CONNECTICUTOral History: CPTV AT 50 | Homeowners Fleeing the ENERGY GRID | FRENCH FETES connecticutmag.com MAGAZINE

Did your doctor makeTop the list? Docs 844 DOCTORS IN 31 SPECIALTIES

PLUS The Friendly New Face of Emergency Departments Customer care and controlled chaos in the old ER

APRIL 2013 $4.95 Yale-New Haven Hospital Adult Emergency Room residents confer while using a COW—Computer On Wheels, a completely portable, self-suffi cient computer-information system that al- lows doctors, nurses, residents and other care providers to send, receive, edit and access patient information. It can also be used to inform patients directly.

'(),1,1*

(0(5*(1&<%<(5,.2)*$1*‡3+272*5$3+<%<-()).$8)0$1

:,7++($/7+&$5(5()2506,1685$1&(&+$//(1*(6$1'7+( ,1&5($6,1*'(6,5()2521(67230(',&$/$66,67$1&(7+( (0(5*(1&<5220+$6(92/9('%(<21'7+(6,03/(´(5µ Back in the 1790s, during the French Revolution, military surgeon Dominique Jean Larrey had an epiph- any. He noticed how rapidly the fl ying artillery (horse-drawn cannons) of the French army transported weapons across the battlefi eld and realized they could be used to save lives instead of destroy them. He created fl ying ambulances, horse-drawn stretchers that quickly transported wounded soldiers away from the front lines to places where they could be treated more eff ectively. It was a giant leap in medical history and saved thousands of lives. As a result, Larrey oft en is acknowledged as the father of emergency medi- cine. More than 200 years later, emergency medicine continues to use cutting-edge technology to save lives. Some Connecticut hospitals are mak- ing emergency department wait times available on their websites, others regularly use video conferencing to have patients examined by experts from other parts of the globe, and emergency departments routinely employ new treatments to save the lives of patients in ways that would not have been possible in the past. Even the name has changed. “I know the TV show was called ‘ER,’ but in the hospital setting you’ll always hear the ‘emergency department.’ We’re no longer a big room where everyone goes,” says Dr. Peter Jacoby, chairman of emergency services at Saint Mary’s Hospital in Waterbury. Th e way emergency departments are being used by the general public also has changed. A report released in October by the Association of American Medical Colleges estimates the nation is short approximately 9,000 primary-care doctors. As the availability of general practitioners declines, emergency departments oft en have fi lled the health care void out of necessity. | APRIL 2013 CONNECTICUT 69 | (above) Hospital of Central Connecticut Dr. John Sottile and nurses evaluate an EKG transmitted remotely from EMTs in the fi eld. (opposite top) Hospital of Central Connecticut Dr Sottile uses an iPad and other technolo- gies to help put a young patient (and mom) at ease. (opposite bottom) Yale-New Haven Hospital Dr. Gail D’Onofrio, Chief, Yale-New Haven Hospital Department of Adult Emergency Medicine, confers with a colleague regarding patient information (EKG, radiology, heartbeat, etc.) accessible on her smartphone.

| 70 APRIL 2013 connecticutmag.com | “We’ve become the answers to everyone’s problems,” Jacoby says. “We are expected to do much more besides the very acute emergencies.” Dr. Gail D’Onofrio, chief of the emergency department at Yale-New Haven Hospital, agrees that “emergency” visits will be increasing. “I think with the Aff ordable Care Act we may see even more people because more will be covered by some type of insurance,” she says. “What we’re hoping for down the road is that we have more primary-care doctors to keep the popula- tion healthy and to work on prevention.” Th ough emergency departments may be busy, both Jacoby and D’Onofrio say the vast ma- jority of patients who come in do need treatment and the services provide a level of conve- nience for them. “You can say, well, is an injured ankle an emergency?” Jacoby explains. “If you decide to wait and call your primary-care doctor, and then go get an X-ray, and then you have to go fi nd crutches and fi gure out how to get off that ankle, and then get an appointment with an orthopedic physician, that might take you a week. If you come to the emergency department you may wait a little while, but we’re going to X-ray you, we’re going to set you up with your crutches, we’re going to fi x your leg and we’re going to get you a referral to an orthopedic physician.” He adds, “In the United States we are used to one-stop shopping. We don’t like to go to 50 stores anymore; we go to malls to shop. We go to emergency departments because we know we can get seen, get diagnosed and get treatment 24/7.” ”IN THE UNITED STATES WE ARE USED TO However, frequent use of emergency de- partments can lead to overcrowding, espe- ONE-STOP SHOPPING,” SAYS DR. PETER cially when there’s an outbreak of an illness, JACOBY, CHAIRMAN OF EMERGENCY SER- as was the case in late December and early VICES AT SAINT MARY’S HOSPITAL IN WA- January when the state saw a spike in infl u- enza cases. TERBURY. “WE DON’T LIKE TO GO TO 50 “Emergency departments everywhere were STORES ANYMORE; WE GO TO MALLS TO fl ooded,” Jacoby says. “We saw a lot of fl u cases and there was a very virulent respiratory viral SHOP. WE GO TO EMERGENCY DEPART- disease, and a GI viral disease going around MENTS BECAUSE WE KNOW WE CAN GET as well. It’s like the perfect storm—you have all that coming in and you have all the car ac- SEEN, GET DIAGNOSED AND GET TREAT- cidents, strokes and heart attacks that you get MENT 24/7.” all the time as well.” Although things may have gotten hectic at Saint Mary’s, Jacoby says that doesn’t mean the emergency department was strained to a breaking point or that patients shouldn’t be en- couraged to come in for treatment. “You still manage to see them all and you just have to examine those who you think are the sickest fi rst,” he says. Ralph Miro, director of nursing and EMS coordinator for the Department of Emer- gency Medicine at Day Kimball Healthcare, which operates Day Kimball Hospital in Putnam, agrees patients should never be discouraged from coming to the emergency department. “Until you’re assessed by health- care professionals, there’s no way to tell if something that may seem minor could be very major,” he says. “Let’s say you have left arm pain or right arm pain or jaw pain—that could be a sign of a heart attack.” | APRIL 2013 CONNECTICUT 71 | He adds, “Patients who feel that their complaints or their symptoms are serious— what they should not do is ignore them.” Patients also needn’t worry that their bro- ken ankle will take away needed resources from sicker people, says Miro. Emergency- staff members are trained in triage, or assess- ing the most critically ill patients to make sure they get priority treatment. Th is ability to quickly assess need is an area where emer- gency medicine has advanced signifi cantly, aided by now common lifesaving practices such as “point-of-care” testing. “It’s a procedure that enables us to de- termine a patient’s condition, or to identify certain disease states, by evaluating the con- tent of a patient’s blood,” Miro says. Blood now can be analyzed at a patient’s bedside thanks to devices like the i-STAT System, a handheld blood analyzer that can provide lab-quality test results on the spot. “Instead of drawing multiple tubes of blood, all we need is a few drops in an i- STAT,” he says. “Th ose drops of blood, as lit- tle as two, are placed into the unit and rather than having to wait for the results from our lab, the results come within a few minutes.” Major advances like this aid in better treating heart attacks and strokes, where time is critical. Using point-of-care treat- ments like i-STAT, which can test for cardiac markers, staff can assess more quickly what type of heart attack a patient is having and then send him or her to a catheterization lab where they can be treated properly. Th ere are also new medications that slow down the damage caused by a heart attack or a stroke, and innovative techniques such as therapeu- tic hypothermia, a method by which medi- cal staff can lower the patient’s body tem- perature to slow down brain damage. Not all the new technology being used is specifi c to the health-care industry. Advanc- es in videoconferencing technology have allowed patients at Day Kimball to be ex- amined remotely by specialists at the UMass Memorial Medical Center. “We can zoom in on the patient and a neurologist all the way over at UMass can assess the pupils and skin color,” Miro says. In addition to technological advances, another trend in emergency medicine today is in customer service. Dr. Jeff rey A. Finkel- stein, chief of emergency medicine and chief medical information offi cer at the Hospital of Central Connecticut, says the hospital | 72 APRIL 2013 connecticutmag.com | treats visitors like “customers as opposed to patients.” Th e hospital, which has campuses in Southington and New Britain, features valet parking at the entrance to the emergency de- partment and people are off ered coff ee and warm blankets as soon as they come in. “We’re not the old ER where it was impersonal,” he says. “We really try to make it as easy as possible and as pleasant an experience as possible when you’re in pain or ill, or visiting some- one who is in pain or ill.” A few years ago the hospital began providing estimated emergency department wait times on the hospital’s website, via text message and through smartphone apps. “Th e number one thing people want is short wait times,” says Finkelstein. “Th ey expect good medical care, they expect people to be nice, but what they really want is to be seen quickly. No one wants to sit in the waiting room for two, three, maybe four hours.” Digital technology also is used to allow doctors to view electrocardiogram results of pa- tients still en route to the hospital. “In the ambulance there are electronic EKG monitors that transmit the EKG to a cloud-based service through cellular transmissions, and then they come onto my iPhone or iPad as a PDF attachment,” he says. “We can diagnose patients before they even arrive.” Modern emergency facilities oft en replace the white and beige institutional walls and tiles (opposite top) Day Kimball In collaboration with a UMass Memorial Medical Center neurologist (on with warmer, more inviting colors. Yale-New computer screen), Day Kimball emergency department personnel assess a stroke patient’s condition Haven Hospital completed a major renovation using the Tele-Stroke Device. of its emergency department in January, ex- (opposite bottom) St. Mary’s Hospital New technology such as the Glide Scope allows quick and easy intu- panding from 30,000 to approximately 48,000 bation and live imagery to help analyze and perform medical procedures. square feet. Th e size of the hospital’s trauma- care unit was tripled and state-of-the-art med- ical technology was installed. Th e expansion also was designed to take into consideration patient privacy and comfort. “I think privacy is the most important thing aft er quality of care,” says D’Onofrio of Yale- New Haven. “When you pick out colors, you want it to have a calming eff ect both on the patient and the patient’s family. We are very attuned to the fact that we are responsible for life-and-death decisions and that families could easily have sent their loved ones to work or off to the store and then a crisis happened. We are oft en the people who have to tell their families this bad news and we really struggle to make sure we do the best that we can. Having a great environment to do that in is just one thing we can off er when things are not going well.” An emergency department is a good indicator of what’s going on in the larger community says D’Onofrio. “Whatever is happening in the community, we see it here,” she says. “If there’s fl u out there we’re going to see it, with the economy down there’s more violence and we see it here, if people are using more prescription drugs and dying of more overdoses we see it here. We try to take an active part in surveillance and treatment and prevention. We constantly are working with the community because we are the community.” In many ways emergency medicine is still in its infancy. It wasn’t until 1979 that the Amer- ican Board of Medical Specialties began to recognize it as a separate discipline. Prior to that, physicians of various specialties would rotate duty at the emergency department. Patients might be seen by a cardiologist one night and a dermatologist the next. Dominique Jean Larrey survived the French Revolution but was later captured by the Prussians in 1815 at the Battle of Waterloo. Sentenced to death, he was saved by a Prussian surgeon who recognized him and pleaded for his life to be spared. While the dangers faced by emergency medical staff today may not be quite as dramatic as those faced by Larrey, to- day’s ER personnel are still expected to do whatever it takes to make sure patients are helped. “Th e emergency department is controlled chaos,” D’Onofrio says. “I cannot plan when something’s going to happen. I always have to have the resources for the worst-case scenari- os. When Hurricane Sandy happened and everything else was closed, my doctors and nurses and techs and secretaries all braved the elements and left their families at home in the dark and came here to help the public. We will always do that. We never are not here. No matter what, the emergency department is open.” | APRIL 2013 CONNECTICUT 73 |