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
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.