At the End of the Ambulance Ride

Medicine
Zachary Meisel '89
Assistant Professor of Emergency Medicine,
University of Pennsylvania School of Medicine

An ambulance—jarring pitch and relentless pulse—threads through a busy street. The scene is universally emblematic of a city. In Philadelphia, many ambulances bring their patients to the Pennsylvania Hospital, part of the University of Pennsylvania Health System, where Zachary Meisel ’89, assistant professor of emergency medicine, helps patients who arrive get the care they need, as quickly as possible.

Zach is interested in ambulances. He is both a clinician and a researcher, and his research has focused on the quality of care during those transitions that patients experience—for instance as they move from home, to ambulance, to hospital. You may have read one of his essays in Slate.com. His research indicates that relatively simple changes standardizing certain systems would reduce errors that may happen in ambulances; and he wants to make sure that valuable information and observations that EMTs or paramedics have gathered moves expeditiously to the decision-making team in the hospital.

Apart from the drama that unfolds weekly on ER, what would drive someone in medical training to specialize in emergency medicine? Zach’s wife (a gynecologist) teases him by pointing to the Neilson ratings for ER: they were peaking when Zach made his choice. Not a factor, says Zach, but at that time emergency medicine was gaining widespread recognition as a bona fide specialty. “The first training directed exclusively to this field happened in the late ’60s and ’70s, but the major East Coast hospitals didn’t buy in until the ’80s and ’90s,” Zach says. The specialty is based on the idea that time-sensitive care is essential to the overall well-being of individuals with certain illnesses. “One of the draws for me was that this specialty had tremendous opportunity for growth.”

Zach went to medical school at Johns Hopkins and participated there in medical situations coming out of a true cross-section of urban life. “The field is very dynamic: experience is so informative and you can make a difference quickly. I was also interested in academics and the young nature of the specialty made it ripe for new entries.

“Academic medicine runs the risk of becoming very ivory tower-esque, but I enjoyed seeing patients, being in the trenches; emergency medicine is a neat fusion and a true antidote to the ivory tower phenomenon. I’m constantly exposed to real life, and I’m afraid otherwise that I wouldn’t be able to envision how to make health care better for people. We’re the front door.

“Specializing in emergency medicine means looking at the time-sensitive, acute issues that develop in many different illnesses. The variety we see is both compelling and intimidating. I am always seeing something that I’ve never seen—or at least haven’t seen recently.”

The idea that emergency departments are full of people who have either waited too long to respond to their symptoms, or who are inappropriately looking for care, is more myth than reality. The majority are sick and need care. “Yes, many have illnesses that could be better managed than they are—mental illness, drug and alcohol addiction, diseases associated with poverty—but the numbers that inappropriately seek emergency care are quite low.”

The irony that many who need care quickly wait six to 12 hours for the completion of their emergency department visit, is not lost. “That’s a tough nut to crack,” Zach says, “and it may be harder for the practitioner than for the patient.”

To a certain extent, “we are the victims of our own success,” Zach notes. The crowding in emergency departments happens partly because so many people rely on that system—the medical safety net that will reliably give patients what they need. Many of the crowding problems relate, however, to what Zach calls “throughput issues,” locating in-house beds and nursing staff.

The mandate of an emergency department is to take care of everyone with medical need. The hospital, however, has “incentive issues”: hospitals like to admit insured patients. The emergency department is a hospital’s main intake source and is therefore critical to the hospital’s bottom line. The upshot is that elective orthopedic or surgical patients are always going to be more desirable for available beds, with the bottom line in mind, than a homeless man with diabetes.

Issues about absorbing the cost of uninsured patients relate to major national policy questions. People are talking about them in many forums, as evidenced by national polls and Democratic and Republican presidential campaign policy engines. The cost-of-care questions relate, as well, to Zach’s research, which is focused on fewer mistakes, increased efficiency, and reliable quality of emergency care for sick people during medical transition time, or pre-hospital care.

This research grew out of Zach’s experience with a group of injury-control scientists at Johns Hopkins. They pioneered concepts in preventing injury by focusing on the weakest links in a web, or network, of factors related to an injury. Focusing on the weak links that were causal, they found that dollars spent on passive system changes (things like guard rails on roadways, air bags, required seat belts) were far more efficient in preventing injuries than dollars spent in changing practices, e.g., required drivers’ education.

During the pre-hospital stage of emergency care, opportunities exist to design systems and standardize procedures that could have a major impact with respect to both communication and treatment. Zach explains, “We’re developing a program, for instance, in cooperation with other Philadelphia emergency departments, to identify in the field what sort of resources will be needed, case by case, when the patient gets to the medical center. Based on observations and a few quick questions, the EMTs can know enough to be able to assess which hospital (at that moment in time) would be best able to provide the right resources. We aim to nuance the treatment by collecting information early. This helps with overcrowding and it more efficiently connects the right medical center with each patient.”

Compiling data on what happens before a patient gets to the hospital is difficult: information from EMTs, paramedics and emergency department staff is anecdotal, retrospective, and avoids naming mistakes. “We have to use creative communication to destigmatize mistakes, to get at how important improving things is,” says Zach.

In the face of how difficult it is to collect relevant data, the fact that responses from lay readers of Zach’s writing for Slate magazine have been extremely informative is ironic. EMTs, paramedics and others who don’t read medical specialty journals write on this topic to Zach, sharing experience and insight that may not come through formal channels.

Zach has written periodically for Slate over three years. Does he see himself among the new, widely read medical writers like Atul Gawandi and Jerome Groopman, opening up the field to general readers? “There’s no question that so much medical reporting is superficial, politically driven and even wrong,” Zach says. As a history major in college he wrote his thesis on “how the polio epidemic was popularized, used, abused, and disseminated to the public.”

“Medical articles often don’t say what you want them to say—things that would truly be helpful,” Zach says. “In addition, the emergency doctor is frequently the victim of problematic reporting. During meningitis scares, for instance, we get three or four times the number of people complaining of that complex of symptoms. I do look forward, in the future, to thinking about ways to bridge my true calling, which is taking care of patients, with my interest in writing, in communication.”

Taking care of Philadelphia’s acutely sick patients is Zach’s primary focus. The commitment includes an awareness of the barriers to good care in our society and a willingness to direct research and collaborative action toward improving care. The crowding in emergency departments is a well-known challenge, as is the number of languages among today’s patient population. Appropriate follow-up to the emergency care, so that patients are better able to manage their underlying chronic conditions (and perhaps avoid future emergency visits) is difficult. “You can do everything within your power to assure the best follow-up, but you can’t control what happens. You can steer the patient in the direction of the resources he needs, but he may not take the next steps. Or people can do all the right things but then not be able to stick with the plan: a specialist visit might involve three weeks of waiting, for instance. Persisting becomes even more problematic for the underinsured, or underhoused. These issues become part of the emergency physician’s decision making with regard to admitting a patient or not. If you know that his condition would be improved by a workup that included an MRI or a stress test, and that admitting him would mean he’d likely get those tests, that becomes a major consideration.”

Overcoming a community perception of emergency departments as repositories of people who take advantage of the system is crucial, Zach feels. “The idea of inappropriate care is often spun as ‘people who are poor use emergency rooms because they get good free care.’ Our departments are valuable to a community; we are the safety net. As the front door to care, we have a great opportunity to identify people at risk and to bring diverse resources to bear so that their ability to negotiate life improves, and that those with lifetime diseases don’t become even more complicated problems to the system later.” Lack of resources to accomplish that effectively, lack of a long-term view to a better plan, is—as always—the elephant in the room.

CDE

Starting next July, Zach will be a Robert Wood Johnson Clinical Scholar at Penn—taking a short-term break from heavy clinical duties to shore up some of his skills, the better to pursue the questions that interest him.

 

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