Health Watch: ER: High tech, high skills save lives

A young man, conscious, but critically injured after his car collided head on with a pickup truck on a two-lane rural highway. A 35-year-old female with an ice pick in her chest. An elderly diabetic woman who has been found comatose in her home after a hypoglycemic attack.

For emergency room staff, life-threatening episodes such as these are an everyday matter. Staff are accustomed to handling these cases while at the same time providing comfort to a domestic abuse victim, stitching a child's cuts suffered in a bicycle accident or sobering up a belligerent alcoholic.

Until age 35, injury is the leading cause of death. Heart attacks, strokes and falls frequently send middle aged and older Americans to the emergency room.

Viewers of television's "ER" are familiar with the daily drama, but they might be surprised to see the calm, methodical way the ER crew go about their business. Perhaps nowhere else in the health care system is teamwork more important.

Trauma care begins at the scene, activated by a call to 911. The voice at the other end - known as a dispatcher or communications coordinator - has the task of inserting calm into a chaotic situation getting all the information that's needed without wasting a second. This role requires medical training, usually as a paramedic or emergency medical technician, plus knowledge of what goes on in the field so that the right questions are asked. The communications coordinator also must have access to and be able to interpret weather and traffic information.

Communicating from the field

EMTs and paramedics are trained in life-saving procedures and must be able to recognize the symptoms, however subtle, and report them so that medical personnel can make the right decisions. Known as first responders, their role is to assess the situation quickly and follow established protocols to ensure the patient arrives safely as well as promptly at the emergency facility best suited to treat the patient's problems.

Telecommunications has brought about major changes in emergency care during the past several decades. If necessary, heart and other monitors can be attached to the patient at the scene, allowing doctors to instruct paramedics as to any medications or treatments that are needed immediately and then follow the patient's progress in case changes take place on the way to the hospital.

Based on the information that they receive, emergency room doctors can get a good idea of what they're going to need at the hospital and start assembling the proper team for treatment.

For the woman with an ice pick in her chest, EMTs reported a dangerously low blood pressure, leading emergency room doctors to suspect periocardial tamponade, a condition where the heart bleeds into a sac, impeding the pumping of blood. Such a condition can be fatal so a heart surgeon was called and arrived at the hospital in time to perform an emergency procedure, drawing off fluid from the sac so the heart could beat satisfactorily until the woman reached the operating room a half hour later.

The man injured in the highway collision was conscious, but gradually became less responsive, and pupil size had changed, indicating he might have a blood clot forming in his head.

When the patient arrived at the hospital, he was having trouble breathing so emergency room doctors inserted a chest tube to restore his airway. A neurosurgeon then arrived on the scene and performed surgery to relieve the pressure rapidly building up in the skull. Because of the timely response of every member of the team, the man not only survived but left the hospital with very little brain damage.

For each type of injury, specific protocols are in place, tasks that must be performed in a certain order to make sure that all possibilities are covered and nothing is forgotten. The trauma surgeon is called, lab tests are ordered, the X-ray department and operating room put on standby.

Instead of the shouting and rushing around that you may have seen on television, there is a calm efficiency as staff perform the tasks they are trained to do.

Harnessing technology

In rural areas where specialists may not be available, telecommunications may again play a crucial role. Teleconsultation and even multi-site teleconferencing can be used to make treatment decisions or determine if transfer to another facility is necessary.

In Vermont, where 68 percent of the population lives in rural areas and where weather is often a factor in patient transportation, a teletrauma project was judged by participating physicians to improve patient care in 83 percent of consultations. In one case, a specialist talked a doctor through a complex surgical procedure, establishing an airway in a head injury patient.

In the past two decades, the helicopter has become an increasingly important part of the trauma system. In some cases, it is the primary means of transportation, air lifting patients injured in rural areas to the most appropriate trauma facility. It also can be used to transport a patient who has taken a turn for the worse or requires more specialized care.

Visits to hospital emergency departments rose from 90 million in 1992 to 107.5 million in 2001, a 20 percent increase, according to the National Hospital Ambulatory Medical Care Survey.

Facilities available for these patients shrank by about 15 percent during the same period as hospitals battled budgetary problems.

The emergency rooms that remain have worked hard to improve their services, delivering ever more sophisticated treatment more efficiently. One hospital boasted a 12 percent decrease in turn-around time and a 56.1 percent reduction in patient complaints despite a 32 percent increase in patient volume during a four-year period.

An affective trauma system requires team management from start to finish. The typical ER patient has multiple problems that require the prompt attention of a highly trained aggregation of doctors, nurses, surgeons, laboratory and imaging specialists, social workers, communications coordinators, paramedics and pre-hospital care providers. When everything is working as it should, the result is very often a life saved or a disability prevented.

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