The Evolution of Connecticut's Emergency Rooms
Dr. John Sottile and nurses evaluate an EKG transmitted remotely from EMTs in the field at the Hospital of Central Connecticut.
Back in the 1790s, during the French Revolution, military surgeon Dominique Jean Larrey had an epiphany. He noticed how rapidly the flying artillery (horse-drawn cannons) of the French army transported weapons across the battlefield and realized they could be used to save lives instead of destroy them. He created flying ambulances, horse-drawn stretchers that quickly transported wounded soldiers away from the front lines to places where they could be treated more effectively.
It was a giant leap in medical history and saved thousands of lives. As a result, Larrey often is acknowledged as the father of emergency medicine. More than 200 years later, emergency medicine continues to use cutting-edge technology to save lives. Some Connecticut hospitals are making emergency department wait times available on their websites, others regularly use video conferencing to have patients examined by experts from other parts of the globe, and emergency departments routinely employ new treatments to save the lives of patients in ways that would not have been possible in the past. Even the name has changed.
“I know the TV show was called ‘ER,’ but in the hospital setting you’ll always hear the ‘emergency department.’ We’re no longer a big room where everyone goes,” says Dr. Peter Jacoby, chairman of emergency services at Saint Mary’s Hospital in Waterbury.
The way emergency departments are being used by the general public also has changed. A report released in October by the Association of American Medical Colleges estimates the nation is short approximately 9,000 primary-care doctors. As the availability of general practitioners declines, emergency departments often have filled the health care void out of necessity.
“We’ve become the answers to everyone’s problems,” Jacoby says. “We are expected to do much more besides the very acute emergencies.”
Dr. Gail D’Onofrio, chief of the emergency department at Yale-New Haven Hospital, agrees that “emergency” visits will be increasing. “I think with the Affordable Care Act we may see even more people because more will be covered by some type of insurance,” she says. “What we’re hoping for down the road is that we have more primary-care doctors to keep the population healthy and to work on prevention.”
Though emergency departments may be busy, both Jacoby and D’Onofrio say the vast majority of patients who come in do need treatment and the services provide a level of convenience for them.
“You can say, well, is an injured ankle an emergency?” Jacoby explains. “If you decide to wait and call your primary-care doctor, and then go get an X-ray, and then you have to go find crutches and figure out how to get off that ankle, and then get an appointment with an orthopedic physician, that might take you a week. If you come to the emergency department you may wait a little while, but we’re going to X-ray you, we’re going to set you up with your crutches, we’re going to fix your leg and we’re going to get you a referral to an orthopedic physician.” He adds, “In the United States we are used to one-stop shopping. We don’t like to go to 50 stores anymore; we go to malls to shop. We go to emergency departments because we know we can get seen, get diagnosed and get treatment 24/7.”
However, frequent use of emergency departments can lead to overcrowding, especially when there’s an outbreak of an illness, as was the case in late December and early January when the state saw a spike in influenza cases.
“Emergency departments everywhere were flooded,” Jacoby says. “We saw a lot of flu cases and there was a very virulent respiratory viral disease, and a GI viral disease going around as well. It’s like the perfect storm—you have all that coming in and you have all the car accidents, strokes and heart attacks that you get all the time as well.”
Although things may have gotten hectic at Saint Mary’s, Jacoby says that doesn’t mean the emergency department was strained to a breaking point or that patients shouldn’t be encouraged to come in for treatment. “You still manage to see them all and you just have to examine those who you think are the sickest first,” he says.
Ralph Miro, director of nursing and EMS coordinator for the Department of Emergency Medicine at Day Kimball Healthcare, which operates Day Kimball Hospital in Putnam, agrees patients should never be discouraged from coming to the emergency department. “Until you’re assessed by health-care professionals, there’s no way to tell if something that may seem minor could be very major,” he says. “Let’s say you have left arm pain or right arm pain or jaw pain—that could be a sign of a heart attack.”
He adds, “Patients who feel that their complaints or their symptoms are serious—what they should not do is ignore them.”
Patients also needn’t worry that their broken ankle will take away needed resources from sicker people, says Miro. Emergency-staff members are trained in triage, or assessing the most critically ill patients to make sure they get priority treatment. This ability to quickly assess need is an area where emergency medicine has advanced significantly, aided by now common life-saving practices such as “point-of-care” testing.
“It’s a procedure that enables us to determine a patient’s condition, or to identify certain disease states, by evaluating the content of a patient’s blood,” Miro says. Blood now can be analyzed at a patient’s bedside thanks to devices like the i-STAT System, a handheld blood analyzer that can provide lab-quality test results on the spot.
“Instead of drawing multiple tubes of blood, all we need is a few drops in an i-STAT,” he says. “Those drops of blood, as little as two, are placed into the unit and rather than having to wait for the results from our lab, the results come within a few minutes.”
Major advances like this aid in better treating heart attacks and strokes, where time is critical. Using point-of-care treatments like i-STAT, which can test for cardiac markers, staff can assess more quickly what type of heart attack a patient is having and then send him or her to a catheterization lab where they can be treated properly. There are also new medications that slow down the damage caused by a heart attack or a stroke, and innovative techniques such as therapeutic hypothermia, a method by which medical staff can lower the patient’s body temperature to slow down brain damage.
Not all the new technology being used is specific to the health-care industry. Advances in video-conferencing technology have allowed patients at Day Kimball to be examined remotely by specialists at the UMass Memorial Medical Center.
“We can zoom in on the patient and a neurologist all the way over at UMass can assess the pupils and skin color,” Miro says.
In addition to technological advances, another trend in emergency medicine today is in customer service. Dr. Jeffrey A. Finkelstein, chief of emergency medicine and chief medical information officer at the Hospital of Central Connecticut, says the hospital treats visitors like “customers as opposed to patients.” The hospital, which has campuses in Southington and New Britain, features valet parking at
the entrance to the emergency department and people are offered coffee and warm blankets as soon as they come in.
“We’re not the old ER where it was impersonal,” he says. “We really try to make it as easy as possible and as pleasant an experience as possible when you’re in pain or ill, or visiting someone who is in pain or ill.”
A few years ago the hospital began providing estimated emergency department wait times on the hospital’s website, via text message and through smartphone apps. “The number one thing people want is short wait times,” says Finkelstein. “They expect good medical care, they expect people to be nice, but what they really want is to be seen quickly. No one wants to sit in the waiting room for two, three, maybe four hours.”
Digital technology also is used to allow doctors to view electrocardiogram results of patients still en route to the hospital. “In the ambulance there are electronic EKG monitors that transmit the EKG to a cloud-based service through cellular transmissions, and then they come onto my iPhone or iPad as a PDF attachment,” he says. “We can diagnose patients before they even arrive.”
Modern emergency facilities often replace the white and beige institutional walls and tiles with warmer, more inviting colors. Yale-New Haven Hospital completed a major renovation of its emergency department in January, expanding from 30,000 to approximately 48,000 square feet. The size of the hospital’s trauma-care unit was tripled and state-of-the-art medical technology was installed. The expansion also was designed to take into consideration patient privacy and comfort.
“I think privacy is the most important thing after quality of care,” says D’Onofrio of Yale-New Haven. “When you pick out colors, you want it to have a calming effect both on the patient and the patient’s family. We are very attuned to the fact that we are responsible for life-and-death decisions and that families could easily have sent their loved ones to work or off to the store and then a crisis happened. We are often the people who have to tell their families this bad news and we really struggle to make sure we do the best that we can. Having a great environment to do that in is just one thing we can offer when things are not going well.”
An emergency department is a good indicator of what’s going on in the larger community says D’Onofrio.
“Whatever is happening in the community, we see it here,” she says. “If there’s flu out there we’re going to see it, with the economy down there’s more violence and we see it here, if people are using more prescription drugs and dying of more overdoses we see it here. We try to take an active part in surveillance and treatment and prevention. We constantly are working with the community because we are the community.”
In many ways emergency medicine is still in its infancy. It wasn’t until 1979 that the American Board of Medical Specialties began to recognize it as a separate discipline. Prior to that, physicians of various specialties would rotate duty at the emergency department. Patients might be seen by a cardiologist one night and a dermatologist the next.
Dominique Jean Larrey survived the French Revolution but was later captured by the Prussians in 1815 at the Battle of Waterloo. Sentenced to death, he was saved by a Prussian surgeon who recognized him and pleaded for his life to be spared. While the dangers faced by emergency medical staff today may not be quite as dramatic as those faced by Larrey, today’s ER personnel are still expected to do whatever it takes to make sure patients are helped.
“The emergency department is controlled chaos,” D’Onofrio says. “I cannot plan when something’s going to happen. I always have to have the resources for the worst-case scenarios. When Hurricane Sandy happened and everything else was closed, my doctors and nurses and techs and secretaries all braved the elements and left their families at home in the dark and came here to help the public. We will always do that. We never are not here. No matter what, the emergency department is open.”