The Challenges and Rewards of Emergency Medicine
By Dorothy Wright
A 40-year-old man suffering with chest pain was brought to the emergency room (ER) of the University of Colorado Hospital, Denver. He didn't speak English, so it was difficult for attending physician Jean Trumpler Abbott '69 to obtain his medical history. Until recently, the patient's age, sex and symptoms most likely would have prompted a physician to diagnose a myocardial infarction (MI). The physician immediately would have administered a thromobolytic drug to break up the blood clot or sent the patient to the cardiac catheterization laboratory for a primary angioplasty — the state-of-the-art treatment for MI — but in this case, the patient might have died as a result. Instead, Abbott ordered a computed tomography (CT) scan of the patient's chest.
Jean Trumpler Abbott '69
"In five minutes, we had the results, which told us that this was an aortic dissection, rather than an MI or a pulmonary embolus — another 'fake-out' diagnosis that gets missed all the time," explains Abbott. "We treated the patient to stop the pressure on the wall of his aorta so that it would not continue to tear, and we sent him up to surgery," Abbott continues. "He recovered."
Today, access to advanced technology is enhancing the emergency team's ability to diagnose and treat critical illnesses and traumatic injuries. At the same time, ER physicians are struggling to cope with a number of challenges, including a steady rise in the number of patients as the number of ERs declines; shortages of nurses and hospital beds; the increasing cost of providing care for low-income and uninsured patients; and a health care system that has exacerbated, if not caused, these conditions. Nevertheless, ER physicians find the intellectual challenges, interactions with patients, opportunities to improve care and predictable work hours very rewarding.
Emergency medicine is a relatively young specialty. "For many years it was a secondary specialty or a 'retirement' specialty — something surgeons did after they were burned out," Abbott recalls. "In most hospitals, an internist, family doc or surgeon on call would come down and take care of anyone who arrived at the emergency department. In the late '60s, people started realizing that accurate diagnosis and effective treatment during the 'golden first hour' of critical illness, whether it is trauma or a heart attack, could make a difference in patients' lives."
In September 1979, emergency medicine became the 23rd recognized medical specialty in the United States; in 1980, the American Board of Emergency Medicine (ABEM) offered the first emergency medicine certification examination and certified its first diplomates. "As with other new specialties, the earliest emergency medicine specialists fulfilled a practice eligibility for the specialty and then sat for the board certification exams," Abbott says. "I guess I'm one of the 'grandmothers' of the specialty since my ABEM I.D. number is 00066."
Today, more than 22,000 physicians are board certified in emergency medicine. The specialty requires completion of a three- or four-year residency, which typically includes rotations in the areas of internal medicine, coronary care, intensive care, ob/gyn and trauma, in addition to adult and pediatric emergency departments. Physicians may further specialize in emergency sports medicine, pediatric emergency medicine, toxicology or international emergency medicine.
Emergency medicine is a high-pressure medical specialty, to be sure, yet practitioners say the clinical aspects of emergency medicine are no more or less stressful than those of other specialties. "As in most careers, 90 percent of what you see you already have under your belt," Abbott says. "It may not seem routine from the outside, but if somebody is having a miscarriage or suffering from a laceration or fall, it is straightforward, and you know what to do during that first critical hour."
However, caring for the rising number of patients is a significant challenge. According to the most recent statistics from the Centers for Disease Control and Prevention (CDC), in 2002 an estimated 110.2 million visits were made to hospital ERs — up 23 percent from 1992, an average increase of 2 million visits per year (Advance Data from Vital and Health Statistics, No. 340, March 18, 2004 ). During the same time period, the number of emergency rooms in the United States decreased by about 15 percent. Increased volume of ER visits can result in longer waiting times for nonurgent visits and increased occurrence of ambulance diversions.
Janet Glass Alteveer '72
This trend is reflected at Cooper Hospital/University Medical Center, Camden, N.J. "When I first came to Cooper in 1991, the emergency department received about 35,000 visits a year," says Janet Glass Alteveer '72, assistant medical director of the 26-bed emergency department. "Now we are receiving 48,000 patients in the same size department. As a result, we routinely are examining people in the hallway, which is a privacy issue."
The hospital is planning a new ER with 36 to 40 beds. Meanwhile, like other hospitals, Cooper is struggling to cope with overcrowding. "Ten years ago, when admissions contracted, the hospital closed some of its inpatient beds," Alteveer recalls. "They've reopened those, but there is still a nursing shortage. On a weekday, we may be holding 14 to 18 admitted patients who are waiting for beds upstairs, which decreases the number of available emergency department beds."
Moreover, there are only two hospitals in Camden. "So when our emergency department goes on bypass because it is full, then the ambulances just alternate between the two hospitals," Alteveer says. "In turn, elective admissions may be delayed. It slows everything down."
In academic medical centers, the workload has increased dramatically for attending physicians even if the number of ER visits has remained static, according to Mary Workman Rutherford '73, president of the medical staff and director of emergency medicine at Children's Hospital and Research Center at Oakland, the only pediatric trauma center in northern California.
Children's Hospital Oakland sees about 54,000 patients a year, down from a one-time high of 64,000. "Part of the reason for our static volume is the tremendous progress in pediatric immunizations, such as the haemophilus influenza type B and pneumococcal vaccines," Rutherford says. "In addition, the development of inhaled bronchodilators and steroids has vastly improved the control of asthma, which has always been our number one pediatric diagnosis."
Another reason for the decline in ER visits at Children's Hospital Oakland may be "suburban flight" from the Oakland metropolitan area. "We hear from our marketing consultants that the growth in population of younger children is in the suburbs to our east," Rutherford says.
Nevertheless, the workload has increased, ironically, due to the presence of residents. "Residents used to work unsupervised," Rutherford explains. "If they examined a patient and said to the attending, 'It's an ear infection,' we'd say, 'Fine; give them medication and send them home.' Now, we could only do that if we weren't going to bill the patient."
The federal Center for Consolidated Medical Services, which administers Medicare and Medicaid and subsidizes residents' salaries, requires the attending physician to confirm the resident's findings. "Either you have to be there with the resident, or independently confirm the history and physical exam on your own," Rutherford says. "The resident is no longer a 'physician extender' in the old sense of the term."
Triage and Technology
To improve the flow of patients through the ER, triage nurses at Children's Hospital Oakland identify less severe patients for a "fast-track" area. "We create as many nursing protocols and clinical practice guidelines as we can, first, to standardize care, decrease variation and increase safety, and second, to get the residents to work independently as much as legally possible," Rutherford says.
Children's Hospital Oakland also instituted electronic bedside patient registration and electronic patient tracking to improve patient flow. "We use electronic tracking to analyze the average time from the waiting room to the bed, from the bed to examination, from examination to discharge, to and from imaging, and so forth," Rutherford says. "We try to shave minutes off each piece to make a difference in the overall length of stay."
As Rutherford explains, "I have a huge emergency department of 40 beds, and it has been built out twice in the last few years. At some point everybody in this field concludes that it's too expensive to keep building — we've got to work smarter.
"It's a lot like air traffic control," Rutherford wryly observes.
Advances in imaging technology have enhanced diagnosis, treatment and patient safety. "When I first started practicing, we diagnosed a ruptured aneurysm by doing a lumbar puncture and analyzing the cerebrospinal fluid for blood," Alteveer says. "Now we can have a CT scan within a half hour."
Bedside ultrasound has become an indispensable tool. "For example, we can quickly diagnose an ectopic pregnancy in the first trimester by correlating a blood pregnancy test with what we see on the ultrasound," Alteveer explains, "so we are not sending someone home who could potentially die of a ruptured fallopian tube."
"Portable ultrasound has become the stethoscope of this decade," Abbott says.
Digital radiography is rapidly replacing film images. "If you look at where mistakes are made in medical care, it's usually in the hand-offs," Rutherford says. "In the emergency department, those hand-offs are critical, both because we change shifts and because we are sending patients to other hospital units, or discharging them into the community. Using digital radiography, we are all looking at the same image, and we can all annotate it with our findings."
The Internet is also helping ER physicians. "The quality of some of the medical search engines still needs improvement, but there is a whole world of medical literature at our fingertips," Rutherford says. "For example, we can quickly do a search on medication interactions. In the old days, we'd have to run to the library or dredge through the little notes in our pockets."
No Safety Net
Given the numbers of patients streaming into ERs, few hospitals have the time or resources to treat nonemergent cases. Yet the CDC survey found that only 47 percent of ER visits are classified as either emergent (requiring care within 15 minutes of arrival) or urgent (requiring care within one hour). The CDC cites many patients' lack of health insurance, capacity constraints by office-based physicians and increased referrals to the ER by community physicians as likely reasons.
At the University of Colorado Hospital, which receives 30,000 to 40,000 ER visits per year, physicians perform medical screening exams to establish whether the patient has an emergency medical condition. If the patient requires emergency care, he or she is admitted, regardless of the cost of care or the patient's ability to pay, in compliance with the federal Emergency Medical Treatment and Active Labor Act. Patients with nonemergent conditions are asked to pay upfront if they want to be treated in the ER and are otherwise referred to their health care providers or a nonemergency facility. The hospital c harges a fee for a medical screening exam even if a patient does not have an emergency medical condition, as well as an up-front fee for service if the patient decides to receive treatment in the ER.
"An insured patient has a co-pay of 50 to 100 dollars, but uninsured patients pay an up-front fee of almost 300 dollars," Abbott says. "The faculty has struggled with this because we have prided ourselves on being the de facto 'safety net' for people who don't have insurance.
"There are 45 million people in this country without health insurance — 80 percent of whom have jobs," Abbott continues. "It's really sad to see them in advanced stages of disease because they haven't had money for treatment and medications."
Patients who have only Medicare coverage and no prescription plan do not fare much better, says Alteveer. "Almost daily we see people with chronic illnesses, such as diabetes, hypertension and heart disease, who have to choose between food, housing or medication," she says. "So they wind up back in the emergency department, perhaps sicker, because our health care system won't pay a modest amount for medication, but it will pay thousands more to treat people in the hospital."
Abbott says about 60 percent of the University of Colorado Hospital's patients are uninsured, and the hospital has a 28 percent collection rate. Similarly, Rutherford says 75 percent of patients at Children's Hospital Oakland are either uninsured or receive Medicaid, which has a low reimbursement rate. Two programs were established to help hospitals offset the costs of providing care for Medicaid and uninsured patients. Jointly funded by federal and state government, the High-Volume Program covers a portion of the actual costs incurred for Medicaid and uninsured patients in teaching hospitals; the Low-Income Program provides funds to hospitals that have a disproportionately high number of low-income patients.
Nevertheless, Rutherford says, "It's still hard to break even."
Some nonemergent patients are sent to the ER because their primary care physicians know they will be examined and receive the specialized tests they may need more quickly than in the community. "The emergency department has become the 'mini-Mayo Clinic' of the medical world," Rutherford says. "Community physicians send all their diagnostic dilemmas to the emergency department.
"In addition, access to specialists is becoming increasingly difficult," Rutherford continues. "The end run is the emergency department — especially the academic emergency department. We can coordinate care so much better under the banner of emergency care, in part because we don't have to get insurers' approval for tests and treatment. We can do the baseline studies that would take weeks or months to get done in the community."
The real fault lies with the health care system in the United States, say these physicians. "There is no master plan, no conscious design," Rutherford declares. "The entire American medical system is a system in name only, superimposed with gatekeeping efforts by for-profit insurers. No one is well served: not doctors, or patients or employers who are faced with 25-percent increases in insurance premiums every year. It's a mess! And nowhere do you see that more clearly than in the emergency department."
After 25 Years
With all its problems and challenges, these physicians say the practice of emergency medicine offers rich rewards, first, because the cases are intellectually challenging. "To pick out the one person in a hundred with chest pain who turns out to have a dissected aorta — the needle in the haystack — is incredibly intellectually satisfying," Abbott says.
Emergency physicians work regular shifts and rarely are called after hours. Moreover, they can scale back their hours when they have children. "It gave me a lot of flexibility and time with my children," Alteveer recalls. Perhaps that is why almost a third of emergency medicine residents today are women, according to ABEM.
There is also an opportunity to make a difference in the quality of care. "Improving care is one of the things that I live for," says Rutherford .
Finally, there is the relationship with patients, however brief. "After 25 years, I still love patient care," Alteveer says. "Someone will arrive at the emergency department in pain, or afraid or really sick, and you'll intervene, stabilizing the patient and sending her or him in the right direction. Or you'll be the first person to effectively explain the patient's problem to her or him, and you'll see the light go on. I still enjoy that person-to-person contact and those kinds of rewards."
About Our Sources
Jean Trumpler Abbott '69 is an attending physician in the emergency department at the University of Colorado Hospital and education director of the Division of Emergency Medicine. A member of the hospital's Ethics Committee, she also serves on the Advance Directives Subcommittee. An associate professor of surgery at the University of Colorado Health Sciences Center, Abbott is a member of the clinical faculty of the Program in Health Care Ethics. With additional interests in domestic violence and care of indigent patients, Abbott is a member of Physicians for Social Responsibility and the Colorado Coalition for the Medically Underserved. Board-certified in emergency medicine, Abbott is a fellow of the American College of Emergency Physicians. She earned her medical degree from the University of Pennsylvania, Philadelphia.
Janet Glass Alteveer '72 is the assistant director of the emergency department and a teaching attending physician at Cooper Hospital/University Medical Center, Camden, N.J . She is an associate professor of emergency medicine at the University of Medicine and Dentistry/Robert Wood Johnson Medical School, Camden. Alteveer's interests include diagnostic ultrasound and domestic violence. Board-certified in emergency medicine, she serves as an oral examiner for the American Board of Emergency Medicine. Alteveer is a fellow of the American College of Emergency Physicians and former — and first female — president of its New Jersey chapter. She earned her medical degree from Jefferson Medical College, Philadelphia.
Mary Workman Rutherford '73 is president of the medical staff, director of emergency medicine and attending physician at Children's Hospital and Research Center at Oakland, the only pediatric trauma center in northern California. Rutherford is an assistant clinical professor of pediatrics at the University of California at San Francisco. She is an author of numerous articles and book chapters, a lecturer and workshop presenter. Rutherford is board-certified in pediatrics, pediatric emergency medicine and emergency medicine. She is a fellow of the American Academy of Pediatrics and a fellow of the American College of Emergency Physicians. Rutherford is also a founding member of the Society for Pediatric Emergency Medicine. She earned her medical degree from the State University of New York at Stony Brook.
Dorothy Wright contributes news and feature articles on science, technology, engineering and general-interest topics to a variety of publications, including Civil Engineering and Engineering News Record.