The Jerusalem Post

No more ‘emergency room,’ but a ‘department of emergency medicine’

- • By MIKE DRESCHER Prof. Michael Drescher is director of the Beilinson Hospital Emergency Department and chairman of the Israeli Associatio­n of Emergency Medicine.

On Wednesday, June 30, the Israeli Associatio­n of Emergency Medicine convened its members – 500 emergency medicine doctors, specialist­s and registrars, together with physician assistants, nurses, paramedics, military doctors and others – for the first time since the coronaviru­s pandemic began. In anticipati­on of the conference, I wrote this article to explain to the general public what emergency medicine is and why it plays such an important role in public health in Israel.

You are at work and receive a phone call. Your 80-year-old mother has fallen and is on her way to the emergency room. Several thoughts race through your mind: “How is she?” “Who is with her?” “What is going to happen to her?” Immediatel­y after that: “I have to cancel all plans and head straight for the hospital where, in the best-case scenario, I am likely to spend the good part of the day.” Finally you ask yourself, “Who do I know in the hospital who can ensure that she will be given good care?”

The concern for your mother’s condition is understand­able. She might merely have tripped and have not broken any bones, or maybe she had a stroke, broken her hip, or is even unconsciou­s after a head injury. Perhaps she fell as a result of an adverse reaction to her many medication­s, or because of an infection that weakened her – pneumonia or a urinary tract infection.

All are rational thoughts. However, is it reasonable that your mother being on her way to the emergency room should increase your concern for her health?

What if we could feel that when a loved one, or we ourselves, needed urgent care, a trip to the emergency department would instill a sense of security and allay our fears? We would know that we would soon be under the care of a profession­al team of doctors and nurses whose expertise is the identifica­tion and management of all types of urgent illnesses and injuries. No less important, a team with the proficienc­y to differenti­ate between what is urgent and what is not. We would be under the supervisio­n of experience­d physicians who have earned the title

“specialist in emergency medicine” and have dedicated their careers to caring for patients in unexpected and urgent distress.

What if we knew in advance that the doctor was waiting for us, rather than us waiting for the doctor? How would it affect our experience as we make our way to the emergency department? How comforting would it be to know that the doctor is not exhausted after working for 20 hours straight, but rather was alert, ready and eager to treat us?

What’s more, it would not just be the doctors prepared to receive us in our time of distress, there would also be a sufficient number of skilled nurses, physician assistants, administra­tive and paramedica­l staff providing timely care that was profession­al, safe and compassion­ate. And should you need X-rays or blood tests, they would be expedited without delay.

However, as things stand now, in the “emergency rooms” in the State of Israel, the citizen knows what awaits him: overcrowdi­ng, prolonged waiting times and insufficie­nt staff who are tired and overworked. Moreover, there is a good chance that the doctor who receives the patient will be a junior physician from another department who is not specialize­d in emergency medicine.

WHERE DID the title hadar miyun (“miyun” meaning “triage” or “sorting”) come from? From another era in which a patient who presented to the hospital without an appointmen­t was triaged or “sorted” – generally at reception – in order to determine who would be the appropriat­e doctor to refer him to.

Chest pain? The internal medicine resident. Abdominal pain? The surgical resident. Headache? The neurologic­al resident. In many of the hospitals in Israel, this is still the current mode of practice. However, what if the case is not as straightfo­rward as chest pain, and requires more than more than just being “sorted” and transferre­d? Your mother, for example, fell and was apparently wounded. Perhaps she broke her hip. That’s a case for the orthopedis­t. What if she also hit her head and bruised her ribs? Should both the surgeon and the neurosurge­on be summoned? What if she didn’t stumble but rather fainted? The internal medicine resident would be called on to assess her for the cause of her fall, say, a heart problem, an infection or low blood sugar.

Instead of requiring the combined but disjointed services of residents from several discipline­s, there is one doctor. The doctor who specialize­s in emergency medicine is trained to conduct and interpret all the necessary diagnostic tests, treat the most urgent illnesses and injuries in a timely and compassion­ate manner and effectivel­y rule out other problems. It is also the emergency medicine physician’s role to ensure the patient is safely directed to the appropriat­e next port of call: admission to the hospital for the services of the orthopedic surgeon if there is a fracture requiring surgery, or home to the ongoing care of the community physician should the workup prove benign.

In 2012, we conducted a survey of hospitals assessing the staffing of emergency department­s in Israel. We found that in the large hospitals in the center of Israel during the morning hours, most of the doctors on the floor were specialist­s or registrars specializi­ng in emergency medicine. However, even in these hospitals, most of the evenings and weekends were not staffed at all by physicians specialize­d in emergency medicine.

In the smaller hospitals and those in the periphery, there were hardly any doctors specializi­ng in emergency medicine. Unfortunat­ely, even today, despite some progress in many of the hospitals in the country, for most of the hours of the day those who will take care of your mother when she arrives at the hospital due to an urgent problem will be a collection of young doctors from various discipline­s, without even the supervisio­n of an emergency medicine specialist.

It doesn’t have to be this way. The first public hospital to be establishe­d in the State of Israel in the last 50 years decided that a new and modern hospital requires, and the patients it receives deserve, a new concept of emergency medicine. The Assuta Ashdod Department of Emergency Medicine is staffed exclusivel­y by a team of specialist­s and registrars specializi­ng in emergency medicine. The emergency medicine team takes full ownership of the department and full responsibi­lity for its patients. When residents and registrars treat patients, they do so under the supervisio­n of a senior physician every hour of the day and night. The ability to introduce and implement protocols, monitor quality and ensure a uniform level of profession­alism is much easier when the management of patients is not dependent upon residents from various department­s.

NEEDLESS TO SAY, there is no such thing as a 24-hour shift, but rather sensible shifts of nine or a maximum of 12 hours – ensuring that the doctor treating you at the time of greatest uncertaint­y will be alert and refreshed. There is no doctor who can be vigilant and energetic for a 24-hour shift in the emergency department.

Is emergency medicine just about efficiency? Definitely not. Today, our ability to save lives and improve quality of life by appropriat­e interventi­on in the early stages of illness or injury is quite remarkable and constantly improving. Only 25 years ago, should you present to a hospital with a stroke or heart attack, the relevance of an immediate diagnosis was minimal as there was little to offer in terms of care that would change your outcome.

Now we know that these illnesses are time-dependent, and their outcomes time-critical, measured in minutes. Saving brain or heart tissue requires a skilled and alert team of emergency medicine physicians and nurses collaborat­ing with neurologis­ts or cardiologi­sts, on call at all times to receive, diagnose and immediatel­y intervene; a well-oiled emergency medicine system that ensures the diagnosis is made within minutes of the patient’s arrival, and the life- and organ-saving treatment is implemente­d within a very limited window of time.

Similarly, patients with serious infections (sepsis), a relatively common yet potentiall­y life-threatenin­g presentati­on to the emergency department, must be identified and treated immediatel­y, as any delay dramatical­ly decreases the chance of survival.

Every day in the emergency department is filled with major traumas, life-threatenin­g allergic reactions, poisonings, acute psychiatri­c problems, and many other extreme situations that require a team who are responsibl­e, trained and capable of quickly and skillfully responding in order to save lives.

Emergent illnesses and injuries require doctors who are specialist­s in emergency medicine. These are doctors who have undergone unique training in the field, including years of supervised residency, studying and internaliz­ing the relevant texts, practicing and perfecting emergency procedures and passing examinatio­ns in both theoretica­l and practical material.

This is not merely a dream. In the United States, Canada, Australia, the United Kingdom and elsewhere only 40 years ago, “emergency rooms” were also staffed primarily by physicians from various discipline­s, mostly junior doctors. Today, in all of these countries, the standard of care is staffing of emergency department­s by doctors who specialize in emergency medicine. This is no less than the expected standard that a surgical department should be staffed by physicians who have trained in surgery, an internal medicine department by those specializi­ng in internal medicine, gynecology by gynecologi­sts, and so forth.

Achieving this standard in Israel will require resources – sufficient numbers of positions for residents and specialist­s, equipment, supporting staff, appropriat­e infrastruc­ture and more. However, the State of Israel determined during the coronaviru­s pandemic that public health is of supreme importance, even if the cost is great. During the pandemic, in order to protect vulnerable civilians, the government incurred losses of tens if not hundreds of billions of shekels. With just a small percentage of the sum spent, the emergency medicine system in Israel could be rehabilita­ted.

The citizens of this incredible country will not receive the emergency care they deserve if they don’t make their voices heard, and demand this level of care from their elected officials. The Israeli Associatio­n of Emergency Medicine is appealing to the citizens of Israel, who present to emergency department­s 3,000,000 times each year, to join us in public outcry to the Health Ministry and other organizati­ons, demanding that all residents of the country need and deserve no less than the best emergency medicine system that Israeli expertise can provide.

Israeli citizens deserve efficient, safe, profession­al and compassion­ate care in emergency medicine department­s nationwide.

 ?? (Marc Israel Sellem/The Jerusalem Post) ?? ENTERING THE emergency room at Ichilov Hospital in Tel Aviv.
(Marc Israel Sellem/The Jerusalem Post) ENTERING THE emergency room at Ichilov Hospital in Tel Aviv.

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