Correspondence http://dx.doi.org/10.1016/j.annemergmed.2013.07.505
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. 1. Cross KP, Cicero MX. Head-to-head comparison of disaster triage methods in pediatric, adult, and geriatric patients. Ann Emerg Med. 2013;61:668-676. 2. New York City Pediatric Disaster Coalition, New York City Department of Health and Mental Hygiene. Recommendations for NYC pediatric disaster triage and transport. NewYork. 2009.
In reply: We appreciate the thoughtful comments of Dr. Kaufman et al1 about our recent article.2 Fire Department of the City of New York’s (FDNY’s) addition of the orange category to mass casualty triage is a unique and valuable contribution to disaster management. As Dr. Kaufman et al1 note, the category denotes a patient in need of urgent transport to the hospital. The orange category empowers the triage officer to flag ambulatory patients with concerning symptoms for urgent transport. Previously, FDNY has provided examples of patients who would be triaged orange, including those with respiratory distress or chest pain.3 Further examples of patients who are appropriately triaged orange include those with signs of hollow organ injury after a blast and those with severe head injury without neurologic compromise. Here, the FDNY has established that the orange category is appropriate for some trauma patients, and that the category is not reserved for medical patients. Dr. Kaufman et al1 raise an important point about multiple casualty incidents (MCIs): many such events have victims who have traumatic injuries, acute medical conditions, or both. In their criticism of our study, Kaufman et al1 overlook the fact that the population we used from the National Trauma Data Bank includes many patients with medical comorbidities that complicated their trauma care and contributed to outcomes we reported. Primary triage systems such as FDNY and Simple Triage and Rapid Treatment (START) are for the initial sorting of patients and guide decisions about whom to treat first. We agree that emergency medical services personnel may choose to transport to nontrauma hospitals, that these decisions are heavily influenced by triage, and that patient maldistribution affects patient outcomes and efficient use of resources.4 Where the scope of existing triage systems ends and clinical decisionmaking at the scene of the MCI begins is when numerous high-acuity patients are identified. Here, MCI responders are confronted with the realities of available resources. In New York City, there is an abundance of specialty hospitals and trauma centers. It is sensible for patients to be shunted to receiving facilities that best fit their clinical needs. In settings with less concentrated populations, the Midwest, for example, there may be fewer out-of-hospital and hospital resources.
Volume 62, no. 6 : December 2013
Therefore, when generalizability of MCI systems is considered, policies that seem good to experts in New York City—such as automatically triaging all infants “red” regardless of medical condition—would be more compelling if backed by data from diverse settings rather than just expert opinion. Perhaps it is time for a national registry of MCI patients, including the nature of the MCI, the triage method used, the setting of the event, and so on. These data would allow the assessment of outcomes for entire incidents, rather than just medical outcomes for individual patients. We hope future research will substantiate the orange triage category, red triage of all infants, and other intriguing and practical proposals to streamline MCI management. Keith P. Cross, MD, MSc Kosair Children’s Hospital University of Louisville Medical School Louisville, KY Mark X. Cicero, MD Yale–New Haven Children’s Hospital Yale Medical School New Haven, MA http://dx.doi.org/10.1016/j.annemergmed.2013.07.504
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). KPC has stated no such replationships exist. MXC reports grants from Emergency Medical Services for Children outside the submitted work. 1. Kaufman B, Ben-Eli D, Asaeda G, et al. Comparison of disaster triage methods. Ann Emerg Med. 2013;62. 2. Cross KP, Cicero MX. Head-to-head comparison of disaster triage methods in pediatric, adult, and geriatric patients. Ann Emerg Med. 2013;61:668-676.e667. 3. Fire Department City of New York. Modified Simple Triage and Rapid Treatment (START) January 6, 2012. FDNY Internal Document, EMS OGP 106-22. 4. Zoraster RM, Chidester C, Koenig W. Field triage and patient maldistribution in a mass-casualty incident. Prehosp Disaster Med. 2007;22:224-229.
Rural Emergency Medicine Rotations: Could Family Practice (ABFM) Faculty Supplement ABEM faculty? To the Editor: We commend the authors of this article1 for the excellent suggestions that promote rural rotations for emergency medicine residents. But much of their commentary on other aspects of the rural emergency medicine workforce is inaccurate and specialty-centric instead of patient-centric. Are American Board of Emergency Medicine (ABEM)–trained physicians the only competent faculty to teach emergency medicine residents?
Annals of Emergency Medicine 645
Correspondence If so, is this evidence based or simply a reflection of scope of practice issues that are historical, rather than forward thinking? As the article describes, one of the most difficult barriers to developing rural emergency medicine rotations is meeting the requirement that faculty be emergency medicine certified. But many emergency medicine attending physicians in rural areas are residency trained in primary care (the majority in family medicine, ABFM). The authors suggest expanding the current policies of the Residency Review Committee but do not discuss the potential training value that can be brought to the specialty by those trained in other specialties. Emergency medicine would benefit from considering the history of family medicine residency training programs in this area because its programs are strengthened by a diversity of clinical faculty. Emergency medicine, given its scope of competencies and practice, would benefit from this multidisciplinary model of education for its residents. Although considerable resources have been devoted to trying to improve the percentage of residency-trained emergency physicians in rural areas during the last decade, most rural emergency medicine is provided by physicians who trained in other specialties. In the early stages of workforce planning, it was expected that these “legacy” physicians would gradually be replaced by residencytrained physicians, even in rural areas. However, the “dream” of an all-emergency-medicine–trained workforce no longer seems likely. In many rural areas, family medicine–trained physicians provide the majority of emergency care.2 The article begins with a reference to the 2006 IOM report, but the authors ignore the recommendations from this same report that call for cooperation with other specialties.3 They also state that “multiple studies have demonstrated an improvement in overall quality of emergency department (ED) care by residency trained, ABEM-certified physicians.” The quality of care in the United States has certainly been improved because of the development of emergency medicine training programs, but the articles cited are mostly anecdotal. It also seems myopic to conclude that these improvements are solely due to the increase in ABEM-certified physicians without considering programs such as CALS.4 Other articles present a different perspective5 and, combined with international models for emergency medicine training, support the concept that family physicians with additional emergency medicine skills provide high-quality rural emergency care. We agree with the presupposition that increasing the rate of rural EDs staffed by residency-trained, ABEM-certified physicians would be beneficial, but the authors’ commentary on workforce issues is focused on what is best for the specialty of emergency medicine, rather than what is best for patient care. It ignores much of the fertile debate in the literature, as well as the mandate from the IOM to move beyond specialty biases in developing rural workforce policy. W. Anthony Gerard, MD Lebanon Emergency Physicians Department of Family Medicine Penn State/Hershey 646 Annals of Emergency Medicine
Perry A. Pugno, MD, MPH Education American Academy of Family Physicians Leawood, KS Kim Bullock, MD Ambulatory Emergency Services Providence Hospital Washington, DC Danny Greig, MD AAFP SIG-EM Emergency Physician Mid-Michigan Medical Center Midland, MI http://dx.doi.org/10.1016/j.annemergmed.2013.06.073
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. 1. Casaletto JJ, Wadman MC, Ankel FK, et al. Emergency medicine rural rotations: a program director’s guide. Ann Emerg Med. 2013;61:578-583. 2. Groth H, House H, Overton R, et al. Board-certified emergency physicians comprise a minority of the emergency department workforce in Iowa. West J Emerg Med. 2013;14:186-190. 3. Bullock KA, Gerard WA, Stauffer AR. The emergency medicine workforce and the IOM report: embrace the legacy generation. Ann Emerg Med. 2007;50:622-623. 4. Carter DL, Ruiz E, Lappe K. Comprehensive advanced life support. A course for rural emergency care teams. Minn Med. 2001;84:38-41. 5. Gerard WA, et al. Family physicians in emergency medicine: new opportunities and critical challenges. Ann Fam Med. 2010;8:564-565.
In reply: We welcome the comments from our experienced rural emergency medicine colleagues. However, their letter comingles emergency medicine workforce issues with residency training issues. The argument that non–American Board of Emergency Medicine (ABEM)/American Osteopathic Board of Emergency Medicine (AOBEM) physicians can deliver high-quality patient care is not at odds with the position that training program accreditation should require ABEM/AOBEM-prepared or -certified instructors. We recognize that the “dream” of staffing all emergency departments (EDs) with emergency medicine residency–trained physicians is beyond reach. However, when it comes to training, we have a responsibility to the public to ensure patient-centered training, which encompasses both patient safety and quality of care. The Emergency Medicine Residency Review Committee must have a standard benchmark to ensure instructor quality; they have chosen board certification. Although it is conceivable that individual emergency medicine residency programs could be allowed to provide alternative credentials for rural faculty members who can prove added qualifications for emergency Volume 62, no. 6 : December 2013
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. 1. Cross KP, Cicero MX. Head-to-head comparison of disaster triage methods in pediatric, adult, and geriatric patients. Ann Emerg Med. 2013;61:668-676. 2. New York City Pediatric Disaster Coalition, New York City Department of Health and Mental Hygiene. Recommendations for NYC pediatric disaster triage and transport. NewYork. 2009.
In reply: We appreciate the thoughtful comments of Dr. Kaufman et al1 about our recent article.2 Fire Department of the City of New York’s (FDNY’s) addition of the orange category to mass casualty triage is a unique and valuable contribution to disaster management. As Dr. Kaufman et al1 note, the category denotes a patient in need of urgent transport to the hospital. The orange category empowers the triage officer to flag ambulatory patients with concerning symptoms for urgent transport. Previously, FDNY has provided examples of patients who would be triaged orange, including those with respiratory distress or chest pain.3 Further examples of patients who are appropriately triaged orange include those with signs of hollow organ injury after a blast and those with severe head injury without neurologic compromise. Here, the FDNY has established that the orange category is appropriate for some trauma patients, and that the category is not reserved for medical patients. Dr. Kaufman et al1 raise an important point about multiple casualty incidents (MCIs): many such events have victims who have traumatic injuries, acute medical conditions, or both. In their criticism of our study, Kaufman et al1 overlook the fact that the population we used from the National Trauma Data Bank includes many patients with medical comorbidities that complicated their trauma care and contributed to outcomes we reported. Primary triage systems such as FDNY and Simple Triage and Rapid Treatment (START) are for the initial sorting of patients and guide decisions about whom to treat first. We agree that emergency medical services personnel may choose to transport to nontrauma hospitals, that these decisions are heavily influenced by triage, and that patient maldistribution affects patient outcomes and efficient use of resources.4 Where the scope of existing triage systems ends and clinical decisionmaking at the scene of the MCI begins is when numerous high-acuity patients are identified. Here, MCI responders are confronted with the realities of available resources. In New York City, there is an abundance of specialty hospitals and trauma centers. It is sensible for patients to be shunted to receiving facilities that best fit their clinical needs. In settings with less concentrated populations, the Midwest, for example, there may be fewer out-of-hospital and hospital resources.
Volume 62, no. 6 : December 2013
Therefore, when generalizability of MCI systems is considered, policies that seem good to experts in New York City—such as automatically triaging all infants “red” regardless of medical condition—would be more compelling if backed by data from diverse settings rather than just expert opinion. Perhaps it is time for a national registry of MCI patients, including the nature of the MCI, the triage method used, the setting of the event, and so on. These data would allow the assessment of outcomes for entire incidents, rather than just medical outcomes for individual patients. We hope future research will substantiate the orange triage category, red triage of all infants, and other intriguing and practical proposals to streamline MCI management. Keith P. Cross, MD, MSc Kosair Children’s Hospital University of Louisville Medical School Louisville, KY Mark X. Cicero, MD Yale–New Haven Children’s Hospital Yale Medical School New Haven, MA http://dx.doi.org/10.1016/j.annemergmed.2013.07.504
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). KPC has stated no such replationships exist. MXC reports grants from Emergency Medical Services for Children outside the submitted work. 1. Kaufman B, Ben-Eli D, Asaeda G, et al. Comparison of disaster triage methods. Ann Emerg Med. 2013;62. 2. Cross KP, Cicero MX. Head-to-head comparison of disaster triage methods in pediatric, adult, and geriatric patients. Ann Emerg Med. 2013;61:668-676.e667. 3. Fire Department City of New York. Modified Simple Triage and Rapid Treatment (START) January 6, 2012. FDNY Internal Document, EMS OGP 106-22. 4. Zoraster RM, Chidester C, Koenig W. Field triage and patient maldistribution in a mass-casualty incident. Prehosp Disaster Med. 2007;22:224-229.
Rural Emergency Medicine Rotations: Could Family Practice (ABFM) Faculty Supplement ABEM faculty? To the Editor: We commend the authors of this article1 for the excellent suggestions that promote rural rotations for emergency medicine residents. But much of their commentary on other aspects of the rural emergency medicine workforce is inaccurate and specialty-centric instead of patient-centric. Are American Board of Emergency Medicine (ABEM)–trained physicians the only competent faculty to teach emergency medicine residents?
Annals of Emergency Medicine 645
Correspondence If so, is this evidence based or simply a reflection of scope of practice issues that are historical, rather than forward thinking? As the article describes, one of the most difficult barriers to developing rural emergency medicine rotations is meeting the requirement that faculty be emergency medicine certified. But many emergency medicine attending physicians in rural areas are residency trained in primary care (the majority in family medicine, ABFM). The authors suggest expanding the current policies of the Residency Review Committee but do not discuss the potential training value that can be brought to the specialty by those trained in other specialties. Emergency medicine would benefit from considering the history of family medicine residency training programs in this area because its programs are strengthened by a diversity of clinical faculty. Emergency medicine, given its scope of competencies and practice, would benefit from this multidisciplinary model of education for its residents. Although considerable resources have been devoted to trying to improve the percentage of residency-trained emergency physicians in rural areas during the last decade, most rural emergency medicine is provided by physicians who trained in other specialties. In the early stages of workforce planning, it was expected that these “legacy” physicians would gradually be replaced by residencytrained physicians, even in rural areas. However, the “dream” of an all-emergency-medicine–trained workforce no longer seems likely. In many rural areas, family medicine–trained physicians provide the majority of emergency care.2 The article begins with a reference to the 2006 IOM report, but the authors ignore the recommendations from this same report that call for cooperation with other specialties.3 They also state that “multiple studies have demonstrated an improvement in overall quality of emergency department (ED) care by residency trained, ABEM-certified physicians.” The quality of care in the United States has certainly been improved because of the development of emergency medicine training programs, but the articles cited are mostly anecdotal. It also seems myopic to conclude that these improvements are solely due to the increase in ABEM-certified physicians without considering programs such as CALS.4 Other articles present a different perspective5 and, combined with international models for emergency medicine training, support the concept that family physicians with additional emergency medicine skills provide high-quality rural emergency care. We agree with the presupposition that increasing the rate of rural EDs staffed by residency-trained, ABEM-certified physicians would be beneficial, but the authors’ commentary on workforce issues is focused on what is best for the specialty of emergency medicine, rather than what is best for patient care. It ignores much of the fertile debate in the literature, as well as the mandate from the IOM to move beyond specialty biases in developing rural workforce policy. W. Anthony Gerard, MD Lebanon Emergency Physicians Department of Family Medicine Penn State/Hershey 646 Annals of Emergency Medicine
Perry A. Pugno, MD, MPH Education American Academy of Family Physicians Leawood, KS Kim Bullock, MD Ambulatory Emergency Services Providence Hospital Washington, DC Danny Greig, MD AAFP SIG-EM Emergency Physician Mid-Michigan Medical Center Midland, MI http://dx.doi.org/10.1016/j.annemergmed.2013.06.073
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. 1. Casaletto JJ, Wadman MC, Ankel FK, et al. Emergency medicine rural rotations: a program director’s guide. Ann Emerg Med. 2013;61:578-583. 2. Groth H, House H, Overton R, et al. Board-certified emergency physicians comprise a minority of the emergency department workforce in Iowa. West J Emerg Med. 2013;14:186-190. 3. Bullock KA, Gerard WA, Stauffer AR. The emergency medicine workforce and the IOM report: embrace the legacy generation. Ann Emerg Med. 2007;50:622-623. 4. Carter DL, Ruiz E, Lappe K. Comprehensive advanced life support. A course for rural emergency care teams. Minn Med. 2001;84:38-41. 5. Gerard WA, et al. Family physicians in emergency medicine: new opportunities and critical challenges. Ann Fam Med. 2010;8:564-565.
In reply: We welcome the comments from our experienced rural emergency medicine colleagues. However, their letter comingles emergency medicine workforce issues with residency training issues. The argument that non–American Board of Emergency Medicine (ABEM)/American Osteopathic Board of Emergency Medicine (AOBEM) physicians can deliver high-quality patient care is not at odds with the position that training program accreditation should require ABEM/AOBEM-prepared or -certified instructors. We recognize that the “dream” of staffing all emergency departments (EDs) with emergency medicine residency–trained physicians is beyond reach. However, when it comes to training, we have a responsibility to the public to ensure patient-centered training, which encompasses both patient safety and quality of care. The Emergency Medicine Residency Review Committee must have a standard benchmark to ensure instructor quality; they have chosen board certification. Although it is conceivable that individual emergency medicine residency programs could be allowed to provide alternative credentials for rural faculty members who can prove added qualifications for emergency Volume 62, no. 6 : December 2013
