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Bad Calls in an Emergency

On the heels of an emergency care crunch in Los Angeles County--with several hospitals curtailing emergency services because of financial problems and patient overloads--comes more dismal news for patients.

The common practice of seeking medical advice by telephone from emergency departments can be iffy, researchers suggested recently in the Annals of Emergency Medicine, noting that such advice can be inconsistent, inadequate and harmful to patients’ welfare.

Trying to determine the consistency and accuracy of phone medical advice from emergency departments, Dr. Vincent P. Verdile of the University of Pittsburgh and his researchers asked an assistant to call 46 emergency departments in Western Pennsylvania and present the same scenario: Her 56-year-old father, a non-drinking smoker with no history of heart disease, was suffering a bad case of indigestion and heartburn. What should she do?

The scenario easily could have been interpreted, the authors note, as a patient experiencing myocardial ischemia, in which there is inadequate blood flow to the heart. In each case, the caller first asked to speak to a physician.

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The results: Only two of 46 emergency departments let her speak to a doctor, though each had one on duty at the time. Staff nurses took 40 calls; ward clerks or secretaries answered the other four. No one asked to speak to the patient; three refused any phone advice, two citing hospital policy.

In all, 20 departments questioned the caller, suggesting they were considering heart problems but only four advised the caller to dial 911, call paramedics or an ambulance to bring the patient in immediately; 28 departments did suggest the patient be brought in, though not necessarily on an emergency basis.

“Fifteen of . . . respondents (32%) instructed the caller to give the patient antacids, several after receiving a response from the caller that suggested myocardial ischemia was likely,” the authors noted.

One department suggested the caller put a nitroglycerin tablet under the patient’s tongue every five minutes, suggesting that persistent heartburn then would rule out a cardiac problem. “When the caller asked what nitroglycerin was and how to obtain it, the respondent told the caller to ‘Ask any cardiac patient; they all have nitroglycerin.’ ”

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A widespread lack of policies governing phone advice from emergency departments worsens problems, the authors said.

A Position Statement

The American College of Emergency Physicians, the Dallas, Tex.,-based national professional group for emergency physicians that publishes the Annals, now is “developing a position statement on phone advice from emergency departments,” which it expects to issue in June, said Judy Young-Drexler, a spokeswoman.

Meanwhile, consumers can try to be their own advocates, said Dr. Joseph Beezy, an emergency department physician at Kaiser Permanente, Los Angeles. When calling emergency departments, “ask to whom you’re speaking,” he suggested. “Try to obtain advice from a physician or an RN. Check the source first. The lesson from this study is that when you call an emergency department for advice you may not be getting it from a licensed health care provider.”

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If the problem isn’t life-threatening, calling family doctors or pediatricians may be a better idea, he added, since they are more likely to know your medical history.

Aiding Breast Exams

Monthly breast self-exams long have been recommended by doctors and the American Cancer Society as a sound preventive way to detect cancer in its early stages. But studies show only a minority of women do the exams; those who remember often say they are unsure they’re doing them well.

Now, several companies are marketing videotapes, breast model kits and other tools designed to help women with the exam. A sampling:

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--MammaCare’s “personal learning system,” designed for home use, introduced in February by Mammatech Corp. of Gainesville, Fla. The $64 kit includes a breast model with simulated tumors, a how-to booklet and an interactive videotape that guides the viewer through a new breast exam technique developed by H. S. Pennypacker, a psychologist at the University of Florida, Gainesville. (Information: (800) 626-2273.)

--Videotapes such as “Breast Self-Exam,” seven minutes of instruction produced by the Scripps Memorial Hospitals Stevens Cancer Center, La Jolla, selling for $10.50. (Information: (800) 248-6848.)

--Sensor Pad, a latex pad with a silicone lubricant designed to be placed over the breast to amplify the sense of touch. The “stethoscope for fingers” can detect lumps “no bigger than a human hair,” claims Earl Wright, vice president of Inventive Products Inc., the Decatur, Ill. firm that introduced the $14.95 pad nearly a year ago. (Information: (800) 747-2525.)

How necessary are these products, and do they help improve the breast self-exam? Here are some experts’ opinions:

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“It is worthwhile to buy these patient aids and to attend a class,” said Dr. Richard Dorsay, chief of radiology at Kaiser Permanente, South San Francisco. “A brochure is not enough.” In his recent study of 459 women, conducted to determine the best approach to teaching the exam, he found that women who took a class and had a chance to ask questions learned best.

When performing exams, women make common mistakes, he found: “They don’t examine the entire breast. They use compressions that are too gentle and they don’t palpate deeply and firmly enough. They pick up their hands and move them, and there’s a tendency to skip areas that way.”

Helene Brown, director of community applications of research for Jonsson Cancer Center/UCLA, observed: “I wouldn’t spend a penny on learning the breast self-exam from any of these commercial ventures.” She recommended that women simply obtain the cancer society brochure on the exam, adding, “The best message we can send out is to get a mammogram (after age 35).”

Another expert’s view on the patient aids: “In and of itself, breast self-exam has not made a major impact in early detection of breast cancer,” said Dr. R. James Brenner, chief, mammography section, Cedars-Sinai Medical Center, Los Angeles. Still, he said that by focusing on the problem of breast cancer, the aids may encourage women to “participate regularly in screening mammography,” the breast X-rays also recommended to detect cancer.

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