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Emergency medical services: Behavioral and planning perspectives
Book reviews
409
nition of’s health care crisis in the United States of the early 1970’s, EMS have emerged as a specific area of concern. with specific Federal regulations and financing, and with an ever-growing cadre of career specialists. The year 1973 was certainly an appropriate time for a 600-page collection of articles on selected aspects of EMS. Unfortunately, the selection and limited editorial commentary on these articles have resulted in a book which, taken as a whole, is less effective than some of its parts. There is undoubtedly a need for a clear overview of EMS as a sub-system of the larger health care system. Part I, “The Emergency Medical Care System”, addresses this need. particularly in Gibson’s chapter on “The Social System of Emergency Medical Care”. This chapter might well have served as an introduction to the entire book, and possibly as an outline to its ultimate intent and a guideline to its approach. Gibson develops a sound conceptual model through careful discussion of EMS system boundaries, zones of perceptual and physical predisposition which induce patients to enter the system and the multiple entry points into the system. These concepts all have immediate and practical relevance to the problems of measuring and understanding who uses EMS, when, how and why. and Gibson has data to illustrate his points. It will be essential to refine this kind of descriptive and analytic framework for particular geographic regions and for the activities of specific emergency care facilities, before developing large-scale normative proposals about what should be done to improve emergency medical care. Gibson’s lucid chapter goes a long way toward defining the problems that face EMS, in the aggregate. King and Sox present statisticaldata on patient utilization (workload) of one particular EMS system (San Francisco; 1963-1964) but &ere are no clear-lesson& for those involved in different cities or organizations. No one can argue with their opening statement: “Knowledge of the population, nature and distribution of emergencies and geography and physical environment of a community is a basic requirement for setting up an emergency medical system and can be used to evaluate existing or proposed systems and facilities”. However, given the variations in existing EMS systems and their locales, it is difficult to know how to use their findings in, say, New York City or Boston. Moreover, this study raises an important issue which it did not address: detailed analysis of a complex EMS system in an urban area is likely to be costly and such studies must therefore be shown to be cost-effective Department ~fConw7unity Medicine MANFRED PFLANZ before they can be encouraged on a wide scale. Since the prod Health Care, important problems in EMS delivery may well prove to UniuersitJ, of Connecticut. be generic ones, it is appropriate to consider developing Farmington. Connecticut. U.S.A. basic protocols for on-going data collection and analysis of EMS function. with different geographic areas adapting these protocols to fit local EMS structures. Emergency Medical Services: Behavioral and Planning PerPart II. “Patterns of Emergency Room Utilization”, spectives. edited by JOHE;H. NOBLE, JR., HENRYWECHSLER, shifts gears and examines how particular emergency rooms MARGARETE. LAMONTAGNEand MARY ANNE NOBLE.Be- are used by their potential and actual populations of havioral Publications. New York, 1973. 595 pp. $25.00. patients. It is notable that two of six chaiteis in Part II are based on studies conducted in OPD’s and not in emerThe reader (and certainly the buyer) of a book consisting gency rooms. The editors have failed to exploit this opporof a collection. of 25 separately authored chapters. some tunity to discuss ER-OPD interrelations, a critical factor original and some reprinted from as long ago as 1958, in many community hospitals, particularly in urban areas, is entitled to a clear statement of purpose from the author. where emergency rooms are often forced to supplement This book on‘Emergency Medical Services (EMS). carrying or substitute for the OPD. It is particularly unfortunate the subtitle Eehat+oral artd Pluming Perspectives. is edited that these OPD articles. by Zola (1963) and by Solon by four non-physicians. clearly suggesting that the intended (1958) are among the oldest in this volume. Both articles, audience is not restricted to practicing emergency-room or their more modern equivalents, could have become a physicians. Fair enough. since the field of emergency medifocus for major interpretive comments by the editors, cine is rapidly becoming one of the most vigorous and using Gibson’s concepts of boundaries. zones of predisposiinfluential sectors of the U.S. health care system. and many tions and entry points. Moreover. none of the articles or professionals at many different levels are involved. Unforcommentaries in Part II provides an adequate discussion tunately. the existence of a ready audience does not of the teaching potential for medical students and house guarantee the communication of a message. and in this staff which is created bv serious efforts to analvse differing case it is unclear just what message is intended. This book patterns of emergency ioom utilizatioli. There-are implied is less significant than symbolic: amidst the growing recogsuggestions, but nothing forthright. The current national
However, this is seen not as structural contradictions but in a temporal dimension. The miracle word “still” is used as the main excuse for some facts in the medical life of DDR which are not according to the normative values of the authors. “Still” means that “dark powers” from the past still are playing a role in health care delivery of the DDR. However, I believe that “still” is not only serving as an excuse but is reflecting the underlying philosophy which is optimistic in the sense that the complete change of society can be accomplished. The underlying philosophy in the FRG book cannot be easily delineated. One could say it is a liberal, moderately anticipatalistic philosophy firmly based on middle-class beliefs about medical efficiency. The philosophy is much less optimistic compared to the DDR book. In a pluralistic society, the contradictions are structural and it is no hope to dissolve the contradictions without destroying the pluralism. In health care, the question is not clearly answered why many aspects are unsatisfactory in the West. The author does not say whether there is (as in the DDR) a conflict between the past and the present or whether some “deviant” health workers are responsible for the suboptima1 level of performance. But similar to DDR, the blame is put more on the physicians than anything else. Medical values are not questioned in both books, but in the DDR the incorporation of medical sociology into medicine, and its branch social hygiene, are underscored; whereas in the FRG some areas of conflicts between medical sociology and medicine are briefly considered. Both books will not be easily understood by medical students and each demand great concentration from the reader. It may be wished that the authors learn from each other and incorporate some topics from each other in their respective books. However, for a medical sociologist interested in comparative health systems it is a real thing to compare them in detail. He probably will enjoy this exercise more than most medical students in both Germanies. The comparison of these two textbooks leads to several questions: will it be possible that medical sociology gain the indisputable status of other disciplines like anatomy or biochemistry in which the content of curricula and of textbooks is essentially the same in all languages, all nations and all medical schools? The DDR textbook is also recommended for. and used by, West German medical students. Will we experience the time in which Siegrist’s textbook can be bought and read in the DDR as well?
410
Book reviews
focus on primary care demands a clear delineation of how emergency medicine relates to existing outpatient departments and how both areas are to be used in the training of primary care physicians. Part III, “Transportation and Communications”. is strongly oriented toward applied epidemiology and systems analysis, and includes articles varying from the trivial to the complex. The basic issue addressed is. How does the patient reach the hospital via the out-of-hospital EMS system in a’given setting? The articles included here are unlikely to stimulate emergency-room physicians into investigating the details of how patients reach their “entry points”, and will appeal primarily to professional planners and health systems specialists. A number of analytic techniques are illustrated, and the complexity of this particular man-machine system comes through clearly. This section of the book may find its best use as a reference in courses on health systems planning. Part IV, “Standards and Policies”, is an uneven catch-all and has all the earmarks of a hastily thrown together “how-to” manual. The one exception is the final chapter
by Keller and Cemma. “Planning Community Emergency Health Care Services: Fitting Together the Fragments”. which asks EMS administrators to step back and define precisely what it is they are trying to do. This chapter might well have accompanied Gibson’s at the start of the book. Perhaps this book. published at a propitious time. simply encompassed too much. It is not a compendium. in the sense of being an abridgement of a larger work. nor is it a manual. nor a review. It is an uneven collection of articles, most of them previously published. which indicate the complexity of EMS. and the need for clearer published statements of how emergency medical services now operate, how they relate to hospital-based ambulatory care services, and how they can be improved. Department
qf Ambulatorv Care
ad
Cort7rnur7ityM&ir7r. Cify Hospital Crr7ter at Ela7hrrrsr.
Elmhurst, N.Y., U.S.A.
MICHAEL M. STEWART
409
nition of’s health care crisis in the United States of the early 1970’s, EMS have emerged as a specific area of concern. with specific Federal regulations and financing, and with an ever-growing cadre of career specialists. The year 1973 was certainly an appropriate time for a 600-page collection of articles on selected aspects of EMS. Unfortunately, the selection and limited editorial commentary on these articles have resulted in a book which, taken as a whole, is less effective than some of its parts. There is undoubtedly a need for a clear overview of EMS as a sub-system of the larger health care system. Part I, “The Emergency Medical Care System”, addresses this need. particularly in Gibson’s chapter on “The Social System of Emergency Medical Care”. This chapter might well have served as an introduction to the entire book, and possibly as an outline to its ultimate intent and a guideline to its approach. Gibson develops a sound conceptual model through careful discussion of EMS system boundaries, zones of perceptual and physical predisposition which induce patients to enter the system and the multiple entry points into the system. These concepts all have immediate and practical relevance to the problems of measuring and understanding who uses EMS, when, how and why. and Gibson has data to illustrate his points. It will be essential to refine this kind of descriptive and analytic framework for particular geographic regions and for the activities of specific emergency care facilities, before developing large-scale normative proposals about what should be done to improve emergency medical care. Gibson’s lucid chapter goes a long way toward defining the problems that face EMS, in the aggregate. King and Sox present statisticaldata on patient utilization (workload) of one particular EMS system (San Francisco; 1963-1964) but &ere are no clear-lesson& for those involved in different cities or organizations. No one can argue with their opening statement: “Knowledge of the population, nature and distribution of emergencies and geography and physical environment of a community is a basic requirement for setting up an emergency medical system and can be used to evaluate existing or proposed systems and facilities”. However, given the variations in existing EMS systems and their locales, it is difficult to know how to use their findings in, say, New York City or Boston. Moreover, this study raises an important issue which it did not address: detailed analysis of a complex EMS system in an urban area is likely to be costly and such studies must therefore be shown to be cost-effective Department ~fConw7unity Medicine MANFRED PFLANZ before they can be encouraged on a wide scale. Since the prod Health Care, important problems in EMS delivery may well prove to UniuersitJ, of Connecticut. be generic ones, it is appropriate to consider developing Farmington. Connecticut. U.S.A. basic protocols for on-going data collection and analysis of EMS function. with different geographic areas adapting these protocols to fit local EMS structures. Emergency Medical Services: Behavioral and Planning PerPart II. “Patterns of Emergency Room Utilization”, spectives. edited by JOHE;H. NOBLE, JR., HENRYWECHSLER, shifts gears and examines how particular emergency rooms MARGARETE. LAMONTAGNEand MARY ANNE NOBLE.Be- are used by their potential and actual populations of havioral Publications. New York, 1973. 595 pp. $25.00. patients. It is notable that two of six chaiteis in Part II are based on studies conducted in OPD’s and not in emerThe reader (and certainly the buyer) of a book consisting gency rooms. The editors have failed to exploit this opporof a collection. of 25 separately authored chapters. some tunity to discuss ER-OPD interrelations, a critical factor original and some reprinted from as long ago as 1958, in many community hospitals, particularly in urban areas, is entitled to a clear statement of purpose from the author. where emergency rooms are often forced to supplement This book on‘Emergency Medical Services (EMS). carrying or substitute for the OPD. It is particularly unfortunate the subtitle Eehat+oral artd Pluming Perspectives. is edited that these OPD articles. by Zola (1963) and by Solon by four non-physicians. clearly suggesting that the intended (1958) are among the oldest in this volume. Both articles, audience is not restricted to practicing emergency-room or their more modern equivalents, could have become a physicians. Fair enough. since the field of emergency medifocus for major interpretive comments by the editors, cine is rapidly becoming one of the most vigorous and using Gibson’s concepts of boundaries. zones of predisposiinfluential sectors of the U.S. health care system. and many tions and entry points. Moreover. none of the articles or professionals at many different levels are involved. Unforcommentaries in Part II provides an adequate discussion tunately. the existence of a ready audience does not of the teaching potential for medical students and house guarantee the communication of a message. and in this staff which is created bv serious efforts to analvse differing case it is unclear just what message is intended. This book patterns of emergency ioom utilizatioli. There-are implied is less significant than symbolic: amidst the growing recogsuggestions, but nothing forthright. The current national
However, this is seen not as structural contradictions but in a temporal dimension. The miracle word “still” is used as the main excuse for some facts in the medical life of DDR which are not according to the normative values of the authors. “Still” means that “dark powers” from the past still are playing a role in health care delivery of the DDR. However, I believe that “still” is not only serving as an excuse but is reflecting the underlying philosophy which is optimistic in the sense that the complete change of society can be accomplished. The underlying philosophy in the FRG book cannot be easily delineated. One could say it is a liberal, moderately anticipatalistic philosophy firmly based on middle-class beliefs about medical efficiency. The philosophy is much less optimistic compared to the DDR book. In a pluralistic society, the contradictions are structural and it is no hope to dissolve the contradictions without destroying the pluralism. In health care, the question is not clearly answered why many aspects are unsatisfactory in the West. The author does not say whether there is (as in the DDR) a conflict between the past and the present or whether some “deviant” health workers are responsible for the suboptima1 level of performance. But similar to DDR, the blame is put more on the physicians than anything else. Medical values are not questioned in both books, but in the DDR the incorporation of medical sociology into medicine, and its branch social hygiene, are underscored; whereas in the FRG some areas of conflicts between medical sociology and medicine are briefly considered. Both books will not be easily understood by medical students and each demand great concentration from the reader. It may be wished that the authors learn from each other and incorporate some topics from each other in their respective books. However, for a medical sociologist interested in comparative health systems it is a real thing to compare them in detail. He probably will enjoy this exercise more than most medical students in both Germanies. The comparison of these two textbooks leads to several questions: will it be possible that medical sociology gain the indisputable status of other disciplines like anatomy or biochemistry in which the content of curricula and of textbooks is essentially the same in all languages, all nations and all medical schools? The DDR textbook is also recommended for. and used by, West German medical students. Will we experience the time in which Siegrist’s textbook can be bought and read in the DDR as well?
410
Book reviews
focus on primary care demands a clear delineation of how emergency medicine relates to existing outpatient departments and how both areas are to be used in the training of primary care physicians. Part III, “Transportation and Communications”. is strongly oriented toward applied epidemiology and systems analysis, and includes articles varying from the trivial to the complex. The basic issue addressed is. How does the patient reach the hospital via the out-of-hospital EMS system in a’given setting? The articles included here are unlikely to stimulate emergency-room physicians into investigating the details of how patients reach their “entry points”, and will appeal primarily to professional planners and health systems specialists. A number of analytic techniques are illustrated, and the complexity of this particular man-machine system comes through clearly. This section of the book may find its best use as a reference in courses on health systems planning. Part IV, “Standards and Policies”, is an uneven catch-all and has all the earmarks of a hastily thrown together “how-to” manual. The one exception is the final chapter
by Keller and Cemma. “Planning Community Emergency Health Care Services: Fitting Together the Fragments”. which asks EMS administrators to step back and define precisely what it is they are trying to do. This chapter might well have accompanied Gibson’s at the start of the book. Perhaps this book. published at a propitious time. simply encompassed too much. It is not a compendium. in the sense of being an abridgement of a larger work. nor is it a manual. nor a review. It is an uneven collection of articles, most of them previously published. which indicate the complexity of EMS. and the need for clearer published statements of how emergency medical services now operate, how they relate to hospital-based ambulatory care services, and how they can be improved. Department
qf Ambulatorv Care
ad
Cort7rnur7ityM&ir7r. Cify Hospital Crr7ter at Ela7hrrrsr.
Elmhurst, N.Y., U.S.A.
MICHAEL M. STEWART