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.
As the director of a single-coverage community ED with about 22,000
visits a year and about 20% admissions, I’ve been fortunate to be left
alone by the administration. The nursing director and I – along with a
team of scribes, advance practice clinicians and staff, have largely
been free to do whatever we could to improve throughput in the ED.
What some call “the art of medicine” I call an unacceptable level of physician practice variability. Electronic medical records now allow us to compare apples to apples and begin bringing over- and under-utilizers in line with the evidence.
Can emergency physicians identify tests and procedures whose necessity
should be questioned? In light of high-radiation, low-yield tests, we
can – indeed we are obligated – to do more than that.
This is the third in a series of columns dealing with non-allergic,
potentially serious reactions caused by antibiotics. In the column
dealing with macrolides, the increased risk of sudden death was noted.
Clearly, the absolute numbers of deaths associated with macrolides has
to be small, but it makes sense to take this fact into consideration
when prescribing these antibiotics to those prone to arrhythmias (such
as patients with congestive heart failure).
Did you know that the macrolide group of antibiotics (erythromycin and
all its cousins) could kill you? Drop dead – sudden death. Well there is
a growing body of literature saying just that.
In My Opinion
Emergency physicians need to lead the charge on halting unnecessary
urinary catheterizations, for the sake of patient safety and the bottom
I often get asked to give presentations on what I think are the most
important articles of the year. Clearly, one’s perspective regarding
what is important varies from individual to individual, however, I tend
to gravitate to articles that look at systems issues and those that I
think can have a major impact on how we practice clinically.
I’m a believer that if an adult patient presents to the ED with chest pain, unless you are very, very positive the diagnosis is not cardiac, you owe it to the patient to pursue a cardiac work-up. Sounds pretty straight forward to me – but many would disagree.
In My Opinion
I think that I have made my view of electronic health records very clear
to anyone who’s cared to listen. I think they are great for monitoring
the movement of patients in larger EDs (electronic tracking boards). I
have concerns that CPOE (computerized provider order entry) through the
use of order sets has the potential to result in over-ordering (and will
result in higher bills, unnecessary tests and less thought by