Emergency Medicine Intro

Sarah Lewis MHS, PA-C

Emergency Medicine on TV

EM Intro Topics1. History and Stats

2. EMTALA

3. Personnel

4. General EM Principles

5. Timing and Schedule

6. Procedural Skills in EM

7. Social Considerations

EM History and Stats

Emergency Medicine History Emergency medicine as a medical specialty is relatively young.

Prior to the 1960’s and 70’s, hospital emergency departments were generally staffed by physicians on staff at the hospital on a rotating basis, among them general surgeons, internists, psychiatrists and dermatologists.

Physicians in training (interns and residents), foreign medical graduates and sometimes nurses also staffed the Emergency Department (ED)

EM was born as a specialty in order to fill the time commitment required by physicians on staff to work in the increasingly chaotic EDs all of the time.

Emergency Medicine HistoryThe first such groups were headed by 5 physicians at Alexandria

Hospital, VA

• established 24/7 year round emergency care which became known as the “Alexandria Plan”.

The first training program started at Cincinnati General Hospital in 1970. At this time it was not yet recognized as a specialty and hence no primary board certification exam.

It was not until 1979 that EM became a recognized medical specialty.

Stats• Number of visits: 136.1 million

• Number of injury-related visits: 45.4 million

• Number of visits per 100 persons: 45.1

• Percent of visits with patient seen in fewer than 15 minutes: 21.7%

• Percent of visits resulting in hospital admission: 12.6%

Table 1. Percent distribution of active physicians in patient care by specialty, 2007

Specialty PercentInternal medicine 20.1

Family medicine/general practice 12.4

Pediatrics 9.6

Obstetrics and gynecology 5.6

Anesthesiology 5.5Psychiatry 5.2General Surgery 5.0Emergency Medicine 4.1

  SOURCE: American Medical Association, 2009 Physician Characteristic and Distribution in the US.

Bright future for PA’s employment in EM

The United States has nearly 40,000 clinically active emergency physicians, but these numbers are not adequate to treat the growing number of people who visit emergency departments each year.  New emergency physicians are not being trained fast enough, and shortages are expected to continue for several decades, particularly in rural areas and the central part of the country. 

Stats5,286 ED PA’s (practicing in 2008)

• 23% rural ED’s

• 41% Inner city ED’s

• 32% Suburban ED’s

• 1% Other

Residency programs for Docs and PA’s

"Millions more people each year are seeking emergency care, but emergency departments are continuing to close, often because so much care goes uncompensated, which is the real economic issue in emergency medicine today," said Dr. Linda Lawrence, president of the American College of Emergency Physicians. "This report is very troubling, because it shows that care is being delayed for everyone, including people in pain and with heart attacks. As policymakers debate proposals to reform the health care system, which focus on early treatment and prevention, it’s essential to remember that none of those reforms will be achieved for years to come. In the meantime, emergency departments are providing a health care safety net for everyone. That’s why any efforts to reform health care must include resources to strengthen the nation’s ERs, which are a critical, often life or death, part of our health care system."

ED’s are a safety net for people unable to obtain medical care elsewhere.

Crisis: hundreds of emergency departments have closed in the US in past 10 years while the number of ED visits increases dramatically.

Why?

EMTALA

EMTALAFederal law - 1986

• Emergency Medical Treatment and Labor Act.

Part of COBRA 1995

Requires "emergency" care to be provided to anyone who needs it, REGARDLESS of their ability to pay or insurance status.

• All pts must be screened (vitals, hx) and offered an evaluation from a provider

EMTALA Emergency Medical Condition

• "a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily function or serious dysfunction of bodily organs."

BUT insurance co. & HMO determine payment by final diagnosis, not risk on entry of pt. to ED !

EMTALA

All pts. with similar medical conditions must be treated consistently.

Care cannot be delayed by questions about methods of payment or insurance coverage

Also to prevent hospitals from transferring those unable to pay to charity/county hospitals.

EMTALA Significant penalties for violation of EMTALA to the

hospital.

• Hospital: $25-50K / violation

• Physician: $50K / violation, excluded from medicare/aid programs

• Pt. can sue hospital for personal injury in a civil court

EMTALA is an unfunded mandate

Thus, ED’s are closing because of burden on the hospital.

Personnel

ED PersonnelProviders

• Staff physician, residents, APC’s (NP’s and PA’s), medical and PA students

Caregivers

• Charge nurse, primary RN supervisor, triage nurse, nurses, ED technicians, paramedics, respiratory therapists, nursing students, IV team, pastoral care

Clerks, secretary, administrators

Consultants, radiologists, PCP, specialists, non-physician therapists, social workers

ED Support PersonnelPre-hospital

• EMS

• Security

• Poison control

• Chaplains

In-hospital

• Unit clerks

• Social services

• Translators

Post hospital

• Chemical dependency units

• Psychiatric facilities

• Shelters

General ED Principles

I don’t know what they’ve got, but I don’t think it will kill them?

General ED PrinciplesIdentify and Stabilize a life-threatening condition

Find an explanation for the condition

Recognize coexistent pathology

Determine why the patient presented NOW rather than earlier or later

Address the patient’s symptoms

Consider the necessity to determine the diagnosis before the patient leaves the ED

General ED PrinciplesH&P

ED course/Plan

Medical Decision Making vs. DDx

Discuss the ED course and plan with the patient or family member.

Decide on the disposition

(Record the entire visit in the record)

Waiting….

The Clock is tickingTimer on every encounter

Door to triage

Door to EKG

Door to “Doc”

Door to CT

Door to Cath lab

ED consult till consultant arrives in ED

Admission orders till pt leaves ED (boarders)

Average LOS (Length of Stay)

Red Flags:LWOT= Left without treatment

AMA= against medical advice (form available to document specifically)

Lectures

Groups

Hands-On

BLS/ACLS

Schedule

EM topics in prior modules Infectious diseases

GYN emergencies

Urologic emergencies

Allergic reactions

Sickle cell, bleeding/clotting disorders

Renal disease, stones

Strokes, bleeds, seizures, CNS infections, delerium

ACS, arrhythmias, failure, etc

Ophtho emergencies

PE, respiratory failure, pneumonia, asthma/COPD

Suicide, psychoses, drug/EtOH

Gout, septic joint, Fractures, osteomyelitis, cauda equina

ENT emergencies

Hepatic failure, GI bleed, IBD, pancreatitis, ab pain, PUD

Surgery and complications

EM topics nowPre-hospital Care and Burns:

John Carroll

Procedures, Headaches: SKL

Chest Pain: Craig Ernst

ED Diagnostics, Access and Monitoring: Doc Freeman

Environmental Emergencies: John Leffort

Burns, Bites and Stings: WAE

Psych Clearance- Dr. Rigberg

Metabolic Emergencies: CG

EM/Trauma topics nowATLS: Dr. Armstrong

Peds Resucitation: Jen Bell

Head Trauma, Toxicology: Dr. Frailey

CBR Threats, ED Flow, Drugs of Abuse: Dr. Scott Goldstein

Penetrating Wounds, Thoracic and Spinal Trauma: Scott Nearhoof

OB-GYN Emergencies: AMS

Shock: Dr. Daniello

Hands-on: IV access

Airway control

BLS/ACLS

Small GroupsClinical scenarios to develop a plan

hands on trauma station

• CPR

• Airway

• Monitor/defibrillator

• IV access

• Foley cath

Discussion

BLS/ACLSOnline Course Completion

BLS hands on session

Optional Q&A

ACLS Mega Code Testing Stations

Emergency Medicine GradesComponent % of grade

EMed Module Exam 60%

Groups 10%

ACLS 10%

Semester Final 20%

TOTAL 100%

Blocks

Wound Care

I&D

Procedural Skills in EM

ProceduresRegional vs local blocks

Laceration repair

Abscess I&D

Joint aspiration

Corneal FB removal- slit lamp

Cerumen impaction

Peritonsillar Abscess I&D

Chest tube (during thoracic trauma lecture)

Nail avulsion

Urine catheterization

FAST exams

Dental repair

Deliveries! (Anna Mae will review)

Topical

Local injected

Local vs Regional blocks

Field Block

Field Blocks

Blocks cont.Regional Blocks

• Nerve blocks

Digital Block- lidocaine

Hematoma block- marcaine/bupivicaine plus epi

Digital block

Irrigation

Laceration repairConsider cosmesis, consult plastics

Consider orthopedics for functional loss

Vascular surgeons?

Neurosurgery?

Another facility?

Nail avulsionSee PDF

http://lifeinthefastlane.com/2009/10/top-ten-foreign-bodies/

FB removal

Corneal FB removal- slit lampForeign body removal

• Alcaine

• Cotton swab needle/forcep

Rust ring removal– eye spud or burr

Fluoroscein

Joint aspirationMark

Sterile prep

Tube to lab for culture, crystals and gram stain- with cap on!

Abscess I&DAnesthetize

Incise and drain

• Septated lesions?

Culture!

Keep open how

• Packing

• Suture in a drain

Antibiotics?

Abscess- specialAsk consults before you I&D in certain areas

Consider imaging, labs

Peritonsillar Abscess I&DAspirate culture

Suction!

Incision- watch this done if possible

(wear a mask)

http://www.entusa.com/surgery_videos_flash/quinsy-drainage-2/quinsy-drainage_flv0.htm

Abscess- SpecialPerianal vs. perirectal

Cerumen impaction Wet vs. Dry

Soften first:

• Water/peroxide 50/50 mix

• Debrox OTC

• Liquid Colase

Irrigate with large soft tipped syringe

• Body temp water

• Can add an astringent

Scoops and hooks vs. dynamite

Cortisporin Otic suspension?

Urine catheterization Tool as well for post void residual, multiports irrigation for

bleeding

Nurses will ask for your help if tricky!

Sterile technique, Use urojet or other numbing lubricant

Consider small catheter vs larger catheter

If foley coming out overinflate the balloon

If can’t get past the prostate try a larger (smaller # french) catheter (more rigid) or a coude tipped catheter

Call Urology

Be open, receptive, non-judgmental

Social Aspects of the ER

Sharing Personal InformationBeliefs

Culture

Religion

Work issues

Relationship/Marital issues

Family situation

Awkwardpeople have trouble asking for help:

• note off work

• request for pain meds

disclosing embarrassing stuff

• H&P

• Financial including lack of insurance

• employment issues

• social/family issues

Language barriers

EmbarassingYou will see and hear jaw-dropping stuff

• history/ mechanism

• PE

Financial constraints

Sexual preference and practice

Infidelity

Get out your Poker Faces!

ExpensiveTests recommended may equal $$$ to the patient

• Some patients even with insurance are responsible for at %, or initial amount for the year

• Unplanned expense

Cost may have delayed their care, or limited them to the ER

• Low collection rates from ERs

FrustrationMay have seen other providers

May have a timing issue outside of this visit

• Work, childcare, travel

May leave with no answer, or little understanding

Hard to get feedback later to new questions

WaitingDid you make an appointment to visit the ER?

Would you like fries with that?

Do you see that person dying over there, with a team working frantically around them- that’s the delay. We’ll see you and your stubbed toe after they die!

Still Waiting . . .Patients with the lowest level of visit, document the most

frustration with wait times on surveys!

• Fast tracks/ quick care/ urgent care centers

Update patients of delays

Tell them the expected process and timing.

Lack of Privacy

Good luck and Enjoy!