Emergency Department Thoracotomy Question Raises Larger Issues urrent debate about emergency department thoracotomy provides a d r a m a t i c forum for e m e r g e n c y medicine's struggle to assert its identity. Similar to the historical maturation of v i r t u a l l y all other specialities, confrontations about patient care between emergency physicians and more established specialists occur every day in almost every hospital in the country. For m a n y years, discrepancies in good p a t i e n t care have t a k e n the form of telephone consultations in which doctors at home give "orders" for patients who are actually under the direct care of emergency physicians. More recently, surgeons have openly criticized emergency physicians for utilizing life-saving surgical procedures. Appallingly, the ACEP 1979 Scientific Assembly offers a symposium given by a "traditional" specialist who will a t t e m p t to i n s t r u c t e m e r g e n c y physicians about what they can and cannot do for him. The time has come for emergency medicine to grow up. In the best interests of patients, emergency medicine leadership must begin to more clearly define and defend the parameters of the practice. Recognizing their unique position of providing direct, constant, and i m m e d i a t e p r i m a r y care, emergency physicians will have to insist upon fulfilling their own legal and moral responsibilities to their patients. As an example, "Emergency Department Thoracotomies in a C o m m u n i t y Hospital" by MacDonald and McDowell (7:423-428, 1978) documents three cases in which victims of penetrating wounds of the heart who might have been dead on arrival were instead successfully resuscitated by open thoracotomy performed by emergency department physicians. This admirable accomplishment attests to the increasing capabilities a n d responsibilities of emergency physicians and the progress of emergency medicine as a specific and necessary branch of medical practice. In an accompanying editorial, Kenneth L. Mattox, MD, ponders whether those three patients would have been as well off and whether the other 25 patients reported would have been better off if they all had been taken to another facility in the metropolitan a r e a w i t h ~ . . . much l a r g e r experience with both penetrating and blunt trauma." Dr. Mattox devotes fully three fifths of his editorial to the familiar yet unresolved "political" questions about community hospital emergency departments versus t r a u m a centers. He concludes t h a t such political questions are the domain of the county medical societies, the regional EMS planners, and others. Aside from serious doubts about whether most county medical societies, EMS planning committees, or "others" are capable of formulating efficacious solutions to these complex problems, I must suggest t h a t specific questions about emergency medical care must first be addressed by those of us who devote ourselves full-time to emergency care of the sick and injured. Now, the standard arguments r e g a r d i n g time-oft r a n s i t versus the q u a l ! t y - o f - c a r e - a t - t h e - a d m i t t i n g facility may be defensible in favor of t r a u m a centers for some kinds and degrees of injuries. Without question, however, for penetrating wounds of the heart accompanied by absence of vital signs, the time element becomes the compelling factor. Even a few minutes
will make the difference of whether these patients will survive or function normally again. To make matters worse, the c a r d i o p u l m o n a r y r e s u s c i t a t i o n skills of paramedics are useless for patients with pericardial tamponade and cardiac standstill. Dr. Mattox says "Do not meddle with an obviously dead patient." But the principle for salvaging patients with cardiac trauma says the opposite. Most of us who have practiced t r a u m a surgery and emergency medicine have seen patients recover from penetrating wounds of the heart and thoracotomy in the emergency department who were otherwise ~obviously dead." Indeed, one must seriously doubt whether the three patients reported by MacDonald and McDowell would have survived a more prolonged ambulance ride to the "nearby" county hospital where they would have been even more "obviously dead." Continuing in a political vein, Dr. Mattox raises the question, "Is the emergency physician being encouraged to participate in operative intervention or has he merely grasped the opportunity?" Aside from the chauvinistic implications of its rhetoric, Dr. Mattox's "either/or" question is answered - - neither. More i m p o r t a n t l y , it d o e n ' t m a t t e r . The . p r a c t i c e of emergency medicine is not a function of the desires of the medical community, neither the "encouragement of p a r t i c i p a t i o n " by the e s t a b l i s h e d specialists nor "grasping at opportunity" by those seen as striplings by the medical hierarchy. Emergency medicine has grown out of the needs of patients. Because of a willi n g n e s s to be i m m e d i a t e l y a v a i l a b l e , e m e r g e n c y physicians have simply moved in to fill voids in lifesaving care which have existed for years in both metropolitan and rural hospitals. Furthermore, once they have become e s t a b l i s h e d and skilled, t h e r e is no reason why emergency physicians should not perform procedures within the scope of emergency care regardless of whatever other specialists might be available. Dr. Mattox says he does not know who is encouraging emergency physicians to apply aggressive resuscitative techniques, including emergency thoracotomy. Answer - - I am. And so are many other thoughtful people. I strongly encourage it because it Will save patients' lives. In most geographic locations - - rural, suburban and metropolitan - - a competent emergency physician in the nearest hospital will be the only person who can perform thoracotomy in time to save victims of p e n e t r a t i n g cardiac t r a u m a with tamponade and standstill. Even in t r a u m a centers on occasion, or in hospitals with surgeons "in-house," the emergency physician m a y not be able to wait for phone calls to summon surgeons or surgery residents from o p e r a t i n g rooms or o t h e r d u t i e s , because thoracotomy must be done immediately., Furthermore, in many hospitals, a competent emergency physician may be better qualified to handle these resuscitative measures t h a n some general surgeons who might be available but, because of training, experience or personality, not highly qualified to handle trauma. Indeed, with more improvement in skills and appropriate recognition by other specialists, emergency physicians should someday be teaching the younger and less experienced surgery residents about indications,
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JACEP
8:9 (September) 1979
operative skills, arid complications of e m e r g e n c y dep a r t m e n t thoracotomy, E m e r g e n c y p h y s i c i a n s should be encouraged to perfect a n d practice the skills of t h o r a c o t o m y in the e m e r g e n c y d e p a r t m e n t for p a t i e n t s w i t h c a r d i a c t r a u m a a c c o m p a n i e d by p e r i c a r d i a l t a m p o n a d e a n d cardiac standstill. Such o p e r a t i v e skills are not only a
n a t u r a l p a r t of the t h e r a p e u t i c a r m a m e n t a r i u m of the c o m p l e a t e m e r g e n c y p h y s i c i a n , t h e y become absolutely n e c e s s a r y when m o r i b u n d p a t i e n t s w i t h wounds of the h e a r t a r e b r o u g h t into the emergency department.
Myron K. Denney, MD, FACS San Leandro, California
The Time Has Arrived for a Concerted Public Relations Thrust i r e c e n t l y came across a p r o m o t i o n a l piece publicizing a m a r k e t i n g seminar. Not j u s t a s e m i n a r , m i n d you, but a marketing warfare seminar! Corporations now a r e a d a p t i n g m i l i t a r y t e c h n i q u e s to t h e i r m a r k e t i n g strategies. Courage, boldness, and decisiveness can p a y big dividends on today's m a r k e t i n g battlefields. These corporations know t h a t in today's socio-economic climate, it is necessary to s t r i k e h a r d and often. They t a k e m a r k e t i n g offensives to achieve t h e i r sales goals. These offensives are necessary to m a t c h competition; t h e y a r e essential for survival! P h y s i c i a n s are p r e t t y much in the s a m e situation. In recent months, medicine and its p r a c t i t i o n e r s have been p u t on the defensive by i n n u e n d o s in n e w s p a p e r and m a g a z i n e articles and on radio a n d television. We have, indeed, our own little "war" w i t h those who would discredit our profession. If we don't p a r t i c u l a r l y care a b o u t our r e p u t a t i o n s and the s u r v i v a l of our profession, we can close our eyes and m i n d s a n d believe no problems exist. However, if we a r e r e a l i s t s - - and I t h i n k we a r e - - we m u s t t a k e an offensive posture and let the public, legislators, media, and the centers of influence know t h a t we do contribute to the good of society. In o t h e r words, the time has a r r i v e d for a concerted public r e l a t i o n s t h r u s t by ACEP. Public r e l a t i o n s has many definitions. The 6ne I like best is D O I N G A GOOD JOB AND G E T T I N G CREDIT F O R IT! The "tools" used by corporate public r e l a t i o n s can easily be used by e m e r g e n c y p h y s i c i a n s : p u b l i c i t y , community activities, speeches, press conferences, radio and television appearances, and n e w s p a p e r interviews. Simply stated, the end r e s u l t of a public r e l a t i o n s effort is goodwill. Public relations is, a f t e r all, k n o w i n g how to get along w i t h others - - l e t t i n g people know who you are, what you are, w h a t you believe, and w h a t you stand
ble public opinion is so i n t a n g i b l e it is difficult to appraise. I n business, a c c o u n t a n t s m a y insist t h a t goodwill h a s no place on a b a l a n c e sheet. Yet t h e r e have been m a n y instances in which businesses have been sold at ten to t w e n t y t i m e s t h e i r net worth because of the goodwill t h e y enjoy. Public r e l a t i o n s is, as I see it, an u n d e r t a k i n g req u i r i n g two-way i n t e r p r e t a t i o n and communications. It i n t e r p r e t s the v i e w p o i n t of the public toward emergency p h y s i c i a n s (in our case) and it communicates the resulting activities of e m e r g e n c y physicians to the public. The u l t i m a t e purpose is, of course, to win public favor for our organization. Good public r e l a t i o n s can be the r e s u l t of m a n y l i t t l e t h i n g s t h a t we do i n d i v i d u a l l y as well as the r e s u l t of s t r a t e g i c a l l y p l a n n e d projects. Some public r e l a t i o n s professionals h a v e told me t h a t an effective p r o g r a m is composed of two parts: int e r n a l a n d external. Since good public relations "begins at home," our first considerations should be e s t a b l i s h i n g policy and s t r a t e g y from within. One way to do this is f o r each of us to become more active in our organization. I cannot stress t h a t point too often. Only w i t h our own "house in order" can we hope to pursue e x t e r n a l public r e l a t i o n s goals. The t r a d i t i o n a l idea of public relations is t h a t it is s o m e t h i n g to be done when a n emergency arises, and t h e n it m u s t be done as quickly - - and as cheaply - - as possible. F a r too m a n y organizations operate on t h a t hit or miss basis. Today's concept of public r e l a t i o n s is t h a t it is a job to be done y e a r in a n d y e a r out in o r d e r to prev e n t adverse s i t u a t i o n s from developing! I feel the t i m e h a s a r r i v e d for A C E P to become sophisticated in its a p p r o a c h to public relations. This is my sincere r e c o m m e n d a t i o n to our organization.
William D. O'Riordan, MD Chairman, ACEP Public Information and Legislation Committee
for. A c t u a l l y , the v a l u e of goodwill a r i s i n g from favora-
8:9 (September) 1979
JACEP
386/77
will make the difference of whether these patients will survive or function normally again. To make matters worse, the c a r d i o p u l m o n a r y r e s u s c i t a t i o n skills of paramedics are useless for patients with pericardial tamponade and cardiac standstill. Dr. Mattox says "Do not meddle with an obviously dead patient." But the principle for salvaging patients with cardiac trauma says the opposite. Most of us who have practiced t r a u m a surgery and emergency medicine have seen patients recover from penetrating wounds of the heart and thoracotomy in the emergency department who were otherwise ~obviously dead." Indeed, one must seriously doubt whether the three patients reported by MacDonald and McDowell would have survived a more prolonged ambulance ride to the "nearby" county hospital where they would have been even more "obviously dead." Continuing in a political vein, Dr. Mattox raises the question, "Is the emergency physician being encouraged to participate in operative intervention or has he merely grasped the opportunity?" Aside from the chauvinistic implications of its rhetoric, Dr. Mattox's "either/or" question is answered - - neither. More i m p o r t a n t l y , it d o e n ' t m a t t e r . The . p r a c t i c e of emergency medicine is not a function of the desires of the medical community, neither the "encouragement of p a r t i c i p a t i o n " by the e s t a b l i s h e d specialists nor "grasping at opportunity" by those seen as striplings by the medical hierarchy. Emergency medicine has grown out of the needs of patients. Because of a willi n g n e s s to be i m m e d i a t e l y a v a i l a b l e , e m e r g e n c y physicians have simply moved in to fill voids in lifesaving care which have existed for years in both metropolitan and rural hospitals. Furthermore, once they have become e s t a b l i s h e d and skilled, t h e r e is no reason why emergency physicians should not perform procedures within the scope of emergency care regardless of whatever other specialists might be available. Dr. Mattox says he does not know who is encouraging emergency physicians to apply aggressive resuscitative techniques, including emergency thoracotomy. Answer - - I am. And so are many other thoughtful people. I strongly encourage it because it Will save patients' lives. In most geographic locations - - rural, suburban and metropolitan - - a competent emergency physician in the nearest hospital will be the only person who can perform thoracotomy in time to save victims of p e n e t r a t i n g cardiac t r a u m a with tamponade and standstill. Even in t r a u m a centers on occasion, or in hospitals with surgeons "in-house," the emergency physician m a y not be able to wait for phone calls to summon surgeons or surgery residents from o p e r a t i n g rooms or o t h e r d u t i e s , because thoracotomy must be done immediately., Furthermore, in many hospitals, a competent emergency physician may be better qualified to handle these resuscitative measures t h a n some general surgeons who might be available but, because of training, experience or personality, not highly qualified to handle trauma. Indeed, with more improvement in skills and appropriate recognition by other specialists, emergency physicians should someday be teaching the younger and less experienced surgery residents about indications,
c
76/385
JACEP
8:9 (September) 1979
operative skills, arid complications of e m e r g e n c y dep a r t m e n t thoracotomy, E m e r g e n c y p h y s i c i a n s should be encouraged to perfect a n d practice the skills of t h o r a c o t o m y in the e m e r g e n c y d e p a r t m e n t for p a t i e n t s w i t h c a r d i a c t r a u m a a c c o m p a n i e d by p e r i c a r d i a l t a m p o n a d e a n d cardiac standstill. Such o p e r a t i v e skills are not only a
n a t u r a l p a r t of the t h e r a p e u t i c a r m a m e n t a r i u m of the c o m p l e a t e m e r g e n c y p h y s i c i a n , t h e y become absolutely n e c e s s a r y when m o r i b u n d p a t i e n t s w i t h wounds of the h e a r t a r e b r o u g h t into the emergency department.
Myron K. Denney, MD, FACS San Leandro, California
The Time Has Arrived for a Concerted Public Relations Thrust i r e c e n t l y came across a p r o m o t i o n a l piece publicizing a m a r k e t i n g seminar. Not j u s t a s e m i n a r , m i n d you, but a marketing warfare seminar! Corporations now a r e a d a p t i n g m i l i t a r y t e c h n i q u e s to t h e i r m a r k e t i n g strategies. Courage, boldness, and decisiveness can p a y big dividends on today's m a r k e t i n g battlefields. These corporations know t h a t in today's socio-economic climate, it is necessary to s t r i k e h a r d and often. They t a k e m a r k e t i n g offensives to achieve t h e i r sales goals. These offensives are necessary to m a t c h competition; t h e y a r e essential for survival! P h y s i c i a n s are p r e t t y much in the s a m e situation. In recent months, medicine and its p r a c t i t i o n e r s have been p u t on the defensive by i n n u e n d o s in n e w s p a p e r and m a g a z i n e articles and on radio a n d television. We have, indeed, our own little "war" w i t h those who would discredit our profession. If we don't p a r t i c u l a r l y care a b o u t our r e p u t a t i o n s and the s u r v i v a l of our profession, we can close our eyes and m i n d s a n d believe no problems exist. However, if we a r e r e a l i s t s - - and I t h i n k we a r e - - we m u s t t a k e an offensive posture and let the public, legislators, media, and the centers of influence know t h a t we do contribute to the good of society. In o t h e r words, the time has a r r i v e d for a concerted public r e l a t i o n s t h r u s t by ACEP. Public r e l a t i o n s has many definitions. The 6ne I like best is D O I N G A GOOD JOB AND G E T T I N G CREDIT F O R IT! The "tools" used by corporate public r e l a t i o n s can easily be used by e m e r g e n c y p h y s i c i a n s : p u b l i c i t y , community activities, speeches, press conferences, radio and television appearances, and n e w s p a p e r interviews. Simply stated, the end r e s u l t of a public r e l a t i o n s effort is goodwill. Public relations is, a f t e r all, k n o w i n g how to get along w i t h others - - l e t t i n g people know who you are, what you are, w h a t you believe, and w h a t you stand
ble public opinion is so i n t a n g i b l e it is difficult to appraise. I n business, a c c o u n t a n t s m a y insist t h a t goodwill h a s no place on a b a l a n c e sheet. Yet t h e r e have been m a n y instances in which businesses have been sold at ten to t w e n t y t i m e s t h e i r net worth because of the goodwill t h e y enjoy. Public r e l a t i o n s is, as I see it, an u n d e r t a k i n g req u i r i n g two-way i n t e r p r e t a t i o n and communications. It i n t e r p r e t s the v i e w p o i n t of the public toward emergency p h y s i c i a n s (in our case) and it communicates the resulting activities of e m e r g e n c y physicians to the public. The u l t i m a t e purpose is, of course, to win public favor for our organization. Good public r e l a t i o n s can be the r e s u l t of m a n y l i t t l e t h i n g s t h a t we do i n d i v i d u a l l y as well as the r e s u l t of s t r a t e g i c a l l y p l a n n e d projects. Some public r e l a t i o n s professionals h a v e told me t h a t an effective p r o g r a m is composed of two parts: int e r n a l a n d external. Since good public relations "begins at home," our first considerations should be e s t a b l i s h i n g policy and s t r a t e g y from within. One way to do this is f o r each of us to become more active in our organization. I cannot stress t h a t point too often. Only w i t h our own "house in order" can we hope to pursue e x t e r n a l public r e l a t i o n s goals. The t r a d i t i o n a l idea of public relations is t h a t it is s o m e t h i n g to be done when a n emergency arises, and t h e n it m u s t be done as quickly - - and as cheaply - - as possible. F a r too m a n y organizations operate on t h a t hit or miss basis. Today's concept of public r e l a t i o n s is t h a t it is a job to be done y e a r in a n d y e a r out in o r d e r to prev e n t adverse s i t u a t i o n s from developing! I feel the t i m e h a s a r r i v e d for A C E P to become sophisticated in its a p p r o a c h to public relations. This is my sincere r e c o m m e n d a t i o n to our organization.
William D. O'Riordan, MD Chairman, ACEP Public Information and Legislation Committee
for. A c t u a l l y , the v a l u e of goodwill a r i s i n g from favora-
8:9 (September) 1979
JACEP
386/77
