The Changing Landscape: ED visits have increased by about 3% per year over 12 years from 369 visits to 451 per 1000 population. The ED population is aging in line with the demographics of the country, and EDs need to prepare to meet the needs of seniors.

Parents bring in their daughter because they pulled on her arm, and now she is not using it. They are thoroughly convinced that the child’s arm is either broken or dislocated. We all recognize this as radial head subluxation or “nursemaid’s elbow” and immediately attempt to reduce it. The provider takes the injured arm, supinates at the wrist and flexes at the elbow. Does the child scream?

Don’t look back. I’m proud to say that each generation of EM residents moves to a higher plane of learning than past generations. The depth and breadth of learning in emergency medicine parallels the lightning-fast growth of knowledge that characterizes modern medicine. Keep it up!

In a recent review of the national Get with the Guidelines (GWTG)-Stroke regristry in which 58,353 tPA treated patients were analyzed, every 15-minute faster interval to treatment was associated with fewer symptomatic intracerebal hemmorhages, reduced in-hospital mortality, more patients with independent abulation at discharge, and more patients discharged to home.12

Perhaps the surest way to drive someone crazy is to expect them to understand the rules and regulations related to coverage and payment by Medicare for hospital inpatient services (Part A), outpatient / observation services (Part B), and skilled nursing facility (SNF) services (also Part A).

An 18-month male presents to the ED with left posterior ear swelling for four days. He was seen in the ED two weeks prior for rhinorrhea and diarrhea, at which time he was diagnosed with a viral illness. The patient’s mother reports bloody drainage from the ear for one day, but denies fever, vomiting, rhinorrhea or cough.

A 500-pound morbidly obese male presents to your ED complaining of mild shortness of breath and palpitations. A quick ECG shows SVT with a rate over 200 bpm. His BP is in the 130s systolic, and he is otherwise stable. You know you have a bit of time. Meanwhile, the nurses begin searching for veins to start an IV.

We’ve written – in these pages and elsewhere – about the great potential of electronic health records to improve emergency care. That potential includes better access to past histories and medications, easier coordination among the care team, improved guideline adherence and evidence-based practice through intelligent decision support. And yet, as the country belatedly moves to adopt EHR, the potential for improved care has often remained just that – potential. 

It doesn’t take a rocket scientist to acknowledge that many patients treated in the ED don’t require the background and training associated with being seen by a board-certified emergency physician. As a result, most emergency departments in the United States are now incorporating “advanced practice clinicians [APCs]” (otherwise known as PAs and NPs) into their ED staffing. 

In a recent issue of SMART EM we went under the evidence sea and into the depths of pediatric orthopedics, where there is a question trainees (and parents) with overdeveloped common sense have been asking for a half century: why do we immobilize bones that are clinically and radiographically normal?

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