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?

Lack of medical staff in public emergency departments is in many ways a global phenomenon, so why should Hong Kong’s public emergency departments be singled out for special attention? Anyone who circuits the globe from country to conference and back will hear many similar stories of a critical shortage of emergency trainees and physicians.

It’s a familiar story: after getting selected and working through thousands of hours of lectures, training, and evaluations, I was told I was ready. Yet after all that, when I heard the first code of my career, my mind went blank, my heart took off, anxiety took over and I was left scared and overwhelmed.

A 56 year old Russian speaking male (limited English capability) presents to the emergency department via EMS with the chief complaint of generalized abdominal pain. In triage he is noted to be rubbing his stomach and touching his lower back. He indicates that this has been bothering him for the past two hours. He is noted to be verbal in triage but appears confused and is moaning in discomfort.

No one can deny the aging of our population in general, and of the emergency department patient load in particular. But there is some disagreement about how EDs should respond – specifically whether it is appropriate to design geriatric emergency departments.

According to the Rand Report, the ED routinely makes the most important decision for hospital survival – whether or not to admit. The next question is what the healthcare system will do with that information.

The numbers don’t lie. The emergency department (ED) is the front door to the hospital for the sickest patients, and those that need inpatient service. The 2012 survey results of the Emergency Department Benchmarking Alliance (EDBA) – which compiled data from about 1,000 EDs comprising over 38 million patients – indicate that over 68% of hospital admissions are processed through the ED.

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