Emergency Department

sciri · Mar 11, 2010

I have 75% of my WIP down. The MC is an emergency physician, and suddenly I realize I have no idea what the structure of an Emergency Department is. I am planning to go visit my local hospital when I'm done with draft one, but I was wondering if some of you out there could already give me some pointers. Basically, this is my question:

The hospital is NOT a teaching hospital, just a small medical center in a small town. What kind of physicians work in the ED of such facility? Do they rotate from the family practice ones or are they separated? I mean: do the family practice physicians have their own clinics, and the emergency physicians work in the emergency department ONLY?
Also, how do the on call nights work? From what I hear, every hospital has its own structure, and if that is the case, I could pretty much make up my own. How standard is the "every fourth shift is a night call"?
If it's not a teaching hospital, then there wouldn't be residents or attending physicians, would there? So how would you call the ER physicians? Just physicians or do they have a more specific titles?

That's a lot to throw at you guys, sorry!!!!

THANKS!

alleycat · Mar 11, 2010

Find kayleamay if she doesn't find this thread.

CheyElizabeth · Mar 11, 2010

I don't know much about this, but I've been to the small emergency clinic in my small town, and it appears to have the same 2-3 physicians each time. I call them 'doctor'. The nurses there are also older and have worked there forever. Its definitely not like a normal hospital that has doctors rotating in and out every few months.

sciri · Mar 11, 2010

Thanks guys! I've PM'ed kayleamay.

jclarkdawe · Mar 11, 2010

First thing to decide is what trauma level you want your emergency department. Not all hospitals provide the same level of care 24/7. In some ED, at least part of the time, the doctor is not dedicated to the ED, and is actually the on-call doctor for the whole hospital. Other hospitals only allow specially trained doctors to work in the ED. (Emergency medicine is now a specialty.)

Ambulance crews have to be aware of the staffing levels of the ED in their area. Sometimes the shortest trip to the hospital is not the best option. One of the smaller hospitals in the area has one specialist, who usually works something like Wednesday through Saturday second shift, has a couple of other doctors who are not specialists, and uses the on-call hospital doctor for the balance of the time.

Needless to say, we have a major car accident at 3 AM on a Sunday morning with major trauma, this is not our first choice hospital. But for most cases, it works fine. For serious cases, we'll spend a few minutes more on the road for the Level I trauma center.

Grabbing from Wikipedia:

Level I
A Level I trauma center provides the highest level of surgical care to trauma patients. It has a full range of specialists and equipment available 24 hours a day and admits a minimum required annual volume of severely injured patients. A Level I trauma center is required to have a certain number of surgeons and anesthesiologists on duty 24 hours a day at the hospital, an education program, preventive and outreach programs. Key elements include 24-hour in-house coverage by general surgeons and prompt availability of care in varying specialties such as orthopedic surgery, neurosurgery, plastic surgery (plastic surgeons often take calls for hand and facial injuries fixing both the bone and soft tissue of these specialized regions), anesthesiology, emergency medicine, radiology, internal medicine, oral and maxillofacial surgery, and critical care, which are needed to adequately respond and care for various forms of trauma that a patient may suffer. Additionally, a Level I center has a program of research, is a leader in trauma education and injury prevention, and is a referral resource for communities in nearby regions.[8]

Level I trauma center hospitals in most states in the U.S. (New York, and Pennsylvania among others are notable exceptions)[citation needed] are designated by the American College of Surgeons (ACS) for a period of three years. Pennsylvania has its own rankings system, based on the criteria of the Commonwealth's Trauma Foundation.

The ACS does not officially designate hospitals as regional trauma centers, however. Numerous U.S. hospitals that are not listed on the organization's trauma roster nevertheless refer to their emergency or trauma units as "Level I trauma centers." The ACS describes that responsibility as "a geopolitical process by which empowered entities, government or otherwise, are authorized to designate." The ACS's self-appointed mission is limited to confirming and reporting on any given hospital's ability to comply with the ACS standard of care known as Resources for Optimal Care of the Injured Patient.[9]
Level II

A Level II trauma center works in collaboration with a Level I center. It provides comprehensive trauma care and supplements the clinical expertise of a Level I institution. It provides 24-hour availability of all essential specialties, personnel, and equipment. Minimum volume requirements may depend on local conditions. These institutions are not required to have an ongoing program of research or a surgical residency program.[8]
Level III

A Level III trauma center does not have the full availability of specialists, but does have resources for emergency resuscitation, surgery, and intensive care of most trauma patients. A Level III center has transfer agreements with Level I or Level II trauma centers that provide back-up resources for the care of exceptionally severe injuries, Example: Rural or Community hospitals.[8]
Level IV

A Level IV trauma center exists in some states where the resources do not exist for a Level III trauma center. It provides initial evaluation, stabilization, diagnostic capabilities, and transfer to a higher level of care. It may also provide surgery and critical care services as defined in the scope of services of trauma care. A trauma trained nurse is immediately available, and physicians are available upon the patients arrival to the Emergency Department. Transfer agreements exist with other trauma centers with higher levels when conditions warrant a transfer

Best of luck,

Jim Clark-Dawe

sciri · Mar 11, 2010

Wow, thanks. I'm struggling because I have a small town, but it's close to a ski facility, so I imagine they would have to be highly specialized for trauma injuries, right? Would it be highly unlikely for such a place to have a Level I ED?

Our local hospital (10 minutes from ski hill) is not level I, and the closest level I is 45 miles away, and when there's an emergency patients are transferred through helicopter.

CEtchison · Mar 11, 2010

I lived in Ruidoso, NM for several years and they had a county hospital, with the next closest being down the mountain at an air force base. The town only had about 7,000 year-round residents. But the numbers would increase during the summer due to those with summer vacation homes. It was a tourist town between horseracing in the summer and skiing in the winter. The emergency room was the busiest part of the hospital during high tourist seasons.

Here is a link to the hospital specifics.... http://health.usnews.com/health/best-hospitals/lincoln-county-medical-center-6859145/details

The hospital had two ER doctors on staff and then they would have two or three residents doing rotations (absolutely no interns). If it was the middle of the night and you were not being transported by ambulance, you had to use the intercom call button. I found this out when I went into labor with my youngest at about 5:30am. After explaining my reason for being there, I was met by the ER nurse on duty and led back to the OB area. The surgical staff is only called in after 6am (unless there is a real emergency). With my second child (first delivery in Ruidoso), I was actually given medication to stop labor because no one wanted to come in to deliver a child after they had just all gone home (this was about 9pm and the delivery required a c-section). The nurse on staff was instructed to contact my OB at 5am to tell her of any changes. When she told her the labor was progressing, then my OB instructed her to call the staff anesthesiologist and surgical staff.

Most physicians have their own practices and then are called to the hospital if needed. Non-emergent MRI's are done one day a week. The MRI system is self-contained in an 18-wheeler truck and travels to outlying facilities. Life-flights were used often for serious injuries. They were either transported down the mountain to Alamogordo or perhaps to Albuquerque.

A hospital of this size is widely different to that of a major trauma center and/or teaching facility in major city. (Before Ruidoso we lived in Dallas, TX and I was a patient in two different hospitals and did administrative work in two others.)

There are good point and bad points. In Dallas, security on the maternity ward was tight. In Ruidoso, there was only one nurse on duty. The first time I was the only patient and I slept great since she rocked the baby all night. The second time the OB ward was "full" with four patients and I was placed on the general medical side of the hallway. I was then warned to not walk the halls since there were "sick people". LOL

During the first trip, I was one of only six people in the entire hospital (between Thanksgiving and Christmas breaks and there wasn't much snow on the mountain). The nutritionist came to ask me personally what I would like to eat since I didn't have a restricted diet. "The hospital cafeteria is serving beef stew if you'd like that," she said, but quickly offered to make me a grilled cheese and chicken noodle soup instead.

Doctors and nurses often stay from year to year. I had the same OB nurse and surgical staff that delivered my two girls, two and a half years apart.

sciri · Mar 11, 2010

This is great, thanks! And the link is very useful to get an idea of the staff numbers, I just have to pick the closest hospital... I'm shooting for a town of 20K people.

jclarkdawe · Mar 11, 2010

sciri said:
Wow, thanks. I'm struggling because I have a small town, but it's close to a ski facility, so I imagine they would have to be highly specialized for trauma injuries, right? Would it be highly unlikely for such a place to have a Level I ED?

Our local hospital (10 minutes from ski hill) is not level I, and the closest level I is 45 miles away, and when there's an emergency patients are transferred through helicopter.

Taken with the 20k population, I can give you some guesses as to staffing. However, let's start with your population figure. Hospitals are licensed by their states, and care is defined by catchment area. Patients are assumed to travel X number of miles to a hospital, with X in New York City being blocks to Alaska where X can be over a hundred miles. Within the catchment area the question becomes whether you can support certain services.

For example, a cardiac unit needs a certain number of patients to be effective. Result is hospitals might not provide cardiac units because of lack of population. Burn units is something that makes this very dramatic. For all of New England (six states), the only burn unit is the Shriner's Hospital in Boston. There aren't enough serious burn cases to make it worthwhile for other hospitals in New England to provide that care.

A ski resort town would produce two type of trauma situations. One is the ski injuries which would occur from roughly noon to maybe 9 PM (assuming lights on the slopes). The other trauma would be auto accidents which would be probably from 4 PM to about three hours after the bars close. (They can happen anytime, but this would be the peak.) Heart attacks would be a frequent case, but chronic heart problems less so. None of the numbers would be very high here.

Because of this situation, there's not much reason to provide a lot of staffing from 3 AM to noon (which is typically the low time for most ED). It's unlikely that a doctor would find enough to keep him/her busy during those hours. But late in afternoon on the weekend? Yeah, he/she is probably going to be running. I would see a Level III facility as the most likely.

According to National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary, table 14 there are 40.5 ED visits per 100 people. Assuming your weekend population is 30k, that would be an average of 33/34 patients per day in the ED. That's not a lot. I don't know what the minimum level for a Level I center, but my guess is a minimum of 100k.

I was on the local volunteer fire/rescue department as an EMT/Captain for way too many years.

Best of luck,

Jim Clark-Dawe

sciri · Mar 11, 2010

That's VERY helpful.
Thank you.

StephanieFox · Mar 11, 2010

This was from a long time ago, but if it's a small town, chances are that a doctor wouldn't be there, just nurses and techs and other staff. When an emergency came the staff would telephone the doctor on call (in the small town I grew up in, the doctors were on call for a week at a time) and he'd drive the five minutes to the hospital.

Just how small a town is this?

Tsu Dho Nimh · Mar 12, 2010

sciri said:
Wow, thanks. I'm struggling because I have a small town, but it's close to a ski facility, so I imagine they would have to be highly specialized for trauma injuries, right? Would it be highly unlikely for such a place to have a Level I ED?

Nope ... I'm a ski patroller. The resort is 30-60 minutes away by snow-covered roads from two small towns' hospitals, and the larger/further of the two doesn't have an orthopedic surgeon on call on weekends during ski season.

It's a Level IV "trauma center" and we have to send some injuries that could be treated there out in a helicopter ($8,000 versus $800) because they can't persuade an orthopedic surgeon to carry a beeper on a winter weekend! We send minor fractures and lacerations to a local walk-in clinic because it's a couple hours faster than the hospital's ER (and cheaper, and just as good).

If there is an injury at the resort from the "list" of things that need helicopters (burns, some head/spine injuries, femur fractures, abdominal trauma), they are flown 200+ miles to the closest level 1 by either a helicopter or a combination of ambulance and fixed-wing plane. Straight out, no stopping at the ER unless they are bleeding out, in which case they are going to die because the blood banks don't have trauma-sized inventories.

The specialists in ski trauma are the patrollers who are very much like EMTs (often they are EMTs and paramedics) who keep the patient alive and pack them up well enough to get them down the mountain to the transportation. We have a small range of relatively minor injuries that we see frequently, and the occasional "oh $@#%" ones that remind us why we train so much.

shaldna · Mar 12, 2010

Ok, I have horses and toddler, so my experiece of the ER is pretty vast (we call it casulty here)

Expect to wait a very long time (3 hours is standard, even for pretty major incidents) for example, when I broke my back I drove myself to hospital (don't ask, long, stupid story) and becuas I wan't assisted in I wasn't a priority. I had to wait nearly three hours for any form of pain relief.

The ER's here operate a 'breathing and bleeding' emergency only practice, everything else gets seen as and when they can.

EDIT - i do have to admit that where I went to college (enniskillen) there was a small local hospital that was exceptional in dealing with horse riding accidents. When they saw you come in in your uniform they didn't even have to ask what had happened. I developed septicemia when I was at collge and was rushed in there, I was seein within minutes of arriving, had that been in Belfast I would have had to wait hours.

Incidently, my daddy had bad chest pains while he was driving home one day and he pulled into the UH in Belfast. He was told by the receptionist that he wasn't a priority. Five minutes later he had a heart attack in the waiting room.

The problem here is not so much the doctors, because they are great, it[sthe waiting times and gettingpast the receptionist

sciri · Mar 12, 2010

Tsu Dho Nimh said:
Straight out, no stopping at the ER unless they are bleeding out, in which case they are going to die because the blood banks don't have trauma-sized inventories.

OK, after reading this, I don't think I'm going to send my family skiing EVER AGAIN!!

Jokes aside, I've decided for a Level III ER, after browsing the webpage of Aspen Valley Hospital, Colorado: population of 5K, but VERY popular ski place.

Thanks folks!

Shaldna, sorry to hear about your dad... Was he OK afterward?

shaldna · Mar 13, 2010

sciri said:
Shaldna, sorry to hear about your dad... Was he OK afterward?

yeah, he was fine, signed himself out the next day because the noise of the heart monitor was too loud for him to sleep. Tough as nails my daddy.

But I know that here there is a massive problem with ER's, in particular the waiting times etc

Tors · Mar 13, 2010

Im in the UK and things are different over here. I work as an accident and emergency nurse. The hospital I work in is not a trauma specialist hospital, although we do recieve traumas, but it does border five counties and were serve two different ambulance counties.

In my hospital we have a minor injuries, majors and resus (and an observation ward). We have a consultant on at all times during the day, and they're on call over night (only coming in for emergencys). Two registrars during the day that over lap slightly and one at night. Over the night, but doing different shifts, we have 4 SHOs no JHOs at all. The is a sister/charge nurse co-ordinating the shift then 5 nurses and two health care assistants.

The SHOs and JHOs do a 6 month rotations.

The doctors usually do four nights, but the previous accident and emergency i worked in the doctors and nurses did seven nights. They started and finished together which was great if you got on, but sucked if you didn't.

Emergency Department

sciri

Maxine Fan

alleycat

Still around

CheyElizabeth

My horn can pierce the sky!

sciri

Maxine Fan

jclarkdawe

Feeling lucky, Query?

sciri

Maxine Fan

CEtchison

sciri

Maxine Fan

jclarkdawe

Feeling lucky, Query?

sciri

Maxine Fan

StephanieFox

Maybull the Bulldog

Tsu Dho Nimh

shaldna

The cake is a lie. But still cake.

sciri

Maxine Fan

shaldna

The cake is a lie. But still cake.

Tors

Can I have my husband home please?