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