I’ve noticed something. At tertiary care hospitals, such as Level 1 trauma centers, there are all manner of specialists on call for the emergency department. In fact all specialties are represented. There’s no need to transfer patients to a higher level of care. It makes sense. After all, these hospitals are affiliated with medical schools, have residency programs, carry on teaching and research, and act as referral centers for a certain geographical area.

At community hospitals (i.e., those that are not designated as tertiary care or Level 1 or Level 2 trauma centers), there is almost never a full complement of specialists. Often there is no neurosurgery, no cardiothoracic surgery, sometimes no plastics, maxillofacial, or vascular services. In many of these hospitals, though a significant portion of the emergency patient population is children, there is no pediatric ICU.

In other words, in many hospitals in the USA, patients with serious medical and/or surgical problems have to be stabilized by the emergency physician and then transferred to a higher level of care.

Who manages these critical care emergency patients? Who manages the trauma patients, until they are transferred out? The emergency physician, of course. All this requires great skill and competence. Ask anyone who’s done it.

Who manages these types of patients at the Level 1 trauma center? The on-call specialists do.

It is believed, by some, that ACEP Legacy physicians are not competent enough to work in tertiary care hospitals and certainly not capable of teaching medical students and residents.

It is also believed, by some, that Emergency Medicine Residency– Trained (EMRT) doctors are more competent than their non-EMRT counterparts.

So, if the EMRT doctors are more competent, why aren’t they working in the community hospitals where a higher level of skill is required?

Why aren’t the non-EMRT docs working at the trauma centers, where all the back-up is available? If we’re less competent, don’t we need all the help we can get?

If the EMRT docs are more competent, shouldn’t they be working at the hospitals where there is less back-up, fewer resources?

Has someone got this whole thing bass-ackwards?

Why are only EMRT docs working at the tertiary care hospitals?

I’m just asking.

Marlene Buckler, M.D., FACEP, CCFP(EM), DABUCM, originally posted this item at www.thecentralline.org on Sept. 16, 2013