Shopping for a Doctor
Be a Smart Consumer of Medical Care

by Edward A. Walton, M.D., F.A.A.P., F.A.C.E.P.

Worst Case Scenario

Johnny Smith has been stung by a bee while at campfire. His face has begun to swell; he is having difficulty breathing. The on-site camp health officer is called, but never having given an EpiPen®, injects it into his finger. The camp doctor is called, but he is on the golf course and can't be reached. 911 is called. The ambulance takes twenty minutes to arrive and gets lost for five minutes driving through camp. When they do arrive, they state that they are first responders and can only give oxygen and transport the patient. They load up Johnny and proceed to East Rural General Hospital. As it is a small ER, the doctor there last saw a similar patient two years ago. He gives medications, but Johnny continues to deteriorate. Dr. Jones decides he needs to pass a breathing tube, but the hospital is out of pediatric sized tubes. Dr. Jones isn't sure what to do next, as he is an orthopedic resident who is moonlighting in the ER. Luckily, the regional medical center has a helicopter service. The flight crew arrives and is able to stabilize Johnny for transport. Johnny's parents find out about this "comedy of errors" and contact an attorney.

Patients vs. Customers

It is a new age in health care. In the not too distant past, no one would ever question "doctor's orders." But now patients are called "clients" or "customers," and parents do exhaustive searches to find the "right doctor" for their family and children. Expectations have also risen for health care at camp. It's no longer the "infirmary" at most camps, but instead the "health center." Campers come to camp with conditions and medications which were unknown twenty years ago. In addition, the heath care system itself has become more complex. Getting ready for camp in the new millennium requires more than mops and paint brushes. It also requires a critical appraisal of your camp's health needs.

Parents expect the most risk-free camp environment possible. Note that the words "safe environment" weren't used. No camp staff can ever make the camp experience entirely safe. Instead, what can be done is to analyze the areas of risk at camp and prospectively plan so that these risks can be minimized. Meeting this goal requires that the staff be given the tools it needs to reduce risk when it is identified. These tools can be physical (e.g., helmets for horseback riding) or the result of increased staff awareness or training (e.g., all staff know how to use an EpiPen®).

Reducing risk also requires a significant amount of advanced research. In this regard, a camp needs to take on the role of the parent, who might have spent a great deal of time looking for the "right doctor." Camps like to think of themselves as self-contained communities — with everything they need on site. Yet camps do not exist in a vacuum. This is most true when it comes to the health of campers. The American Red Cross speaks of the "Chain of Survival" — the steps that address how an ill or injured person should be initially treated until he or she arrives at a hospital. Camps too have a "Chain of Survival," which begins with the camp health provider, extends through the camp doctor, and on to the emergency medical services or the hospital.

How well do you know the parts of your "Chain of Survival?" Advanced preparation can help you be ready for smooth interactions with the health-care team outside of camp.

Policies, Procedures, and Your Camp Doctor

American Camping Association (ACA) and some state licensing regulations require camps to establish a relationship with a doctor. Some camps are fortunate to have a doctor on their staff. However, this is the exception — not the rule. A relationship with a doctor is required because only physicians are able to practice medicine independently. All other providers must practice under the medical authority of a physician who has agreed to provide this service. Each year, camps must establish written policies, standing orders, and protocols that outline the "scope of practice" of their on-site camp health provider, and have them reviewed and approved by a physician. ACA requires health policies to be reviewed every three years, and standing orders to be reviewed yearly (American Camping Association 2002).

Some of the protocols usually found in a camp's health-service policy include:

• medical control and provider scope of practice
• health screening
• first aid standing orders
• emergency contact and transportation
• supplies and equipment
• medication administration and storage
• parent notification
• infection control
• documentation

These documents give guidance as to what that provider can do independently. When a physician signs off on these policies and procedures, he or she is assuming legal responsibility for any actions which are performed by the on-site provider. The American Academy of Pediatrics asks its members to help camps by providing this service (Pediatrics 2000). However, this is a great deal of legal responsibility for the physician to assume. As a result, camps are having a much more difficult time finding physicians to sign off on these policies.

Your relationship with your camp doctor will vary depending on the nature of your camp, the training of your on-site health-care staff, and your access to medical care. The needs of a day camp in an urban setting certainly differ from those of a resident camp in a remote location. ACA standards require all day or resident camps to have staff members trained in first aid and cardiopulmonary resuscitation on site at all times. In addition, resident camps must have a physician or registered nurse on site for a part of each day, with phone contact (for the off-site times), also arranged (American Camping Association 2002).

Anyone who has tried to get an appointment recently knows that doctors are busier than ever. Preparation will make you more successful in your effort to recruit a doctor. The best doctor for a camp would be a family practitioner or pediatrician — as they have advanced training in the care of children. Before camp, arrange a meeting. This is your opportunity to discuss your needs for the upcoming season — and to establish a relationship. Be ready to provide information and ask questions so that you and your doctor can reach an understanding as to what kind of support you need at camp. Your camp doctor should be a resource for your camp health provider, and also to you as you access the medical system. Some of the items you should be prepared to discuss include:

• Your camp population. Do you accept special needs children? What is your camp's experience with common long-term illnesses, such as asthma, diabetes, or seizures? What about behavioral disorders, ADHD, or depression? How does your camp handle food allergies or special diets? Provide a copy of your health-care policies and procedures for review.
• The availability you expect from your camp doctor. Most day camps only require a review of policies and procedures — in the event of illness or injury the camper is likely to be treated by his or her own family doctor or in an emergency department. Resident camps, on the other hand, should ask the doctor who reviews their policies and procedures whether he or she is available for appointments — or will campers need to be evaluated in an urgent care or emergency department?
• The training and experience of your on-site provider. An experienced camp nurse requires much less guidance and intervention than a new graduate or a health-care provider without camp or pediatric experience. Would you like the doctor to provide training for your staff in the use of special medical devices such as inhalers and nebulizers for asthma or an EpiPen® for allergic reactions — or is your on-site provider capable of providing this training?
• In these days of managed care, your doctor is also likely to be concerned about being paid. Make sure that if the camp provides health insurance, your doctor accepts it. If camp does not provide insurance, you should require the parents or guardians to ensure that their private insurance will pay for care while the child is at camp.
• Your doctor is also likely to ask about liability. Ensure that your camp's liability policy covers your camp physician, as most physician malpractice policies do not.
• While this meeting is an opportunity to let your doctor learn about camp, it is also your opportunity to learn about the doctor. The following questions are helpful to ask:
• Is the doctor board certified by the American Board of Medical Specialties (ABMS)? Certified doctors have passed tests relating to their specialties and are required to participate in continuing medical education and quality assurance. Most state medical boards also provide Web sites which report doctors who have had malpractice cases or have undergone disciplinary actions.
• Ask about the office and staff. How does the doctor make appointments? What are the office hours? Is the doctor available by phone at night or do you talk to a nurse? Will the campers see only this doctor or are there physician extenders such as physician assistants or nurse practitioners?
• Ask the doctor to visit your camp. It is a great idea to have the doctor come and meet your general and health center staffs, tour your facilities, and maybe even stay for lunch.

Call an Ambulance

Some of the greatest advancements in medicine in the last forty years have occurred in the care of emergencies. As recently as the 1960s, there were no emergency rooms. Patients were seen in doctors' offices or at home. If they were very ill, a hospital-based ambulance was called or the family transported them. With the advent of emergency departments and community-based emergency medical services, emergency care has improved greatly. Dial 911 anywhere in the United States and you can reach an ambulance — which will transport you to the nearest emergency room. But few outside the medical community are aware of the variations which exist in the care that is available.

Here is what you need to know about the system you hope you never use.

• When you dial 911, the call is routed to the local Emergency Medical Services (EMS) dispatcher. EMS usually controls police, fire, and ambulance response. Based on the nature of the emergency, any of these could be dispatched to the scene. When an ambulance crew arrives on site, they assume care of the patient — under the medical control of a base hospital physician in the local area. At that time the legal responsibility of care for that patient by camp ends.
• While 911 calls are handled in a similar manner throughout the United States, the type of Emergency Medical Services provider who responds to the call can vary greatly. In most urban areas, ambulances are staffed by paramedics, who have up to 550 hours of training before they are licensed. In these areas, response times are in the range of five to ten minutes. The scope of practice of most paramedics includes placing IVs, giving medications, or even intubations (placing a tube in the throat to aid in breathing). In rural areas, however, ambulances are often staffed by volunteers with more limited training. Response times could be prolonged, with hospitals even hours away. First responders only require fifty hours of training — and as a result, are limited in the procedures they can perform. They would be able to secure a patient to a backboard, splint a fracture, or perhaps defibrillate (provide electricity to a heart in an abnormal rhythm), but they wouldn't be able to place IVs or give medications.
• Unfortunately, the level of training of a local ambulance service is often constrained by location and by the funding available. But there are things that a camp can do to ensure that when an emergency occurs the response is as prompt and coordinated as possible — whether the ambulance station is across the street or hours away. To be better prepared for an emergency, contact your local EMS providers prior to the opening of camp. Find out the following:
• Ask about the level of training and scope of practice of the local ambulance crew. This may influence the level of training your own health staff requires. It might be wise to have an on-site provider with more advanced skills and experience if your camp is remote or the local crews are less highly trained providers. If you have questions or concerns, discuss them with your camp doctor.
• Are your local crews trained in Pediatric Advanced Life Support, and how do they maintain their pediatric skills?
• Ask for the response time of the ambulance and the transport time to the nearest hospital. Prolonged times (greater than ten minutes) may lead you to look closely at having a more experienced provider on site. If you choose to have a higher-level provider, discuss with the local EMS if your camp health provider should accompany a patient in the ambulance.
• Most importantly, create a response plan. Have the crew visit, tour the camp, and identify the locations where emergencies are most likely to occur. Discuss with the EMS providers where you will meet to guide them to the critical locations. Make sure EMS knows how to contact you (with specified radio frequencies or phone numbers). This plan should be kept on file with the local 911 dispatcher — and should be included in staff training prior to camp.

Most camps are not in a position to change their local EMS system. However, with advanced contact and appropriate questions and planning, you can be ready to use the system to its greatest potential.

To the Hospital

Every year, approximately 30 million children are evaluated in Emergency Departments in the United States (ACEP 2004). Slightly less than half of these visits are injury related. The public assumes that any hospital with a red "Emergency Department" sign out front delivers the same level of care. Unfortunately, this is not the case. As is true with EMS providers, there is wide variation in the type and severity of emergencies any given emergency department can handle. It has been shown that small or rural emergency departments may lack the equipment or their staff may lack the training needed to adequately treat a pediatric patient (Gausche-Hill and Wiebe 2001). However, by asking good questions you could help raise the level of care of what might be a marginal ER.

Emergency medicine is still a developing specialty. At the present time 32,000 doctors practice emergency medicine, but only 17,000 are board certified by the American Board of Medical Specialties. The board-certified doctors tend to congregate in larger medical centers, while those with less training or experience tend to practice in smaller volume ERs or urgent cares. While most of these physicians are caring and competent, they may not have had the specific training in care of critically ill patients provided by an emergency medicine residency. As camps are members of the community served by a local hospital, parents expect you to have done some checking into the level of services that are available nearby.

Talk to the medical director at the local emergency department, and also to your camp doctor, and ask the following questions:

• What is the certification status of the emergency physicians, and if they are not board certified, what is their training in pediatrics? Is the department using moonlighting physicians from specialties outside of emergency medicine, pediatrics, or family practice — do they have specific training in caring for children? If they do use moonlighters, what is their experience and where is the nearest facility with pediatric trained specialists?
• Is there a physician and a nurse who direct pediatric quality assurance? The role of these individuals is to coordinate continuing pediatric medical education and to examine critically the care provided to children by the emergency department. If this position doesn't exist ask, why doesn't it?
• What pediatric equipment is available in the emergency department?
• What are the transfer arrangements if the local hospital does not admit children? Where will a critically ill child be sent, and where is the nearest trauma center? It is also important to know transfer times by ground and by air — if helicopter transfer is available.

Be wary of free-standing, urgent-care facilities. While they may be convenient, they are often staffed with physicians with minimal pediatric training or supplies. As a result, they must frequently transfer children to an ER — thus turning one trip into two and one bill into two. If you choose to use an urgent care, talk to the local primary care and emergency physicians for their impressions of the care provided.

Best Case Scenario

Johnny Smith has been stung by a bee while at the campfire. His face has begun to swell and he is having difficulty breathing. The camp health officer arrives and gives an EpiPen®® into Johnny's right thigh. The ambulance meets Johnny at the pre-arranged pickup point. The paramedic crew places an IV and gives medication into the vein and begins breathing treatment, as well. Dr. Jones has been notified and has the pediatric team ready. He has seen lots of cases like this and continues treatment until Johnny's wheezing and swelling are gone. Johnny's parents, who have been contacted by camp, call Dr. Jones to thank him for the excellent care provided in saving Johnny's life.

Medicine has changed. With the proper information, you can be an intelligent consumer of medical care. You should be as comfortable with the arrangements you have made for your campers as you are with those for a family member. Ask the right questions — so you only have "best case scenarios."

Edward A. Walton, M.D., F.A.A.P., F.A.C.E.P., is assistant clinical professor of emergency medicine and pediatrics at the University of Michigan in Ann Arbor, Michigan. He has been involved in camp and camp health research for seventeen years and is currently working with the American Camping Association (ACA) and American Academy of Pediatrics (AAP) to revise the Health Appraisal Guidelines for Day and Resident Camps. For questions or more information, contact Dr. Walton at ewalton@umich.edu.

Originally published in the 2004 September/October issue of Camping Magazine.