East Asian Culture the Health

East Asian Culture

The health care system in the United States is often a point of pride within and outside the U.S. Here we have some of the best facilities, doctors and researchers as anywhere in the world. Clearly historically healthcare has been a number one priority of the culture and the government, despite the inability of the nation to establish a universal health care delivery system, instead relying on an intricate set of private and publicly funded institutions that serve the health care needs of the people. Healthcare in the United States offers advancements to this country and the world, especially in the case of specialization in surgical and emergency medical care and also in trauma and emergency medical services.

This being said it is also important to understand why it is so important to have specialized emergency care available, and especially Level I trauma centers in any given community. It is important, because in emergency medicine time matters almost more than anything else with regard to mortality and recovery. This is true with regard to illness or injury and is true regardless of location, be it urban or rural, regardless of socioeconomic status of the individual, and regardless of age of the individual, though the very young and the very old often require special care. Health care subsystems are also important and should be maintained, developed and expanded to meet the needs of as many people as possible. The development of the American College of Surgeons quadratic system of Levels of care ability ranging from Level I to level IV with regard to trauma centers is a significant modern element in the further development of emergency health care in the United States. Yet, there are challenges to the system that require significant interest on the part of the health care systems and those who utilize it and even study it. This work will briefly discuss the history of the Emergency Medical System in the United States, it will address key problems within the system and lastly will look at why it is important to have access to Level I trauma centers in as many communities as possible.

Background

In 1987 the American College of Surgeons created a system of classification and certification for trauma centers that include four classifications and certifications, I-IV, with level I being the highest ranking service, with the greatest level of care offerings, especially with regard to specialized surgical services. The development of such systems is a cumulative one, and frequently needs revision and change, to help it best meet the needs of a changing demographic. The system of Emergency Medicine, in general also has a long history, from the development of war-time triage systems to those that better meet the needs of the civilian crisis situation.

Civilian triage criteria, developed and refined over the past 25 years, rely on physiologic, anatomic, and mechanistic indicators of severe injury in an attempt to optimize overtriage and undertriage. As organized trauma systems continue to mature, the need for more accurate direction of high- versus low-acuity patients to regional centers, stratified by their capabilities, becomes more apparent and is essential in avoiding a completely 'exclusive' trauma system... The care of injured patients requires special resources, regardless of the era or situation. This is particularly so with larger numbers and/or more severe injuries... The development of civilian field triage criteria for trauma has paralleled the development of specialized trauma centers and was linked to the concept of bypassing closer facilities in favor of those with superior capabilities. (Mackersie, Sept. 2006, pg. 1)

The development of the Field Triage decision protocol and its implementation has also clearly impacted the development of a system of emergency medicine that makes immediate decisions based upon patient condition and other factors to determine the best prehospital protocol for service.

In September 1966 the National Academy of Sciences National Research Council outlined the grievous state of affairs in the now classic report entitled, "Accidental Death and Disability: The Neglected Disease of Modern Society" [12]. Only 65% of the nation's ambulance attendants had even "first aid" training; 10% had no training whatsoever. Radio equipment, dispatching, and emergency departments were all grossly inadequate. Fifty percent of "ambulances" were driven by morticians, since they had the only business in town with vehicles that could transport a person horizontally. The Council document prompted the passage of the National Highway Safety Act, which proposed that the Department of Transportation provide guidelines for EMS, that money be allotted for ambulances, equipment, and communications, and that training be made available for prehospital care providers [13]. (O'Brian, 1998, pg. 105)

Without such a system this triage would have to be performed in the hospital ED and in so doing precious time is lost, and the nearest hospital may not be a level 1 trauma center, and unable to provide immediate emergency surgical care. (Mackersie, Sept. 2006, pg. 290)

This set of protocols determines, more than any other set of standards who is treated, in what order and where. Level I -IV trauma center classifications are called for in nearly every community in the world on a daily basis. Though it is true that this need is greater in urban areas, simply because there is a greater concentration of people, the system is needed frequently in rural areas as well and the time it takes to get a person to proper medical care may change but the urgency does not.

Trauma systems provide rapid, organized treatment to critically injured patients. From the out-of-hospital phase through emergency department (ED) treatment, disposition, and rehabilitation, trauma systems help optimize and expedite care. The benefits of an organized trauma system for patient outcomes have been demonstrated in numerous studies. (Fishman et. al., October 2006, pg. 347)

The emergency medical system, as well as the Level System designed and certified by the ACS have undergone changes and requires a high level of compliance, among trauma centers and communities where they are located in several areas, for recertification, which occurs every three years as a service of the American College of Surgeons. In order for a hospital and/or community to be certified as a level I trauma center several conditions must be met and most services must be available 24 hours a day. According to the ACS some of the key elements of a Level I trauma center include 24-hour in house availability of general surgeons and rapid availability of specialized surgeons and support staff, including those in the orthopedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology, internal medicine and critical care. The ACS also demands that a Level I trauma center retain individuals who provide cardiac surgery, hand surgery, microvascular surgery and hemodialysis on a 24-hour on call basis.

In addition there are several other aspects that must be included, in the community and the hospital setting for a trauma center to be certified as a Level I center and those include centers that provide leadership in prevention, public education and continuing education to trauma staff. The center must also be committed to constant improvement and be supportive of a continual quality assessment program and a research driven change process. (Barnes-Jewish Hospital Website at (http://www.barnesjewish.org/groups/default.asp?NavID=1093)

Level I trauma center designation signifies to consumers of the health care system as well as other institutions, who may be in geographic locations that are able to transfer patients to such centers that the center can receive and treat high level traumas in an efficient and life saving manner. Without such a center individuals who live in the area are put at risk for not being able to receive life saving care that could mean not only the difference between life and death but also the difference between any achieved quality of life after the emergency or none, as so many traumatic events, be they as a result of injury or infirmity require a timely response to care that cannot always be achieved if a patient requires transport to different facilities to be treated in the best possible manner, with the best possible known outcome.

Our nation's EDs provide the one point of universal access to our health care system. They are the nation's final safety net. Indeed the public fully expects such access, and it is doubtful that patients realize it is eroding. Yet, policy experts and decision makers seem to be unaware of the trend, and certainly no focused efforts are under way to resolve the problem." (ACS Publication June 2006 A Growing Crisis In Patient Access to Emergency Surgical Care at (http://www.facs.org/ahp/emergcarecrisis.pdf)

The ACS stresses in this publication that the whole of the emergency medical care system is under attack, as it is eroding from within and it is the foundation of the nation's ability to respond to terrorist attacks and natural disasters. "Emergency care capability has never been more important that it is in the post 9/11 world, and the need to strengthen it has never been more urgent." Emergency care has become a more utilized institution than it has ever been and hospitals and EDs are reporting increased numbers of patients and an increased need to divert patients to other hospitals as a result of over census situations or simply as a result of not being able to provide specialized care all of the time. (ACS Publication June 2006 A Growing Crisis In Patient Access to Emergency Surgical Care at (http://www.facs.org/ahp/emergcarecrisis.pdf)

Statement of Problem

There is a growing problem in the ability of individuals and communities to receive care, according to the American College of Surgeons, as the changing face of emergency care and medical care in general is putting patients at risk. The ACS and the AMA have both recently conducted professional surveys that indicate that the source of the problem is a lack of specialized surgical providers to cover existing trauma centers and a lack of those same staff members to help to establish new centers of care in areas, with the lowest numbers of provider services. (ACS Publication June 2006 A Growing Crisis In Patient Access to Emergency Surgical Care at (http://www.facs.org/ahp/emergcarecrisis.pdf)

The ACS Publication A Growing Crisis In Patient Access to Emergency Surgical Care stresses that the existing system is not meeting patients needs, as it should and some of the reasons include the inability of existing surgical specialists to adequately cover the number of trauma centers that exist currently. Those surgery specialists are experiencing a burdensome circumstance of work load that is unsustainable at its current level, according to the article specialists surgeons take call 10 or more days a month with those in less frequently utilized specialties taking call much more frequently than that, and this is on top of the requirements of their often overtaxed professional practice responsibilities. These surgeons also often take call at more than one institution at any given time sighting frequent difficulty managing on call responsibilities. These professionals are also required to take part in on-call panels but are frequently opting out of such responsibilities as a result of the overtaxing nature of their work. Furthermore, such a high number of surgeons have been sued by patients and families for services that began in the emergency department, creating a liability situation that offers a deduction in liability insurance if the surgeon limits or eliminates his or her ED call times, and as liability insurance has skyrocketed for physicians in general over the last twenty or so years many surgical providers are taking this option therefore reducing the availability of surgical specialists even further. (ACS Publication June 2006 at (http://www.facs.org/ahp/emergcarecrisis.pdf)

Another issue that is crucial to the continued improvement, rather than dissolution of the emergency medical care system in the United States is that if nothing is done the system may break down to a point where we return to a time that is reality in most low-middle income nations.

A the absence of organized and trained emergency medical services in most low/middle-income countries. This situation lengthens the critical time interval before trauma victims are treated, contributing to increased morbidity and mortality. Even in the largest hospitals in these countries, internationally accepted guidelines for treatment of trauma and injuries are often not followed, diagnostic and imaging facilities are poorly equipped, resources are strained, and treatment practices routinely used in high-income countries are not being implemented. For example, advances in resuscitation, wound-closing procedures, and infection control have greatly increased the survival of children in the United States who experience massive burns; however, these practices are not yet commonly used in low/middle-income countries. (Hofman, Primack, Keusch, & Hrynknow, Jan. 2005, at (http://hestia.unm.edu.libproxy.unm.edu/search/i0090%2D0036/i00900036/1,1,1,B/l856~b1044007&FF=i00900036&1,1,1,0/startreferer//search/i0090%2D0036/i00900036/1,1,1,B/frameset&FF=i00900036&1,1,/endreferer/)

From this and other information on the history and development of the Emergency Care System within the United States and elsewhere it is easy to determine why it is crucial for these systems to be protected, improved and expanded. This is particularly true in the case of rural health care, which is in and of itself in a serious state of perpetual concern.

Urban areas are more attractive to health care professionals for their comparative social, cultural and professional advantages [13]. Large metropolitan centers offer more opportunities for career and educational advancement, better employment prospects for health professionals and their family (i.e. spouse), easier access to private practice (an important factor in countries where public salaries are low) and lifestyle-related services and amenities, and better access to education opportunities for their children [6,14,15]. In addition, the low status often conferred to those working in rural and remote areas further contributes to health professionals' preference for settling in urban areas, where positions are perceived as more prestigious [16,17]. While it is in the most remote and underserved areas that health problems are more prominent (Dussault & Franceschini, 2006 at (http://www.human-resources-health.com/content/4/1/12)

Though it is hardly the case that there are more doctors that can fill these vacancies, as they are all concentrated in the urban areas, it is also the case that doctors, and especially those in specialties are scarce even in the urban areas and positions often go unfilled. The development of systems that have increased efficiency has to a large extent occurred and yet many people are still considered underserved in the United States populations. The need for Level I trauma centers is essential to the continued success with regard to low mortality rates and decreased emergency deaths.

Why Level I Trauma Centers are Needed

Within many regional locations level I trauma centers are available, and the need for specialized surgical care is to a large degree being met, despite urgent issues about surgical shortages, there are still many locations where these centers are needed. Though life flight systems of emergency medical care, and even specialized web hosting technology sites that link doctors to emergency medical specialized personnel in remote locations are improving the odds for patients in critical care situations where specialized services are not available, there is still urgencies in many cases that warrant even faster service.

In severe weather conditions, such as thunderstorms, heavy snow and fog where visibility and ceiling heights are low, helicopters cannot fly and ground transport to the nearest Level I trauma center could take up precious time in traffic. (Krishnamurthy, 2004, p. 1)

Additionally, emergency care physicians are not always allowed the time to research options, broadband high speed or not, sitting down to a computer screen in order to come up with the best possible treatment option for an emergency trauma is usually not an option. Physicians are busy with critical and non-critical care in the emergency room and this is not a logical option for most.

The reasons they are needed have to do with the efficiency and efficacy of technological medical advances which have been repeatedly proven to reduce emergency deaths. Specialized diagnostic and treatment options must be available to every individual within a relatively short time after trauma event s occur and as more is understood and therefore treatable than ever before there is a greater demand for such services.

Sixty-eight percent of ED administrators surveyed indicated that patient volumes increased in the past 12 months. Eighteen percent indicated that overcrowding, due to increased patient volume, had caused them to divert patients to other hospitals; however, that number was down from 36% in a 2001 survey. Schumacher speculates that the decrease may be because many hospitals have expanded their EDs in response to rising patient numbers and are better able to handle higher volumes. Surprisingly, the lack of specialty coverage seems to be driving patient diversions at most facilities. Of those surveyed, 76% indicated that lack of physician speciality coverage was responsible for diversions -- "up 65% from 2001 -- "and 23% believed the lack of specialty coverage posed a significant risk to their ED patients. An increasing shortage of specialists has made ED coverage more difficult; and rising malpractice rates and uncompensated care make some specialists reluctant to cover the ED. In fact, 15% of the administrators said they would go to a facility other than their own in the event they were seriously injured -- "primarily (73%) due to the lack of specialty backup in their own ED (Emergency Medical Services, July 2004)

It is a difficult testimony that emergency care providers would rather be seen at other institutions as a result of the lack of specialized care in their own institution. Challenges to this systems and its set of subsystems seem imminent and yet not a lot is being done to investigate the causes. Why are individual surgeons not specializing, or is it simply that there are not enough surgeons at all?

The demand for specialized care will not end any time soon and the need for proliferation of Level I trauma centers, into areas where populations are underserved is essential and yet these things do not seem to be occurring at a rate that is significant enough to meet the growing demand that is seen at the local Emergency department level. An issue that is also paramount to answer is why are so many people seeking medical care from EDs when their illnesses and/or injuries are not life threatening. (Emergency Medical Services, July 2004) "...demand for care from these providers among the uninsured exceeded available supply." (Gold, 1998, p. 296) many health care economists would say that available health insurance coverage is often the answer to man of these problems, in fact one expert contends that the reason why specialization is actually waning in the face of increased knowledge, when it should be growing has to do with the development of insurance situations where primary care physicians actually get paid not to refer patients to specialist. This same individual also contends that the growth of the problem is seated not in health care but in the fact that it is for the most part a for profit industry. (Gold, 1998) Though we hear many politicians and for profit organization heads tell us that health care advances would not be possible without the financial incentives that drive the technology of health care the problem is growing and changing, to a degree that many individuals and providers feel that the health insurance company is acting as the physician, telling the patient what kind of care they can and cannot receive, what kind of medications they can and cannot take and what kind of surgery they can and cannot have. This in and of itself undermines the ability of health care providers to do their jobs and it may be a significant reason why level I trauma centers are not available in a regionally equal distribution.

A dedicated trauma service staffed by full-time specialists at hospitals can significantly reduce patient treatment times in the emergency department (ED), help reduce overcrowding, and lower death rates, a Johns Hopkins University, Baltimore, Md., study shows. Researchers compared trauma registry data at The Johns Hopkins Hospital for the three-year time periods immediately before (1995-97) and after (1999-2001) the hospital's implementation of a full-time trauma service. The hospital was designated a Level I trauma center in 1998, featuring 24-hour, in-house coverage by an attending trauma surgeon, a dedicated two-bed triage admitting unit, and a regular emergency care core curriculum for physicians, nurses, and medical students. The number of major cases increased from 2,240 to 2,513 over the two time periods. The average time in the ED for those going to the operating room, intensive care unit, or observation wards all decreased: from 84 to 52 minutes for operating room patients; from 197 to 118 minutes for intensive care unit patients; and from 300 to 140 minutes for patients headed to the observation wards. Moreover, the number of hours the center was closed to new patients because of ED overcrowding decreased from 56 to 2.7 hours pen month. The study also found a decline in hospital lengths of stay among trauma patients, from 4.3 to 3.8 days, and a reduction in mortality rates among blunt trauma patients, from 7.2 to five percent. ("Trauma Teams to the, Rescue " 2003, pg 1)

Despite the growing evidence that Level I trauma designation seriously addresses many of the risk factors that are increasing as the days go by with regard to overcrowding and other issues, there is a sense that certification is to costly and also a strong belief, that is often founded in the inability of regional hospitals to recruit the needed specialists to achieve certification.

The closure of Las Vegas' only Level-I trauma center this week is believed to be the nation's first in an urban area of more than 1 million residents and one of the first caused by an inability of doctors to find affordable medical liability insurance.But no one rules out the possibility that sharply rising insurance rates could become a factor in more such shutdowns of trauma facilities, which provide rapid treatment for critical injuries when timely care can make the difference between life and death."In some single-hospital communities, the liability crisis could push some" trauma centers or other units where risks are considered greater "to the edge," Rick Wade, senior vice president of the American Hospital Association, said in an interview."Trauma centers usually close because they are small and have financial competition," said Dr. John Fildes, medical director of the 10-year-old trauma unit at the University of Nevada Medical Center (UMC) in Las Vegas, reportedly one of the 10 busiest in the United States, which closed for business at 7 a.m. Wednesday."But we were forced to close" as a result of mass resignations of physicians from "high-risk" activities because they've been unable to find medical malpractice insurance they can afford, Dr. Fildes said in a telephone interview. He said the physicians concluded this drastic step was necessary to "protect their livelihoods and their families."Everyone has been charged two to three times higher rates" this year than last, he added.As a result, 11 of UMC's 13 general trauma surgeons and 57 of 58 orthopedic surgeons resigned from trauma-care responsibilities. ("Las Vegas Trauma Center," 2002, p. A04)