Summer Blockbusters By Neal E. Flomenbaum, MD, Editor-in-Chief

In June, the Institute of Medicine (IOM) of the National Academies issued three reports on the future of emergency care in the United States. Last month, I considered the report entitled “Hospital-Based Emergency Care.” This month, I would like to offer some observations on the other two reports, “Emergency Medical Services” and “Emergency Care for Children.”

The IOM report on emergency medical services (EMS) notes that after providing the fuel that powered the considerable advances in prehospital care in the 1970s, federal funding declined abruptly in the 1980s. Prehospital care in the United States currently suffers from a lack of coordination, a lack of nationwide training and care standards, and a lack of resources necessary for its important new role in disaster preparedness. Some of these issues—not to mention what will be necessary to fix them—are beyond the scope of the practicing emergency physician.

But if EMTs and paramedics are the first responders, then we are the first responders to the first responders. There are great advantages to having a seamless continuum of care from the time when contact is first established with a patient through arrival in the emergency department. Although we are trained to be able to handle “anyone, anything, anytime,” as the title of a new book about emergency medicine suggests, think how much more we could do if we had a brief but accurate description of the patient one minute or five minutes or 15 minutes before arrival.

In some areas of the country this may not be an issue. But in those areas where hospitals are served by a variety of ambulances dispatched from multiple locations, the notifications are often irregular, undependable, or nonexistent. Eliminating the problems with this interface is an important goal of the IOM report and not beyond the capacity of emergency physicians to advance by meeting regularly with local prehospital care providers.

In one sense, many of the problems preventing optimum emergency care for children are at the opposite extreme of those discussed in the IOM report on EMS. The EMS report points out that there are 16 million ambulance transports each year, with a large percentage involving elderly patients. On the other hand, although the percentage of annual pediatric visits to the emergency department may be as high as 25% of total visits, the percentage of infants and children with severe or life-threatening illnesses is lower than in the adult population.

Nevertheless, ensuring optimum care of sick infants and children requires appropriately trained emergency department physicians and nurses on duty 24/7.

Keeping a facility adequately staffed through the night with staff capable of caring for sick children may be an expensive proposition. Even more of a challenge is ensuring that emergency physicians maintain the appropriate skill level for procedures performed relatively infrequently. These are the two major problems that must be solved if pediatric patients are to receive adequate emergency care at all hours, and it is unfortunate that the IOM report does not offer more specific recommendations on how to solve them.

Ironically, by releasing their three reports simultaneously, the IOM has replicated a problem that afflicts both EMS and pediatrics. Issues in those areas receive much less attention than the “adult” problems of overcrowding and hospital diversion. Similarly, there is reason to be concerned that the IOM’s 2006 reports will not have as much impact in driving changes as its 2000 report on medical errors. Perhaps the IOM should have paid more attention to the Hollywood studios and not released all three of its “blockbusters” at the same time.

Emerg Med 38(8):6, 2006