Sunday, November 18, 2018

Sonoma Medicine

The magazine of the Sonoma County Medical Association

Download Editorial Policies 
View PDF of current issue
rss

EDITORIAL
Defining Emergency Medicine

Allan Bernstein, MD

Who gets to define emergency medicine? Is it the doctors, the EMTs, the insurance companies or the 911 operators? As evident from the articles in this issue of Sonoma Medicine, there are lots of competing interests.

No one can argue about the need and benefit of a trauma center, and we’re all glad to know there’s one nearby, fully staffed with qualified people. Cardiac and stroke centers, likewise, fill an important niche in our medical safety net. The local EMS team, including helicopter service, gets patients to emergency care quickly. For a true emergency, we in Sonoma County are fortunate to live where we do. But often patients who show up in emergency departments have medical needs or perceived medical needs that could be managed differently, and better, elsewhere.

Working people often have to make a choice between earning a day’s pay or going to the doctor during office hours. The frequent alternative is to present in an ED after they get home from work, have dinner and arrange for child care. After a long wait in the ED, they see a physician who doesn’t know them. The physician can treat the immediate problem but has to count on the primary care physician (PCP) to arrange for follow-up. In an ED, chronic problems like diabetes, hypertension, epilepsy or asthma can be treated but not managed. Yet, how can the ED communicate with the PCP when none of the hospital electronic medical records (EMR) systems can talk to each other, or with the PCP’s office? Kaiser has an integrated EMR only if their patients show up at a Kaiser facility. If their patients go to another ED, Kaiser PCPs are still waiting for paper records and faxes like everyone else.

Certain conditions build slowly, only to be deemed an emergency when ignored long enough by patients or their caregivers. Respiratory infections, bladder infections and bedsores are conditions that should be handled during office hours but often aren’t. Strains, sprains and chronic pain likewise need care, but rarely on an emergency basis. Do these patients have a PCP? Can they get an appointment with the PCP in a timely manner?

Lack of access to specialty care also drives people to EDs. The best example is mental health. With few providers for outpatient services and even less access to inpatient care, mental health patients needing urgent care often rely on EDs to deal with their current crisis. Sonoma County’s newly opened mental health facility in Santa Rosa is certainly a step in the right direction.

The EDs themselves have another type of crisis. Where can they put patients who need to be admitted to the hospital when there are no beds to be found? There are fewer hospital beds in Sonoma County than there were three years ago, but the number of people seeking hospital care has gone up. The aging population is also driving the need for more inpatient beds. Some busy EDs look like an ICU, with multiple critically ill patients lining the halls. Transfers to out-of-area facilities have been increasing, adding to communication problems with local PCPs.

Some of the solutions proposed in this issue of Sonoma Medicine could make a difference. Extending office hours for primary care teams could allow our working population access to outpatient urgent care with physicians who have the patient’s medical records. The teams could provide continuity of care and prevent the complications of waiting for a crisis. Increasing mental health care into the evening hours may reduce the burden on EDs for a type of illness they are poorly equipped to handle. Educating families and caregivers to recognize small problems before they become big problems may reduce the delay in getting appropriate care. Having a medical professional patients can call at any time may prevent an ED visit. Home health visits can keep patients well cared for, avoiding hospitals and EDs as much as possible.

Preventing falls in our senior population would decrease emergency visits as well as reduce the devastating fractures that often accompany the falls. Orthostatic hypotension in this group is common and is often secondary to medications. Balance issues from age-related neuropathy are also frequent. Doing orthostatic checks on office visits may identify a potential problem. Referring patients to yoga, Pilates or dance classes can reduce fall risks.

The ED is the safety valve for all of us. It is essential that we work with our patients and colleagues to make optimal use of this essential resource. ::

Dr. Bernstein, a Sebastopol neurologist, serves on the SCMA Editorial Board.
Email: bernsteinallan@gmail.com

SONOMA MEDICINE  |  Spring 2016  |  Sonoma County Medical Association

Return to Contents page


<< Spring 2016 - Emergency Medicine | PATIENT EDUCATION
What if Primary Care Was as Easy to Access as the ED? >>
Home   |   About Us   |   Membership   |   For Patients   |   Physician Finder   |   Events   |   Advocacy   |   Advertising
Copyright (c) 2018 North Bay County Medical Societies