Emergency medicine: an anaesthesiologist's concept

1 Emergency medicine: an anaesthesiologist's concept HERMAN

H. DELOOZ

HISTORICAL BACKGROUND

We consider a reflection on the historical background against which the department was developed as essential when describing the current concept. This historical background concerns emergency medical practice in Belgium and in Leuven (a university town located in the Flemish part of Belgium and also known by its English name, Louvain) in particular, as well as the antecedents of the author. It therefore contains autobiographical notes, which are however only meant to clarify the motives behind certain developments. Since the end of 1963, 16 emergency telephone exchanges have been operational in Belgium, covering the whole country and responding to the unique number '900'. Since 1987, this number has been changed to '100'. The calls are received by an attendant of the Fire Brigade, who is in charge of organizing the emergency medical service (EMS) response (Delooz, 1987). A law passed on July 8, 1964 on emergency medical services (Wet van 8 July, 1964) took the responsibility for emergency care in public places away from the local Committee of Public Assistance (Wet van 8 April, 1958) and made the State responsible for it. This responsibility includes control of the '100' telephone exchanges, the transport of victims of sudden illness or trauma to the hospital and, finally, their admission to a hospital-based emergency care facility. The Ministry of Public Health made agreements with ambulance companies, both public (mainly fire brigade based) and private, the main condition being availability for emergency care around the clock. The minimum requirement for the ambulance crew was a certificate showing they had successfully attended a 20-h course in first aid organized by the Red Cross or a similar organization. As far as the admitting hospitals are concerned, the criteria included having an emergency entrance, at least one room equipped for resuscitation, and the availability of a doctor-on-call. However, no specifications were made as to the competence of the doctor-on-call, and it was not requested that the doctor actually be present on the hospital premises. The University Hospitals of Leuven have been part of the '100' system since the inception of the law in 1964. The ambulance entrance and the Bailli~re's CIinical Anaesthesiology-Vol. 6, No. 1, March 1992 ISBN 0-7020-1616-0

1 Copyright 9 1992, by Bailli6re Tindall All rights of reproduction in any form reserved

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resuscitation room were located close to the operating theatres, because emergencies emanating from public places were thought to be largely due to trauma. The general public, however, increasingly used the number '900' (later '100') for emergencies occurring in private homes and thus more and more emergencies involved acute illness. Those emergencies were admitted to different parts of the hospital, mainly on 'triage' performed by the joint efforts of the ambulance crew and the doorman of the hospital. Even if this triage was effective, most emergencies were cared for in outpatient clinics or on hospitalization floors, interfering with planned activities and not receiving the attention they deserved according to the severity of the illness or injury. Around 1970, the University Hospital authorities decided on the creation of an Emergency Department (ED) as part of a building project planned on the site of the existing hospital. The lay out of the first ED provided four areas: (1) reception, dispatching and permanency; (2) first diagnostic workup area; (3) therapy units; and (4) a section for night hospitalization. It was considered to be part of the task of the department to hospitalize patients arriving after 7 p.m. within its own facilities. The hospital management considered that a dedicated structure, room, equipment and personnel were a more efficient way to accommodate emergencies. Emergency medicine as a discipline was at that time of no concern. At the end of 1971 I was asked to direct the newly conceived ED, which was to open in October 1972. I was not told the basis of this choice, but I presume various different motives induced it: I trained as an anaesthesiologist and had started the first intensive care unit in the University Hospitals in December 1965, while completing my last year of residency, andwas shown to be capable of introducing a new way of practising medicine (intensive care) at a time when the large majority of traditional disciplines considered this type of medical activity as futile and undesirable. The same attitude prevailed concerning the planned ED. As an anaesthesiologist I did not have hospitalization facilities (except intensive care) and therefore could not be suspected of using the ED for the recruitment of patients. Finally I had presented my PhD thesis in November 1971 on 'The patient with low cardiac output after open-heart surgery', investigating the effect of controlled ventilation, volume loading and alpha-blocking on the respiratory, circulatory and metabolic status of the patient, introducing thermodilution as a technique for repeated determination of cardiac output. This investigation made me the recognized authority in the field of critical care medicine and as such acceptable to the academic community. I decided to accept the challenge because my experience in intensive care had taught me that patients arrived in intensive care via two main routes: they were screened as critical by the anaesthesiologist at the end of surgery, or they were transferred from a hospitalization unit of the University Hospital after they had been recognized as critically ill, usually by a junior doctor who required confirmation and authorization for a transfer from his senior staff. The process of diagnosing the critical condition and authorizing the transfer usually brought the patient to intensive care several hours, or sometimes days, after the critical condition had been evident, as could be

EMERGENCY MEDICINE: AN ANAESTHESIOLOGIST'S CONCEPT

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derived from reviewing the medical and nursing records. My hypothesis was that bringing the expertise of critical care to the 'entrance' of the hospital (the ED) would save on mortality and morbidity, increase the potential for critical care and improve the use of the existing critical care facilities. It was agreed that I would not have to report to any of the traditional department heads, but instead would report directly to the medical director of the University Hospitals.

CHARACTERISTICS OF E M E R G E N C Y MEDICINE

The characteristics of emergency medicine can be summarized as follows: 1. The referring doctor, the patient or his environment determine what constitutes an 'emergency', and define the reason, time and point of entry into the system, regardless of age and the ultimate nature of the illness or injury. 2. Emergency medicine manages the unanticipated and unscheduled unpredictable volume of patients with injuries and conditions of undetermined and varying severity and complexity. 3. Initial recognition of life-, organ- or limb-threatening conditions requires rapid establishment of priorities for a given patient among many patients. 4. Stabilization of the patient requires the critical care necessary to move the patient toward biological and psychological homeostasis, which may involve any of the body systems. 5. Evaluation includes the assessment of physical and behavioural systems as they relate to complications or associated underlying conditions. Evaluation may include the use and interpretation of appropriate diagnostic support and may also include specialty consultation. 6. Emergency medicine provides definitive care or facilitates orderly transfer for the continuing management of the patient. Our University Hospital, situated in a small community (with less than 200 000 inhabitants within a radius of 15 kin), was already in those days largely a referring hospital and would probably attract as emergencies patients from outlying hospitals who would be transferred as an emergency, either because they were critical or required the medical expertise for diagnosis and/or therapy that only the University Hospital was able to offer. Because of the complexity of the role of the ED, we considered multidisciplinary input to be essential in setting up a department that would have to function around the clock as a centre for acute diagnosis and therapy. Permanent access to the expertise of trauma surgery, general internal medicine, radiology, anaesthesiology and psychiatry were therefore considered mandatory. The horizontal integration of the traditional vertical medical disciplines will assure high quality emergency medical care, but this may not be evident for those colleagues who prefer to function in the 'safe' environment of their own discipline and authority.

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G O A L S OF E M E R G E N C Y

DELOOZ

MEDICINE

There are two main goals: 1. 2.

To create a spatial and functional structure dedicated to the care of all medical emergencies. To assure within this structure as a top priority the limitation of mortality (early and late), morbidity (single or multiple organ failure) and invalidity through early diagnosis and therapy of life-, organ- or limb-threatening conditions caused by illness or injury.

THE MULTIDISCIPLINARY

APPROACH

Medical care

Early diagnosis and therapy was intuitively felt to improve chances for survival and recovery, but recent research has confirmed that the oxygen debt (the cumulative oxygen deficit over time) accumulated in the acute phase of illness of injury largely determines mortality and morbidity (Guyton and Crowell, 1961; Crowell and Smith, 1964; Shoemaker et al, 1988). Therefore expertise in critical care has to be provided 24 h out of 24 within the ED. This task is considered to be specific to emergency medicine staff, while the other disciplines, as members of the team, provide their specific diagnostic and therapeutic competence (Figure 1). The multidisciplinary approach requires certain organizational measures to assure continuity of care and responsibility. In a private hospital where a system of fee for service is applied, a patient may find more than one medical doctor or discipline eager to be in charge; in a university hospital where the medical staff is working on salary basis, more patients may mean more power to some, but more work load to others. We therefore made it a rule that any patient referred to a medical discipline or to one of its staff members (about 50% of the total patient population) is registered in the ED for that discipline and is the final responsibility of that discipline, except for the responsibility shared by the emergency medicine staff for the critical aspects of care. Patients not referred to any particular medical discipline are registered by the dispatchers for one of the disciplines with medical permanency in the ED. The role of dispatcher, which involves reception and registration of patients, dispatching of all in- and outgoing communications and information, and the dispatching of visitors and consulting physicians, is performed around the clock by a group of people of varying backgrounds and education, but selected for their ability to cope with stress, their proficiency in human contact and their sincere concern for the human being as an individual personality. Choice is based on the apparent medical problem and the availability of the disciplines according to the actual work load. Trauma is registered for trauma surgery, medical problems for internal medicine, intoxications and drowning, etc. for anaesthesiology, and

EMERGENCY MEDICINE: AN ANAESTHESIOLOGIST'S CONCEPT

5

CEMERGENCY DEPARTMENT~)

I

(medical care) 1. Critical care - in Emergency Department in EMS

specific task

Emergency medicine

in University Hospital during in- and interhospital transport - 24 h out of 24 - for patient population of incontrollable quantity and quality 2. Causal diagnosis + therapy

- - - ~ task shared with

Trauma surgery Internal medicine

Anaesthesiology Radiology Psychiatry Neurology Paediatrics Figure 1. T h e multidisciplinary input into medical care in the ED.

psychiatric disturbances for psychiatry; children are always seen by someone from the paediatric department, even if they are also referred to other medical disciplines. Of a total of 34000 new patients a year, about 50% have surgical problems; 42% of the total are victims of trauma. All medical disciplines and subdisciplines active within the University Hospitals can be invited to give medical advice, or to perform technical investigations or therapeutic acts on patients admitted to the ED. Advice is always given in the ED, in order to keep the patient under close observation and to permit direct discussion with the doctor in charge and assure immediate implementation of the advice. Transfer to another medical discipline can only be considered after consultation with the other discipline on the premises of the E D and with common consent of both disciplines. Nursing care

To assure total patient care of a high quality, the E D has to have its own nursing staff, specially trained for a large diversity of activities, including outpatient work, ambulatory surgery, resuscitation and critical care, and

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observation. Basic training is provided by a 100-h course on 'critical care nursing' organized within the University Hospitals as a joint effort of the medical and nursing staff of the different intensive care units and the Department of Emergency Medicine. Specific training is provided within the ED. Psychosocial care Preparedness is a basic attitude in emergency medicine and this has to include preparedness for psychosocial care. The patient who comes to the ED is looking for safety, but frequently is faced with a rather large number of people (dispatchers, nurses, technicians, residents, medical staff) who may not immediately provide the urgent answer sought by the patient. Adequate and efficient action can induce some rest and trust. At the same time the confrontation with emergency medicine is usually a frustrating experience, for it interferes with plans already made, often threatens major projects or evokes the possibility of temporary or permanent disability, loss of health or even loss of life. This fear and frustration experienced by patients and relatives often creates aggressiveness. Life-threatening situations induce the staff to concentrate all their attention on the physical condition of the patient, while erecting fences against emotional impact. We therefore consider every patient brought to the ED as potentially in need of psychosocial care, and consider that being prepared for this type of care an essential part of the challenge of emergency medicine. The general principle which rules our approach to psychosocial care is to consider it as a task to be shared by the whole team (Delooz, 1981). This avoids psychosocial care getting into a rut or becoming a burden or emotional load. In collaboration with the Patient Counselling Department of the University Hospitals, structural and functional measures were developed. The task of the dispatchers includes the guiding and counselling of patients and their family within the confines of the ED. Two social workers are available daily during working hours to share in this task of guidance and counselling, but are also in charge of all problems that cross the confines of the ED, such as contacts with social security, insurance companies, referring physicians, organizations providing home care, etc. Functional measures include the rule that psychosocial needs can be identified by any member of the ED staff, be it an ambulance man, a nurses' aid or a physician. After morning rounds, at 10.30 a.m. every patient is discussed in a staff meeting attended by the ED medical staff, the staff members in charge of the supervision of medical and surgical patients, the chief nurse on duty, the social workers, the pastor and the admission officer. Discussion not only concerns medical and nursing care and disposition, but also identifies psychosocial problems and designates which team member will be in charge of further psychosocial care, taking into account the specific competence of dispatchers, social workers and pastor but also assuring the active partici-

EMERGENCY MEDICINE: AN ANAESTHESIOLOGIST'SCONCEPT

7

pation of medical and paramedical personnel. Dispatchers and social workers are essential as go-betweens, while doctors and nurses can play a key role by providing the medical information that may be needed for patient counselling and guidance. Finally, formal training and education are essential to assure preparedness for psychosocial care. This training also provides t e a m m e m b e r s of the D e p a r t m e n t of E m e r g e n c y Medicine with psychological and emotional counselling and guidance. For this purpose two special training sessions are organized for all employees of the E D , half of the team participating in each of the sessions. The sessions are held out of the hospital, start at noon on the first day and finish the evening of the second day. Live-in facilities are considered of utmost importance to provide ample time for reflection and exchange of ideas. Psychosocial problems are acted out, analysed and discussed, and a consensus for m a n a g e m e n t is derived. The participation of all t e a m m e m b e r s in one group stresses the principle that psychosocial care is a task to be shared by all the m e m b e r s of the team (Delooz, 1986a) (Figure 2).

dEPARTMENTof EMERGENCYMEDICINE~

+ Nursing staff

Medical staff

Dispatching Social .~.~. workers i 1 Patient Counselling internal medicine ( Critical care) Dept of UH traumatology ,~ Registration radiology --,~, Medicalcoverage I anaesthesiology +consultations-~ r~ledical

Emergency~physicians

psychiatry (neurology) (paediatrics)

(Nursing care)

I

I

1

disciplinesI of UH

(Medical care) ,= If+Acutediagn~

(Psycho-socialcare~ ..,

r

kTherapy

.)

Figure 2. The system of patient care within the ED. Acute diagnosis and therapy involves medical care, inclusive of critical care, nursing care and psychosocialcare. UH = University Hospital.

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THE OBSERVATION CARE UNIT The ED functions as an acute care centre, assuring diagnosis and therapy of the syndrome or injury presenting as an emergency. Of course pre-existing pathology and complicating disease have to be taken into consideration in both surgical and non-surgical cases. An important proportion of the patients presenting at a university ED constitute such diagnostic and therapeutic challenges that short-term observation and therapy facilities are of utmost value (Delooz, 1986b). Whereas the hospital management had originally planned for night hospitalization, daily practice immediately turned the hospitalization facilities into a short-term (max 24 h) observation care unit for a broad variety of patients: 1. 2. 3. 4.

Patients requiring a short observation to identify the nature of their pathology so that they can receive follow-up and therapy. Patients requiring close observation to detect possible early complications or deterioration. Patients receiving a therapeutic trial under close observation before admission to the appropriate ward. Patients whose pathology only requires about 24 h of observation and/or therapy.

Very often patients belong to a combination of several categories. One example is the patient admitted in septic shock who requires shock therapy while diagnostic work-up determines the origin of the sepsis and decides on whether surgery is indicated. Another example is the patient with thoracic trauma who may develop respiratory failure, when they will show the first signs of this complication within 12 to 24 h after the injury. Titrated pain therapy, associated with chest physiotherapy and incentive spirometry or intermittent mask continuous positive airway pressure breathing will prevent respiratory failure. Close observation of respiratory frequency, checking for any loss of symmetry of the chest movements and serial blood gas determinations and chest X-rays will allow the early detection of the development of respiratory failure. Other examples are the observation of probably benign head injuries and the diagnosis and therapy of acute intoxication; 96% of the patients admitted with an overdose or intoxication are discharged from the ED to psychiatric or ambulatory care after an average of 21 h, including psychiatric evaluation and advice. From some of these examples it will be clear that the observation care unit must include facilities for short-term critical care. Of a total of 24 beds in the observation care unit, seven beds are fully equipped for critical care. Twelve per cent of the total number of patients, or an average of ten patients a day, are admitted in a critical condition (respiratory failure, circulatory failure, heavy metabolic disequilibrium or varying degrees of impaired consciousness). The high incidence is due to the fact that only 50% of the patients admitted to the ED come from the immediate locality; 20% come from regions nearby, while 30% are referred from all over the country. When looking at the destination of the critical patients, one-third are transferred to the operating theatre for emergency

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EMERGENCY MEDICINE: AN ANAESTHESIOLOGIST'S CONCEPT

surgery, one-third are admitted to an intensive care unit, while one-third are admitted to an ordinary ward after short-term intensive therapy in the ED. This last result fits in with one of the main goals of emergency medicine--the limitation of morbidity through early diagnosis and therapy of lifethreatening conditions. It also warrants the permanent availability of expertise in critical care medicine in the E D (Delooz, 1983) (Figure 3).

(DEPARTMENT ofEMERGENCY MEDICINE~ I Non-critical patients 88%

o~

~ o~ ,

ambulatory care

ward in UH

Critical patients 12% (Observation Care Unit'~

A

L, 24beds )

/ I\

, be s I ]~176

I 7beds I

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home

ward in UH

ICU

I critical I

I

\

\

OT

Figure 3. T h e proportions of patients using the critical and non-critical facilities and their ultimate designations. T h e observation care unit has 17 beds for non-critical patients and seven beds for short-term critical care. U H = U n i v e r s i t y Hospital; I C U = i n t e n s i v e care unit; O T = operating theatre.

Of course, a short-term observation care unit can complicate life when traditional medical disciplines consider these beds as an extension of their own admission facilities. We avoid this problem in two ways: at the 10.30 a.m. staff meeting we discuss, as mentioned above, every patient, including his disposition. Only if indicated for medical reasons can the patient stay in the observation care unit. At 5 p.m. the same exercise is performed. Since we require 14 beds as an average for night admissions and

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DELOOZ

eight beds as an average for admission on medical grounds, only a very limited number of beds can be offered as a buffer waiting for suitable admission facilities to become available.

P R E H O S P I T A L AND INHOSPITAL E M E R G E N C Y CARE

In 1970 the anaesthetic department together organized a system for acute resuscitation care within the D e p a r t m e n t of Surgery, and then the Department of Radiology. This involves an alarm system and equipment stationed in every unit and maintained in a state of preparedness by the nursing staff of each unit. When the E D was opened, it was considered to be part of its duty to maintain these facilities and to provide the whole hospital with the necessary resuscitation care. A few months after the inception of the E D it was proposed that we also be in charge of ambulances, which up to that time had functioned under the authority of the head of patient administration. We were only interested in this task if the available ambulance crew and vehicles could be turned into an EMS system. When looking into the activities of the ambulance team it was clear that, although officially they were active within the '100' system of the Ministry of Public Health, they reported every morning as not available for emergencies, having a full programme of planned patient transport, and would only report as available for emergency calls after 8 p.m. and on Saturday afternoons and Sundays. The training of the ambulance crew was certainly not above the level of basic life support (BLS), and when discussing with them the need for continuous availability for EMS and the need for extra expertise, they replied that, through their limited experience, they were aware of the possibilities of EMS and the associated needs. They also declared that the extra expertise needed could not be provided by them, not even after supplementary training. This latter statement was acceptable since these ambulance men had not been selected at their recruitment for EMS activities. Two possibilities were considered: 1.

2.

Leave the ambulance man the planned patient transport and start recruiting new crews for EMS work. This option was not considered to be cost-effective, for it would mean maintaining two parallel ambulance systems for the University Hospitals. Add to the ambulance men's expertise by adding an extra crew member.

Discussion was then started on who would provide the extra expertise. There were few doctors proficient in EMS within the department, and doctors without specific training in EMS were considered of no value. The director of the nursing department offered to provide nurses to train in mobile emergency care and be sent on every EMS call. It must be kept in mind that no triage of calls is done in our '100' system, but that on the other hand the incidence of futile or hoax calls is only 2 to 3% due to the fact that our telephone system allows immediate identification of the number from which the call has been made and that the public still considers the '100' system as being for important emergencies. As a matter of fact, the hospital

EMERGENCY MEDICINE: AN ANAESTHESIOLOGIST'S CONCEPT

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admission rate of the patients brought through the 100 system is more than double the admission rate of the whole E D population. We organized a training programme of 4 months that was offered to nurses with at least i year of full-time experience in the ED, who had volunteered for EMS and who had successfully followed the course on critical care nursing. I was personally in charge of the practical training. It included weekly audit of the ambulance runs made with or without my presence aboard the ambulance, and resulted in the production of 'standing orders' for nursing activities within the EMS system (Delooz and Verbruggen, 1975). Since the Belgian law has only very recently accepted a list of nursing acts that can be performed without delegation from a medical doctor in charge of the patient, the only legal framework for our initiative was to have these nurses function under my responsibility according to a number of standing orders, for which I would be able, if requested, to prove before a court that they were internationally considered to be life saving. In fact, according to the Belgian law, every citizen has to provide assistance to his fellow citizen in great danger, whether he is witnessing the condition or whether he is informed about it. He has to assist as long as no danger to himself or others will ensue and according to his competence. Immediately after having provided the region of Leuven with this improved EMS system, only 40% of our EMS calls were received from the regional 100 telephone exchange, whereas 50% of the calls were made directly to our department by medical doctors and 10% by lay people. This illustrates that both the medical and general communities were appreciating from the outset the extra dimension we had been adding to our EMS service (Delooz and Verbruggen, 1976). When auditing our system, however, it was soon realized that in a selection of cases emergency medical expertise would have offered an extra dimension. In the mean time our ambulance system was also increasingly asked by outlying regional hospitals to transfer patients in a critical condition to our E D (Delooz, 1979). A pilot study carried out in 1979 in order to determine the need for the presence of an emergency physician (EP) on the scene and during transport showed us that, independently of each other, EMS nurses and EPs judged about 10% of the EMS cases to be an indication for EP intervention (Delooz et al, 1980). We then decided to train first residents in anaesthesiology and later EPs (see below) in EMS. We organized a tiered EMS system in which every call is answered by the EMS ambulance crew, including a specially trained EMS nurse, as a first tier. The second tier consisting of an intervention car with a crew of another EMS nurse together with an EMS trained physician attends when judged to be necessary, either from the nature of the call or more frequently when requested by the first tier at the scene. This tiered system has been evaluated both for its effectiveness in the care of victims of sudden cardiac arrest (Delooz et al, 1989a) and for victims of major trauma (Rommens et al, 1989, 1990). Both tiers were found to be important for the overall result, while the whole system appeared to be highly cost effective. We have integrated all our out-of-department activities within one group dedicated to mobile emergency care, consisting of nurses and EPs. Thus 12

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physicians and 25 nurses share the yearly experience of 200 inhospital resuscitation efforts, 5000 out-of-hospital first tier interventions, 500 out-ofhospital second tier interventions and about 500 secondary transports of critical patients in complete mobile intensive care conditions. In between mobile emergency care duties, they function as part of the indepartment medical and nursing staff, enabling them to follow-up on the prehospital care provided by them. As far as cost-benefit and quality assurance are concerned, we know of no other way to achieve the same result. Of course, having all the EMS concentrated within our department for the whole region of Leuven is only possible on account of the relatively small dimensions of the region (10 km of action radius for the first tier, 19 km of action radius for the second tier), serving a total population of 250 000 inhabitants. But in a densely populated country such as Belgium (10 million inhabitants for 11781 square miles), one EMS system for 200 000 inhabitants with the proposed distances is achievable, except for the south-eastern part of the country (the Ardennes). Our experience with EPs and ED nurses involved in prehospital, inhospital and interhospital emergency medicine care has been very rewarding because

DEPARTMENTof EMERGENCYMEDICINE~ Ministry of Public Health City of Leuv Coordination committee

II

,~,. :,:..

J Interhospitaltransport I J in hospital EMS I of critical patients

one,S

5000 runs/year 500 runs/year UH ambulance man EMS nurse ~

Ii

ambulance 1

200 runs/year

inlervention

ambulance / ~ 0 0 runs/year

vehicle

Fire Brigade [ ambulance man -->- ambulance 2 EMS nurse

~Emergency Physician ~ helicopter ~,EMS nurse j) " 100 runs/year

Red Cross/ Flemish Cross -->~ ambulance 3 ambulance man EMS nurse

New Heli Samu (Air Force) (State Police)

&

Figure 4. The EMS system for pre- and inhospital emergency care and the interhospital transport of criticalpatients. These are organizedinto one systemintegratedin the Department of EmergencyMedicine. UH = UniversityHospital.

EMERGENCY MEDICINE: AN ANAESTHESIOLOGIST'S CONCEPT

13

of the expertise brought to the scene or the outlying hospital, the quality assurance built in through continuous evaluation and training, and the human aspect of bringing the feeling of security normally only offered in the ED to the patient in need of emergency care. The integration of all the EMS for the region of Leuven into one system was achieved through the EMS council installed by the Lord Mayor of Leuven, chaired by the chairman of the Department of Emergency Medicine, and governing the EMS for Leuven and the surrounding towns and villages covered by the Fire Department of the city of Leuven. The responsibility legally given to the Lord Mayor in cases of disaster has allowed us to create this EMS council and gives it legal authority as part of the Disaster Management Council chaired by the Lord Mayor himself. Thus all the participating organizations--Red Cross, Flemish Cross, Fire Department, University Hospital Department of Emergency Medicine, regional hospitals, the '100' regional centre, local and regional health authorities and local organizations of general practitioners--are directly involved in the EMS system (Figure 4).

M A N A G E M E N T IN EMERGENCY MEDICINE

The multidisciplinary activities within the ED call for the coordination and development of organizational and medical protocols. As an example, our major trauma protocol is coordinated by the EP and indicates the order of interventions and acts as well as the team member(s) who will have to perform them (Delooz, 1992). The daily application of such a protocol allows major trauma care to be administered in both a smooth and effective way and brings the patient in the shortest time ready for surgery to the operating theatre. At least yearly this protocol is discussed with all the disciplines involved (emergency medicine, anaesthesiology, trauma surgery, radiology, neurology and the ED nursing staff) and is updated according to our own experience or data from the current literature. The definition of the scope of activities is a constant concern to the physician in charge of an ED. Colleagues not daily involved with the department will tend to make use of it for all kinds of purposes, without looking for alternatives. Others might consider their patient fit for admission to their department before the patient has received the first work-up necessary to delineate the nature of the complaint that brought him to the ED and thus interfering with the orderly disposition of the ED patients. The necessity to perform equally effectively around the clock and to cope with an uncontrollable quantity of patients with medical problems of all natures requires a dedicated system of quality assurance that functions both in real time and off-line and which takes into consideration the medical care as well as the administration and organization of the department. Registration of activities, both in and out of the department, and regular audit are important quality assurance tasks, and represent a consistent part of the workload of the staff of the ED (Figure 5).

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DEPARTMENT

of EMERGENCY

DELOOZ

MEDICINE~

4, MANAGEMENT) I

Medical staff

Nursing chief + deputies

Administrative staff

- horizontal integration of multidisciplinary input - organization of personnel and material infrastructure - coordination of medical and nursing activities - definition of scope of activities - development of medical and organizational protocols - quality assurance - disposition of patients - budget control

Figure 5. Management within the ED. Management is an important part of the role of emergency medicine in order to provide the 'system' approach to emergency care.

T R A I N I N G AND E D U C A T I O N Daily training on the job is the mainstay of education in emergency medicine both for medical and paramedical personnel. Nevertheless, formal training sessions have to be organized, as mentioned earlier, for nurses and ambulance crews to prepare them for their activities within the EMS system. H o w e v e r , emergency medicine's task in teaching goes far beyond this. The first task concerns the general public, who constitute the first link in the system of emergency care (Figure 6). They have to be taught to recognize a vital emergency, to alarm the EMS system and to give first aid. W e have demonstrated that education (according to the principle that

I

DETECTION "~ (EMERGENCY"~ _(FIRST AID OF THE j-~l CALL j--~ ON THE EMERGENCY.) [ 1) [,.SPOT

DURING I-~1 DEPARTMENT I--~1 CAR E TRANSPORT . ) I. ) I , FAOILITIES Figure 6. The chain of facilities required for emergency care.

EMERGENCY MEDICINE; AN ANAESTHESIOLOGIST'SCONCEPT

15

'schools are for teaching') is both feasible and effective in a school population starting from the age of 12, provided use is m a d e of video tapes to carry the standardized message and of manikin training supervized by teachers in physical education, themselves trained by experts in cardiopulmonary resuscitation (Van Kerschaver et al, 1989). Undergraduate students in medicine, pharmacy and dentistry and medical secretaries are given courses on first aid and resuscitation, while final-year medical students spend periods of 4 weeks in the E D assisting the residents and staff in patient care. Of course, the residents, who assure the medical p e r m a n e n c e in the E D and have to be at least in their third year of residency, receive a great deal of training, through experience, collaboration with the EPs and on-the-job quality assurance.

~

DEPARTMENT

of EMERGENCY

MEDICINE)~

Gao,,EDU

OUTSIDE~

E~

I WITHIN T H E ED l

+ Emergency physician

Residents

Last year medical students

Nurses

'Certificate of Special Competence in Emergency Medicine'

- Anaesthesiology - Internal medicine

- Family medicine - Intemal medicine - Surgery - Anaesthesiology

- Emergency medicine - EMS

- Surgery - Neurology - Psychiatry

- critical care

course

First

Laymen

responders

- industrial helpers

- private ambulances - Fire Brigade - Po co'

Medical secretaries

- schools - Red Cross - Fem sh Cross

Ambulance men EMS

- Fire Brigade

City of Leuven - Red Cross/ Flemish Cross

University Students - pharmacy school - medical school - dental school

Figure 7. Training and education in emergency medicine. These are provided both within the department and outside of the department for a large range of medical and paramedical personnel, as well as laymen and first-aid providers.

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H.H.

DELOOZ

Last but not least, a training programme for 'Special Competence in E m e r g e n c y Medicine' has been implemented by the Department of Emergency Medicine of the University of Leuven since 1986 and was proposed for official approval by the Belgian Society for Emergency and Disaster Medicine. This programme aims to introduce emergency medicine as a discipline, not as a new medical specialty. It offers specialists in anaesthesiology, surgery, internal medicine or paediatrics a certificate of 'Special Competence in Emergency Medicine' after completion of 2 years' full-time extra residency training. Credit for up to i year can be obtained for full-time training in critical care and/or emergency medicine received during their basic specialty training. At least 1 year of supplementary full-time residency training in the Department of Emergency Medicine is mandatory after certification as a specialist. The ED training includes involvement in all the emergency medicine activities: prehospital, inhospital and interhospital EMS, medical management, teaching and research activities within the department, and considerable experience in critical care. In fact, these trainees, whose number does not exceed that of the staff members of the ED, provide 24-h coverage of the ED, assuring coordination and critical care, under supervision of a staff member on call (Figure 7).

DISASTER MEDICINE

'The emergency physician, through training, practice and day-to-day involvement with large numbers of undifferentiated patients, has developed a responsibility and unique role in mass casualty disaster management. Emergency physicians should be involved in the planning, management and evaluation of the system at the local, state and federal levels.' This statement (American College of Emergency Physicians, 1975) clearly delineates a role for the EP in disaster preparedness. Nevertheless, disaster medicine has dimensions that clearly exceed the limits of emergency medicine: the disproportion between the need for emergency medical care and the available facilities, the need for triage according to a principle of collective rather than individual ethics, the need for coordination between rescue services, the police force and the EMS system, the need to downgrade the technology of acute care, and finally the need for the study of the specific epidemiology of disasters and of the risks due to the development of the industrial environment. To quote E. L. Quarantelli (Disaster Research Center, University of Delaware, Newark): 'The difference between everyday delivery of EMS and EMS delivery in a large mass casualty situation is one of kind, rather than just degree.' We consider disaster medicine and emergency medicine to be complementary, not identical. The Department of Emergency Medicine of the Faculty of Medicine of the Catholic University of Leuven has therefore organized, in collaboration with the Medical Department of the Belgian Armed Forces, a postgraduate course of 120h on disaster medicine and disaster management. The course is concluded by theoretical and practical disaster training sessions and a written

17

EMERGENCY MEDICINE: AN ANAESTHESIOLOGIST'S CONCEPT

and oral examination. This course is open to physicians, nurses and officers of health and rescue services. Together with the course, our involvement in concrete disaster planning has evolved. The disaster plan of the ED is the backbone of the University Hospitals' disaster plan, and the chairs of both the medical and the nursing committees on hospital disaster planning are occupied by the medical and nursing specialists of the ED. Through our activity within the Leuven Coordination Committee for EMS, we are in charge of the medical part of the disaster planning of the city of Leuven, as well as the disaster planning of the Province of Brabant. We also coordinate all medical facilities organized in response to non-everyday situations, be it a rock concert with a large audience or a visit of the Pope (Figure 8). DEPARTMENT

Postgraduate Course on Disaster Medicine 120 hrs + exercise + written/oral exam - physicians - nurses - officers

MEDICINE

DISASTER MEDICINE)

Medical Department of the Armed Forces

,+

of EMERGENCY

+

I

+

+

Disaster planning Dept EM UH .~

Disaster planning City of Leuven

Disaster planning Province of Brabant .$

Committee on disaster planning UH

Committee on disaster planning City of Leuven

Province Committee for advice on EMS for disaster management

Figure 8. Involvement of the Department of Emergency Medicine (Dept EM) in disaster medicine, which includes both education and planning. UH = University Hospital.

RESEARCH

As indicated earlier, quality assurance is one of the top priorities of the ED and thus a large part of the research performed in the Department of Emergency Medicine will be quality assurance oriented. A programme of registration and audit of cardiopulmonary resuscitation, in collaboration with the Study Group on Cardiopulmonary Cerebral Resuscitation of the Belgian Society of Emergency and Disaster Medicine, has been ongoing since 1982 (Delooz et al, 1989b) and has now been expanded to the European Resuscitation Council (Chamberlain et al, 1991).

18

H.H. DELOOZ

A project for the evaluation of early nurse defibrillation inhospital has been started this summer. Early and continuous patient-oriented data acquisition and management in emergency medicine aim to document physiological patient data and therapeutic interventions from the scene of the emergency and during E D care, including during any moving about imposed by investigations or therapy. An interactive video disk computer program developed in collaboration with the Audio-visual D e p a r t m e n t of the University of Leuven is being tested against conventional teaching of cardiopulmonary resuscitation on a student population of the School of Medical Secretaries. A Leuven Major Trauma Outcome Study will register and follow-up the major trauma population admitted over a period of 2 years to our ED. It is funded by the Ministry of Health, Flemish Community of Belgium, is running in collaboration with the Department of Trauma Surgery, and is for international comparison integrated with the USA and the U K major trauma outcome studies.

~DEPARTMENTofEMER?ENCYMEDICINE~__~ (RESEARCH)

+ Teaching CPR with interactive video program

l

Institute Paramedical Training University of Leuven

§

I

Registration and audit of CPR

l

- CPCR Study Group of Belgian Society of Emergency and Disaster Medicine - European Rescuscitation Council

~

Faculty of Medicine, University of Leuven

§ Early nurse MTOS defibrillation in hospital

Early and Thesis promotion continuous patient oriented data acquisition and management ,~, EM

in

Laerdal Foundation for Acute Medicine, Norway

- MTOS USA - National - MTOS UK Research - Ministry of Council Public - Dept Health, Informatics Flemish UH Community - R+D Apple

- School for hospital management - Dept of Clinical Nursing - Faculty of Law, Dept of Criminology

Figure 9. The research activitiesof the EmergencyMedicine (EM) Department. These involve topics not covered by the traditional medical specialties. CPR= cardiopulmonary resuscitation; CPCR= cardiopulmonary cerebral resuscitation; MTOS= Major Trauma Outcome Study; R + D Apple = Apple Research and Development Fund.

EMERGENCY MEDICINE: AN ANAESTHESIOLOGIST'S CONCEPT

19

A study on the pathophysiology and epidemiology of intoxication with tricyclic antidepressant drugs is also in progress, in collaboration with the E D of the University of Ghent. Finally, each year one or more students make a licentiate thesis under the promotion of one of the staff members of the Department of Emergency Medicine. Subjects submitted over the last few years include 'Guidance and counselling of trauma victims in the E D ' , 'The observation care unit's role in the management of presumed benign craniocerebral trauma' and 'Quality assurance in emergency medicine'. This overview of research activities is given to illustrate the fact that they all concern topics of specific interest to emergency medicine not covered by any other medical discipline (Figure 9).

EMERGENCY MEDICINE AS A DISCIPLINE

A new discipline can come about in different ways: 1. 2. 3.

The body of knowledge within one discipline becomes too large and subspecialization evolves into a new discipline (e.g. the evolution of cardiology within internal medicine). The technical complexity becomes so important that complete devotion to the new technology is mandatory (e.g. nuclear medicine). Society requests a dedicated medical interest. For example, tuberculosis in the last century required a dedicated medical discipline even before chest disease as a discipline existed.

Emergency medicine has grown into a discipline on all of the three grounds cited above. The body of knowledge is not provided by any of the traditional medical disciplines; emergency medicine has his own scientific societies, journals and publications. The 'technique' of emergency medicine is the dedicated system needed to provide expert emergency care on a 24-h basis, and society expects the medical profession to provide emergency care at any time and any place, irrespective of the nature of the illness or injury. As such, emergency medicine is in the first place involved with patient care. Anaesthesiologists might argue that the best place to become familiar with critical care is the operating theatre and postoperative intensive care. Those areas of experience are certainly very valuable for somebody who wants to devote himself to emergency medicine. However, even just the critical care side of emergency medicine has a much broader scope, due to the fact that critical conditions as complications of all kinds of pathology and in all age groups will present at the ED, and foremost because the critical patient or the patient likely to become critical will be hidden among the large population of non-critical patients. The expertise necessary for the recognition or diagnosis of the critical condition is in our experience much more difficult to acquire than the expertise to care for the critical patient. The only place to acquire this expertise is the ED, and the only way to acquire it is through full-time dedication to this activity.

20

n . n . DELOOZ

Traditionally, every specialist would be in charge of the emergencies occurring within his patient population. This concept, however, no longer holds true when it comes to real emergencies--life-threatening, organthreatening and limb-threatening conditions--for the response to these conditions requires availability around the clock, incompatible with planned activities outside of the ED, and expertise which cannot be gained from occasional confrontation with such urgent conditions. Up to the early 1970s, it was left to the young inexperienced colleagues to perform the most demanding task, the diagnosis of the critical condition, before deciding to call for a more experienced senior colleague. Whereas traditional academic medicine works with a pyramidal system, giving the youngest trainee the first chance to examine the patient, followed by a senior trainee, eventually by a staff member and only exceptionally by the professor himself, emergency medicine should ideally practice the inversed pyramidal system, whereby the most experienced EP should screen every patient and decide on the level of competence needed to further handle the case. Closest to this concept is the coverage of the ED around the clock by a staff EP. The organization of the dedicated system of emergency care, with its specific demands, involves important input as far as management, training and education and research are concerned. Disaster medicine, as has been argued, is different from emergency medicine, but relies on emergency medicine and its EMS system for the actual patient care. CONCLUSION The concept of emergency medicine as it has been developed in the Department of Emergency Medicine of the Catholic University of Leuven, Belgium, is based on multidisciplinary input from several traditional disciplines, among which anaesthesiology has played a key role. Multidisciplinary input, however, is not contradictory with emergency medicine as a new discipline. Recent advances in medicine have mainly come about through the horizontally integrated activity of traditional vertical disciplines. Only through the coordinated effort of traditional disciplines will the patient in need of expert emergency care fully benefit from all the expertise that a university hospital can offer. Emergency medicine provides the system through which immediate expert emergency care is provided, while multidisciplinary input is available to recognize as soon as possible the necessity to call in even greater specific expertise when required. Only by accepting emergency medicine as the entity which can make this happen will the traditional disciplines continue to achieve what they have always claimed to do--provide the patient with the expertise that only they can offer. Of course, this concept requires a new way of thinking and practising in medicine.

EMERGENCY MEDICINE: AN ANAESTHESIOLOGIST'S CONCEPT

21

Alternative concepts are possible. We wanted to report on a concept that has been developed over almost 20 years and which probably owes a lot to the fact that it was conceived by an anaesthesiologist. Anaesthesiology is in essence a discipline relying on collaboration and servitude. The concept has certainly added a new dimension to the medical care provided by our University Hospital. This new dimension is highly appreciated by the colleagues, general practitioners and specialists who refer patients to us, as well as by the general public and the numerous visitors from far and near countries. Numerous colleagues have been inspired by the integration into one system of pre- and inhospital emergency care and the as-a-matter-of-course collaboration of several disciplines around the patient.

SUMMARY Against the historical background of both the Belgian legislation and the tradition of the Leuven University Hospitals, the evolution of the E D as a centre for acute diagnosis and therapy is described (Figure 10). It involves medical care, nursing care and psychosocial care. The medical care is based on multidisciplinary input under emergency medicine's leadership. Within the medical care, critical care expertise is provided by emergency medicine.

DEPARTMENT of EMERGENCY MEDICINE

--~( Patientc a r e ~

the ED inside the ED outside

4 ( Management) ~ ~_TrainingandEducation~ --~(Disaster Medicine~ ---~(Research) Figure 10. A summary of the Department of Emergency Medicine's activities.

22

i-i. H. DELOOZ

Emergency medicine is also responsible for the pre- and inhospital EMS systems, as well as for interhospital transport of critical patients by means of mobile intensive care units. Horizontal integration of the traditional vertical medical disciplines relies on management, protocol implementation and quality assurance provided by the staff of the D e p a r t m e n t of E m e r g e n c y Medicine. Specific teaching tasks and research are the basis for emergency medicine as a discipline. Disaster medicine is complementary to emergency medicine, but relies on its daily EMS system for its medical care component. The concept of emergency medicine described is certainly not the only one possible, but can be considered to be the anaesthesiologist's concept, based on a tradition of collaboration and servitude. Acknowledgement We would like to acknowledge the contribution to the development of the Department of Emergency Medicine of the Leuven University Hospitals by all its team members past and present. In particular we wish to thank our closest collaborators, Drs A. Meulemans, F. Gijsenbergh, B. Winnen, M. Sabbe and Lic H. Verbruggcn, as well as the medical director of the University Hospitals, Professor J. Peers.

REFERENCES American College of Emergency Physicians (1975) The role of the emergency physician in mass casualty disaster management (position paper). Journal of the American College of Emergency Physicians 5: 901-902. Chamberlain D, Cummins RO, Abramson N et al (1991) Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the 'Utstein style'. Resuscitation 22: 1-26. Crowell JW & Smith EE (1964) Oxygen deficit and irreversible hemorrhagic shock. American Journal of Physiology 196: 313. Delooz H (1979) The organization of emergency care. Emphasis on mobile emergency care. In Tavares BM & Frey R (eds) Acute Care, pp 143-148. Berlin, Heidelberg, New York: Springer-Verlag. Delooz H (1981) Psycho-social care in the emergency department: a task to share by the whole team. Critical Care Medicine 9: 227. Delooz H (1983) The integration of emergency care in a total critical care medicine (CCM) system. Disaster Medicine 1: 129-130. Delooz H (1986a) Pati6ntenbegeleiding: beleidselement in een spoedgevallendienst. In Keirse M & Van Herck A (eds) Pati~ntenbegeleiding in her ziekenhuis van morgen, pp 53-60. Louvain, Amersfoort: Acco, Delooz H (1986b) Voorlopige hospitalisatie: noodzaak of luxe? Acta Chirurgica Belgica 86: 178-181. Delooz H (1987) Emergency medical service systems in Belgium. Anaesthesiologie und Reanimation 12: 223-229. Delooz H (1992) Trauma anesthesia practices throughout the world: Belgium. In Grande CM (ed.) Textbook of Trauma Anesthesia and Critical Care. St Louis: Mosby Year Book (in press). Delooz H & Verbruggen H (1975) An advanced emergency care delivery system. Acta Anaesthesiologica Belgica 26: 72-77. Delooz H & Verbruggen H (1976) Two years' experience with an advanced emergency care delivery system. Proceedings of the VIIth Congress on Emergency Medical Services, Praha.

EMERGENCY MEDICINE: AN ANAESTHESIOLOGIST'S CONCEPT

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Delooz H, Verbruggen H, Mangelschots G e t al (1980) Six years' experience with an advanced emergency care delivery system based on mobile emergency care. Acta Anaesthesiologica Belgica 31(supplement): 119-126. Delooz H, Lewi P & The Cerebral Resuscitation Study Group (1989a) Are inter-center differences in EMS management and sodium bicarbonate administration important for the outcome of CPR? Resuscitation 17(supplement): $161-$172. Delooz H, Lewi P, Buylaert Wet al (1989b) Cardio-pulmonary-cerebral resuscitation. Resuscitation 17(supplement): $1-$206. Guyton AC & Crowell JW (1961) Dynamics of the heart in shock. Federation Proceedings 10: 51. Rommens P, Delooz H & Carlier H (1989) Transport of severely injured patients. In Vincent JL (ed.) Update in Intensive Care and Emergency Medicine 8, Update 1989, pp 439-444. Berlin, Heidelberg, New York: Springer-Verlag. Rommens PM, Miserez MJ, Delooz HH et al (1990) Early mortality after polytrauma: a retrospective study. Hefie zur Unfallheilkunde 212: 591-592. Shoemaker WC, Appel PL & Kram HB (1988) Tissue oxygen debt as a determinant of lethal and non-lethal postoperative organ failure. Critical Care Medicine 16: 1117-1120. Van Kerschaver E, Delooz H & Moens G (1989) The effectiveness of repeated cardiopulmonary resuscitation training in a school population. Resuscitation 17: 211-222. Wet van 8 April (1958) Betreffende het begrip medische urgentie. Belgium. Wet van 8 Juli (1964) Betreffende de dringende geneeskundige hulpverlening. Belgium.