Finalmontana

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  • Finalmontana

    1. 1. Rural Emergency Medicine 101 Stephen Wegner MD Medical Director of Emergency Medical Services Blackeet Community Hospital Indian Health Service
    2. 2. Top Ten Ways You know You are in Montana
    3. 3. Top Ten Ways to Know You are in Montana <ul><li>#10. A trip to Wal-Mart takes all day. </li></ul>
    4. 4. Top Ten Ways to Know You are in Montana <ul><li>#10. A trip to Wal-Mart takes all day </li></ul><ul><li>#9. Fencing is a job not a sport </li></ul>
    5. 5. Top Ten Ways to Know You are in Montana <ul><li>#10. A trip to Wal-Mart takes all day. </li></ul><ul><li>#9. Fencing is a job not a sport </li></ul><ul><li>#8. There are prayer requests for livestock at church </li></ul>
    6. 6. Top Ten Ways to Know You are in Montana <ul><li>#10. A trip to Wal-Mart takes all day. </li></ul><ul><li>#9. Fencing is a job not a sport </li></ul><ul><li>#8. There are prayer requests for livestock at church </li></ul><ul><li>#7. Your next door neighbor lives 10mi away </li></ul>
    7. 7. Top Ten Ways to Know You are in Montana <ul><li>#10. A trip to Wal-Mart takes all day. </li></ul><ul><li>#9. Fencing is a job not a sport </li></ul><ul><li>#8. There are prayer requests for livestock at church </li></ul><ul><li>#7. Your next door neighbor lives 10mi away </li></ul><ul><li>#6. There are more cows than people. </li></ul>
    8. 8. Top Ten Ways to Know You are in Montana <ul><li>#10. A trip to Wal-Mart takes all day. </li></ul><ul><li>#9. Fencing is a job not a sport </li></ul><ul><li>#8. There are prayer requests for livestock at church </li></ul><ul><li>#7. Your next door neighbor lives 10mi away </li></ul><ul><li>#6. There are more cows than people. </li></ul><ul><li>#5 Rodeo is the #1 spectator sport </li></ul>
    9. 9. Top Ten Ways to Know You are in Montana <ul><li>#4. Your next door neighbor proudly announces he’s finally finished stockpiling his bunker with enough weapons and ammo to start and finish WWIII </li></ul>
    10. 10. Top Ten Ways to Know You are in Montana <ul><li>#4. Your next door neighbor proudly announces he’s finally finished stockpiling his bunker with enough weapons and ammo to start and finish WWIII </li></ul><ul><li>#3. 40 mph wind is a “good breeze </li></ul>
    11. 11. Top Ten Ways to Know You are in Montana <ul><li>#4. Your next door neighbor proudly announces he’s finally finished stockpiling his bunker with enough weapons and ammo to start and finish WWIII </li></ul><ul><li>#3. 40 mph wind is a “good breeze </li></ul><ul><li>#2. Your next door neighbor knows Ted Kazinksi </li></ul>
    12. 12. Top Ten Ways to Know You are in Montana <ul><li>#4. Your next door neighbor proudly announces he’s finally finished stockpiling his bunker with enough weapons and ammo to start and finish WWIII </li></ul><ul><li>#3. 40 mph wind is a “good breeze </li></ul><ul><li>#2. Your next door neighbor knows Ted Kazinksi </li></ul><ul><li># 1. It’s a constitutional right to hunt and fish </li></ul>
    13. 13. Rural Medicine <ul><li>Define Rural Medicine </li></ul><ul><ul><li>Definition </li></ul></ul><ul><ul><li>Pros and cons of definitions </li></ul></ul><ul><li>Describe 2 major issues in Rural Medicine </li></ul><ul><ul><li>Case Study </li></ul></ul><ul><ul><li>EMS </li></ul></ul><ul><ul><li>Physician Staffing </li></ul></ul>
    14. 14. Definition <ul><li>Census Bureau 1 </li></ul><ul><ul><li>UA= 50,000 or 1000/sq mi </li></ul></ul><ul><ul><li><2.5K rural. </li></ul></ul><ul><li>OMB 1 </li></ul><ul><ul><li>County based </li></ul></ul><ul><ul><li>50K metro, 10K-49k micro, 2.5k-9k small town </li></ul></ul><ul><ul><li><2.5k rural </li></ul></ul>
    15. 15. Definition <ul><li>USDA-ERS 1 </li></ul><ul><ul><li>Rural Urban Continuum Codes </li></ul></ul><ul><ul><li>1-9 scale </li></ul></ul><ul><ul><li>1-3 = metro =250K to 1million </li></ul></ul><ul><ul><li>4-9 non metro </li></ul></ul><ul><ul><li>8-9 <2.5K </li></ul></ul>
    16. 16. Metropolitan RUCC 1
    17. 17. Nonmetropolitan RUCC 1
    18. 18. Definition <ul><li>EMS-C in rural and frontier America 2 </li></ul><ul><ul><li><2500 pop </li></ul></ul><ul><ul><li><20K/county </li></ul></ul><ul><ul><li>No McDonalds </li></ul></ul><ul><ul><li>Cattle outnumber people </li></ul></ul>
    19. 19. Problems <ul><li>County based codes are for statisical use only 3 </li></ul><ul><li>Definition by exclusion 1,3 </li></ul><ul><li>Definitions are economically driven 3 </li></ul><ul><li>Definitions are a distraction </li></ul>
    20. 20. Good things <ul><li>Provide framework for resource allocation </li></ul><ul><li>Brings attention to a problem </li></ul><ul><li>Provides framework for dialogue </li></ul>
    21. 21. Definition <ul><li>Mine: Practicing medicine in an area where geography and population affects patients access to definitive care. </li></ul><ul><li>Microscope Principle </li></ul>
    22. 22. Disclaimer <ul><li>You can trust your government…..just ask the indians. </li></ul><ul><li>I do rez medicine, not just rural medicine </li></ul>
    23. 23. Disclaimer <ul><li>Second busy ed in the state </li></ul><ul><li>Utilizes a marginally functional social medicine system </li></ul><ul><li>No ct scan </li></ul><ul><li>Higher volume of MVC’s and substance abuse related visits than most rural EDs </li></ul><ul><li>“ it’s a ghetto looking for a city”—FP doc of 15yrs </li></ul>
    24. 24. MVC <ul><li>Call on box: three victim single vehicle collision </li></ul><ul><li>Driver and passenger ejected </li></ul><ul><li>EMS dispatched </li></ul>
    25. 25. Rural EMS <ul><li>More likely to be volunteer staffed </li></ul><ul><li>Long transport times </li></ul><ul><li>Cost more to run than urban </li></ul><ul><li>Undertrained </li></ul><ul><li>Underfunded </li></ul><ul><li>Limited medical control </li></ul><ul><li>Hard to retain well-trained people </li></ul>
    26. 26. Rural EMS <ul><li>2000 survey of EMS directors by NASEMD 4 </li></ul><ul><ul><li>88% state covered with EMS same for rural </li></ul></ul><ul><ul><li>Medical Oversight- 76% vs 69% </li></ul></ul><ul><ul><li>E-911- 81% vs 67% </li></ul></ul><ul><ul><li>EMT-P 72%vs 47% </li></ul></ul><ul><ul><li>Communications and retention two main challenges </li></ul></ul>
    27. 27. Funding <ul><li>Sources </li></ul><ul><ul><li>Insurance reimbursements-medicaid 3 </li></ul></ul><ul><ul><li>Local municipalities and taxpayer money </li></ul></ul><ul><li>Rural Challenges </li></ul><ul><ul><li>Less calls less money </li></ul></ul><ul><ul><li>Less population less tax income </li></ul></ul>
    28. 28. Medical Control <ul><li>NAEMSP position paper 5 </li></ul><ul><ul><li>Need to be MD or DO </li></ul></ul><ul><ul><li>Knowledge of local EMS </li></ul></ul><ul><li>Brown et al 6 </li></ul><ul><ul><li>Survey of physicians and lay people </li></ul></ul><ul><ul><li>41% of docs knew ems capability </li></ul></ul><ul><ul><li>49% of laypeople did </li></ul></ul>
    29. 29. Possible Solutions <ul><li>Expanding scope of practice </li></ul><ul><ul><li>Endorsements </li></ul></ul><ul><ul><li>Ancillary ER staff </li></ul></ul><ul><ul><li>ALS and public health? 7 </li></ul></ul><ul><li>Increase funding </li></ul><ul><ul><li>Using emts in above areas </li></ul></ul><ul><ul><li>Rural scholarships </li></ul></ul>
    30. 30. MVC <ul><li>On scene </li></ul><ul><li>Two victims, the third is dead </li></ul><ul><li>#1-30 yo male gcs 10, has nl BP tachy </li></ul><ul><li>#2-17 yo female GCS 12, open tib/fib, screaming, high bp, tachy </li></ul><ul><li>EMS board, collar, scoop, run </li></ul>
    31. 31. ED staffing <ul><li>FP in ED </li></ul><ul><li>No surgeon for 60 mi. </li></ul><ul><li>Two RNs </li></ul><ul><li>No ct scan, xr standing by </li></ul>
    32. 32. Who Staffs the Rural ED <ul><li>AEM 1998 from WV 8 </li></ul><ul><ul><li>7.5% residency trained, 12% BC </li></ul></ul><ul><ul><li>33% not boarded in anything! </li></ul></ul><ul><ul><li>Included low volume ED’s (<10K) </li></ul></ul>
    33. 33. Who Staffs the Rural ED <ul><li>1999 Emergency Medicine Workforce study 9 . </li></ul><ul><ul><li>25% hospitals “rural” </li></ul></ul><ul><ul><li>67% physicians not BE/BC-direct opposite of standard </li></ul></ul><ul><ul><li>40% hospital employee (25% overall) </li></ul></ul>
    34. 34. Who Staffs the Rural ED <ul><li>JEM in (5)2005 10 </li></ul><ul><ul><li>30% BC/BE vs 68%BC/BE </li></ul></ul><ul><ul><li>Similar general admission and ICU admission rates </li></ul></ul><ul><ul><li>10-60k visit ED </li></ul></ul>
    35. 35. IF not EM BE/BC then who????? 9 <ul><li>37% FP </li></ul><ul><li>30% IM </li></ul><ul><li>8% Ped </li></ul><ul><li>5% Gen Surgery </li></ul><ul><li>1% Anes </li></ul>
    36. 36. 16% not residency trained in anything!!!!!
    37. 37. Is a non board certified doc in the ED so bad?
    38. 38. Trauma <ul><li>Hall et al 13(4) JABFP 2000 11 </li></ul><ul><ul><li>Self report of FP grads </li></ul></ul><ul><ul><li>70% uncomfortable with trauma </li></ul></ul><ul><li>Esposito et al in 1995 and 1999 J of Trauma 12,13 </li></ul><ul><ul><li>MT rural trauma deaths and mismanagement </li></ul></ul><ul><ul><li>68% of adults and 36% of pediatrics mismanaged in ED </li></ul></ul>
    39. 39. Airway <ul><li>Levitan et al 14 </li></ul><ul><ul><li>EM residents as good as anesthesia residents </li></ul></ul><ul><li>Esposito et al 1995 and 1999 12,13 </li></ul><ul><ul><li>MT rural trauma deaths and mismanagement </li></ul></ul><ul><ul><li>Airway and chest injury mismanagement </li></ul></ul>
    40. 40. My observations <ul><li>3 FP and 1 IM on staff </li></ul><ul><li>3 with ER experience, 1 without </li></ul><ul><li>All need more airway training </li></ul><ul><li>Two of them do well with peds </li></ul><ul><li>3 do well with trauma </li></ul><ul><li>1 does procedural sedation OK </li></ul>
    41. 41. Barriers to BC Providers <ul><li>Historical </li></ul><ul><ul><li>Most Rural ED’s covered by on call docs 15 </li></ul></ul><ul><ul><li>Lifestyle issues prohibit </li></ul></ul><ul><li>Cost </li></ul><ul><ul><li>-BC/BE cost more 9 </li></ul></ul><ul><ul><li>Williamson et al--$100/pt 15 </li></ul></ul>
    42. 42. Barriers to BC Providers <ul><li>Training Bias 16 </li></ul><ul><ul><li>EM residencies are urban </li></ul></ul><ul><ul><li>Residents are urban </li></ul></ul><ul><ul><li>No rural exposure </li></ul></ul><ul><li>Contract Groups 9,10,15 </li></ul><ul><ul><li>1-29% depending on study </li></ul></ul><ul><ul><li>Use cheapest labor </li></ul></ul>
    43. 43. Options to Improve Care <ul><li>Combined residencies. </li></ul><ul><ul><li>EM/IM </li></ul></ul><ul><ul><li>EM/Peds </li></ul></ul><ul><ul><li>EM/FP? </li></ul></ul><ul><li>EM organizations being more inclusive. </li></ul><ul><ul><li>Williams et al 2001 Annals 16 </li></ul></ul><ul><ul><li>Offering post grad training to FP’s </li></ul></ul>
    44. 44. Options to Improve Care <ul><li>Increase exposure </li></ul><ul><ul><li>Lectures </li></ul></ul><ul><ul><li>Rural rotations </li></ul></ul><ul><ul><li>Colorado medical control model 17 </li></ul></ul>
    45. 45. MVC <ul><li>Pt #1 </li></ul><ul><li>100/p, 120, 16, 98%, GCS 8-9 </li></ul><ul><li>Primary survey </li></ul><ul><li>To intubate or not </li></ul><ul><li>Is his neck cleared? </li></ul>
    46. 46. MVC <ul><li>Pt #2 </li></ul><ul><li>110/p, 140, 40 (screaming) 92% </li></ul><ul><li>Primary survey </li></ul><ul><li>Intubated </li></ul>
    47. 47. MVC <ul><li>Pt #1- HD stable, acetab frx, CHI </li></ul><ul><li>Pt#2- develops tpx, decompressed, ct placed </li></ul>
    48. 48. Future Topics <ul><li>Disposition </li></ul><ul><ul><li>Living without knowing </li></ul></ul><ul><ul><li>Giving good discharge instructions </li></ul></ul><ul><ul><li>How to transfer patients </li></ul></ul><ul><li>Knowing ancillary capabilities </li></ul><ul><ul><li>Lab </li></ul></ul><ul><ul><li>XR(+ read) </li></ul></ul><ul><li>Crossing lines </li></ul>
    49. 49. Future Directions <ul><li>Multitasking Well </li></ul><ul><li>EMS </li></ul><ul><ul><li>Expand paramedic roles </li></ul></ul><ul><ul><li>Improve medical control </li></ul></ul><ul><li>Physician staffing </li></ul><ul><ul><li>Utilize combined residencies </li></ul></ul><ul><ul><li>Decrease exclusive attitudes </li></ul></ul><ul><li>Move everyone to the city. </li></ul>
    50. 50. Consider it if: <ul><li>Playing different roles are fun for you </li></ul><ul><li>You don’t mind being recognized </li></ul><ul><li>You liked to be stretched. </li></ul><ul><li>Its ok not knowing a diagnosis. </li></ul><ul><li>You want leadership roles </li></ul><ul><li>You want to do a lot of procedures. </li></ul>
    51. 51. Do Not Do If: <ul><li>You need rigid roles </li></ul><ul><li>You like anoyminity </li></ul><ul><li>You like being a drone </li></ul><ul><li>Need to know a diagnosis on everyone you see. </li></ul>
    52. 52. references <ul><li>1 http://www.rupri.org/resources/context/rural.html </li></ul><ul><li>2 Hirschfeld et al, Pediatrics. “Emergency Medical Services for Children in Rural and Frontier America..” 7/1995; 96(1pt2): 179-84. </li></ul><ul><li>3 Unknown, An Alternative Approach for Defining Rural….for EMS. http://tasc.ruralhealth.hrsa.gov </li></ul><ul><li>4 Unkown, Challenges of Rural Emergency Medical Services, Opinion Survey of State EMS Directors: June 22, 2000. www.nasemsd.org/rural_emergency_medical_servic.html </li></ul><ul><li>5 Alonso-Serra, H; Prehospital Emergency Care . “Physician Medical Direction in EMS” 1998; 2(2): 153-7. </li></ul><ul><li>6 Brown et al; Prehospital Disaster Medicine . “Public Perceptions of a Rural EMS System” 1996; 11(4): 285-90. </li></ul><ul><li>7 Shoup et al; JEMS , “Red River Project. Expanded Scope Program for New Mexico” 12/1995; 20(12): 43-7. </li></ul><ul><li>8 McGirr et al; Academic Emergency Medicine . “Physicians in Rural West Virginia Emergency Departments…” 5/1998; 5(4):333-6. </li></ul><ul><li>9 Moorhead et al; Annals of Emergency Medicine . ‘A Study of the Workforce in Emergency Medicne 1999”. 7/2002; 40(1): 3-15. </li></ul>
    53. 53. references <ul><li>10 Wadman et al; Journal of Emergency Medicine . “Qualification Discrepancies between Rural and Urban Emergency Department Phsyicians”. 4/2005; 28(3): 273-6. </li></ul><ul><li>11 Hall et al; JABFP. “Colorado Family Practice Graduates’ Preparation for and Practice of Emergency Medicine” 2000; 13(4): 246-50. </li></ul><ul><li>12 Esposito et al; Journal of Trauma. “Anaylysis of Preventable Trauma Deaths….in a Rural State.” 11/1995; 39(5): 955-62. </li></ul><ul><li>13 Esposito et al; Journal of Trauma. “Analysis of Preventable Pediatric Trauma Deaths……in Montana” 8/1999; 47(2): 243-53. </li></ul><ul><li>14 Levitan et al; Annals of Emergency Medicine. “Alternating Day and EM and Anesthesia Residents Responsibility for Managing the Airway” 1/2004; 43(1): 48-53. </li></ul><ul><li>15 Williamson et al; Journal of Rural Health . “Physician Staffing of Small Rural EDs….” 1992; 8(3): 171-7. </li></ul><ul><li>16 Williams et al; Annals of Emergency Medicine. “Emergency Medical Care in Rural America” 9/2001; 38(3): 323-327. </li></ul><ul><li>17 Custalow et al; Academic Emergency Medicine. “Unique Curriculum for Emergency Medicine Residents…” 6/2000; 7(6): 674-8. </li></ul>

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