It seems to be a common notion that an emergency room is an emergency room, capable of handling whatever problem is presented to it, and that this is true for all emergency rooms everywhere. While we appreciate your confidence it is somewhat misplaced. To understand why it is first necessary to understand the difference between the emergency room and the physicians staffing it.
To become a board certified specialist in Emergency Medicine one must graduate medical school and then complete an Emergency Medicine residency. This is generally a four-year training program based at a large and busy university-affiliated hospital. The resident will, during the course of those four years, see and do pretty much everything germane to the specialty.
Upon completion of the residency program the candidate is qualified to sit for the board exams. The first of these is a written test lasting the better part of a day. Pass this and you are invited to take the oral exam held about six months later. Pass that and you are declared board certified. At least for the next ten years, because every ten years you have to take and pass a re-certification exam or lose your board certified status.
So a residency-trained, board certified ER doctor is actually capable of handling the gamut of emergency medical problems. But in order to be maximally effective the physician needs proper back up. This is where things get a bit murky, because not all hospitals provide a full range of services. This means you can walk into any well-staffed ER with chest pain and get diagnosed with an acute myocardial infarction, or heart attack. But if the hospital you chose doesn’t have the ability to do cardiac catheterization and open-heart surgery, you are not going to get state of the art treatment immediately. You will get some treatment, but you will have to be transferred to another hospital with the proper equipment and personnel to get the good stuff.
The same is true for pediatrics, trauma, and stroke. Optimal treatment of these types of patients requires not just a properly trained ER doctor, but a host of other physician and nursing specialists, sophisticated equipment, and intensive care units. Certain hospitals have certain special designations. We in the business know which. You should, too.
For instance, some hospital ER’s are EDAP certified. This means an Emergency Department Approved for Pediatrics. So in addition to having an expert ER staff, they also have on-call pediatricians and pediatric sub-specialists, nurses with expertise in pediatric nursing, in-patient pediatric beds, and possibly a PICU, or Pediatric Intensive Care Unit. If your child was born with a congenital heart defect that required multiple surgeries at the Major University Hospital to repair and now has difficulty breathing, you don’t want to take him to the local community hospital ER. Sure, the ER doctor can diagnose the problem, but treating it is going to require the help of all the people I just listed, and none of them work at Mayberry Community.
Other hospitals are designated Stroke Centers. This means they have CT, and probably MRI, capability 24/7. There is a neurologist on call to assist with the patient’s evaluation and treatment. The ER and ICU nurses have been specially trained to treat stroke patients. And, if it is a Comprehensive Stroke Center, there are neurosurgeons and interventional radiologists who can do procedures to unclog the artery in the brain causing the stroke. Mayberry has no such designation.
When you suddenly find yourself slurring your words, dropping things, or dragging your leg for no obvious reason you don’t want to get dropped off at Mayberry Community. If for some reason you are, there will hopefully be a transfer agreement in place with the nearest stroke center and you will be taken there by ambulance. But not without first having caused a great deal of unnecessary stress for the ER doctor who was unable to do all he knew needed to be done because he lacked the proper back up.
The “specialty” ER that is most familiar is the Trauma Center. These come in two varieties, Level 1 and Level 2. A Level 2 center has a trauma surgeon, anesthesiologist, and surgical nursing team available within twenty minutes of being called. The ER staff has had special training in the care of trauma patients. A Level 1 center has all these specialists in-house around the clock. Plus they have neurosurgeons, orthopedists, and others available in minutes. And a heliport.
So you had maybe one too many and rolled your car down the embankment of the freeway on-ramp. It’s cool, you were wearing your seat belt and the airbags went off. You’re stuck, though, and have to wait in the car, upside down, until the paramedics arrive to pry open the door and drag you out. They immediately want to put a hard collar around your neck and strap you to a backboard for a ride to the nearest trauma center. You insist you are fine, and demonstrate by removing the collar, hopping off the board, and walking around. A conversation ensues, and ends with you signing out Against Medical Advice and calling your roommate to come pick you up. It was maybe only one too many, after all. It’s not like you’re falling down drunk.
On the way home you pass Mayberry Community Hospital. Your roomie suggests stopping by the ER “just to be safe”. You figure “why not”, since you now have some pain in your neck and your stomach doesn’t feel quite right. You check in, tell your story to the triage nurse who then rushes you into the ER. The doctor does a quick assessment, a bedside ultrasound of your abdomen, and orders CT scans of your head, neck, abdomen and pelvis. It takes a while because the CT tech isn’t in house. He’s on-call, thirty minutes away.
When the scans are finally done, and the results are called to the ER by the on-call radiologist reading them on his home computer, you are told you have a fracture of one of the vertebrae in your neck and a laceration of your liver, which is bleeding into your abdomen. A hard collar is re-applied to your neck and a call is placed to the on-call general surgeon.
It takes the surgeon twenty minutes to return the call and another thirty to get to the hospital. By then your blood pressure has dropped, IV’s are running, and the ER doctor is becoming frantic. Fortunately, you stay alive long enough to get to the operating room and the liver laceration is repaired. Unfortunately, Mayberry Community doesn’t have a neurosurgeon on staff. The following day, when you are stable, you get transferred to the Level 1 trauma center for neurosurgical fixation of the broken neck. You are told afterward that with some luck, and a lot of physical therapy, you should be able to walk again in six months or so.
None of this drama and stress is necessary. Knowing whether or not your local hospital has any special designations is important. Knowing when to call the paramedics is equally important. If you are having chest pain, if your special needs child is turning blue, if you think you might be having a stroke, or if you’ve had a serious accident or injury, call 911. The paramedics know where to take you.
Mayberry Community Hospital does a great job, it just doesn’t do everything. If you show up there with a problem they do not have the resources to solve, you—and they—are stuck. The triage nurse can’t turn you around and point you in the direction of the appropriate hospital. That’s against the law, and the topic of a later installment.