emergency departments in the hospitaLs wouLd then leave

the choice up to the hospital as to the LeveL of at tainment they wished,

and that this approach could faciLi tate some of the planning probl-errs

on a local leveL when you got into the ni t ty gr i . t ty of saying whi.ch

hospitaL wiLL take whlch pat ient. Thls probLem was separated fro,sr that

of disaster planning when everybody works together for survl .val .

I t was aLso brought out that i " t was necessary for locaL pl .anntng to

be done by a counci l or. a comit tee. There wae realLy no def ini t ion of

the slze or the structure of thi .s conunit tee, except that t t should be

broad based in a general. way. It wouLd vary from community to cotrununity and

the areas, or the def ini t ion of the areas, rdor l ld be probabLy aLong natural

pol i t lcaL or medical referral Lines, rather than upon the cetebl l .ehed

gutde l ines o f , i .e . e one conmi t tee per 501000 popuLat ion , L t wae e t ressed

that the ruLings or the reconmendations of these commi.t tees probabLy shouLd

not be dictator ial mandates (both on the nat iaral or the Local- LeveL), but

that act ion on these recommendations should be obtained by having poLit icaL

representa t ion .

I t was mentioned that there \ ,vas a strong leadership role in these

counci ls by the physicians, but this did not necessari ly mean that he had

- 6 3 -

to chair these commi.t tees or counci! .s. vartous probl-ems associated with

this were discussed generai l .y, and r think that i t r ras a stong under-

current that he is the f,LnaUrguLderrr of the couneil, tho one who nayn

what the crlteria for performance should be, but he doesnrt heve to Bat

involved in the rout ine of dat ly admtnistrat ion. There is a need for

a strong codmi.tnent on the part of the consumer to this counciL.

Nor, we Left this topic to discuss the other charge, to discu.ss

the role of such a group of peopre as have met here today. No one,

when the quest ion was f i . rst broached, had a cLear def inl t ion of the goaLs

and alns of or the nead for this group to meet. r think, though, as the

discuselon Progressed there seemed to be trends that the universi t ies

are cormtitted to cormunity involvement in emergency medicaL servi.ce planni.ng

and such care is a legi t tmate academlc pursuit by members of the universi ty

faculty. there ls a need for this type of society that should have i ts

membership at the untversi ty level of achievement; that al l the special t ies

tn te res ted in emergency med icaL serv ices , no t jus t surgeons shou ld be

incLuded; but that thls membershi.p should not be inclusi .ve of the non-

un ivers i ty Persons except fo r spec ta l in te res t o r need or sk i . l l . I t was

feLt that the group probabLy should discuss the ent ire spectrum of emergency

medicaL services, rather than Just the probl.ems attendant upon an emergency

department tn a hospttal . or in a unlversi ty type of hoepltal . , because l t

was feLt that you real l -y cannot separate at 1. of theee problems from your

educat ional role or the pat ient care rol ,e which you have to part tc ipate in

as a universi ty member. r t was fel t that these types of acttv i t ies by

th is g roup wou ld no t rea l l y dup l l ca te the ac t iv i t ies o f o ther we l l -known

national groups; ol ei ther the Associat ion for the surgery of Trauma, because

the emergency services are much broader based than just t reat ing tnJuries;

- 6 4 -

or the American College of Surgeons Conunittee on Trauma, because they

deal at a different lreveL and nlth certain di.f ferent emphasis upon

other types of probLems rather than those this group wouLd deaL with. We

feLt that these groups would overlap in some of their activit les and

probabLy f i- l ' l in some vac&nt spaces, but would not be true dupLicates.

rt was felt that the time is ripe qoy for the formation of such a group

and that this covers alL spectra;. of the medicel and the tay problems.

- 6 5 -

SIft{MARY BY DR. JoiIN J. voNDRE&Ii,- Milwaukee, wisconsin

We spoke about the ut l l - izat ion of hel icopter ambulances in quite a

bit of detai l , ta lk lng pr lmari ly about the cost of the hel icopter and i ts

inpract ical- i ty in using i t solely for an amb6lance. I t must be used as a

mult l -mlssion vehlcle, e.g., for pol ice survei l lance, ambulance, etc. we

also talked around some of the legal problens with the helicopter and the

feastbiLlty of landing on the expressr^rays, and the non-practicarlty of

ut l l iz lng the heLicopter in the ci ty, except for the expreseway system.

Another problem we taLked about wae the J- iabiLi ty factor, whether var lous

hoepltal's and gity governments wll-l al-low you to land a helicopter on rheir

property' and we mentloned an example of this occurrLng recently in a

I'Iisconsin area where we do have a Bell Jet hellcopter owned and operated by

a private l-and ambulance company. The ambuLance operators wanted to take a

Patlent from MlLwaukee lnto wieconsin and the lngurance carrlers at the

unlversl ty of wleconsin obJeeted to the hel- lcopter landlng on thelr property.

The cost of any ambulance servlce, incrudlng land amburances, rs

probably golng to get so expensive that it will end up betng a municipal

proJect. The reaaon we feel thi le way is that as we keep adding more rules

and regulations for the ambulance attendants and the ambuLancea, the cost may

get eo high that the lndlvldual operators can no longer cope with thls. r t

was feLt by the group that Lt liras more important to have an expert at the

scene of the accident than it was to have a rapldly movlng vehicre from the

accldent scene back to the hospital . Therefore, we should probably work

harder for havtng experts brought to the scene than we shouLd for hel lcopter

transport away from the accident sl te.

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Next,, we rilent into the communication systems. We spoke briefly about

the I I .E.A.R. systen-.and some of the problems the var ious hospitals are having.

Some sets are not turned on and the people are afraid to use t,hem because they

have to pick up a mlcrophone and talk lnto i t . Because of this, one of the

companles produclng this type of system ( i ts not Just Motorola-*GE and other

companies are produclng sound equlpment) has changed to hand sets much l-ike a

telephone instead of a hand mf-crophone like I an holding. It nakes it easier

for peopJ-e uslng the equLpment. Our representatlve fron Nebraska told us a

l l t tLe about hls eytenr, and after l ietening to hlm talk for a few mlnutes, i t

was pretty much unanlmous €rmong the group that perhaps Nebraske ls ahead of

everybody el-se ln the cornrnunication system. I^le thought it mlght be practical

for hin or one of his membere fron Nebraska to speak to the entlre group on

thelr communicatlons Bystem. Thls wouLd be at our next rneetlng, hopefully.

We aLso talked about dlfferent types of training programs for rescue

people, and agaln Nebraeka looked pretty good. They are uslng a two-year,

part-tine program wlth ln-hoepltal rotations in emergency room, operating room,

and deLlvery roon. It was nentLoned that thls surnmer a tralnlng booklet ls

being printed by the AmerLcan Acadeury of Orthopedic Surgeons. It might be a

good ldea lf everybody used the same instructLon plan lnetead of every com-

munlty havlng lts own llttle teachl.ng progran.

We flniehed by having Mr. Dowllng speak about the program {n Jacksonvllle,

Florida' and I think most of you w111 agree that they probabl.y htve one of the

best rescue units in the country. Thts le operated, ae we aL1 know, by CaptaLrt

Waters. They have a superb program using physicians in the tralnlng progratr,

as well as theLr own technLclane tralning people to use backboards, splinting,

e t c .

l

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our group addressed itserf principalry to Emergency care councir_

atructure and the establldhnent of councils in conmunltles throughout the

country' rt was pointed out that very few communlties in the country have

councl ls such as we 8re dtscussion, and we fel t that guidel ines for the

estabrlehment of these councils are necessary. There are guldelines which

w111 be publlshed by the Al'lA council on Emergency Medlcal Servlces, but it

was the feel lng of our group that th18 0rganizat lon should part lc ipate

act lvely in the dlrect lon of guldel ines for such counciLe in the future.

we fel t that the counci l structure shoul-d protect special interests

ln the comnunity such as the medlcal school or the local and pol i t lcal sub-

divls lons from attaek, whlch is frequentJ-y lnl t iated when change occurs.

we felt that regl0nal councils should be estabLlshed on an lndlvldual basis

euch as De' Mackenzle out l lned ln hle excel lent preeentat lon. These would

vary ln slze and Pol i t lcal aspects but should, ae Dr. Mackenzie pointed out,

lnclude a naJor receiving faci l i ty. r t wae also fel t that the counci l shoul-d

dLrect l teel f toward lmprovLng the care of pat iente in Batel- l i te hospitals

whlch mlght aerve as a pr irnary source of care of a part lcular pat lent or a

referral source' r t was fel t that the counci l - should include a1r areas of

lnterest ln emergency medlcal servlces ln the cornmunlty, and that the best

talent avallabl-e ln the cormunity shoul-d participate. rt was the feeling of

the group that rhe councLl shoul-d be heavily buttressed by the appropriate

act lve cLinlclans. r t was fert that many of the counci ls or conrmlt tees whlch

are aet up to gulde var lous nedlcal act lv l t iea are set up and governed bypeople who have no current actlve practlce ln the area in whlch they are lnvolved.

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It was strongly suggested that those of us who are activeLy working "

ln the emergency medical service area direct the activities of the council

and thereby the activLtles of the community.

The councll ehoul"d survey the cormunity problems. Its inttlal function

should be to survey the problerns that exlst before lt moves to recommend

changee ln the conmunltyrs emergency servlce structure.

I t wae ernphaslzed that such a counci l rrehouLd ldent i fy l tsel f wlth

power structures of the comrunlty, economic and otherwlse, in order to garner

for i tsel f as much support , as poselble to implernent l ts goaLe. One of the

lnl t la l responslbl l i t les of the counci l ln each comrnunlty, our group fel t ,

was publ lc relat ions; 1.e., the generat ion in the comnunity of an appreciat i .on

of the need for improvement in our emergency medlcaL servlces.

I t was etressed that the or ientat l -on of medical students to the

importance of the conmunlty health service aspect of the emergency medLcal

services council and its activlties earl-y in the currlcul-um ls important.

The councLL, we feeLe ehouLd address l teeLf, to the general problems of:

1. Cornmunicatlon and transportation for emergency care.

2. Individual hospltal emergency servlces in the communlty.

3, Pl-annlng for energency care in the outJ.ylng or referrlngcoununities.

4. Cont inuing educat ion for physlclans.

5. Establ ishing personnel requirement.g for emergency care, notonly Ln the hospltal but in the var lous agencLes, ambulance,pol ice and f l re departments.

6. Establ ishLng educat ional prograns for emergency personnel forparamedical personnel ln the hospltal , for pol iee and f i repeopl-e, ambulance drivers, and the l_ike.

7 . D ieas ter p lann ing .

8. I l igh lntensity treatment unlts.

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9, Laboratory servtces, brood banking, and forensi.c nedr.cine.

10. Addttion of a legal advlsor on the council- was felt to belnportant.

I t . Flnancla]- resourcea.

L2. A contlnulng revl.ew conmlttee to evaluate the progress ofthe council_.

We focused our attent lon on sources for funds for the counci l . I t

was polnted out that the Department of Transportation may have available

funde for such counci ls. Local government, of course, wiLl heve to act ively

part ic ipate in the product ion of monlee to operate such a counci l . Dr. 0wen

polnted out that there rnay be CivlL Defense money available for comnunicatlon

prograns and transPortat, lon programs. I t was aLso polnted out that there are

monles available through conmunity or metropolitan area counclL of Govern-

ment organlzatione. The Natlonal JAYCEES have addreesed themseLves to the

problem of energency nedlcal- services as one of their prlrnary obJectlves for

the year 1970' and they may be counted on to heJ-p wlth probleurs tn this regard.

The National Safety Council ai.so has an actl.ve interest in the general problem.

We' J- lke the other workehop groups, onJ-y ecratched the surface. We

sensed the tremendous need ln this area and we feel that thls particular

organlzatlon hae a definlte rol-e to play, not onLy to study the problems

and deflne what the needs are currently, but to try and define rf,hat the

probleme w111 be ln 1990, and to proJect our plannlng in our conmunltles and

in our universi t les to meet these needs. Ln addit ion, we feel that this

organizat ion of act iveLy part lc ipat lng surgeons ln the emergency medical f ie ld

properly should offer dlrect lon for emergency medlcal services in the eountry.

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RNFERENCES

1. Nat i .onaL Academy o f Sc iences . 1966. Acc identa l death and d isab i l - i ry :The neglected disease of modern society. Committee on Trauma and Commigteeon Shock , ,D iv is ion o f Med icaL Sc iences , Nat ionaL Academy o f Sc iences ,Nat iona l Research Counc i l - , Wash iongton , D.C.

2 . W a 1 l e r , J . A . L 9 6 7 . C o n t r o l o f a c c i d e n t s i n r u t a L a r e a s . J . A . M . A .2OLzL76-L8L.

3 . F r e y , C . F . , H u e L k e , D . F . , G i k a s , P . W . R e s u s c i t a t i o n a n d S u r v i v a l i nmotor veh ic l -e acc idents . The JournaL o f Trauma. 9 t292-3L0, 1969.

4 . Von Wagoner , F .H. 1961. D ied in Hosp i ra l : A th ree year s tudy o fdeaths fo l low ing t rauma. J . T rauma. 1 :401_-408.

5 . Pant r idge, J .F . The mob i . I -e Coronary Care Un i t . Hosp i ta l Prac t ice ,August , 64-73 , L969.

6 . S issouras , A .A. , Moores , B . : P lann ing fo r Coronary Care Serv ices in aCorununity. Progress Report No. I and No. 2. The Universi ty of ManchesterInst i tute of Science and TechnoLogy. Department of Management Sciences,Hea l th Serv ice Opera t ionaL Research Un i t , L969.

7 . W a s s n e r , U . J . / E c k e , H .Mogl ichkeiten Einer Intensivierung Der Ersten Hi l fe Fur Unfal lver l-etzteIn Stadten Mit Landl icher Umgebung. Chirurgischen Universi tatskt inikGiessen. Monatsschr i f t fuer Unfa lLhe ikunde Vers icherungs , Versorgungsund Verkehrsmediz in , Vo l . 67 , Jan . L964rpp. 32-44 .

8 . Mah ler , l { .Der Operat ionswagen Der Chirurgischen Universi tatskl inik Heinde lberg.Ch i " ru rg ischen Un ivers i ta tsk l in ik He ide lberg . Ch i ru rg , 3Lz42L-425, 1960.

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