The Hospital Emergency Medicine Department is a Busy Place

By Dan Barber

Public Affairs Officer

Robert E. Bush Naval Hospital

One of the important benefits of serving in the U.S. Military is the health care provided to active duty service members and their families as well as eligible military retirees and their families.

Here at the Marine Corps Air Ground Combat Center the Robert E. Bush Naval Hospital provides an Emergency Medicine Department staffed with highly trained individuals. “The Emergency Medicine Department employs a mix of both military and civilian staff,” said Commander Raul Carrillo, a Nurse Corps Officer and Department Head for the Emergency Medicine Department. “All are highly trained, with all the physicians being board certified in Emergency Medicine. Both the civilian and military nurses are registered nurses and are also trained in Emergency Medicine. The corpsmen also receive specialized training to work in the department,” he added.

A typical 12 hour shift in the hospital’s Emergency Medicine Department (EMD) is staffed with one certified emergency medicine physician, two registered nurses and two corpsmen. Others can be called in as needed.

To operate the Emergency Medicine Department twenty-four hours a day, 365 day a year takes a staff of 14 emergency medicine physicians, 12 registered nurses, 10 corpsmen and 2 clerks. The physicians and nurses are a mix of both military and civilian personnel.

The definition of emergent care is the threat to life, limb or eyesight… that could be a threat to your life, a fractured bone or an injury to your eye.

The hospital’s EMD should never be treated as a walk-in clinic; however, no one is ever turned away from receiving care.

 “I would highly encourage patients get seen by their Primary Care Manager (PCM), if possible. Here at the hospital we have established a Patient Centered Medical Home with the philosophy that the PCM who is assigned to the patient is responsible for providing their medical care needs. The Patient Centered Medical Home has been established in Pediatrics, Gold Team, and Blue Teams only. If their provider is on leave, TAD or ill, then their Medical Home Team, regardless of who they see for care can see any other provider on their team,” said Carrillo.  “There are times when patients cannot come in during clinic hours for care then yes, they will be seen in the Emergency Medicine Department,” he added.  But Carrillo pointed out that patients need to keep in mind “we are an Emergency Medicine Department and we always take the sickest first, and everyone else will be prioritized for care.”  Sometimes patients may have a wait between 2 to 4 hours… depending on multiple factors to include patient acuity, patient census, ambulance arrivals, and critical care transport coordination to higher levels of care.

According to Carrillo patients arriving at the EMD by ambulance are always seen first. “I would highly encourage patients to keep in mind that if they are calling for an ambulance to make sure it is a life threatening emergency. The use of Emergency Services shouldn’t be used at the whim of making a trip to the ER… if you have shortness of breath, if you have chest pain and you perceive it as a life threatening illness, then yes I would encourage you to call 911,” said Carrillo.  “If a patient comes in by ambulance and it isn’t a life threatening illness or injury you will essentially have taken one ambulance out of service,” said Carrillo.  “There are only two ambulances on base, and if one is responding then that ambulance is off line when it could be responding to a true emergency on base,” Carrillo added.

According to Carrillo the best times to be seen in the ER, if needed, are pretty much anytime of the day on Tuesdays through Thursdays. He pointed out that off payday weekends, the day prior and after a holiday and military special liberties are busy times in the EMD.

Patients coming into the Emergency Medicine Department need to check in at the window in the Emergency Medicine Department Waiting area. If there is no one at the window because they are busy in the back, then there is a button that can be pushed and someone will respond.

Once a patient is checked in, they will be called for triage by a Registered Nurse. The patient will be assessed and assigned an appropriate triage category of 1 through 5, known as the Emergency Severity Index. The number assignment is based on age, chief complaint, history of present illness, and vital signs upon presentation.

Number one category is a life threatening injury or illness, in most cases a one is assigned when a person has stopped breathing or their heart has stopped. A number one can also be assigned for mental illness for a patient who is actively suicidal or homicidal with altered mental status. A level 2 or 3 patient may be someone with shortness of breath or chest pain. “In the cases of one through 3 we would provide immediate care,” said Carrillo. According to Carrillo a level four patient is someone who may have a sprained ankle or sustained some orthopedic injury but is not a life or limb threatening injury. A level five category would be someone with an upper respiratory infection with no fever and they have had these symptoms greater than 48 hours. “This system allows us to prioritize patients in the order that they will be taken care of,” said Carrillo.

“Sometimes there are delays in the Emergency Department because our staff is working on a critical patient that requires a more comprehensive evaluation and they need to be stabilized so they can be transported by ambulance or flown out by air transportation. Our role in the Emergency Medicine Department is to stabilize patients, and we do have a mix of different patients with different triage categories and based on the number of staff, we do the best we can to expedite care so we can get patients feeling better and discharged, transported or admitted as soon a possible,” said Carrillo. The EMD has the capacity to call in a back-up provider if there is greater than 4 hour wait, a level one category patient that results in  greater than 4 hour wait in the EMD, and patient surges from a single incident (e.g. vehicle roll-over) that overburdens resources and staffing.

 The typical time a patient will spend in the Emergency Room here at the hospital for a non urgent problem is around 2-hours. “We are a nine-bed emergency department with patients suffering from various illnesses or injuries. Some patients require more care than others and keep in mind that we have one provider on duty with two registered nurses and two corpsmen. When patients come in the ED during busy times they can expect a longer wait to be seen and possibly a longer disposition time before they can be discharged,” said Carrillo.

 Patients requiring medical advice can call TRICARE Online at 1-800- or Military One Source at 1-800-342-9647.  A consultant is available 24/7.  The National Suicide Prevention Hotline is at 1-800-273-TALK (8255). Another option is to contact the Naval Hospital Quarterdeck at (760)830-2190. A physician or Nurse Practitioner is available from 1600-0700 to answer any questions. Emergency Medicine Providers can treat most acute illnesses or injuries, but the Emergency Medicine Department is not a patient’s Primary Care Manager. If the Emergency Medicine Provider recommends a patient to have a follow-up appointment within 24-48 hours, the department will have a copy of the Emergency Treatment Record available for clinic staff to pick-up the following morning. The clinic will contact the patient to schedule a date and time for an appointment. If the Emergency Medicine Department recommends follow-up as needed, the patient is required to call the clinic or use Relay Health in contacting the clinic for a requested appointment. “There seems to be some confusion for the patient when told to follow up with their primary care provider and they show up without making an appointment,” said Carrillo.  The Naval Hospital is a small community-type hospital where most specialty care is referred out. “We have a small Emergency Medicine Department,” said Carrillo. The Department has a small waiting room. When people come in with an upper respiratory infection, everything is done to prevent the spread of illnesses.  “We do provide masks to prevent the spread of illness and we advise patients with chicken pox or any skin infection to inform our check-in staff so they can isolate them from other patients in the waiting area to minimize exposure,” said Carrillo.

The Emergency waiting area of any hospital is not a very comfortable place for someone with a cold or flu to be waiting for care, and it can prove hazardous for someone with a reduced immune system, or a newborn waiting to see an Emergency Medicine provider. All efforts are made to triage and deliver care to patients in a timely fashion.

Routine or acute appointments can be made at the Robert E. Bush Naval Hospital, and even in many cases a same day appointment can be scheduled with your Primary Care Manager by calling 760-830-2752.  Patients enrolled to the Naval Hospital Twentynine Palms Patient Centered Medical Home Pediatrics, Gold Team, or Blue Teams can sign up for Relay Health at www.relayhealth.com.