European. 😉
No neurosurgery, nor cardiac surgery. Orthopedics and plastic surgery are available but limited.
No CT/MRI in the ED, only on another floor.
Usually staffed by 4 ER-nurses at night and 1 radiology technician (he's for the whole hospital).
Two trauma beds, about 10 non-critical beds.
Note that the figure of 15,000 includes people coming to the hospital on their own with non-emergent issues (like a baby who doesn't stop crying, boy who scratched his knee when falling while playing football). 15000 / 365 yields an average of 41 patients per 24 hours, which doesn't seem like all that much when you consider that the level of trauma patients isn't really all that high.
There is also a "family physician's post" in the hospital building, which is staffed only outside of office hours: evenings, nights, weekends, holidays. There is usually one GP there (whatever you want to call a family physician) who is responsible for an area of about 100,000 people. He works on appointment only; patients have to make an appointment by phone first before coming there. He is at times assisted by a second GP who does home visits for urgently sick patients. The home visits are made with a "GP-Mobile" which is somewhat like the "NEF"-vehicle used by German emergency physicians for transport to accident scenes and urgently ill patients. It's equipped with priority systems (blue flashlight, siren) and painted like an ambulance vehicle, though it isn't equipped for patient transport. It's driven by an ambulance driver (who has had a 4-week course in assisting ambulance nurses; ambulances here are always manned by a driver + very highly trained nurse) who also assists the GP.
I don't like this system because I think urgent home visits should never be made by GP's, who are primarily trained to deal with non-urgent cases and do not have regular experience in these things: the GP duties at the post are equally divided among the area's GP's, I think about 30 of them. My main problem with the system lies in the fact that when a patient turns out to be seriously ill (for example, a [threathening or developing] MI), this GP 1) doesn't have the materials needed to be of any help (for example, no ECG) and 2) there is still no way to get the patient to the hospital and the GP (or his assistent) will now have to call an ambulance and wait for it to arrive (which costs valuable time which could have been saved if an ambulance would have gone there in the first place).
Ambulance nurses here are highly trained. If you want to become an ambulance nurse here, you'll first have to complete nursing school (4 years), then accumulate working experience as a nurse for about 2 years after which you can apply to a specialization for ED or IC nurse, which again takes about 2 years. After that, you can apply to the ambulance nurse course, which takes about 1 year. All together, that's 8-10 years of education from the moment you enter nursing school until graduating as an ambulance nurse. Ambulances here are also equipped and maintained very well, with facilities that most ambulance services in the world could only dream of.
So, according to me, the whole concept of a GP driving around to see urgently sick patients in the middle of the night (patients who are that sick that they cannot drive themselves to the ED/GP post or have someone else drive them there) is madness. Patients who are that ill should always be taken to a hospital and their calls for help should be answered by sending an ambulance with a nurse who is trained for these things, instead of sending a GP without sufficient training, without sufficient means and without transport capability.
Patients with serious and urgent health problems which cannot wait until the morning or until Monday have to choose between calling the emergency number (112, like American 911) in which case an ambulance will be sent or choosing to call the GP post in which case they will speak to a "doctor's assistent" (slightly more educated then a secretary) who will judge on the phone whether the patient needs to see a doctor before office hours and if so, whether the patient is sick enough to send the mobile GP to him or to ask him to come to the GP post by himself when an appointment time is available in 2 hours or so.
It's clear that for example, someone who gets serious diarrhea on Friday night should go to the GP on service (or let him come to them). But what does an old man whose wife woke up in the middle of the night with chest pain while coughing badly do? He will call the GP post, where the assistant will tell him to give her a glass of water and a painkiller and to call back if things don't get better in an hour or two. Half an hour later, his wife dies from an acute MI. Severe coughing may be the only presenting symptom in women with acute MI. Had he called 112, an ambulance would have come, the ambulance nurse would have recognized the situation and would have correctly diagnosed the woman's situation immediately allowing for her to be transported to the ED (either here or somewhere else where they have PCA facilities) before dying.
Such incidents have occured numerous times. No assistant has ever been found guilty of negligence or anything, because, after all, such things are not theirs to know.
The 'mobile GP' should be coordinated and controlled by the 112 ambulance callcenter. The people who answer calls there are sufficiently trained to recognize potentially dangerous situations. If there is any possibility of this being necessary, an ambulance should be sent (possibly together with the mobile GP) to the scene right away. People should be taken to the ED for advanced diagnostic and therapeutic facilities (anything from laboratory results to x-rays to the proximity of a resuscitation team) earlier than now. The ED should be able to accept all of these cases right away.
Currently, the GP post is located in a separate building from the ED. Patients generally have to walk through the open air and up a set of stairs to go from the GP post to the ED entrance. During daytime, patients can go through the inside part of the hospital (the GP post is located in the hospital's entrance building) to the ED which means that they have to navigate their way around the hospital through the main lobby. (At night, the entrance from the entrance building [which houses the GP post] to the main lobby of the hospital is closed and anyone wishing to enter the hospital must go through the ED entrance outside the hospital.)
The GP post should be integrated with the ED. That way, the hospital physician on duty and the GP can interact easier, can give each other back-up when needed, the physician on duty (usually a surgery resident) can refer people to the GP and vice versa, the two can ask each others advice more easily (resident to GP: "How do I explain this old lady how to use her medication?"; GP to resident: "Should I suture this wound or not?"). Also, the GP will have easier access to hospital facilities such as x-ray and laboratory facilities.
The mobile GP should not be seen as a cheap substitute for a true mobile emergency physician such as those existing in several other countries. Family physicians are not sufficiently trained in emergency medicine to be sent to potentially critically ill patients. These patients should be transported to the hospital by ambulance and be evaluated on the ED by an emergency physician (or, in the absence of emergency physicians, by a surgery resident trained in emergency medicine) backed up by experienced ED nurses and possible backed up by an experienced GP who can offer new insights based on invaluable years of clinical experience.
I'll post this on the EM forum also. Anyone interested in replying is requested to reply there, to keep things in a single thread. (I didn't intend to write this much when I started writing...)
