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記事「容体安定の患者に転院求めトラブルも 救命救急センター」

関西asahi
『容体安定の患者に転院求めトラブルも 救命救急センター』

ちょっと古い記事ですけれど。

ここしばらくERで仕事していますけれど、救急科の医師たちのとても重要な仕事っ
て何かといえば、【転院交渉】。
これがとてもとても気力を蝕む仕事なんです…。だって、ベッドがあかないと、
毎晩発生する救命救急治療が必要な患者を救うことができないから。

でも今時どこの病院もベッドなんていっぱいで。患者さんの都合も考えながらい
くつも電話して頭下げて、それでもなかなか転院先なんて見つからなくって。
だいたい、救急のベッドはよくめがとどいているし、看護も厚い。外に出たらもっ
と看護のレベルは落ちることも多い。救急病院みたいに新しい機械はおいていな
いことも多い。検査とか看護とかで質の落ちる外病院に行くことを嫌がったり、
そんな処置をする救急科医師に不満を持ったりする患者もいるなと感じます。
(そもそもは不要だから余計なコストを全ての病院が背負うべきではないのが日
本の保険財政のためであり患者のためであり日本の未来のためである、というの
は患者の理解は得られるはずもない理屈で…)。

「つらい仕事が嫌だからと開業医として逃げ出すモラルのない医者たちがいるか
ら日本の医療が崩壊するんだ」なんて好き勝手なことをTVでしゃべっている不勉
強な知識人がいたりしますけれど、まあ、いろいろな無知が重なって、無茶を現
場が背負わざるを得なくなっているのを、もうちょっと知識人たちぐらい理解し
てほしいなと思ったりします。

時間を選んでくれない産科医療に最近光があたってきましたが、
より時間を選んでくれない救急科医療にも、もっと光をあててほしいなと感じま
す。


(以下転載)
2008年02月25日

 生命の危機に陥った救急患者を一人でも多く受け入れるため、救命救急センター
が空きベッドの確保に躍起になっている。比較的症状の軽い患者も押し寄せた結
果、満床状態が慢性化。救急隊の搬送要請を断る理由の一つになっている。入院
患者を院内の各診療科やほかの病院に移すのも救急医の仕事だが、転院を望まな
い患者や家族とのトラブルは尽きない。国の医療費抑制で病床数が減らされる中、
「綱渡り」のやりくりが続く。
   
    ◇

 朝9時、2〜3人の医師がカルテを片手にタウンページをめくり、おもむろに
電話をかけ始めた。大阪市立総合医療センター(同市都島区)に併設された救命
救急センターのいつもの光景だ。満床で重篤患者の受け入れが不能になる事態を
避けようと、入院患者の転院先をひたすら探す。

 患者の自宅近くに移ってもらうのが理想だが、つてがない。「電話帳で上から
順にかけるのが手っ取り早い」。週末はほかの病院が休みで交渉が難しいため、
毎週金曜日は最低でも10床は空けておきたい。大半は数回の電話で受け入れ先
が見つかるが、入院が長引きそうな高齢者は苦労する。

 全国の医療機関の病床数は96年の191万床から06年は179万床に減少。
一方、救急搬送される患者は324万人から489万人に急増した。厚生労働省
は「地域の病院との役割分担や院内の連携を深め、空床を確保してほしい」と呼
びかけるが、現実は厳しい。

 「冬場は特に病床の確保が難しい」。高度救命救急センターに指定されている
兵庫県災害医療センター(神戸市中央区)の小沢修一センター長は嘆く。寒くな
ると、脳血管障害や心筋梗塞(こうそく)、火災による重度熱傷などの患者が増
加。午前中に転院させた患者のベッドに午後、急患を運ぶ。病床稼働率は100
%超だ。

 救急病院が減る阪神地区や姫路市周辺からの搬送例も目立つ。「それぞれの地
域内で急患を引き受ける体制を再構築してもらわないと、こちらがパンクしてし
まう」

    ◇

 この年末年始、奈良県立医科大付属病院(橿原市)の高度救命救急センターで
は、集中治療室(ICU)と救急治療室を合わせた30床の患者がほとんど入れ
替わった。

 特にICUは常に2〜3床を確保しておく必要がある。このため、入院患者の
家族の同意をあらかじめ取っておき、深夜に救急搬送があれば、患者が横たわる
ベッドごと別の部屋へ移す。救急医は「事前に了解を取らないとトラブルになる」。

 軽症患者まで幅広く受け入れる神戸市立中央市民病院の救命救急センター(同
市中央区)。ベッド確保のため、各診療科の病棟を見回るのが佐藤慎一救急部長
の日課だ。

 入院する救急患者は1日平均18人。救急用の30床はすぐに埋まり、2日ほ
どで一般病棟に移ってもらう。各科の協力が不可欠だが、がんなどの手術も多く、
退院や転院が追いつかない。やむを得ず、救急患者に外来用のベッドで「待機」
してもらうこともある。

 容体が安定した患者に「手術を待っている人がいる」と転院を促しても、なか
なか納得が得られない。「こんなに早く放り出すのか」「なぜ最後まで診てくれ
ない」。病室に非難の声が飛ぶ。

 佐藤部長は強調する。「病院全体で救急用ベッドを探しているが、ぎりぎりの
状態だ。緊急性のない救急病院の利用で、ほかの患者が犠牲になることを知って
ほしい」

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