CORRESPONDENCE Opinions expressed in the Correspondence Section are those of the authors, and not necessarily of the Journal editors, A CEP, or UAEM.
Free-Standing Emergency Clinics To the Editor: Should free-standing clinics treat all emergencies? What responsibilities do these clinics have to the public? Is organized emergency medicine too intimately involved financially with these clinics to speak for the public? These are some of the questions which we, as emergency physicians, must address if we are to promote the full spectrum of emergency care. We know that the concept of emergency care is viewed differently by the public than by the medical profession. 1 Many patient problems treated in emergency facilities could just as easily be treated in an office practice. Yet patients often choose to visit emergency departments because of convenience and expedience. Many believe a one- to two-hour wait under the worst of circumstances is better than a wait of days to weeks for an office visit. There is another, perhaps more appropriate, reason for patients seeking care at emergency facilities. The factor often overlooked is security. Security is critical when one realizes that 75% of patients believe their problems should be treated within minutes to hours. 2 Why not put an "emergency" clinic in every shopping center? Beyond thelobvious financial problem of paying for all those centers along with the preexisting hospital-based facilities, there is the question of how the clinics would fit into the totality of emergency services. How will the public determine where to take its ~¢emergency"? Is the public sophisticated enough to know where to take life-threatening problems? When 55% of patients aware of an emergency medical services system initially bypass it while having cardiac pain, 3 one questions publi c sophistication. When 25% of patients requiring medical attention within minutes are unaware of the urgency of their illness, 2 one must again question public sophistication. Doesn't organized emergency medicine have a responsibility to the public to provide guidelines for emergency facilities? Shouldn't this responsibility be extended to freestanding clinics? Our local emergency services system, the Thurston County Medic 1 System, will not recognize freestanding clinics as emergency facilities unless certain requirements are met. The system has recommended that local convenience clinics not use words such as '~emergency" or "urgent" to advertise until the following basic conditions are met: 1) Well-marked facility with marked entrance; 2) Stretcher and wheelchair entrance; 3) Separate approach specifically identified and maintained for emergency vehicles; 4) 24-hour staffing, i n c l u d i n g physician(s),
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nurse(s), radiology technician(s), and laboratory technician(s); 5) Physician and nursing staff trained in emergency care (preferably ABEM and EDNA certified); 6) Resuscitation equipment, including cardiac monitor, defibrillator, cardiac medications, intubation equipment, and intravenous line equipment; 7) Radio communication with local hospital(s) and emergency vehicles; 8) Specific defined role for clinic in local emergency medical services system; 9) Protocols for stabilization and transportation of patients requiring hospitalization or other more definitive care; 10) On-premises radiologic services, including portable radiographic equipment; 11) Availability of services regardless of ability to pay; 12) Ability to provide documentation of need for additional emergency facility in area of service, and endorsement of local health systems agency (regional health planning council). When will ACEP and UAEM provide a position paper on this important issue? My hope is that this letter will stimulate constructive discussion, followed by action on the part of organized emergency medicine. Jerris R. Hedges, MD Olympia, Washington 1. Wolcott BW: What is an emergency? Depends on whom you ask. JACEP 8:241-243, 1979. 2. Gifford MJ, Franaszek JB, Gibson G: Emergency physicians' and patients' assessments: urgency of need for medical care. Ann Emerg Med 9:502-507, 1980. 3. Alonzo AA: The mobile coronary care unit and the decision to seek medical care during acute episodes of coronary disease. Medical Care 18:297-318, 1980.
Treatment for Atrial Flutter To the Editor: I was on duty recently when a 55-year-old woman presented to our emergency department with a rapid heart beat and the sensation of ~my heart feels like it is in my throat." The attack had begun seven hours earlier and the patient had taken 0.25 mgm digoxin one hour before presentation. Medication included 0.1 mgm Synthroid ® for hypothyroidism. The patient was known at the hospital, and she had experienced several documented episodes of atrial fibrillation. She was placed on the cardiac monitor and I diagnosed atrial flutter with a 3:1 block. Vital signs at the time of admission were blood pressure 120/60 mm Hg; respirations, 24 per minute; temperature, 36.33 C; and an irregular pulse. She was placed in a MAST suit in order to aug-
10:6 (June) 1961