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Acute Department Syndrome
In this issue of Emergency Medicine, Greg Weingart, MD, and Shravan Kumar, MD, guide readers through the diagnosis, monitoring, and treatment of acute compartment syndrome, a relatively uncommon but devastating injury that may affect an extremity following a long bone fracture, deep vein thrombosis, or rhabdomyolysis from crush injuries or high-intensity exercising. Compartment syndrome occurs when increased pressure within a limited anatomic space compresses the circulation and tissue within that space until function becomes impossible. Even with heightened awareness of the disastrous sequelae, and with very early pressure monitoring of the injured compartment, physicians are at a loss to effectively intervene to prevent the continuing rise in pressure until a fasciotomy is required.
The disastrous consequences of rising pressure in a closed space suggests what can occur in the severely overcrowded EDs that now are common in every city in this country—EDs with too many patients waiting for treatment and inpatient beds.
Pressure on the nation’s ED capacity has been steadily increasing for the past three decades. Hospital/ED closings, demand for preadmission testing by managed care and primary care physicians, increasing numbers of documented and undocumented people seeking care, a rapidly aging population with more comorbidities, and increased numbers of patients seeking care under the Affordable Care Act have not been met with a commensurate increase in ED capacity. Between 1990 and 2010, the country’s urban and suburban areas lost one quarter of their hospital EDs (Hsia RY et al. JAMA. 2011;305[19]:1978-1985). In that same period, New York City lost 20 hospitals and about 5,000 inpatient beds; after 2010, when the state stopped bailing out financially failing hospitals, four more hospitals closed and were replaced by three freestanding EDs (FSEDs). Though FSEDs may partially fulfill the need for 24/7 emergency care at their former hospital sites, when patients in FSEDs require admission, they must compete with patients in hospital-based EDs for inpatient beds.
Despite the many and varied sources of increasing numbers of patients arriving in EDs, by all accounts this influx in and of itself is not the major driver of ED overcrowding. Trained, competent EPs, supported by skilled and highly motivated RNs, NPs, and PAs, are capable of efficiently managing even frequent surges in patient volume—as long as the “outflow” is not blocked. In many cases, this means having adequate, timely outpatient follow-up available to allow for safe discharge. But overwhelmingly, it means having adequate numbers of inpatient beds.
The discomfort and loss of privacy that patients experience from spending many hours or days on hallway stretchers are bad enough, but eventually patient safety also becomes a concern. With some creative approaches varying by location and circumstances, EPs have generally been able to successfully address the safety issues—so far. For example, many years ago, we began holding in reserve a small portion of our fee-for-service EM revenue available to supplement the hospital-provided base salaries. By frequently monitoring conditions throughout the day, taking into account rate of registration in the ED, day of the week, OR schedules, etc, we were able to decide before noon whether there was a need to offer 4, 6, or 8 evening/night hours at double the hourly sessional rate to the first EPs, PAs, and NPs in our group who responded to the e-mails. The hours worked did not earn these “first responders” any additional “RVU” credits as, for the most part, they were working closely with the inpatient services to moni
In this issue of Emergency Medicine, Greg Weingart, MD, and Shravan Kumar, MD, guide readers through the diagnosis, monitoring, and treatment of acute compartment syndrome, a relatively uncommon but devastating injury that may affect an extremity following a long bone fracture, deep vein thrombosis, or rhabdomyolysis from crush injuries or high-intensity exercising. Compartment syndrome occurs when increased pressure within a limited anatomic space compresses the circulation and tissue within that space until function becomes impossible. Even with heightened awareness of the disastrous sequelae, and with very early pressure monitoring of the injured compartment, physicians are at a loss to effectively intervene to prevent the continuing rise in pressure until a fasciotomy is required.
The disastrous consequences of rising pressure in a closed space suggests what can occur in the severely overcrowded EDs that now are common in every city in this country—EDs with too many patients waiting for treatment and inpatient beds.
Pressure on the nation’s ED capacity has been steadily increasing for the past three decades. Hospital/ED closings, demand for preadmission testing by managed care and primary care physicians, increasing numbers of documented and undocumented people seeking care, a rapidly aging population with more comorbidities, and increased numbers of patients seeking care under the Affordable Care Act have not been met with a commensurate increase in ED capacity. Between 1990 and 2010, the country’s urban and suburban areas lost one quarter of their hospital EDs (Hsia RY et al. JAMA. 2011;305[19]:1978-1985). In that same period, New York City lost 20 hospitals and about 5,000 inpatient beds; after 2010, when the state stopped bailing out financially failing hospitals, four more hospitals closed and were replaced by three freestanding EDs (FSEDs). Though FSEDs may partially fulfill the need for 24/7 emergency care at their former hospital sites, when patients in FSEDs require admission, they must compete with patients in hospital-based EDs for inpatient beds.
Despite the many and varied sources of increasing numbers of patients arriving in EDs, by all accounts this influx in and of itself is not the major driver of ED overcrowding. Trained, competent EPs, supported by skilled and highly motivated RNs, NPs, and PAs, are capable of efficiently managing even frequent surges in patient volume—as long as the “outflow” is not blocked. In many cases, this means having adequate, timely outpatient follow-up available to allow for safe discharge. But overwhelmingly, it means having adequate numbers of inpatient beds.
The discomfort and loss of privacy that patients experience from spending many hours or days on hallway stretchers are bad enough, but eventually patient safety also becomes a concern. With some creative approaches varying by location and circumstances, EPs have generally been able to successfully address the safety issues—so far. For example, many years ago, we began holding in reserve a small portion of our fee-for-service EM revenue available to supplement the hospital-provided base salaries. By frequently monitoring conditions throughout the day, taking into account rate of registration in the ED, day of the week, OR schedules, etc, we were able to decide before noon whether there was a need to offer 4, 6, or 8 evening/night hours at double the hourly sessional rate to the first EPs, PAs, and NPs in our group who responded to the e-mails. The hours worked did not earn these “first responders” any additional “RVU” credits as, for the most part, they were working closely with the inpatient services to moni
In this issue of Emergency Medicine, Greg Weingart, MD, and Shravan Kumar, MD, guide readers through the diagnosis, monitoring, and treatment of acute compartment syndrome, a relatively uncommon but devastating injury that may affect an extremity following a long bone fracture, deep vein thrombosis, or rhabdomyolysis from crush injuries or high-intensity exercising. Compartment syndrome occurs when increased pressure within a limited anatomic space compresses the circulation and tissue within that space until function becomes impossible. Even with heightened awareness of the disastrous sequelae, and with very early pressure monitoring of the injured compartment, physicians are at a loss to effectively intervene to prevent the continuing rise in pressure until a fasciotomy is required.
The disastrous consequences of rising pressure in a closed space suggests what can occur in the severely overcrowded EDs that now are common in every city in this country—EDs with too many patients waiting for treatment and inpatient beds.
Pressure on the nation’s ED capacity has been steadily increasing for the past three decades. Hospital/ED closings, demand for preadmission testing by managed care and primary care physicians, increasing numbers of documented and undocumented people seeking care, a rapidly aging population with more comorbidities, and increased numbers of patients seeking care under the Affordable Care Act have not been met with a commensurate increase in ED capacity. Between 1990 and 2010, the country’s urban and suburban areas lost one quarter of their hospital EDs (Hsia RY et al. JAMA. 2011;305[19]:1978-1985). In that same period, New York City lost 20 hospitals and about 5,000 inpatient beds; after 2010, when the state stopped bailing out financially failing hospitals, four more hospitals closed and were replaced by three freestanding EDs (FSEDs). Though FSEDs may partially fulfill the need for 24/7 emergency care at their former hospital sites, when patients in FSEDs require admission, they must compete with patients in hospital-based EDs for inpatient beds.
Despite the many and varied sources of increasing numbers of patients arriving in EDs, by all accounts this influx in and of itself is not the major driver of ED overcrowding. Trained, competent EPs, supported by skilled and highly motivated RNs, NPs, and PAs, are capable of efficiently managing even frequent surges in patient volume—as long as the “outflow” is not blocked. In many cases, this means having adequate, timely outpatient follow-up available to allow for safe discharge. But overwhelmingly, it means having adequate numbers of inpatient beds.
The discomfort and loss of privacy that patients experience from spending many hours or days on hallway stretchers are bad enough, but eventually patient safety also becomes a concern. With some creative approaches varying by location and circumstances, EPs have generally been able to successfully address the safety issues—so far. For example, many years ago, we began holding in reserve a small portion of our fee-for-service EM revenue available to supplement the hospital-provided base salaries. By frequently monitoring conditions throughout the day, taking into account rate of registration in the ED, day of the week, OR schedules, etc, we were able to decide before noon whether there was a need to offer 4, 6, or 8 evening/night hours at double the hourly sessional rate to the first EPs, PAs, and NPs in our group who responded to the e-mails. The hours worked did not earn these “first responders” any additional “RVU” credits as, for the most part, they were working closely with the inpatient services to moni
The New Opioid Epidemic and the Law of Unintended Consequences
In this issue of EM, EP-toxicologists Rama Rao, MD, and Lewis Nelson, MD, review the salient features of the current opioid epidemic in the United States. The authors differentiate this epidemic from prior patterns of heroin and opioid abuse partly by the clinical features that now make timely diagnosis and treatment in the ED more difficult.
According to the CDC, between 2000 and 2015, the number of opioid overdose deaths in this country quadrupled to half a million, or 91 deaths a day (
The road to the current epidemic began to be paved with good intentions in the late 1990s when, soon after the FDA approved the controlled-release form of oxycodone (Oxycontin), the American Pain Society introduced the phrase “pain as the fifth vital sign.” In 1999, the Department of Veterans Affairs embraced the statement, as did other organizations. The Joint Commission standards for pain management in 2001 stated “pain is assessed in all patients” (all was dropped in 2009) and contained a passing reference to pain as the fifth vital sign. In 2012, CMS added to its ED performance core measures timely pain treatment for long bone fractures, emphasizing parenteral medications.
By 2010, the problems created by emphasizing effective pain management had become evident, and measures began to be introduced to restrict the prescribing and availability of pharmaceutical opioids. The restrictions sent many patients to EDs seeking pain meds. Others sought substitutes on the street and ultimately ended up in EDs as overdoses from very potent synthetics. Many EPs began to limit opioid prescriptions to 3 days for acute painful conditions, though not all patients were able to obtain follow-up appointments with PCPs within that time period.
In April 2016, the Joint Commission issued a statement claiming it was not responsible for “pain as the fifth vital sign” or for suggesting that pain be treated with opioids. In June 2016, the AMA urged dropping “pain-as-the-fifth-vital-sign” policies, and in 2014, CMS modified its core measure emphasis on parenteral medication in the timely treatment of long bone fractures. But the damage has been done, leaving many people requiring help managing their pain and others suffering the consequences of opioid dependence.
EPs must continue to deal with victims of overdoses without denying pain treatment to those with acute, acute-on-chronic, and recurrent pain. Increased use of effective non-opioid pain meds such as NSAIDs may help, although not everyone can tolerate them and there are long-term risks. For large, overcrowded, urban EDs where treatment of pain is not always timely or consistent, 24/7 ED pain management teams working with EPs could be a tremendous asset, just as 24/7 ED pharmacists have proven to be. Until both effective pain treatment and the resultant opioid dependence and overdoses can be successfully addressed, regulatory agencies should deemphasize, without completely eliminating, pain treatment questions in scoring patient satisfaction.
In this issue of EM, EP-toxicologists Rama Rao, MD, and Lewis Nelson, MD, review the salient features of the current opioid epidemic in the United States. The authors differentiate this epidemic from prior patterns of heroin and opioid abuse partly by the clinical features that now make timely diagnosis and treatment in the ED more difficult.
According to the CDC, between 2000 and 2015, the number of opioid overdose deaths in this country quadrupled to half a million, or 91 deaths a day (
The road to the current epidemic began to be paved with good intentions in the late 1990s when, soon after the FDA approved the controlled-release form of oxycodone (Oxycontin), the American Pain Society introduced the phrase “pain as the fifth vital sign.” In 1999, the Department of Veterans Affairs embraced the statement, as did other organizations. The Joint Commission standards for pain management in 2001 stated “pain is assessed in all patients” (all was dropped in 2009) and contained a passing reference to pain as the fifth vital sign. In 2012, CMS added to its ED performance core measures timely pain treatment for long bone fractures, emphasizing parenteral medications.
By 2010, the problems created by emphasizing effective pain management had become evident, and measures began to be introduced to restrict the prescribing and availability of pharmaceutical opioids. The restrictions sent many patients to EDs seeking pain meds. Others sought substitutes on the street and ultimately ended up in EDs as overdoses from very potent synthetics. Many EPs began to limit opioid prescriptions to 3 days for acute painful conditions, though not all patients were able to obtain follow-up appointments with PCPs within that time period.
In April 2016, the Joint Commission issued a statement claiming it was not responsible for “pain as the fifth vital sign” or for suggesting that pain be treated with opioids. In June 2016, the AMA urged dropping “pain-as-the-fifth-vital-sign” policies, and in 2014, CMS modified its core measure emphasis on parenteral medication in the timely treatment of long bone fractures. But the damage has been done, leaving many people requiring help managing their pain and others suffering the consequences of opioid dependence.
EPs must continue to deal with victims of overdoses without denying pain treatment to those with acute, acute-on-chronic, and recurrent pain. Increased use of effective non-opioid pain meds such as NSAIDs may help, although not everyone can tolerate them and there are long-term risks. For large, overcrowded, urban EDs where treatment of pain is not always timely or consistent, 24/7 ED pain management teams working with EPs could be a tremendous asset, just as 24/7 ED pharmacists have proven to be. Until both effective pain treatment and the resultant opioid dependence and overdoses can be successfully addressed, regulatory agencies should deemphasize, without completely eliminating, pain treatment questions in scoring patient satisfaction.
In this issue of EM, EP-toxicologists Rama Rao, MD, and Lewis Nelson, MD, review the salient features of the current opioid epidemic in the United States. The authors differentiate this epidemic from prior patterns of heroin and opioid abuse partly by the clinical features that now make timely diagnosis and treatment in the ED more difficult.
According to the CDC, between 2000 and 2015, the number of opioid overdose deaths in this country quadrupled to half a million, or 91 deaths a day (
The road to the current epidemic began to be paved with good intentions in the late 1990s when, soon after the FDA approved the controlled-release form of oxycodone (Oxycontin), the American Pain Society introduced the phrase “pain as the fifth vital sign.” In 1999, the Department of Veterans Affairs embraced the statement, as did other organizations. The Joint Commission standards for pain management in 2001 stated “pain is assessed in all patients” (all was dropped in 2009) and contained a passing reference to pain as the fifth vital sign. In 2012, CMS added to its ED performance core measures timely pain treatment for long bone fractures, emphasizing parenteral medications.
By 2010, the problems created by emphasizing effective pain management had become evident, and measures began to be introduced to restrict the prescribing and availability of pharmaceutical opioids. The restrictions sent many patients to EDs seeking pain meds. Others sought substitutes on the street and ultimately ended up in EDs as overdoses from very potent synthetics. Many EPs began to limit opioid prescriptions to 3 days for acute painful conditions, though not all patients were able to obtain follow-up appointments with PCPs within that time period.
In April 2016, the Joint Commission issued a statement claiming it was not responsible for “pain as the fifth vital sign” or for suggesting that pain be treated with opioids. In June 2016, the AMA urged dropping “pain-as-the-fifth-vital-sign” policies, and in 2014, CMS modified its core measure emphasis on parenteral medication in the timely treatment of long bone fractures. But the damage has been done, leaving many people requiring help managing their pain and others suffering the consequences of opioid dependence.
EPs must continue to deal with victims of overdoses without denying pain treatment to those with acute, acute-on-chronic, and recurrent pain. Increased use of effective non-opioid pain meds such as NSAIDs may help, although not everyone can tolerate them and there are long-term risks. For large, overcrowded, urban EDs where treatment of pain is not always timely or consistent, 24/7 ED pain management teams working with EPs could be a tremendous asset, just as 24/7 ED pharmacists have proven to be. Until both effective pain treatment and the resultant opioid dependence and overdoses can be successfully addressed, regulatory agencies should deemphasize, without completely eliminating, pain treatment questions in scoring patient satisfaction.
Physician Communications: Avoiding the Blame Game
A recent opinion piece in MedPage Today by an internist about poor communications between emergency physicians (EPs) and primary care physicians (PCPs) was subtitled “We’ve gotten better going from office to ER, but not the other way,” and complained about the lack of a “live, warm handoff” from EPs to PCPs of patients being discharged from EDs. Similar complaints were examined in two recent Emergency Medicine (EM) editorials (Anger Management, 2015;47[4]:149 and Broadside Journalism, 2015;47[6]:244). In the first, we noted that PCPs sometimes are angered when they are not consulted about one of their patients in the ED or about a treatment or disposition plan with which they disagree, while EPs are frustrated by the number of phone calls required to reach some PCPs or a knowledgeable covering physician.
Only 2 months later, we expressed concerns about a New York Times opinion editorial describing a young patient whose vertebral artery dissection had been “diagnosed correctly and acted on in the ED,” but then angrily criticizing an initial recommendation that the patient curtail her physical activities based on what a famous neurologist considered an erroneously interpreted vascular imaging study. (Presumably, the recommendation was by another neurologist and the interpretation by a radiologist, but all of the neurologist’s caustic criticism was directed at the EP and ED.) Although the neurologist subsequently apologized in a letter to his emergency medicine colleagues for “being quoted out of context,” few if any
We concluded the second EM editorial with the suggestion that “all physicians must be very, very careful in framing statements to the media, and should assume that their remarks will not be placed ‘in context’ or nuanced as they may have been intended....Most important, is to not disparage entire specialties or use belittling terms such as ‘ER docs’....[that] heighten...patients’ fears” of being treated in EDs.
Why another editorial about physician-to-physician miscommunications and name-calling? Because patient care is significantly affected.
The Centers for Medicare and Medicaid Services originally classified four medical specialties as “primary care” for reimbursement purposes: family medicine, internal medicine, pediatrics, and obstetrics-gynecology, and the 2010 Affordable Care Act added geriatrics. Although emergency medicine had been considered initially, it has never been categorized as a primary care specialty. That being the case, isn’t it incumbent upon us to learn as much as we can from PCPs about their ill patients en route to the ED for treatment or admission, and afterward ensure that an ED visit is part of a continuum of patient care and not an isolated episode?
In 1996, when I accepted an offer to become New York Presbyterian-Weill Cornell’s first Emergency Physician-in-Chief, I created a new position of full-time “ED follow-up nurse practitioner” to track and report test results to discharged patients and their designated PCPs. When we added a fourth unit to the ED a few years later, I designated an experienced, senior attending EP among the four on duty as the “administrative attending” (AA) who, among other tasks, took all phone calls from PCPs about patients they were sending to the ED and entered the information in the “en route” section of our electronic tracking board. In this way, important patient information, including PCP contact information, was no longer misplaced during shift changes. The AA carried a direct-dial cell phone-like device and eventually all attending EPs and the charge nurse were equipped with such phones. In a short time, most of the communications problems and complaints about incoming patients were eliminated.
But despite numerous attempts, for the reasons mentioned above, systematically ensuring effective communications with PCPs for discharged patients has proven to be a more difficult task. At present, handing off discharged patients to PCPs still depends largely on a combination of judgment, understanding, compassion, and respect.
A recent opinion piece in MedPage Today by an internist about poor communications between emergency physicians (EPs) and primary care physicians (PCPs) was subtitled “We’ve gotten better going from office to ER, but not the other way,” and complained about the lack of a “live, warm handoff” from EPs to PCPs of patients being discharged from EDs. Similar complaints were examined in two recent Emergency Medicine (EM) editorials (Anger Management, 2015;47[4]:149 and Broadside Journalism, 2015;47[6]:244). In the first, we noted that PCPs sometimes are angered when they are not consulted about one of their patients in the ED or about a treatment or disposition plan with which they disagree, while EPs are frustrated by the number of phone calls required to reach some PCPs or a knowledgeable covering physician.
Only 2 months later, we expressed concerns about a New York Times opinion editorial describing a young patient whose vertebral artery dissection had been “diagnosed correctly and acted on in the ED,” but then angrily criticizing an initial recommendation that the patient curtail her physical activities based on what a famous neurologist considered an erroneously interpreted vascular imaging study. (Presumably, the recommendation was by another neurologist and the interpretation by a radiologist, but all of the neurologist’s caustic criticism was directed at the EP and ED.) Although the neurologist subsequently apologized in a letter to his emergency medicine colleagues for “being quoted out of context,” few if any
We concluded the second EM editorial with the suggestion that “all physicians must be very, very careful in framing statements to the media, and should assume that their remarks will not be placed ‘in context’ or nuanced as they may have been intended....Most important, is to not disparage entire specialties or use belittling terms such as ‘ER docs’....[that] heighten...patients’ fears” of being treated in EDs.
Why another editorial about physician-to-physician miscommunications and name-calling? Because patient care is significantly affected.
The Centers for Medicare and Medicaid Services originally classified four medical specialties as “primary care” for reimbursement purposes: family medicine, internal medicine, pediatrics, and obstetrics-gynecology, and the 2010 Affordable Care Act added geriatrics. Although emergency medicine had been considered initially, it has never been categorized as a primary care specialty. That being the case, isn’t it incumbent upon us to learn as much as we can from PCPs about their ill patients en route to the ED for treatment or admission, and afterward ensure that an ED visit is part of a continuum of patient care and not an isolated episode?
In 1996, when I accepted an offer to become New York Presbyterian-Weill Cornell’s first Emergency Physician-in-Chief, I created a new position of full-time “ED follow-up nurse practitioner” to track and report test results to discharged patients and their designated PCPs. When we added a fourth unit to the ED a few years later, I designated an experienced, senior attending EP among the four on duty as the “administrative attending” (AA) who, among other tasks, took all phone calls from PCPs about patients they were sending to the ED and entered the information in the “en route” section of our electronic tracking board. In this way, important patient information, including PCP contact information, was no longer misplaced during shift changes. The AA carried a direct-dial cell phone-like device and eventually all attending EPs and the charge nurse were equipped with such phones. In a short time, most of the communications problems and complaints about incoming patients were eliminated.
But despite numerous attempts, for the reasons mentioned above, systematically ensuring effective communications with PCPs for discharged patients has proven to be a more difficult task. At present, handing off discharged patients to PCPs still depends largely on a combination of judgment, understanding, compassion, and respect.
A recent opinion piece in MedPage Today by an internist about poor communications between emergency physicians (EPs) and primary care physicians (PCPs) was subtitled “We’ve gotten better going from office to ER, but not the other way,” and complained about the lack of a “live, warm handoff” from EPs to PCPs of patients being discharged from EDs. Similar complaints were examined in two recent Emergency Medicine (EM) editorials (Anger Management, 2015;47[4]:149 and Broadside Journalism, 2015;47[6]:244). In the first, we noted that PCPs sometimes are angered when they are not consulted about one of their patients in the ED or about a treatment or disposition plan with which they disagree, while EPs are frustrated by the number of phone calls required to reach some PCPs or a knowledgeable covering physician.
Only 2 months later, we expressed concerns about a New York Times opinion editorial describing a young patient whose vertebral artery dissection had been “diagnosed correctly and acted on in the ED,” but then angrily criticizing an initial recommendation that the patient curtail her physical activities based on what a famous neurologist considered an erroneously interpreted vascular imaging study. (Presumably, the recommendation was by another neurologist and the interpretation by a radiologist, but all of the neurologist’s caustic criticism was directed at the EP and ED.) Although the neurologist subsequently apologized in a letter to his emergency medicine colleagues for “being quoted out of context,” few if any
We concluded the second EM editorial with the suggestion that “all physicians must be very, very careful in framing statements to the media, and should assume that their remarks will not be placed ‘in context’ or nuanced as they may have been intended....Most important, is to not disparage entire specialties or use belittling terms such as ‘ER docs’....[that] heighten...patients’ fears” of being treated in EDs.
Why another editorial about physician-to-physician miscommunications and name-calling? Because patient care is significantly affected.
The Centers for Medicare and Medicaid Services originally classified four medical specialties as “primary care” for reimbursement purposes: family medicine, internal medicine, pediatrics, and obstetrics-gynecology, and the 2010 Affordable Care Act added geriatrics. Although emergency medicine had been considered initially, it has never been categorized as a primary care specialty. That being the case, isn’t it incumbent upon us to learn as much as we can from PCPs about their ill patients en route to the ED for treatment or admission, and afterward ensure that an ED visit is part of a continuum of patient care and not an isolated episode?
In 1996, when I accepted an offer to become New York Presbyterian-Weill Cornell’s first Emergency Physician-in-Chief, I created a new position of full-time “ED follow-up nurse practitioner” to track and report test results to discharged patients and their designated PCPs. When we added a fourth unit to the ED a few years later, I designated an experienced, senior attending EP among the four on duty as the “administrative attending” (AA) who, among other tasks, took all phone calls from PCPs about patients they were sending to the ED and entered the information in the “en route” section of our electronic tracking board. In this way, important patient information, including PCP contact information, was no longer misplaced during shift changes. The AA carried a direct-dial cell phone-like device and eventually all attending EPs and the charge nurse were equipped with such phones. In a short time, most of the communications problems and complaints about incoming patients were eliminated.
But despite numerous attempts, for the reasons mentioned above, systematically ensuring effective communications with PCPs for discharged patients has proven to be a more difficult task. At present, handing off discharged patients to PCPs still depends largely on a combination of judgment, understanding, compassion, and respect.
A Holiday Visit to the ED (With Apologies to Clement Clarke Moore)
‘Twas the night before New Year, when all through the land
Every ED was busy—Can you give us a hand?
Treating chest pains, and traumas, and hot swollen knees,
While clinics were shuttered, along with UCs.
The handoffs were done with hardly a frown,
In hopes that the volume soon would slow down.
Babies were nestled all snug in a sheet,
Watching sutures applied to their hands and their feet.
And amateur athletes unpadded, uncapped,
Had brains that were rattled after balls had been snapped.
When out on the deck there arose such a clatter
We sprang from the doc box to help with the matter.
To Resusc room 1 we flew in a flash,
Tearing open the curtain before the patient could crash.
The leads on the breast of the now-fallen fellow,
Made lustrous white circles near sclerae bright yellow.
When what to our wondering ears did we hear,
But an overhead page that inspired some fear:
Notifications of a Level 1 trauma,
And several ODs, to add to the drama.
More rapid than eagles the new patients came,
All victims of poisons with rather strange names:
Poinsettia, and holly, and dried mistletoe,
Angel hair, leaded tinsel, polyacrylate snow.
And a man who was tarnished with ashes and soot,
With a cherry red color from his head to his foot.
Smoke inhalation and a toxic epoxide?
Or alcohol, cyanide, carbon monoxide?
But “Holiday Poisonings” on the pages ahead,
Soon reassured us we had nothing to dread…
When patients were discharged to families waiting,
They promised to give us all a good rating.
So to all EMTs, NPs, and PAs,
RNs, and EPs who work holidays,
And to all ED staffs who “fight the good fight,”
Have a Happy New Year, and a nice quiet night!
—Neal Flomenbaum, MD
‘Twas the night before New Year, when all through the land
Every ED was busy—Can you give us a hand?
Treating chest pains, and traumas, and hot swollen knees,
While clinics were shuttered, along with UCs.
The handoffs were done with hardly a frown,
In hopes that the volume soon would slow down.
Babies were nestled all snug in a sheet,
Watching sutures applied to their hands and their feet.
And amateur athletes unpadded, uncapped,
Had brains that were rattled after balls had been snapped.
When out on the deck there arose such a clatter
We sprang from the doc box to help with the matter.
To Resusc room 1 we flew in a flash,
Tearing open the curtain before the patient could crash.
The leads on the breast of the now-fallen fellow,
Made lustrous white circles near sclerae bright yellow.
When what to our wondering ears did we hear,
But an overhead page that inspired some fear:
Notifications of a Level 1 trauma,
And several ODs, to add to the drama.
More rapid than eagles the new patients came,
All victims of poisons with rather strange names:
Poinsettia, and holly, and dried mistletoe,
Angel hair, leaded tinsel, polyacrylate snow.
And a man who was tarnished with ashes and soot,
With a cherry red color from his head to his foot.
Smoke inhalation and a toxic epoxide?
Or alcohol, cyanide, carbon monoxide?
But “Holiday Poisonings” on the pages ahead,
Soon reassured us we had nothing to dread…
When patients were discharged to families waiting,
They promised to give us all a good rating.
So to all EMTs, NPs, and PAs,
RNs, and EPs who work holidays,
And to all ED staffs who “fight the good fight,”
Have a Happy New Year, and a nice quiet night!
—Neal Flomenbaum, MD
‘Twas the night before New Year, when all through the land
Every ED was busy—Can you give us a hand?
Treating chest pains, and traumas, and hot swollen knees,
While clinics were shuttered, along with UCs.
The handoffs were done with hardly a frown,
In hopes that the volume soon would slow down.
Babies were nestled all snug in a sheet,
Watching sutures applied to their hands and their feet.
And amateur athletes unpadded, uncapped,
Had brains that were rattled after balls had been snapped.
When out on the deck there arose such a clatter
We sprang from the doc box to help with the matter.
To Resusc room 1 we flew in a flash,
Tearing open the curtain before the patient could crash.
The leads on the breast of the now-fallen fellow,
Made lustrous white circles near sclerae bright yellow.
When what to our wondering ears did we hear,
But an overhead page that inspired some fear:
Notifications of a Level 1 trauma,
And several ODs, to add to the drama.
More rapid than eagles the new patients came,
All victims of poisons with rather strange names:
Poinsettia, and holly, and dried mistletoe,
Angel hair, leaded tinsel, polyacrylate snow.
And a man who was tarnished with ashes and soot,
With a cherry red color from his head to his foot.
Smoke inhalation and a toxic epoxide?
Or alcohol, cyanide, carbon monoxide?
But “Holiday Poisonings” on the pages ahead,
Soon reassured us we had nothing to dread…
When patients were discharged to families waiting,
They promised to give us all a good rating.
So to all EMTs, NPs, and PAs,
RNs, and EPs who work holidays,
And to all ED staffs who “fight the good fight,”
Have a Happy New Year, and a nice quiet night!
—Neal Flomenbaum, MD
Bertrand M. Bell, MD: An Iconoclast Who Became an Icon
Bertrand M. Bell, MD, Distinguished University Professor Emeritus at Albert Einstein College of Medicine, died at the age of 86 in his Manhattan home on October 4, 2016. For decades, Dr Bell was the Director of Ambulatory Care, which included the ED at Einstein’s teaching hospital, the Bronx Municipal (Jacobi) Hospital Center. But, as Dr Bell was aware for the last 25 years of his life, he would always be remembered for a committee he chaired the year he was on sabbatical from Einstein and Jacobi in 1987.
After the death of 18-year-old Libby Zion from a dangerous drug interaction, the New York State Commissioner of Health asked Dr Bell to chair an ad hoc committee to investigate the care of hospitalized patients by residents and to make recommendations regarding medication ordering and administration, the use of patient restraints, attending supervision, and resident work hours. The “Bell Commission,” as it came to be known, recommended that residents not be allowed to work more than 80 hours a week or more than 24 consecutive hours, and that attending physicians be present in the hospital 24/7. These recommendations were made part of the New York State Health Code in 1989 and adopted nationwide by the Accreditation Council for Graduate Medical Education in 1993.
The Bell Commission changes in resident work hours were not enthusiastically received by all, with most of the criticism centering on a perceived lack of continuity in resident education resulting from the shortened work hours. Largely ignored, however, was the committee’s call for 24/7 attending supervision, which would have provided both continuity in patient care and enhanced resident education and experiences. Dr Bell was outspoken in defending his committee’s recommendations and his views on the inadequacies of graduate medical education (GME), occasionally infuriating those who disagreed with him.
Ironically, though the formal name of the Bell Commission was the “Ad Hoc Advisory Committee on Emergency Services,” the recommendations did not address prehospital care issues and probably affected emergency medicine (EM) residents less than they did residents from other specialties. Both the work-hour rules and mandated attending presence had already been implemented by many EM residency training programs from the time EM became a specialty in 1979, and were required of all EM programs by the end of the 1980s. (See “’My Patient’—More Than Ever,” Emerg Med. 2013;45[4]:1.)
Yet, Bert Bell may have had as profound an effect on the birth and survival of academic EM on the East Coast as did his committee’s recommendations on GME nationwide. Together with his ED Director, Sheldon Jacobson, MD, Bert secured for Einstein/Jacobi the first federally funded paramedic training program in New York State in 1974, followed a year later by the first EM residency in New York State, and one of the earliest in the nation. Bert also hired and trained nurse practitioners and physician assistants to care for patients in the ED and clinics, realizing their potential and the value of their contributions to patient care, years before others did.
The group of emergency physicians that Bert and Shelly assembled at Einstein/Jacobi in the 1970s included John Gallagher, Peter Moyer, Mark Henry, Gregg Husk, Paul Gennis, a young Wallace Carter, me, and several other EM pionee
At Dr Bell’s funeral on October 7, the rabbi alluded to a description of the prophet Elijah, in describing Bert as a “holy troublemaker.” Bert Bell was a larger-than-life iconoclast whose name became an icon for graduate medical education reforms and whose patient care values will survive in future generations of physicians.
Bertrand M. Bell, MD, Distinguished University Professor Emeritus at Albert Einstein College of Medicine, died at the age of 86 in his Manhattan home on October 4, 2016. For decades, Dr Bell was the Director of Ambulatory Care, which included the ED at Einstein’s teaching hospital, the Bronx Municipal (Jacobi) Hospital Center. But, as Dr Bell was aware for the last 25 years of his life, he would always be remembered for a committee he chaired the year he was on sabbatical from Einstein and Jacobi in 1987.
After the death of 18-year-old Libby Zion from a dangerous drug interaction, the New York State Commissioner of Health asked Dr Bell to chair an ad hoc committee to investigate the care of hospitalized patients by residents and to make recommendations regarding medication ordering and administration, the use of patient restraints, attending supervision, and resident work hours. The “Bell Commission,” as it came to be known, recommended that residents not be allowed to work more than 80 hours a week or more than 24 consecutive hours, and that attending physicians be present in the hospital 24/7. These recommendations were made part of the New York State Health Code in 1989 and adopted nationwide by the Accreditation Council for Graduate Medical Education in 1993.
The Bell Commission changes in resident work hours were not enthusiastically received by all, with most of the criticism centering on a perceived lack of continuity in resident education resulting from the shortened work hours. Largely ignored, however, was the committee’s call for 24/7 attending supervision, which would have provided both continuity in patient care and enhanced resident education and experiences. Dr Bell was outspoken in defending his committee’s recommendations and his views on the inadequacies of graduate medical education (GME), occasionally infuriating those who disagreed with him.
Ironically, though the formal name of the Bell Commission was the “Ad Hoc Advisory Committee on Emergency Services,” the recommendations did not address prehospital care issues and probably affected emergency medicine (EM) residents less than they did residents from other specialties. Both the work-hour rules and mandated attending presence had already been implemented by many EM residency training programs from the time EM became a specialty in 1979, and were required of all EM programs by the end of the 1980s. (See “’My Patient’—More Than Ever,” Emerg Med. 2013;45[4]:1.)
Yet, Bert Bell may have had as profound an effect on the birth and survival of academic EM on the East Coast as did his committee’s recommendations on GME nationwide. Together with his ED Director, Sheldon Jacobson, MD, Bert secured for Einstein/Jacobi the first federally funded paramedic training program in New York State in 1974, followed a year later by the first EM residency in New York State, and one of the earliest in the nation. Bert also hired and trained nurse practitioners and physician assistants to care for patients in the ED and clinics, realizing their potential and the value of their contributions to patient care, years before others did.
The group of emergency physicians that Bert and Shelly assembled at Einstein/Jacobi in the 1970s included John Gallagher, Peter Moyer, Mark Henry, Gregg Husk, Paul Gennis, a young Wallace Carter, me, and several other EM pionee
At Dr Bell’s funeral on October 7, the rabbi alluded to a description of the prophet Elijah, in describing Bert as a “holy troublemaker.” Bert Bell was a larger-than-life iconoclast whose name became an icon for graduate medical education reforms and whose patient care values will survive in future generations of physicians.
Bertrand M. Bell, MD, Distinguished University Professor Emeritus at Albert Einstein College of Medicine, died at the age of 86 in his Manhattan home on October 4, 2016. For decades, Dr Bell was the Director of Ambulatory Care, which included the ED at Einstein’s teaching hospital, the Bronx Municipal (Jacobi) Hospital Center. But, as Dr Bell was aware for the last 25 years of his life, he would always be remembered for a committee he chaired the year he was on sabbatical from Einstein and Jacobi in 1987.
After the death of 18-year-old Libby Zion from a dangerous drug interaction, the New York State Commissioner of Health asked Dr Bell to chair an ad hoc committee to investigate the care of hospitalized patients by residents and to make recommendations regarding medication ordering and administration, the use of patient restraints, attending supervision, and resident work hours. The “Bell Commission,” as it came to be known, recommended that residents not be allowed to work more than 80 hours a week or more than 24 consecutive hours, and that attending physicians be present in the hospital 24/7. These recommendations were made part of the New York State Health Code in 1989 and adopted nationwide by the Accreditation Council for Graduate Medical Education in 1993.
The Bell Commission changes in resident work hours were not enthusiastically received by all, with most of the criticism centering on a perceived lack of continuity in resident education resulting from the shortened work hours. Largely ignored, however, was the committee’s call for 24/7 attending supervision, which would have provided both continuity in patient care and enhanced resident education and experiences. Dr Bell was outspoken in defending his committee’s recommendations and his views on the inadequacies of graduate medical education (GME), occasionally infuriating those who disagreed with him.
Ironically, though the formal name of the Bell Commission was the “Ad Hoc Advisory Committee on Emergency Services,” the recommendations did not address prehospital care issues and probably affected emergency medicine (EM) residents less than they did residents from other specialties. Both the work-hour rules and mandated attending presence had already been implemented by many EM residency training programs from the time EM became a specialty in 1979, and were required of all EM programs by the end of the 1980s. (See “’My Patient’—More Than Ever,” Emerg Med. 2013;45[4]:1.)
Yet, Bert Bell may have had as profound an effect on the birth and survival of academic EM on the East Coast as did his committee’s recommendations on GME nationwide. Together with his ED Director, Sheldon Jacobson, MD, Bert secured for Einstein/Jacobi the first federally funded paramedic training program in New York State in 1974, followed a year later by the first EM residency in New York State, and one of the earliest in the nation. Bert also hired and trained nurse practitioners and physician assistants to care for patients in the ED and clinics, realizing their potential and the value of their contributions to patient care, years before others did.
The group of emergency physicians that Bert and Shelly assembled at Einstein/Jacobi in the 1970s included John Gallagher, Peter Moyer, Mark Henry, Gregg Husk, Paul Gennis, a young Wallace Carter, me, and several other EM pionee
At Dr Bell’s funeral on October 7, the rabbi alluded to a description of the prophet Elijah, in describing Bert as a “holy troublemaker.” Bert Bell was a larger-than-life iconoclast whose name became an icon for graduate medical education reforms and whose patient care values will survive in future generations of physicians.
The Long Hot Summer of 2016
Months of extremely high temperatures throughout the United States made the summer of 2016 one of the hottest summers on record. The summer may also be remembered for the excessive amounts of hot air generated in the run-up to the 2016 presidential election. But most oppressive of all has been the failure of Congress to appropriate funds for Zika virus research, prevention, and treatment before it recessed for vacation.
Emergency physicians (EPs) in the United States are already dealing with frightened, symptomatic patients who may have been exposed to the Zika, dengue, or chikungunya viruses, transmitted by the bite of the Aedes aegypti mosquito. In the First EDition section of this issue, dermatologist Iris Z. Ahronowitz, MD, describes some of the similarities in the acute clinical presentations of those infections (see page 438). But among this group of related viruses, only Zika has been positively linked to microcephaly and severely underdeveloped, damaged brains in babies born to women who are infected during pregnancy. An increasing number of newborn babies severely affected by Zika virus in utero began appearing in South America in late 2015. By summer’s end (September 21, 2016), the Centers for Disease Control and Prevention reports of Zika virus disease in the United States included over 3,300 travel-related cases, 43 locally acquired mosquito-borne cases, 28 sexually transmitted cases, and eight cases of Guillain-Barré syndrome (http://www.cdc.gov/zika/geo/united-states.html). Most importantly, as of September 15, 2016, there have been 20 live-born infants with birth defects and five pregnancy losses with birth defects—numbers that do not reflect the outcomes of ongoing pregnancies.
The life expectancy of babies severely affected by Zika virus and the nature and extent of disability in less physically affected babies are presently unknown. But according to The Washington Post (http://wapo.st/29Y5CnR), estimates of the cost of caring for a severely affected Zika baby through adulthood run as high as $10 million or more, and as high a total price as we will pay for the congressional intransigence this summer, such cost estimates do not even consider the terrible human suffering these babies will experience or the anguish their parents may have for the rest of their lives.
Emergency physicians are all too familiar with the emotional and behavioral problems that complicate our efforts to manage acute medical problems of children and adults born with autism or Down syndrome when they present to the ED. Most such congenital illnesses are not preventable, but when one potentially is, delaying needed resources because of partisan politics is unconscionable.
By summer’s end, as the last of leftover Ebola dollars were being spent on Zika-related programs, Democrats and Republicans finally appeared to be reaching a consensus to provide $1.1 billion of the $1.9 billion originally requested by the President long before the long hot summer began. This sudden agreement may be driven by the importance both parties place on winning the Florida vote in the upcoming election. But whatever the reason, Zika funding now will help prevent untold hardships and suffering in the years to come. In the meantime, EPs will continue to evaluate, diagnose, counsel, and, hopefully someday soon, be able to treat all who come to our EDs with Zika infection.
Months of extremely high temperatures throughout the United States made the summer of 2016 one of the hottest summers on record. The summer may also be remembered for the excessive amounts of hot air generated in the run-up to the 2016 presidential election. But most oppressive of all has been the failure of Congress to appropriate funds for Zika virus research, prevention, and treatment before it recessed for vacation.
Emergency physicians (EPs) in the United States are already dealing with frightened, symptomatic patients who may have been exposed to the Zika, dengue, or chikungunya viruses, transmitted by the bite of the Aedes aegypti mosquito. In the First EDition section of this issue, dermatologist Iris Z. Ahronowitz, MD, describes some of the similarities in the acute clinical presentations of those infections (see page 438). But among this group of related viruses, only Zika has been positively linked to microcephaly and severely underdeveloped, damaged brains in babies born to women who are infected during pregnancy. An increasing number of newborn babies severely affected by Zika virus in utero began appearing in South America in late 2015. By summer’s end (September 21, 2016), the Centers for Disease Control and Prevention reports of Zika virus disease in the United States included over 3,300 travel-related cases, 43 locally acquired mosquito-borne cases, 28 sexually transmitted cases, and eight cases of Guillain-Barré syndrome (http://www.cdc.gov/zika/geo/united-states.html). Most importantly, as of September 15, 2016, there have been 20 live-born infants with birth defects and five pregnancy losses with birth defects—numbers that do not reflect the outcomes of ongoing pregnancies.
The life expectancy of babies severely affected by Zika virus and the nature and extent of disability in less physically affected babies are presently unknown. But according to The Washington Post (http://wapo.st/29Y5CnR), estimates of the cost of caring for a severely affected Zika baby through adulthood run as high as $10 million or more, and as high a total price as we will pay for the congressional intransigence this summer, such cost estimates do not even consider the terrible human suffering these babies will experience or the anguish their parents may have for the rest of their lives.
Emergency physicians are all too familiar with the emotional and behavioral problems that complicate our efforts to manage acute medical problems of children and adults born with autism or Down syndrome when they present to the ED. Most such congenital illnesses are not preventable, but when one potentially is, delaying needed resources because of partisan politics is unconscionable.
By summer’s end, as the last of leftover Ebola dollars were being spent on Zika-related programs, Democrats and Republicans finally appeared to be reaching a consensus to provide $1.1 billion of the $1.9 billion originally requested by the President long before the long hot summer began. This sudden agreement may be driven by the importance both parties place on winning the Florida vote in the upcoming election. But whatever the reason, Zika funding now will help prevent untold hardships and suffering in the years to come. In the meantime, EPs will continue to evaluate, diagnose, counsel, and, hopefully someday soon, be able to treat all who come to our EDs with Zika infection.
Months of extremely high temperatures throughout the United States made the summer of 2016 one of the hottest summers on record. The summer may also be remembered for the excessive amounts of hot air generated in the run-up to the 2016 presidential election. But most oppressive of all has been the failure of Congress to appropriate funds for Zika virus research, prevention, and treatment before it recessed for vacation.
Emergency physicians (EPs) in the United States are already dealing with frightened, symptomatic patients who may have been exposed to the Zika, dengue, or chikungunya viruses, transmitted by the bite of the Aedes aegypti mosquito. In the First EDition section of this issue, dermatologist Iris Z. Ahronowitz, MD, describes some of the similarities in the acute clinical presentations of those infections (see page 438). But among this group of related viruses, only Zika has been positively linked to microcephaly and severely underdeveloped, damaged brains in babies born to women who are infected during pregnancy. An increasing number of newborn babies severely affected by Zika virus in utero began appearing in South America in late 2015. By summer’s end (September 21, 2016), the Centers for Disease Control and Prevention reports of Zika virus disease in the United States included over 3,300 travel-related cases, 43 locally acquired mosquito-borne cases, 28 sexually transmitted cases, and eight cases of Guillain-Barré syndrome (http://www.cdc.gov/zika/geo/united-states.html). Most importantly, as of September 15, 2016, there have been 20 live-born infants with birth defects and five pregnancy losses with birth defects—numbers that do not reflect the outcomes of ongoing pregnancies.
The life expectancy of babies severely affected by Zika virus and the nature and extent of disability in less physically affected babies are presently unknown. But according to The Washington Post (http://wapo.st/29Y5CnR), estimates of the cost of caring for a severely affected Zika baby through adulthood run as high as $10 million or more, and as high a total price as we will pay for the congressional intransigence this summer, such cost estimates do not even consider the terrible human suffering these babies will experience or the anguish their parents may have for the rest of their lives.
Emergency physicians are all too familiar with the emotional and behavioral problems that complicate our efforts to manage acute medical problems of children and adults born with autism or Down syndrome when they present to the ED. Most such congenital illnesses are not preventable, but when one potentially is, delaying needed resources because of partisan politics is unconscionable.
By summer’s end, as the last of leftover Ebola dollars were being spent on Zika-related programs, Democrats and Republicans finally appeared to be reaching a consensus to provide $1.1 billion of the $1.9 billion originally requested by the President long before the long hot summer began. This sudden agreement may be driven by the importance both parties place on winning the Florida vote in the upcoming election. But whatever the reason, Zika funding now will help prevent untold hardships and suffering in the years to come. In the meantime, EPs will continue to evaluate, diagnose, counsel, and, hopefully someday soon, be able to treat all who come to our EDs with Zika infection.