Emergency Medicine Comes of Age
Mark Graber, MD, worried when Iowa City teens started showing up at the
UI Hospitals and Clinics Emergency Treatment Center with Benadryl overdoses
last summer. "We’re afraid it’s the start of something," Graber,
associate professor (clinical) of emergency medicine and family medicine,
told a local newspaper.
Trends in injury, illness and even teen stupefaction
often show up in the emergency room, along with cut fingers, sprained
ankles, crushed pelvises
and troubled hearts. The American Hospital Association has called emergency
departments "a critical entry point to our health care delivery
system."
Now emergency medicine is coming of age at the UI with the
appointment of a new director, accreditation of a residency program
that begins
July 1, and approval of a $30 million expansion. Also on the horizon
is formal
organization of the program as an academic department of the UI Carver
College of Medicine.
Eric Dickson, MD, began his new duties as director
of the Emergency Treatment Center (ETC) and the Department of Emergency Medicine Oct. 1. He comes to
the UI from the University of Massachusetts Medical Center in Worcester,
where he served as director of emergency medicine research.
Dickson
became acquainted with Iowa as a consultant to the committee that developed
the residency program proposal. "As I began to hear more,
I became more and more interested in applying for the job myself," he
said.
Among the factors Dickson found so appealing were the UI’s "tremendous
strength in non-emergency specialty services. Strength in those areas
is critical to developing an emergency medicine center," he
said.
Staff and facilities at the Emergency Treatment Center—which
saw about 31,000 patient visits during the last fiscal year—also
impressed him, as did the center’s close relationship with
the UI’s
Level I Trauma Service.
Finally, Dickson said, "The sealer for
me was hearing a common vision [from Dean Jean Robillard and UIHC
CEO Donna Katen-Bahensky] for what they
wanted in an EM program." Such a vision for emergency medicine
is all too rare in academic medicine, he added.
"It’s hard for people from within to look at a situation and
appreciate its potential," he said. "There is tremendous potential
here, and it’s my job to help realize that potential."
The
emergency medicine program already is an established part of UIHC
and the regional health care system. The ETC receives patients
from
surrounding counties and is a control center for the Johnson County
Ambulance Service.
The program also supervises the Air and Mobile Critical Care Service,
with two helicopters and two ground-based mobile units.
The new residency
is Iowa’s first emergency medicine training program,
coming at a time when hospital emergency departments are pressed
to provide more patient care. A 2001 report by the AMA and the Lewin
Group noted a
15 percent increase in ER visits nationwide during the 1990s as
the number of hospitals with emergency departments decreased about 8
percent.
Thus,
average ER volume grew about 20 percent.
That trend is reflected
in the 6 to 8 percent yearly increase in ER visits at the UI, leading
officials to project more than 42,000
visits
by 2006.
Medical school graduates have had to leave Iowa to train
as emergency medicine physicians, said Alfred Hansen, MD, vice chair
of emergency
medicine education
and former ETC director. Twelve 2003 UI grads joined that exodus.
Hansen,
who helped draft the successful residency program proposal, said Iowa
will benefit from the program. For one thing, many
doctors end up
practicing in the communities where they did their residencies,
and Iowa needs more board-certified emergency medicine physicians.
Also,
Hansen said, although many physicians who are not board-certified provide
excellent emergency care, the specialty is making "quantum
leaps in how services are delivered and providing a focus
for advances in care. A lot of leadership about how to manage patients
with
chest pain,
for example, came out of emergency departments."
The
new program, a partnership between the UI and St. Luke’s
Hospital in Cedar Rapids, will take six physicians a year,
totaling 18 when all
the three-year residencies are filled. In addition to working
in the ETC itself, residents will rotate through every UIHC
critical care unit and
spend two months in both their second and third years at
St Luke’s.
St. Luke’s sees more than 52,000 patients
a year in its emergency department. This volume and variety
of emergency cases will complement
the UI’s patient mix and strengthen the residency experience,
Hansen said.
The UI residency aims to provide "rock solid" clinical
experience and exposure to all facets of academic emergency
medicine, Dickson said.
It is designed to let residents pursue specific areas of
interest—teaching,
administration, research or subspecialty training—and
gain experience to practice in rural settings. Hans House,
MD, associate professor of emergency
medicine, will direct the residency program.
Dickson also
plans to consolidate emergency medicine training with training
for paramedics, who receive certification
through the
UI’s Emergency
Medical Services Learning Resources Center.
"By tying the training of paramedics into resident training, we can
create a stronger connection between the doctors and the people
on the street," Dickson
said. The program also will boost opportunities for medical
students in emergency medicine.
Research has not played a prominent
role in the emergency
program until now. But faculty and staff are involved in
several ongoing
studies and
look forward to expanding activity in basic and clinical
research. Graber has been appointed director of research
for the program.
Of course clinical service ultimately will
stand as the measure of the program for most Iowans, patients and physicians
alike. Dickson
is confident
the ETC can build on its reputation for excellent care.
Already
in the works are a chest pain center and separate treatment rooms for
children. In the former case, Dickson
said bringing
the needed equipment
and resources into the ETC will "make it possible
for us to evaluate and care for cardiac patients and
get them back home as quick as we can."
Similarly,
emergency care for pediatric patients justifies dedicated
facilities for this purpose. "The EM environment
is a very harsh one," Dickson
said, "and kids just need a separate space."
In
broader terms, Dickson wants the ETC to "take hold
of our tertiary care role" by improving support
for emergency departments at community hospitals throughout
the region. Noting that the majority of physicians
staffing ERs are not emergency medicine specialists,
Dickson said the UI can lead development of a "trauma
like system for all critically ill patients" that
would improve care "extending out as far as our
helicopters can fly."
Medicine’s oldest profession
It’s a symphony orchestra or a dance, a front door or perhaps an
airport control tower. Whatever the metaphor, emergency
medicine is a thing of depth and wonder for those who choose it as a
career.
Eric Dickson, MD, director of the Department of Emergency Medicine, calls it "the oldest profession in medicine." The
emergency physician, he said, is the "jack of
all trades," determining if patients
are critically ill and supporting them through the
early stages of illness.
That simple mission can require
extraordinary coordination, said Barbara Schuessler,
nurse manager of the UI ETC.
Collaboration begins at the
triage desk, where the primary nurse calls for resources
to evaluate
and treat
each patient. Depending on the case, the nurse partners
with paramedics, physician assistants or physicians.
Radiology, nuclear medicine,
pharmacy and other personnel may all become involved.
"It’s quite a dance," Schuessler said, "but when
it all comes together it works beautifully."
A slightly
different metaphor comes to mind for Jeffry Gauthier,
emergency medicine program administrator. "The
staff is the conductor of the philharmonic," Gauthier
said, and like any struggling orchestra, emergency
departments must meet demand with limited resources.
"The guideline is to be flexible and creative in your approach," Gauthier
said. "You only think you’re short a resource
until you come up with a creative solution."
This
can-do attitude is an important part of the field’s
appeal, said Alfred Hansen, MD. "We don’t
have the luxury of saying, ‘No
that’s not my problem,’" he said.
Emergency medicine "is
the safety net for the health care system both by philosophical
disposition and by law, and most of us are pretty
proud of that."
For the record, Hansen sees the
emergency department not as pilot but as air traffic
controller, "keeping the priorities straight and
managing traffic flow."
That flow, for up to a
quarter of emergency patients, leads through the ER
to the hospital’s other units. "The emergency
department is the front door to your hospital," Dickson
said.
That door, he continued, must always be open. "We
can never be considered too full, we can never turn
patients away," he said. "No matter
what happens, we’ll take them in." |
