Editorials] f

personal Contact Can Reduce Noncompliance

THE CONTINUING EMERGENCY CARE CLINIC proposed by Anwar and col leagues at the Medical College of Penn- sylvania is i n n o v a t i v e and t h o u g h t - p r o v o k i n g ( Ju ly , JACEP 1977). I t points to an increased responsiveness among emergency depa r tmen t pa t ien t s who have repu- tations for noncompliance.

Personal contact wi th an in te res ted phys ic ian has long been t h o u g h t an i m p o r t a n t a s p e c t of t he p a t i e n t / physician re la t ionsh ip and one many cri t ics f ind l ack ing in the organiza t ion of emergency medicine. This ar t ic le provides some evidence t ha t such personal r e la t ionsh ips not only exist in an emergency depar tmen t , but are more likely to develop wi th emergency special is ts who choose to work in the emergency depar tmen t .

I would l ike to see the economic feasibi l i ty of such an endeavor a s c e r t a i n e d , p a r t i c u l a r l y w i t h an i n d i g e n t population since the inner ci ty emergency d e p a r t m e n t is most l ikely to have difficulty mee t ing costs.

An a l t e rna t ive to a s epa ra t e a r ea t h a t migh t prove more cost effective is to have the pa t i en t s r e t u r n to the

emergency d e p a r t m e n t i tsel f du r ing the hours of m i n i m a l service. C o m m u n i t y hosp i t a l e m e r g e n c y d e p a r t m e n t s :might find this more desi rable since they also have diffi- culty being cost effective at nonpeak hours. As A n w a r points out, th is does cause some disorder in the emer- gency depar tmen t but it can be min imized if pa t i en t s re- turn during slow hours.

We have used th i s p rocedure a t the U n i v e r s i t y of Chicago for a number of years also due to the inab i l i t y to predict pa t ien t compliance to the r egu l a r clinic sys tem The percentage of r e tu rn has been from 47% in the regu- lar c l inics to 70% in t he e m e r g e n c y d e p a r t m e n t . A special recheck charge has been ins t i tu ted , and there has been no increase in cost to the in s t i t u t ion to follow these patients.

A major problem of the con t inu ing care clinic occurs when a pa t i en t mus t r e tu rn to o ther t h a n the p r i m a r y physician., due to the phys ic ian ' s t ime off, a ho l iday or service change.

I hope t h a t o t h e r s w i l l e x p e r i m e n t f u r t h e r w i t h methods of improving care to the emergency pa t i en t and defining the l imi t s of emergency medicine. Many un- Solved problems remain , such as how to improve care for Other than self- l imited problems such as Anwar out l ines . COmplex diagnost ic procedures and chronic disease main- tenance st i l l suffer from the noncompliance problem bu t the emergency d e p a r t m e n t cannot hope to recrea te the raedical cosmos, nor should the emergency phys ic ian at-

J~]~P 8:s (Aug)1977

t e m p t to rep lace o t h e r med ica l specia l is ts . There are more t h a n enough re spons ib i l i t i e s wi th in the field of emergency medicine.

Peter Rosen, MD JACEP Contributing Editor

(Dr. Rosen, formerly Director of the Division of Emer- gency Medicine, University of Chicago Hospitals and Clinics is now Director of the Division of Emergency Medi- cine, Denver General Hospital, Denver, Colorado.)

Major Tranquilizers In the Emergency Department

THE PHENOTHIAZINES WERE DISCOVERED to have po- t en t ant ipsychot ic effects in the ea r ly 1950s. 1 Since then, a number of drugs, c lassif ied as major t ranqui l izers , have been developed wi th s imi l a r propert ies . The use of these drugs is in no smal l way re l a t ed to the decline of chroni- cally hospi ta l ized psychia t r ic pa t ients , and the growth of the communi ty men ta l hea l t h movement . However, there are dangers t ha t go along wi th the success of these drugs.

Fi rs t , the drugs themse lves have serious side-effects and long t e rm effects, some of which are i r revers ib le and even l i fe - th rea ten ing . Secondly, there is po ten t ia l for the s t ree t abuse of drugs wi th cen t ra l nervous sys tem effects. In the sixties, the ~flower chi ldren" laced the i r LSD wi th Thorazine to min imize the bad tr ip.

F ina l ly , phys ic ians ' misuse of these powerful drugs is re la ted to the r ap id deve lopment and concomitant diffi- culty of keep ing informed about new drugs, coupled wi th our discomfort wi th "crazy" behavior .

Major t r anqu i l i ze r is a misnomer . In cont ras t to the minor t r anqu i l i ze r s and sedat ives , the group of drugs re- ferred to as major t r anqu i l i ze r s has specific ant ipsychot ic propert ies , which re l ieve the symptoms of an organic or funct ional psychosis usua l ly wi th min ima l sedat ion. In the nonpsychot ic pa t ien t , however , the effects m a y be qui te different. The pa t i en t m a y become profoundly se- dated, often for m a n y hours, and may experience m a r k e d d y s p h o r i a w i t h n o r m a l t h e r a p e u t i c doses of t h e s e agents, l~plSsl The use of these drugs to control behavior , as in prisons, ins t i tu t ions for the men ta l ly r e t a rded and menta l hospi ta ls , is a horr ib le subs t i tu te for adequa te t r a in ing and staffing.

Emergency d e p a r t m e n t s should also be encouraged to t r a i n nu r ses and o the r profess iona ls to recognize and manage behav io ra l d isorders wi thout resor t ing to the in- appropr ia te use of medicat ion.

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