On Wednesday, June 30, the Israeli Association of Emergency Medicine will convene 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.
Prof. Michael Drescher is director of the Beilinson Hospital Emergency Department and chairman of the Israeli Association of Emergency Medicine.