US Falls Short of EM Trained Physicians in Hospital Emergency Departments

"Emergency Medicine Specialists in Short Supply"

by Elizabeth Cooney, www.Boston.com

December 17, 2008

Even under the rosiest of scenarios, it's unlikely the nation's emergency rooms will be staffed with only emergency medicine specialists anytime soon, Boston researchers predict.

Writing in the journal Academic Emergency Medicine, lead author Dr. Carlos A. Camargo of Massachusetts General Hospital estimates that it would take until 2019 to find enough fully-trained, board-certified emergency physicians to work in the 4,828 emergency departments that are open 24 hours a day. And that best-case projection assumes that no current doctors who meet those qualifications die or leave their jobs.

The Institute of Medicine said in 2006 that ERs should ideally be staffed by doctors who had spent their residency training in emergency medicine and had later passed tests to become certified in the specialty. But only about 55 percent of doctors working in ERs meet that standard, Camargo and his co-authors write.

"The mismatch between the supply and demand for residency-trained, board-certified emergency physicians is a longstanding problem," Camargo said in a statement. "We probably should explore alternatives, such as giving the family physicians who currently staff many US emergency departments extra training in key emergency procedures. We might also increase our reliance on nurse practitioners and physicians assistants, who can help emergency physicians of any training background better handle the continually rising number of patients."

Visit the Boston Globe Website to read more, view comments and post your ideas about solving this issue.

EM in War Time: A True Story in Iraq

I was reading an article in the November 2008 volume of Emergency Physicians Monthly (www.EPmonthly.com) that really touched me. The article was written by CDR Mark Plaster of the Marine Corps, United States Navy. He wrote about the importance of disassociation when treating patients anywhere, and especially within a unit during war time. 

His story begins by describing his team of providers preparing to treat fellow marines who had driven  over a land mine. His providers set up equipment and IV's, divided into teams to treat each possible injury, pulled security outside the tent, and waited for their patients to arrive. 

CDR Plaster then has a flash back to another incident when he had two injured marines from a grenade going off. One Marine, which he and the rest of his crew knew well from their unit, had a horrible injury that required immediate attention; while the other Marine was left by the wayside. Over a few minutes, it became obvious that the seemingly unhurt Marine was actually hurt rather badly and required neurosurgery to stop a subdural bleed from shrapnel to the brain. Because of the relationship between the providers and the Marine whose injuries were obvious, they focused their attention on him, and almost missed a potentially fatal diagnosis on the other Marine.

The story then goes back to the present tense and describes the tension as they wait for the victims of the land mine to enter the tent. After a few moments, one of the crew members notified them that no one was injured. The vehicle they were driving took a beating, but that was all. CDR Plaster could sense the relief of his crew and, astonishingly, some disappointment that the casualty didn't happen. Their adrenaline was pumping and they were excited at the prospect of testing their skills, both individually, and as a team. 

CDR Plaster started to tell them they should be thankful the situation hadn't escalated as they thought, that none of their fellow Marines were going to die this day; but he then realized the importance of this exercise, of learning to disassociate oneself from emotion, in order to provide the best emergency care for every patient. They decided it was a day "to celebrate the victory of pushing [death] back another day."

Whether or not your personal beliefs support the war, the reality is that our EM physicians, PA's, NP's, nurses, and many other providers are serving our fellow men as they fight to keep our country, our homes, our families safe from the evils of this world. I'll use this opportunity to thank all of our servicemen, medical or other professionals, for their commitment to our nation. We should all be so thankful to their sacrifices to make the world a better place.

Does Your State Make the Grade in Emergency Medicine?

The American College of Emergency Physicians (www.ACEP.org) released a report this week that "grades"  Emergency Care in the United States. They gave the nation a C- overall, and didn't grant anything higher than a B for any state in the union. 

Click the link below to see how your state measures up.

Click Here for the Full Report

Gasping After Cardiac Arrest Associated with Improved Survival

By Todd Neale, Staff Writer, MedPage Today

Published: November 24, 2008

Reviewed by Zalman S. Agus, MD; Emeritus Professor

University of Pennsylvania School of Medicine.

TUCSON, Ariz., Nov. 24 - Out-of-hospital cardiac arrest patients who gasp or have labored breathing derive the most survival benefit from immediate chest compressions, a retrospective analysis showed.

Explain to interested patients that this study found that gasping after cardiac arrest is common and is associated with higher rates of survival to hospital discharge.

Point out that the researchers said that chest compressions should be initiated on all out-of-hospital cardiac arrest patients, even those who are gasping.

Of patients who received compressions from a bystander, those who were gasping were more likely to survive to hospital discharge than those who were not breathing at all (39% versus 9.4%; OR 5.1, 95% CI 2.7 to 9.4), Gordon Ewy, M.D., of the University of Arizona, and colleagues reported online in Circulation: Journal of the American Heart Association 

"Gasping is an indication that the brain is still alive," Dr. Ewy said, "and it tells you that if you start and continue uninterrupted chest compressions, the person has a high chance of surviving."

Witnesses to cardiac arrest sometimes interpret gasping as normal breathing and don't call 911 or start chest compressions as quickly as they should, according to the researchers.

"These results suggest that the recognition and importance of gasping should be taught to bystanders and emergency medical dispatchers so as not to dissuade them from initiating prompt resuscitation efforts when appropriate," the researchers said.

This is especially important because chest compressions may cause a patient to begin gasping, Dr. Ewy said.

"This scares many people and they stop pressing on the chest," he said. "This is bad because gasping is an indication that you're doing a good job."

To determine the occurrence of gasping after out-of-hospital cardiac arrest, the researchers examined transcripts from the Phoenix Fire Department Regional Dispatch Center.

Of 113 patients who had a witnessed or non-witnessed cardiac arrest, 38.9% gasped or had labored breathing.

In a separate analysis, the researchers looked at emergency medical services' first-care reports of 1,218 patients who had a witnessed cardiac arrest.

Overall, 191 gasped and 1,027 didn't. The two groups did not differ significantly by age, arrest location, or receipt of bystander CPR.

For those who collapsed after EMS personnel arrived, 32.8% started gasping.

Rates of gasping declined as arrival time increased. There were 20.1% who had labored breathing when the arrival time was less than seven minutes, 13.9% when it was seven to nine minutes, and 7.4% when it was greater than nine minutes.

Gasping was significantly more common in the witnessed ventricular fibrillation group than in patients who had a witnessed arrest with a different rhythm (18.4% versus 13.6%; OR 1.7, 95% CI 1.2 to 2.4).

Survival to hospital discharge was significantly higher in patients who had some residual breathing than in those who did not (28.3% versus 7.8%; OR 3.4, 95% CI 2.2 to 5.2).

Of patients who were gasping when EMS personnel arrived, those who were receiving chest compressions from a bystander were more likely to survive than those who were not (39% versus 21%, P<0.01).>

Patients who had gasping or labored breathing still had a survival advantage even if they weren't receiving CPR from a bystander (21.1% versus 6.7%; OR 2.4, 95% CI 1.2 to 4.3).

The researchers said that the results call into question the importance of rescue breathing for cardiac arrest patients, especially in light of previous findings of no survival benefit from rescue breathing.

"Interruptions for rescue breathing make CPR efforts more complicated and result in fewer compressions during this crucial period when perfusion is key to successful resuscitation," they said.

In addition, gasping is likely more beneficial than rescue breathing, Dr. Ewy said.

"When the patient gasps, there is a negative pressure in the chest, which not only sucks air into the lungs but also draws blood back to the heart," he explained.

"In contrast, mouth-to-mouth breathing creates overpressure in the chest and actually inhibits blood flow back to the heart," he continued. "Gasping during cardiac arrest is much better than mouth-to-mouth breathing."

The authors acknowledged that the study was limited by the possibility that the EMS reports did not accurately record the presence or absence of gasping.

In addition, they said, gasping is not diagnostic of ventricular fibrillation arrest.  

New Doctors Still Too Tired for Safety

Report recommends extended rest breaks after 30-hour shifts

WASHINGTON - Doctors-in-training are still too exhausted, says a new U.S. report that calls on hospitals to let them have a nap.

Regulations that capped the working hours of bleary-eyed young doctors came just five years ago, limiting them to about 80 hours a week.

Tuesday, a panel of the prestigious Institute of Medicine recommended easing the workload a bit more: Anyone working the maximum 30-hour shift should get an uninterrupted five-hour break for sleep after 16 hours.

"Our committee's charge was not to focus necessarily on longer scheduling or shorter scheduling, but smarter scheduling to try to really identify the areas where we could have an impact in preventing excessive fatigue, both acute and chronic, that might contribute to medical errors," Dr. Daniel Munoz of Johns Hopkins University School of Medicine in Baltimore, a member of the panel, said in a telephone interview.

At issue is how to balance patient safety with the education of roughly 100,000 medical residents, doctors fresh out of medical school who spend the next three to seven years in on-the-job training for their specialty.

These junior doctors frequently are the front-line medical staff on duty around the clock in teaching hospitals. The long hours are in some ways a badge of the profession; doctors cannot simply clock out if a patient is in danger.

But sleep deprivation fogs the brain, a problem that can lead to serious medical mistakes. So in 2003, the Accreditation Council for Graduate Medical Education issued the first caps. Before then, residents in some specialties could average 110 hours a week.

As an illustration of the fatigue residents may experience, the panel noted that research has shown they have an increased risk of being involved in traffic accidents or falling asleep at the wheel after an extended-duty shift.

The panel urged the ACGME to adopt the recommendations within two years. The independent Institute of Medicine provides advice to U.S. policymakers.

The accreditation council didn't immediately say if it would follow the recommendations.

Common violation
The government asked the institute to study the current caps. Violations of current limits are common and residents seldom complain, the committee found. While quality of life has improved, there's still a lot of burnout.

And despite one study that found residents made more errors while working longer shifts, patient safety depends on so many factors that it is impossible to tell yet if the caps helped that problem, the report said.

It also recommends:

• Experienced physicians should more closely supervise residents.
  
• Better overlap of schedules during shift changes to reduce chances for error as one doctor hands patients' care over to the next.
  
• Increase mandatory days off each month, and extend hours off between shifts depending on how long the resident worked, during day or night.
  

"Cutting hours alone won't do it," added Dr. Ann Rogers of the University of Pennsylvania School of Nursing in Philadelphia, who also served on the committee. 

"We need to pay attention to work load. We need to pay attention to supervision. The whole package will make a difference. Without it, you could end up with a more severely stressed resident trying to do more work with less hours."

Rebecca Sadun of the American Medical Student Association said the recommendations are "unambiguously a step in the right direction." She said the 2003 limits have proven to be insufficient because the current 30-hour shifts do not enable residents to remain at a high level of functioning throughout. 

Sadun, a medical student at University of Southern California's Keck School of Medicine, added that her association hears many accounts from residents about how the current 80-hour work weeks in reality are 100-hour work weeks, with school administrators insisting that residents fill out time logs dishonestly.