The Pittsburgh Press from Pittsburgh, Pennsylvania • Page 18

A18 The Pittsburgh Press Sunday, September 9. 1984 Emergency Jrom page Al ERNST STRAUSS 910 911 Stylish and understated the signature of an Ernst Strauss creation. His exquisitely tailored collection of suits, coats, separates are versatile enough to work for you from sunrise to sunset, yet dramatic enough to attract attention. INFORMAL MODELING tals, Allegheny General, Mercy and West Penn. Major differences were found between the practices in these hospitals and Presbyterian-Univer- sity's.

For example, Allegheny General, Mercy and West Penn have between seven and nine full-time physicians on their emergency department staffs. Presbyterian's emergency department has one full-time physician. Levey says that one full-time physician is adequate for the 23,000 patients that go through Presbyterian's ER in a year. "Given the volume of business and what we do and what our goals are we run a first class program," he says. "To run their emergency rooms, Mercy and West Penn would have to have physicians in their emergency rooms," Levey says.

"We have dif-. ferent kinds of interns and residents that come to this kind of hospital. We're getting the cream of the crop this university hospital." "The volume of business in Presby's emergency room is not very great," the chief of medicine says. "It's not, as emergency rooms go, very active." However, the difference in emergency room volume at other emergency departments is only slightly greater, with Mercy seeing 25,000 patients and West Penn, 26,200 a year. Levey says "most of the (training hospitals) are doing it exactly the way we are doing it." But doctors at other training hospital disagree.

The Press contacted Massachusetts General, where Levey trained in 1965 and 1966, and 21 other Please see Emergency, A19 to stop it. Levey and hospital President Daniel Stickler say that at night and on weekends, when the attending physicians are not on duty in the emergency room, there are experienced physicians elsewhere in the hospital that the residents can call. However, Whipkey says "it rarely happens. They (the residents) almost always make the decisions themselves because they think what they are doing is right" Not so, says Levey. "The faculty is here.

We're called in if there's a reason to call us," he says. "I'm confident that they call us more often than they don Whipkey says the residents don't view the incoming patients from the perspective of what emergency medicine demands. "One day we were told that a patient was coming in from the Hill (District) who had fallen 30 feet from a window and landed on his back. His blood pressure was low, he was breathing fast and in severe pain. I urged the attending to get the trauma room ready or at least get people prepared to handle this patient and he couldn't understand the urgency.

We got into a screaming match before he agreed to pay the proper attention to the incoming patient who wound up having a fractured spine." Stickler says the hospital's medical supervision is appropriate and is handled the way it is usually done at other hospitals. "I don't consider it an untoward risk to the quality of patient care," he says. The Press closely examined the staffing and supervision in the emergency departments of three of Pittsburgh's major teaching hospi- 5433 Walnut PA 15232 Monday thru Saturday 10 a.m.-5 p.m. Wednesday Until 8:30 p.m. (412) 621-1000 their neck," Vollmer says.

Heller did not return telephone calls placed to him by The Press. Neither Peitzman nor any of the other doctors at Presbyterian would comment on the record. Stewart is director of the Center for Emergency Medicine of Western Pennsylvania, a group created by the university hospitals to promote research and education in emergency medicine. Under the center, Presbyterian, Mercy and West Penn hospitals created a residencyprogram in emergency medicine. Those residents are not allowed to work in Presbyterian's emergency room because Levey says including them would mean "too many physicians for too few patients." Last year, a pilot project to assign senior emergency medicine residents to Presbyterian's emergency, for the purpose of adding some supervision, was scrubbed after only five months.

Physicians in that program say it was too frustrating to watch what was happening and not be able to change anything. The first to be assigned was Dr. Robert Whipkey, now on the emergency department staff at West Penn. "The medical residents made it clear that they didn't want us, and they insisted on continuing to do things their own way," Whipkey says. "As an emergency physician trained in acute care and outpatient medicine, I just don't think they always give quality care to the patients at Presby's ER," Whipkey says.

"The review, the examination of the patients that were seen while I was there, was inadequate. Things were missed because the supervising expertise wasn't there." "For hours, every day, there is just no one watching what the residents are doing to the patients," Whipkey says. Levey acknowledges the three physicians who share the responsibility for supervising the residents with Heller have other responsibilities but says, 'Between the three of them, by and large, someone's easily accessible" Whipkey says that if there is a problem, a missed diagnosis or something done improperly, the first chance to find it is the following day when the charts are reviewed by the attending physicians. "Retrospective reviews (are) a poor method of quality assurance and even a poorer method of education. All the attendings have to review is the information the residents write on the patient's chart," Whipkey says.

"They have no way of knowing if (the residents) caught everything that should have been caught. If the residents don't record Stewart stresses that the residents "are excellent, dedicated people" who are in a training environment "but all people in training must have highly experienced people that they can immedi-lately turn to for help." Dr. Tim Vollmer, who was a senior emergency medicine resident in a program run by Presbyterian, i West Penn and Mercy, criticizes Presbyterian's emergency room, i Until two months ago he was one of the physicians providing medical command instructions to the city's paramedics. He now is director of the emergency room in an Arizona hospital. "As long as they continue to have unsupervised residents running that emergency department, I would never go to Presby as a patient," said Vollmer.

"When it comes to emergency medicine, Presby is 10 12 years behind the time. They are still doing things that have become history in most good ERs." "There are too many glaring ex-lamples of inappropriate care. Their priorities are wrong," he says. "The medical residents often treat insig- nificant problems on a severely injured patient while other problems in that patient, that can be life threatening, are ignored." For example, Vollmer cites a college student struck by a car and brought into Presbyterian's emer-jgency room with a severe head injury and several fractures. "With all trauma, maintaining a i good airway, ensuring the patient can breathe, is vital.

With a head i injury, intubation can easily mean the difference between life and i death. lZ "When I got to the ER, 15 minutes after the patient arrived, I found the residents setting a cast on a broken leg, but no one, absolutely no one, was in charge of the resuscitation of that patient," Vollmer says. "They hadn't even intubated him, yet they were working on his 'broken leg. That just doesn't make sense." The recent assignment of Dr. Andrew Peitzman as director of the hospital's trauma unit and the emergency room's supervisor of surgery has greatly improved the care of patients with severe trauma, say vollmer, other doctors and paramedics.

Peitzman supervises the departments surgical residents, but medical residents activities are guided by Levey. About 150 medical and surgical residents rotate through Presbyterian's emergency room during the year. "Peitzman's efforts only diminish part of the problem," Vollmer says, ''He and Mike Heller (the depart-i ment's only full-time physician) are fighting like mad to improve medi-i cal care there, but there little they i can do with the medical residents because (chief of medicine) Levey i doesn't want Ron Stewart or any other emergency medicine physi-i cians telling his people what to do. "Peitzman's people try to do it right. They'll intubate when it's needed, and they know when to do it.

Peitzman will rush to that ER in a I moment's notice, day or night, and there is no question that his surgical i residents had better call him or it's 2 lines. 7 days in The Press 6 deys in the Post-Gszette. For items valutd up to 1 SO. No commer-cial. real estate or help wanted.

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