The Morning Report
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Saturday, Nov. 4, 2006 | Dr. James Dunford is one of those people who wears two pagers on his belt. As the medical director of the city’s emergency medical service and a professor of clinical medicine and surgery at the University of California, San Diego, he’s that important and that busy.
In his current role with the city, which he has held since 1997, Dunford serves as the city’s top doctor, oversees the performance of the private-public partnership that runs the city’s ambulance service and is responsible for keeping its 425 paramedics and approximately 600 emergency medical technicians up to speed on the latest life-saving technology and techniques. Dunford also supervises the city’s fire communications center, which handles about 80,000 requests for service a year. If that’s not enough, the astute doctor is also a member of the city’s urban search and rescue team, which responds to disasters across the country, and keeps a packed bag in the corner of his office just in case.
When Dunford isn’t working for the city, he’s practicing medicine, treating patients and teaching medical students at UCSD’s emergency rooms in Hillcrest and La Jolla.
Dunford’s jobs put him at the crossroads of public health and safety and give him unique insight to some of the region’s most pressing healthcare issues.
Overcrowded emergency rooms have been a concern in communities all over the U.S. What’s the situation in San Diego?
The Abaris report, this county-wide safety-net study that was just completed … made the comment that San Diego was not as under-bedded from an emergency medicine standpoint as a lot of other places but you would have a hard time selling that to any ER doc in San Diego. When you are actually in the trenches seeing patients and there are 25 people waiting, it’s kind of difficult to tell them ‘Don’t worry there’s no problem with overcrowding in the ERs.’
What’s driving that overcrowding?
We’ve had a lot of emergency departments close in this county in the last 10 years. … True enough, some of the [remaining] emergency departments have started to expand out of necessity and have started trying to catch up, but the bottom line is the infusion of patients coming in is real both in volume and especially in acuity. … In a lot of places in the country, San Diego included, what you are ending up with is log jams where you can’t bring people into new beds because people are occupying those beds for prolonged periods of time trying to get upstairs.
You literally end up with quasi-intensive care patients for a day or a day and a half in the emergency room when you could be seeing three people an hour in that same bed. So a lot of the problem-solving is trying to work backwards from all of the other in-patient services because the emergency departments feel hostage to the inefficiencies of the hospitals. And then the hospitals feel that they are being strangled by all of these other factors, not the least of which is nursing shortages, and we are short thousands of nurses in this state.
How much of a role do undocumented immigrants play in ER overcrowding?
I think that’s almost a zero problem to be perfectly honest. That, to me, is the least of our worries in terms of who comes to the emergency room and the facts bear that out. Somebody who is in this country illegally is something like 50 percent as likely as the average white guy to come into the emergency room. If anything, those folks would be afraid to come, I think, and would under-use the system.
A lot of cities are facing problems with ambulance diversion, the practice of redirecting incoming ambulances from one overcrowded emergency room to another that’s often further away and just as busy. Is that a problem in San Diego?
The ambulance diversion issue is, where do you think the patients go if they don’t go to the hospital? If everybody is overcrowded and on bypass does anybody think that we are going to bring the patient to Fashion Valley and drop them off? No, they are going to go to somebody’s ER.
So what we did is the San Diego Medical Society worked with the county medical director and created a system that says you can’t go on bypass under certain circumstances. … So it’s rule based, realizing that otherwise what you had was nothing more than a shell game, where you get my patients and I get yours. By looking systemically from above, San Diego got a little sanity at least on that issue.
If emergency rooms are stretched thin now by day-to-day pressures, how are they going to be able to function in the event of a disaster?
That’s the $64 million question. Do we really have the surge capacity to manage a mass casualty? I’m sure the answer is no, we don’t. … When you have got 18 beds in an emergency room … and you have 1,000 patients, it doesn’t take an Einstein to know that the place you are going to get the majority of that care is not going to be in one of those beds.
Depending on the scale of the disaster, you are going to end up basically looking outside the community to prepare the care that you need, including exporting your patients outside the system. That’s easy to do if you have an earthquake, relatively speaking, but if you are trying to export a bunch of people with smallpox, that’s a different thing.
Traditionally, it’s one of the county’s main responsibilities to handle public health. Does your job with the city fill a void in their coverage?
A public health system is more than the public health department. The public health system includes the (American) Cancer Society, the (American) Heart Association and the (American) Diabetes Society. When the Centers for Disease Control came to review our public health system a couple of years ago, it was an eye opener to me to realize that the county Health and Human Services Agency has the lead responsibility but when you really look at what’s going on in San Diego, many of the responsibilities for the public health are assumed by volunteer organizations and a plethora of clinics that form the public safety network.
But are outside groups having to step up because the county isn’t fulfilling its public health responsibilities?
In some instances its not. … I’m not sure that San Diego’s is that much weaker than others, although I think there are some traditionally strong public health systems, like Boston and San Francisco, that have these legacies of really spectacular public health systems.
You could easily say that San Diego’s Health and Human Services has benefited tremendously from the largess of the organizations in the community that have picked up and run with a lot of projects. I don’t know where we would be without the community clinics and folks like Alliance Healthcare Foundation and other philanthropies that help subsidize public health programs.
But does the county fulfill its public health duties?
There are some things that kind of rankle me here. … I think it is comical that we don’t have fluoride in the water. I wouldn’t say that’s the case study of the public health system in San Diego but I mean, to me, any time you see a community that has still not implemented one of the recognized 100 top public health accomplishments of the 20th century, you have to scratch your head and say how can that be possible.
What else rankles you?
Well, my personal pet issue is syringe exchange. … That has been something that I have basically been championing here in San Diego as a physician. … This is a big deal. I’m not a hepatitis C specialist; I’m not an HIV specialist. I’m an ER doc. But not a day goes by on a shift that I don’t take care of an HIV patient, see needle sticks or drain an abscess of a drug addict. … I have a particular issue with the fact that the syringe exchange has been championed by the city, who is not the public health department. … I am hoping that the county will be able to come on board and help us.
What do you think of the county’s opposition to medical marijuana?
I don’t have very much of an opinion about medical marijuana. I don’t see very many patients smoking dope but I think that may be an abused privilege to be quite honest with you. I’m a liberal guy at heart but I think that one has been taken advantage of by a lot of people.
How about the level of services that the county provides to the homeless?
I don’t have the best handle on what all of the services are that are provided by the county. But I’m in a position to say that everyday patients leave my emergency room and have no place to go. I think that’s no good. … What bothers me probably more than anything is the mentally ill people that still haven’t been able to get access. I understand that there is new money coming but when we consider the number of funded psychiatric beds in this community as being the lowest of any in California on a per capita basis and you see the number of homeless and mentally ill people in the streets, it’s very pressing.
– Interview by DANIEL STRUMPF