Keeping Patients Out of the ED
I just finished reading Randy Danielsen’s editorial in the May issue (A return to prehospital care. Clinician Reviews. 2011;21: cover, 2-3). Thanks for the great insight!
When I finished my first Army hitch in 1974, I went to work for a private ambulance company that wasn’t far removed from its funeral home roots. The town of Palm Beach had a mobile cardiac care unit staffed with firemedics. It was the same model RV as the one in Stripes. The county was just starting the fire-rescue program, there was no 911, and medical calls in the city of West Palm Beach were being answered by pumpers (complete with Elder valve resuscitators fitted with pedi masks).
But despite the technological advances since that time, we’re still responding much in the same way. It’s little wonder that the cost of protective services is out of sight and always a major target of budget reductions.
In the late 1990s, I joined an Assertive Community Treatment Team, a radical but proven approach to treating the severe and persistently mentally ill in the community. Same pitfalls: How are we going to pay for it, and who is going to be in charge? These issues could not be resolved, and the program folded.
Primary care and, in this case, prehospital care will eventually default to PA/NP practice. I’m thinking that we shouldn’t wait for the government to fund it. We (NPs/PAs) need to put a human face on this when we go before the lawmakers.
I want to be brief. It doesn’t make any sense for a person to walk around with triple-digit blood pressure, courting any number of cardiovascular events, considering they could be managed from a department store formulary. In the present mode of thinking, it is perfectly OK to deny access to primary care due to funding constraints but not to expend enormous sums on emergency response and subsequent hospitalization (ie, emergency department, ICU, critical care unit, stroke unit). This information should make fiscally conservative folks stand up and take notice; but it won’t.
The three greatest roadblocks to ours becoming a healthier nation are stress, access (to primary care), and attitudes (about one’s own wellness).
George Copeland, NP, West Palm Beach, FL
Your “prehospital care” article was very intriguing, and I wanted to let you know about a pilot program we designed to provide health care for our local rescue squad members. The squad does not have enough money in the budget to cover health insurance for the employees, so we opened an office in one of our underutilized stations. I see squad members and their families at no charge, and I am reimbursed per patient by the squad.
The practice is set up like an old-fashioned primary care office, and quite often I will have to suture or provide emergency nebulized medications or other treatments to keep our members out of the emergency department (ED).
The practice operates on an on-call basis; I can be reached by phone, text message, and even Facebook messages. The practice patient volume doubled when I opened my personal Facebook page, and I have never advertised the practice in that format. This generation of patients is very tech savvy, and that is how they communicate. I have even found that it is a great way to do follow-up on visits. I can log in and send patients a quick private note, and they can contact me when they are able. The reaction is so positive, because their perception is that we care and check up on them.
Basically, I would like to expand the practice into the community that we serve. I feel confident that if we do not accept insurance, we can deliver good, solid primary care that is very cost effective.
In closing, there are many ways to minimize nonemergent ED visits and help contain costs. This is just one way that works in our small town.
Steven Marks, RN, MSN, APN-C, COHN-S, Weymouth, NJ
Vaginal Strep and Sexual Pain
The recent CE/CME article on sexual pain disorders (Clinician Reviews. 2011;21:32-38) mentioned many causes for this problem, but one cause was not discussed.
I have been an NP for 23 years; most of this time was spent in primary care, but my first practice site was in Ob-Gyn. When I started there, a nurse-midwife said, “I suffered for many months with vaginal burning and was found to have vaginal strep. It completely resolved with penicillin. You won’t see this in the books, but test for it with vaginal cultures and treat it if the patient has symptoms.”
I took her advice to heart and have listened to the debate over the years about only treating vaginal strep when a pregnant woman is about to deliver. A young mother once spontaneously told me a story of having incredible vaginal burning for several months that no one could help her with. Then she got a breast infection and was treated with antibiotics, and the vaginal burning resolved too.
When I mentored a PA, I told him about this as something to add in the differential if a woman complained of vaginal burning. He went on to become the head of a PA department at a local university and e-mailed me once to say, “Kathy, you are not crazy—they treat this regularly in England. They call it ‘aerobic vaginitis.’”
I understand that for some women, strep is normal flora and does not cause symptoms. But for many, vaginal strep is painful and so easily treated. There are diseases where some people are symptomatic and others are not, and—in general—we treat only the symptomatic ones (think arthritis, depression, herpes). I’m not sure why that hasn’t been applicable to vaginal strep.
Kathy Van Beeck, ANP-BC, Beaverton, OR
The authors respond:
On page 35 of our article, under “Physical Examination,” we mention, “If there is suspicion of pelvic organ prolapse, vaginitis, or sexually transmitted infection, further assessments are made.”
Ms. Van Beeck raises some important additional points about vaginitis as a possible cause of sexual pain in women. We acknowledge this, but a more detailed discussion was beyond the scope of our paper.
Vaginal bacterial conditions, including bacterial vaginosis, and vulvar skin infections with strep or staph can cause chronic irritation and pain, including sexual pain. Vulvovaginal cultures for aerobic and anaerobic organisms can be obtained if an infection is suspected, and where appropriate, antibiotic treatment can be initiated.
In our experience, streptococcal infection of the vulva or vagina is a rare cause of sexual pain in women who present to our specialized program in treating female sexual concerns. However, we have seen such cases.
For further information, an expert who has written extensively in this area is Jack Sobel, MD, at Wayne State University School of Medicine.
Shirley R. Baron, PhD, and Stacy T. Lindau, MD, Chicago