The Golden Hour, Patient Acuity, and the CDC

[Veneficus]

Note my comment above (above the above one). My closest hospital and former employer did make a built-in emergent care next to the ED as a triage chic, but they ended up not using it and still referring the cases through the ED. Afraid of missing something, or all the pts c/o chest pain to get in quickly.

Yea, I saw that comment

But it seems that it is put into practice more during my US ER time.

It greatly reduces the burdon of the ED, and as I witnessed, was staffed with IM and Peds docs which made it function more efficently even for follow ups. It also allowed more than "temporary" treatments as people started using it as their form of primary care since the docs were the same.

What really brought it into its own though was 24 hour operations. Many people who need medical care also have to work, which makes the hours wasted in the docs office obsolete. As well as having more convienient hoursof operation. 10-3 might work for a doctor's schedule, but it certainly doesn't work for most of the working population. Especially those without adequete insurance who not only lose paying a deductable or full cost, but also the lost wages from the missed day of work, which brings the visit without tests into the hundreds of dollars.

Why even bother going to a PCP when you could pay $90 for urgent care and follow up there at your convenience?

Furthermore, if you find something sinister (other than us left handed people), you can simply cart them over to the ED or admit them to the hospital.

IM and Peds have direct admit capability unlike most EMs, so their patient flow really flows.

I have also noticed how efficent it works in the Euopean countries that don't have EM as a specialty. Docs can follow up during their ED hours, especially in the evenings, and the direct adit capability takes a lot of the advanced diagnostic workups out of the ED.

It is yet another reason why I htink EM as a specialty is something of a farse. (Not to say they are not outstanding doctors, they are just seemingly only useful in the US system, and a change towards efficency could render them obsolete.)

 

[rescue1]

I have also noticed how efficent it works in the Euopean countries that don't have EM as a specialty. Docs can follow up during their ED hours, especially in the evenings, and the direct adit capability takes a lot of the advanced diagnostic workups out of the ED.

It is yet another reason why I htink EM as a specialty is something of a farse. (Not to say they are not outstanding doctors, they are just seemingly only useful in the US system, and a change towards efficency could render them obsolete.)

Out of curiosity, how does it work in the countries without EM specialties? Do IM doctors rotate between their ward and the ER?

 

[Veneficus]

Out of curiosity, how does it work in the countries without EM specialties? Do IM doctors rotate between their ward and the ER?

Around here, (a large academic hospital in central Europe) the ED is split. The adult surgical ED is run usually by orthopedics, but can be staffed by any surgeon on any given day. Trauma centers obviously have multiple surgeons in house, basically at the ACS level I capability.

The adult medical ED is staffed with one anesthesiologist and one or two other doctors, usually GPs or IM and its subspecialties.

The ped EDs are much simpler, there is a pediatric surgeon, and a peds anesthesiologist with a pediatrician. For some reason peds plastics docs really like to staff the peds ED. So suturing is always done really well.

All of these docs have admitting ability. So if something is not a simple fix, they can admit for further Dx or Tx.

They can also function similar to a GPs office, treating people for an illness and having them follow-up in the slower ED hours.

All of these people have to have current alphabet soup cards, but operating in an emergency environment is part of the basic medical education. So all of the emergency skills are taught in school. Many docs also moonlight on the ambulances, with full emergent, direct admitting, and treat and release capability.

 

[Aidey]

Why the anesthesiologists?

 

[Veneficus]

Why the anesthesiologists?

Outside of the US, emergency and critical care is almost exclusively the realm of anesthesia.

Infact in Miller's there are whole chapters on it.

 

[Wheel]

Around here, (a large academic hospital in central Europe) the ED is split. The adult surgical ED is run usually by orthopedics, but can be staffed by any surgeon on any given day. Trauma centers obviously have multiple surgeons in house, basically at the ACS level I capability.

The adult medical ED is staffed with one anesthesiologist and one or two other doctors, usually GPs or IM and its subspecialties.

The ped EDs are much simpler, there is a pediatric surgeon, and a peds anesthesiologist with a pediatrician. For some reason peds plastics docs really like to staff the peds ED. So suturing is always done really well.

All of these docs have admitting ability. So if something is not a simple fix, they can admit for further Dx or Tx.

They can also function similar to a GPs office, treating people for an illness and having them follow-up in the slower ED hours.

All of these people have to have current alphabet soup cards, but operating in an emergency environment is part of the basic medical education. So all of the emergency skills are taught in school. Many docs also moonlight on the ambulances, with full emergent, direct admitting, and treat and release capability.

I guess this is way simpler than the jack of all trades, master of none that EM is here in the states. This way, medical complaints are triaged to the IM docs, critical care to anesthesia, and trauma to surgeons. That way everyone is still treating in their comfort zone. I have a few questions though.

1. Does this help with physician burnout in the ED, since they rotate and can treat cases more up their alley?
2. Does this decrease the amount of expensive diagnostic tests that are run, since providers are treating cases in their comfort zone?

 

[Veneficus]

1. Does this help with physician burnout in the ED, since they rotate and can treat cases more up their alley?

It depends really. For residents of the selected specialties, this is a mandatory assignment. I see a lot of disgruntled residents in the ED because they get upset they are often treating stuff that isn't really "emergent" or the less than desirable members of society. (drunks, addicts, etc.) But for all of the fully qualified specialists, they choose to work there, so generally they are not burnt out, because when it becomes to much they have the ability to go back and work only in their specialty area. Some of them even make their primary career the ED, but they must still meet the ongoing requirements for their specialty. With the exception of a few interested individuals most of the docs are just starting their careers and it is a good way to make extra money for a few years.

2. Does this decrease the amount of expensive diagnostic tests that are run, since providers are treating cases in their comfort zone?

Yes and no. The system is different so the diagnostic requirements are not the same as in the US. Generally there is much less CT and MRI, a lot more ultrasound, and not so much defensive medicine. By virtue of that there are fewer routine expensive diagnostics. But they are still available.

I would not attribute it to provider comfort.

 

[Wheel]

Yes and no. The system is different so the diagnostic requirements are not the same as in the US. Generally there is much less CT and MRI, a lot more ultrasound, and not so much defensive medicine. By virtue of that there are fewer routine expensive diagnostics. But they are still available.

I would not attribute it to provider comfort.

So it's more of a litigation issue? Sometimes it disgusts me how often this is the case in many aspects of US society.

 

[Veneficus]

So it's more of a litigation issue? Sometimes it disgusts me how often this is the case in many aspects of US society.

The litigation system here heavily favors the doctors. It is almost impossible to win a malpractice suit unless there was an obvious and grevious error. Even then, the payouts are generally not that big.

But there is also an economic factor. Most insurance will not pay for "defensive" tests not indicated "just in case." So there isn't really an incentive to do them.

I would say the major difference is cultural. Here, people generally view medicine as help with life, not what I call "McMedicine" where you come in, choose your treatment off the menu, it always works perfectly, and expect to go back to what you were doing as if nothing ever happened.

The more realisitic view of how medicine works here helps keep litigation under control.

 

[Wheel]

The litigation system here heavily favors the doctors. It is almost impossible to win a malpractice suit unless there was an obvious and grevious error. Even then, the payouts are generally not that big.

But there is also an economic factor. Most insurance will not pay for "defensive" tests not indicated "just in case." So there isn't really an incentive to do them.

I would say the major difference is cultural. Here, people generally view medicine as help with life, not what I call "McMedicine" where you come in, choose your treatment off the menu, it always works perfectly, and expect to go back to what you were doing as if nothing ever happened.

The more realisitic view of how medicine works here helps keep litigation under control.

That makes sense. Thank you for taking the time to answer my questions. The woes of the American medical system, especially in the emergent care setting is really interesting to me, and I know you have strong opinions regarding that. I may eventually begin to look into getting involved with helping to fix the system, but those are very lofty long distance goals.

 

[Veneficus]

I know you have strong opinions regarding that. I may eventually begin to look into getting involved with helping to fix the system, but those are very lofty long distance goals.

I wish you the best of luck with that goal.

I spent most of my career in the US medical system, you don't really see just how crazy it is until you are looking at it from the outside.

When you are in it, you see people you know doing their best, so it seems like the providers are the best. There is also a lot of ethnocentric propaganda put out usually to cover up the faults in the system. So it really doesn't look as bad as it is.

I would suggest that you go and spend some time in any of the various overseas systems and see them first hand. None of them are without their faults. Some are better than others and I doubt the perfect system exists.

But if you are going to fix anything, you have to see what works and what doesn't or what you are willing to accept.