titleWhat lies ahead for the Patient Protection and Affordable Care Act (PPACA)? Many wonder if it can or will be implemented and whether there is any infrastructure to implement it. Another consideration is Accountable Care Organizations (ACOs).

An in-depth look at how the Affordable Care Act will attempt to cut $1 trillion over the next two decades, and how it will present both obstacles and opportunity for emergency medicine.

The Hawthorne Medical Center emergency department (ED) sees 50,000 patients each year. The fast track, open 16 hours a day, often sends patients to the main ED when it shuts down at 1 AM. The staff is convinced that adding another mid-level is the solution, although the numbers indicate the current staffing should be adequate. Will adding a mid-level solve their issue?

When Karen Sibert, an anesthesiologist with four children, wrote an op/ed piece in the New York Times about the deleterious economical and societal impact of physicians who choose to work part time, my email inbox exploded. Comments were all over the place, from “You’ve gotta be kidding,” to “Wonder if it would have been printed if a man wrote it,” to “Raises some interesting points.”

altA 21-year-old, right-hand dominant male without significant past medical history, presents to your emergency department after a pallet of bricks fell on his left, ring finger, while at work just prior to arrival.  His vaccinations are up to date.  On exam, he has amputated his ring finger just distal to the DIP joint, and bone is exposed  at the site of injury.You’re in small town U.S.A.  No orthopedic service around. What do you do?

altIn recent years, the growth of emergency medicine around the globe has been exponential, with nearly 70 countries now granting some form of formal recognition to the field. At the same time, interest in Global Emergency Medicine (GEM) as a unique subspecialty of emergency medicine has also grown rapidly over the past decade.

altThe CDC reports that 123.8 million patients visited an emergency department last year. That’s 41.4 visits per 100 population. That number has risen every year despite numerous, concerted efforts by the government and the insurance industry to stem the rising tide. Could it be that patients see what the politicians and planners seem to be missing, that the model of emergency care by qualified specialists, when and only when you need it, is a good model for health care delivery?

altImagine you are the CEO of St. Elsewhere Hospital, which is a suburban hospital with a 35,000 yearly visit emergency department (ED). The ED is a mess: average door-to-doctor times of 110 minutes, a left-without-being seen (LWBS) rate of 7%, and poor Press Ganey scores. Most everyone in the hospital, including the patients, refer to it as “That ER.”

An emergency physician recently contacted me to tell me a story. It all started when her local hospital emergency department received notice that they were on an award list published by a well-known health care grading company. “Terrific!” she said.

A patient is suffering from two life threatening events. Treatment for one condition may exacerbate the other condition. The standard of care is based upon a “reasonable person” standard, so I asked my friend what a reasonable doctor would do in the same or similar circumstances. He wasn’t sure.

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