Emergency And Critical Care Medicine Grows Rapidly: Filling The Demand For Specialists Proves Difficult.

Rachel Boyce, DVM, a veterinarian in rural Illinois, spent most of the night on an emergency call, delivering a stillborn calf.

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With just a couple hours of sleep, Dr. Boyce will spend all day at her practice before she goes home for a good night’s sleep. At least that’s what she hopes will happen.

She’s on call again tonight, and one emergency call could mean another day of working 24 hours straight.

Boyce said she loves being a veterinarian, but providing emergency care has taken its toll. Working in the only veterinary practice in the entire county of Crawford and wanting to ensure 24-hour emergency care for animals, she and her two co-workers, also veterinarians, have little choice but to alternate being on call every third week.

 Quality of Life

“Emergency duty probably has the most negative impact on my quality of life as a vet,” Boyce said.

Veterinarians who work alone or in small practices burn out quickly when they try to provide around-the-clock emergency care, said James Ross, DVM, Dipl. ACVECC, executive secretary of the American College of Veterinary Emergency and Critical Care and professor at Tufts University in North Grafton, Mass.

“The difficulty working in such a demanding job with so little sleep and so many hours of work is one of the reasons for a trend that has been going on during the last 20 years—more and more vets have referred their patients to emergency services,” Dr. Ross said.

According to Ross, beginning in the ‘70s, advances in veterinary medicine and societal changes, such as pet owners working longer hours, led to a higher demand for after-hours emergency care. In response, veterinarians banded together to provide emergency coverage for each other.

ER Clinics Emerge

“Eventually, ER clinics started erupting and rapidly grew into financially successful ventures and are continuing to do so,” Ross said.

Tom Sifers, DVM, M.Ed, the director of After Hours Small Animal Emergency Clinic of Wake County, in Raleigh, N.C., an after-hours emergency clinic founded in 1978, recalls the state of emergency care years ago.

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 The growing demand for after-hours care, combined with the limited number of emergency clinics, limited the care a small emergency clinic staff could provide to their huge clientele.

Training Hospital

Since that time, the After Hours Emergency Clinic of Wake County has evolved to provide much more than tertiary care. It is now one of the few locations where DVMs can do supervised internships in emergency medicine.

The training provided in Dr. Sifers’ clinic is useful because of the high demand for veterinarians in emergency medicine.

Although nationwide only 130 veterinarians are board certified in emergency and critical care, this year alone, more than 40 people will take the boards and 100 veterinarians are doing post-doctorate work.

 “Emergency medicine is the most rapidly growing specialty—growing 20 to 25 percent a year,” said Gary Stamp, DVM, Dipl. ACVECC, executive director of the Veterinary and Emergency Critical Care Society.

The demand for qualified staff grew even more when emergency clinics began providing 24-hour emergency service.

“In 1990, there were between three and five 24-hour practices. Now there are a huge number—I’d guess 300 to 500,” Dr. Stamp said. “Some clinics can’t go 24 hours because they can’t get enough people to even staff their clinics now. Their first priority is [hiring] weekend and evening staff.”

Finding qualified staff can be a challenge, said Kevin Concannon, DVM, Dipl. ACVA, hospital administrator of the Veterinary Specialty Hospital of the Carolinas in Cary, N.C., a 24-hour specialty and emergency practice.

Staffing Is Critical

Running an after-hours emergency clinic, a specialty practice during the day and an intensive care unit supported by skilled emergency staff 24 hours a day requires a large number of experienced and educated staff.

 Dr. Concannon deals with the staff shortage by recruiting nationally and offering slightly higher salaries. (According to Ross of ACVECC, the starting salaries of emergency specialists coming out of Tufts and going into private practice are more than $100,000.)

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Even though there is the perception that emergency hospitals make a lot of money because of the higher client fees they charge, the high staff salaries and expensive medical equipment eat into profits, Concannon said. Despite challenges, the hospital provides excellent care, he said.

“Our practice makes it easier for the patient because we are the only hospital in the area where the animal can stay during the daytime and have a variety of specialists to direct continuous, high-quality care.”

ontinuous care and animal transportation become issues for an animal that needs care for several days.

 Frank Lavak, DVM, Dipl. ABVP, the medical director of VCA Wilshire Animal Hospital in Santa Monica, Calif., said that deciding to refer and transport one of his patients depends on the situation.

“There are cases where I have a very sick diabetic dog or cat where transferring them back and forth between a day practice and night practice is not for the best of the client or the patient,” Dr. Lavak said.

 “In those cases we usually transfer them to a 24-hour facility to have them monitored there until they’re ready to go home or stable enough to come back here.”

With all types of emergency care, both regular and emergency veterinarians need to know their limitations and be willing to refer animals to other vets or facilities, medical authorities say.

“Emergency vets have one of the same ethical issues that regular pactitioners do in that they need to know when to get the next level of specialist involved,” Stamp said.

“Not every person involved in emergency and critical care is a specialist. Their level of skills vary and in some cases the case dictates that care should be provided by somebody who has a higher level of training.”

As to fears about losing patients due to referrals, Dr. Lavak believes this is unlikely.

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 “As long as you’re constantly doing what’s right for patients, they’re going to come back to you,” Lavak said. “I found that clients really appreciate when you send them to a situation where their pet is well taken care of and they’re happy, the patient’s happy, and the patient gets better.”

Andrew J. Triolo, DVM, MS, Dipl. ACVIM, the regional medical director for VCA/Antech Inc. who manages approximately 40 hospitals in California, said that most veterinarians do an excellent job referring out patients when needed, with their primary concern being the well-being of their patient and not lost income.

 He recommends that veterinarians follow a simple rule about referrals: “When in doubt, ship them out.”

Overall, veterinarians and other experts in the field agree that emergency clinics, particularly 24-hour emergency clinics, will continue to grow as a segment.

While Stamp acknowledges that smaller communities—like the county with Boyce’s lone practice—will be unable to have the same level of care as an urban area, he believes that communities should strive for the best emergency care possible.

Stamp’s vision for emergency care in the future: “The use of high technology and 24 hour care—not just left alone in a clinic, but really 24-hour care and monitoring—should be the standard within a community.”

Kalani MacGregor, MPH, is a free-lance writer in North Carolina.

This article first appeared in the September 2004 issue of Veterinary Practice News.


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