Neal Flomenbaum, MD

Past…

Almost 40 years have elapsed since the American Board of Medical Specialties recognized emergency medicine (EM) as the 23rd medical specialty. Though the fundamental principles of patient care, medical education, and certification established by the American Board of Emergency Medicine (ABEM) have stood the test of time, the ED of today is a very different place than the “ER” of 1979. So too, today’s emergency physicians (EPs) are not only better trained and more capable of providing the highest quality of care in the ED, but are also increasingly doing so in venues outside of the traditional hospital-based ED.

Present...

In 1996, The New York Hospital – Cornell University Medical Center recruited me to be their first emergency physician-in-chief and EMS medical director, and to establish a first-rate academic ED and EM residency program. Starting with an “ER” staff of eight full-time and part-time non-EM-boarded attending physicians and a varying number of medical and surgical residents, over the next 20 years I expanded the complement of board-certified attending EPs to over 50, added attending-supervised nurse practitioners (NPs) and physician assistants (PAs), recruited a residency director, and helped him start a 4-year EM residency on both our Cornell and Columbia campuses. I also supported the initiation of 1-year ED nurse, PA, and NP residency programs. In corroboration with the chair of radiology, we added 24-hour dedicated sonography technologists to supplement the bedside emergency sonography that we had just been credentialed to perform, and established one of the very first divisions of emergency radiology, headed by EM board member and columnist, Keith Hentel, MD. Keith staffed his division with 24/7 attending radiologists to interpret all ED radiographic studies and provide imaging advice. More recently, I was able to arrange for dedicated 24/7 ED pharmacists, 24/7 ED social workers, and a patient safety/quality assurance division.

When I arrived at New York – Cornell, I supported the expansion of the ED patient services already in place, headed by an incredibly skilled and compassionate director, Constance Peterson, MA, who always insisted that her small office open directly off of the ED waiting room. Constance recruited and supervised a group of dedicated patient greeters and facilitators to ensure that no patient would get lost or fall through the “cracks” of our ever-expanding ED.

The plans for a new ED located at the front entrance to the hospital had literally been “carved in stone” by the time I arrived, but a decade later a magnificent gift from a donor gave me the opportunity to design a fourth patient-care area that expanded our ED to two full city blocks. I designed the new addition to serve the specific needs of a rapidly aging population and to provide a secure unit capable of managing patients with new or emerging infectious diseases and those with compromised immune systems. I also included in the new unit a large, state-of-the-art gynecologic (GYN) examination suite for conducting sexual assault exams and other GYN exams while providing the patient with a maximum level of comfort.

To coordinate activities throughout the ED and to provide a rapid expansion of staff when needed to manage surges in patient volume, I divided the ED into three acute areas and one urgent care area, each headed by an attending physician 24/7. One of the attendings was designated as the “administrative attending” or “AA.” Among other responsibilities, the AA was required to e-mail me and Associate Director Jeremy Sperling, MD, (now chair of EM at Einstein/Jacobi) a detailed note on patient volume, rate of new registrations, and any problems, at the end of every 8-hour shift—or more frequently when the need arose. Whenever patient volume was in danger of exceeding capacity, Jeremy immediately sent an urgent e-mail to all of our attending EPs, PAs, and NPs, offering double the hourly rate for 4 to 8 hours of patient care, while adhering to all relevant work-hour requirements. To cover the cost of these additional emergency clinical hours, I made a small portion of our fee-for-service revenues available. Two years ago, I initiated a physician scribe program to restore the physician-patient relationship during patient evaluations and treatments.

With the successful establishment of our EM residency program by Wallace Carter, MD, in 2003, I started 1- and 2-year fellowships in new disciplines for a 21st century ED—using a portion of our fee-for-service revenues designated for research and development to supplement the part-time attending base salaries of non-ACGME fellows. Beginning in 2005, I established the nation’s first geriatric EM fellowship, supported our newly established global EM program, recruited one of our attending EPs, Jay Lemery, MD, to start a wilderness medicine program in the Adirondack Mountains with Cornell (University) Outdoor Education, and appointed a director of EM/critical care. The ED expansion in 2009 enabled me to hire five attending EPs who were also board eligible/certified in medical toxicology, creating a “tox” group for bedside guidance and care in the ED and consultations throughout the hospital. The tox group also provided invaluable assistance to our secure psychiatric ED, headed by renowned emergency psychiatrists Lisa Sombrotto, MD, and Sharon Hird, MD. I also supported the activities of the pediatric EM fellowship, which had been established and nurtured by our extremely capable chief of pediatric EM, Shari Platt, MD. Most recently, I began to develop a new program in women’s health emergencies.

To expedite emergently needed care for an increasing number of oncology patients, I created a special “fast-track” to ensure that febrile cancer-treatment patients received needed antibiotics within an hour of arrival. I created a second fast-track to expedite the diagnosis and treatment (ie, transfer to the OR) of patients with surgical abdomens, and a third track to expedite the care of patients with community-acquired pneumonia.

And Yet to Come…

The programs and divisions described were developed over a 20-year period, always mindful of the standards and quality measures first promulgated by ABEM in 1979. New hospital-based ED initiatives will undoubtedly continue to be created in the future by EPs who are challenged to develop new and effective ways of caring for the ever-increasing numbers of patients in the face of continued hospital and ED closings.

At the same time, the increased numbers of patients seeking care in EDs, most recently created by the Affordable Care Act of 2010, is leading many EPs to apply the skills they learned as residents and their hospital-based ED experiences in new venues for emergency care. In recent years, there has been a virtual explosion in the number of urgent care centers, freestanding EDs, “convenient-care” centers, and even remote patient care in the form of “telehealth” or “telemedicine.” In 2014, when the National Hockey League mandated the presence of EPs at all games, I negotiated a contract that also enables our attending EPs to have senior residents accompany them and observe the practice of EM outside hospital walls. Prehospital and “interhospital” care also continues to expand with an increasing need for critical care and long-distance patient transfers to and from hospitals, and with a growing interest in community para-medicine programs.

In an October 2012 editorial (Emerg Med. 2012;44[10]:4), I wrote about French high-wire acrobat Philippe Petit who had rigged a cable between the two towers of the World Trade Center in August 1974, and then “aided only by a long, custom-made balancing pole, crossed, re-crossed, and danced on the wire without a safety net, for 45 minutes.” Most observers that day were certain he would fall to his death, and no one imagined that he would survive and outlast the 110-story towers he had anchored his cable to. So too, with EM: Hospital-based EDs will certainly remain an essential part of EM in the years to come, but EPs will also have increasing opportunities to practice their specialty in other important venues as well. The EP of the future will not be bound to a particular location to practice EM.

As I have this time of year for the past 11 years, I wish all of our readers, and all EPs everywhere, a joyous and safe holiday season and many happy and healthy new years to come. 

Past…

Almost 40 years have elapsed since the American Board of Medical Specialties recognized emergency medicine (EM) as the 23rd medical specialty. Though the fundamental principles of patient care, medical education, and certification established by the American Board of Emergency Medicine (ABEM) have stood the test of time, the ED of today is a very different place than the “ER” of 1979. So too, today’s emergency physicians (EPs) are not only better trained and more capable of providing the highest quality of care in the ED, but are also increasingly doing so in venues outside of the traditional hospital-based ED.

Present...

In 1996, The New York Hospital – Cornell University Medical Center recruited me to be their first emergency physician-in-chief and EMS medical director, and to establish a first-rate academic ED and EM residency program. Starting with an “ER” staff of eight full-time and part-time non-EM-boarded attending physicians and a varying number of medical and surgical residents, over the next 20 years I expanded the complement of board-certified attending EPs to over 50, added attending-supervised nurse practitioners (NPs) and physician assistants (PAs), recruited a residency director, and helped him start a 4-year EM residency on both our Cornell and Columbia campuses. I also supported the initiation of 1-year ED nurse, PA, and NP residency programs. In corroboration with the chair of radiology, we added 24-hour dedicated sonography technologists to supplement the bedside emergency sonography that we had just been credentialed to perform, and established one of the very first divisions of emergency radiology, headed by EM board member and columnist, Keith Hentel, MD. Keith staffed his division with 24/7 attending radiologists to interpret all ED radiographic studies and provide imaging advice. More recently, I was able to arrange for dedicated 24/7 ED pharmacists, 24/7 ED social workers, and a patient safety/quality assurance division.

When I arrived at New York – Cornell, I supported the expansion of the ED patient services already in place, headed by an incredibly skilled and compassionate director, Constance Peterson, MA, who always insisted that her small office open directly off of the ED waiting room. Constance recruited and supervised a group of dedicated patient greeters and facilitators to ensure that no patient would get lost or fall through the “cracks” of our ever-expanding ED.

The plans for a new ED located at the front entrance to the hospital had literally been “carved in stone” by the time I arrived, but a decade later a magnificent gift from a donor gave me the opportunity to design a fourth patient-care area that expanded our ED to two full city blocks. I designed the new addition to serve the specific needs of a rapidly aging population and to provide a secure unit capable of managing patients with new or emerging infectious diseases and those with compromised immune systems. I also included in the new unit a large, state-of-the-art gynecologic (GYN) examination suite for conducting sexual assault exams and other GYN exams while providing the patient with a maximum level of comfort.

To coordinate activities throughout the ED and to provide a rapid expansion of staff when needed to manage surges in patient volume, I divided the ED into three acute areas and one urgent care area, each headed by an attending physician 24/7. One of the attendings was designated as the “administrative attending” or “AA.” Among other responsibilities, the AA was required to e-mail me and Associate Director Jeremy Sperling, MD, (now chair of EM at Einstein/Jacobi) a detailed note on patient volume, rate of new registrations, and any problems, at the end of every 8-hour shift—or more frequently when the need arose. Whenever patient volume was in danger of exceeding capacity, Jeremy immediately sent an urgent e-mail to all of our attending EPs, PAs, and NPs, offering double the hourly rate for 4 to 8 hours of patient care, while adhering to all relevant work-hour requirements. To cover the cost of these additional emergency clinical hours, I made a small portion of our fee-for-service revenues available. Two years ago, I initiated a physician scribe program to restore the physician-patient relationship during patient evaluations and treatments.

With the successful establishment of our EM residency program by Wallace Carter, MD, in 2003, I started 1- and 2-year fellowships in new disciplines for a 21st century ED—using a portion of our fee-for-service revenues designated for research and development to supplement the part-time attending base salaries of non-ACGME fellows. Beginning in 2005, I established the nation’s first geriatric EM fellowship, supported our newly established global EM program, recruited one of our attending EPs, Jay Lemery, MD, to start a wilderness medicine program in the Adirondack Mountains with Cornell (University) Outdoor Education, and appointed a director of EM/critical care. The ED expansion in 2009 enabled me to hire five attending EPs who were also board eligible/certified in medical toxicology, creating a “tox” group for bedside guidance and care in the ED and consultations throughout the hospital. The tox group also provided invaluable assistance to our secure psychiatric ED, headed by renowned emergency psychiatrists Lisa Sombrotto, MD, and Sharon Hird, MD. I also supported the activities of the pediatric EM fellowship, which had been established and nurtured by our extremely capable chief of pediatric EM, Shari Platt, MD. Most recently, I began to develop a new program in women’s health emergencies.

To expedite emergently needed care for an increasing number of oncology patients, I created a special “fast-track” to ensure that febrile cancer-treatment patients received needed antibiotics within an hour of arrival. I created a second fast-track to expedite the diagnosis and treatment (ie, transfer to the OR) of patients with surgical abdomens, and a third track to expedite the care of patients with community-acquired pneumonia.

And Yet to Come…

The programs and divisions described were developed over a 20-year period, always mindful of the standards and quality measures first promulgated by ABEM in 1979. New hospital-based ED initiatives will undoubtedly continue to be created in the future by EPs who are challenged to develop new and effective ways of caring for the ever-increasing numbers of patients in the face of continued hospital and ED closings.

At the same time, the increased numbers of patients seeking care in EDs, most recently created by the Affordable Care Act of 2010, is leading many EPs to apply the skills they learned as residents and their hospital-based ED experiences in new venues for emergency care. In recent years, there has been a virtual explosion in the number of urgent care centers, freestanding EDs, “convenient-care” centers, and even remote patient care in the form of “telehealth” or “telemedicine.” In 2014, when the National Hockey League mandated the presence of EPs at all games, I negotiated a contract that also enables our attending EPs to have senior residents accompany them and observe the practice of EM outside hospital walls. Prehospital and “interhospital” care also continues to expand with an increasing need for critical care and long-distance patient transfers to and from hospitals, and with a growing interest in community para-medicine programs.

In an October 2012 editorial (Emerg Med. 2012;44[10]:4), I wrote about French high-wire acrobat Philippe Petit who had rigged a cable between the two towers of the World Trade Center in August 1974, and then “aided only by a long, custom-made balancing pole, crossed, re-crossed, and danced on the wire without a safety net, for 45 minutes.” Most observers that day were certain he would fall to his death, and no one imagined that he would survive and outlast the 110-story towers he had anchored his cable to. So too, with EM: Hospital-based EDs will certainly remain an essential part of EM in the years to come, but EPs will also have increasing opportunities to practice their specialty in other important venues as well. The EP of the future will not be bound to a particular location to practice EM.

As I have this time of year for the past 11 years, I wish all of our readers, and all EPs everywhere, a joyous and safe holiday season and many happy and healthy new years to come. 

Past…

Almost 40 years have elapsed since the American Board of Medical Specialties recognized emergency medicine (EM) as the 23rd medical specialty. Though the fundamental principles of patient care, medical education, and certification established by the American Board of Emergency Medicine (ABEM) have stood the test of time, the ED of today is a very different place than the “ER” of 1979. So too, today’s emergency physicians (EPs) are not only better trained and more capable of providing the highest quality of care in the ED, but are also increasingly doing so in venues outside of the traditional hospital-based ED.

Present...

In 1996, The New York Hospital – Cornell University Medical Center recruited me to be their first emergency physician-in-chief and EMS medical director, and to establish a first-rate academic ED and EM residency program. Starting with an “ER” staff of eight full-time and part-time non-EM-boarded attending physicians and a varying number of medical and surgical residents, over the next 20 years I expanded the complement of board-certified attending EPs to over 50, added attending-supervised nurse practitioners (NPs) and physician assistants (PAs), recruited a residency director, and helped him start a 4-year EM residency on both our Cornell and Columbia campuses. I also supported the initiation of 1-year ED nurse, PA, and NP residency programs. In corroboration with the chair of radiology, we added 24-hour dedicated sonography technologists to supplement the bedside emergency sonography that we had just been credentialed to perform, and established one of the very first divisions of emergency radiology, headed by EM board member and columnist, Keith Hentel, MD. Keith staffed his division with 24/7 attending radiologists to interpret all ED radiographic studies and provide imaging advice. More recently, I was able to arrange for dedicated 24/7 ED pharmacists, 24/7 ED social workers, and a patient safety/quality assurance division.

When I arrived at New York – Cornell, I supported the expansion of the ED patient services already in place, headed by an incredibly skilled and compassionate director, Constance Peterson, MA, who always insisted that her small office open directly off of the ED waiting room. Constance recruited and supervised a group of dedicated patient greeters and facilitators to ensure that no patient would get lost or fall through the “cracks” of our ever-expanding ED.

The plans for a new ED located at the front entrance to the hospital had literally been “carved in stone” by the time I arrived, but a decade later a magnificent gift from a donor gave me the opportunity to design a fourth patient-care area that expanded our ED to two full city blocks. I designed the new addition to serve the specific needs of a rapidly aging population and to provide a secure unit capable of managing patients with new or emerging infectious diseases and those with compromised immune systems. I also included in the new unit a large, state-of-the-art gynecologic (GYN) examination suite for conducting sexual assault exams and other GYN exams while providing the patient with a maximum level of comfort.

To coordinate activities throughout the ED and to provide a rapid expansion of staff when needed to manage surges in patient volume, I divided the ED into three acute areas and one urgent care area, each headed by an attending physician 24/7. One of the attendings was designated as the “administrative attending” or “AA.” Among other responsibilities, the AA was required to e-mail me and Associate Director Jeremy Sperling, MD, (now chair of EM at Einstein/Jacobi) a detailed note on patient volume, rate of new registrations, and any problems, at the end of every 8-hour shift—or more frequently when the need arose. Whenever patient volume was in danger of exceeding capacity, Jeremy immediately sent an urgent e-mail to all of our attending EPs, PAs, and NPs, offering double the hourly rate for 4 to 8 hours of patient care, while adhering to all relevant work-hour requirements. To cover the cost of these additional emergency clinical hours, I made a small portion of our fee-for-service revenues available. Two years ago, I initiated a physician scribe program to restore the physician-patient relationship during patient evaluations and treatments.

With the successful establishment of our EM residency program by Wallace Carter, MD, in 2003, I started 1- and 2-year fellowships in new disciplines for a 21st century ED—using a portion of our fee-for-service revenues designated for research and development to supplement the part-time attending base salaries of non-ACGME fellows. Beginning in 2005, I established the nation’s first geriatric EM fellowship, supported our newly established global EM program, recruited one of our attending EPs, Jay Lemery, MD, to start a wilderness medicine program in the Adirondack Mountains with Cornell (University) Outdoor Education, and appointed a director of EM/critical care. The ED expansion in 2009 enabled me to hire five attending EPs who were also board eligible/certified in medical toxicology, creating a “tox” group for bedside guidance and care in the ED and consultations throughout the hospital. The tox group also provided invaluable assistance to our secure psychiatric ED, headed by renowned emergency psychiatrists Lisa Sombrotto, MD, and Sharon Hird, MD. I also supported the activities of the pediatric EM fellowship, which had been established and nurtured by our extremely capable chief of pediatric EM, Shari Platt, MD. Most recently, I began to develop a new program in women’s health emergencies.

To expedite emergently needed care for an increasing number of oncology patients, I created a special “fast-track” to ensure that febrile cancer-treatment patients received needed antibiotics within an hour of arrival. I created a second fast-track to expedite the diagnosis and treatment (ie, transfer to the OR) of patients with surgical abdomens, and a third track to expedite the care of patients with community-acquired pneumonia.

And Yet to Come…

The programs and divisions described were developed over a 20-year period, always mindful of the standards and quality measures first promulgated by ABEM in 1979. New hospital-based ED initiatives will undoubtedly continue to be created in the future by EPs who are challenged to develop new and effective ways of caring for the ever-increasing numbers of patients in the face of continued hospital and ED closings.

At the same time, the increased numbers of patients seeking care in EDs, most recently created by the Affordable Care Act of 2010, is leading many EPs to apply the skills they learned as residents and their hospital-based ED experiences in new venues for emergency care. In recent years, there has been a virtual explosion in the number of urgent care centers, freestanding EDs, “convenient-care” centers, and even remote patient care in the form of “telehealth” or “telemedicine.” In 2014, when the National Hockey League mandated the presence of EPs at all games, I negotiated a contract that also enables our attending EPs to have senior residents accompany them and observe the practice of EM outside hospital walls. Prehospital and “interhospital” care also continues to expand with an increasing need for critical care and long-distance patient transfers to and from hospitals, and with a growing interest in community para-medicine programs.

In an October 2012 editorial (Emerg Med. 2012;44[10]:4), I wrote about French high-wire acrobat Philippe Petit who had rigged a cable between the two towers of the World Trade Center in August 1974, and then “aided only by a long, custom-made balancing pole, crossed, re-crossed, and danced on the wire without a safety net, for 45 minutes.” Most observers that day were certain he would fall to his death, and no one imagined that he would survive and outlast the 110-story towers he had anchored his cable to. So too, with EM: Hospital-based EDs will certainly remain an essential part of EM in the years to come, but EPs will also have increasing opportunities to practice their specialty in other important venues as well. The EP of the future will not be bound to a particular location to practice EM.

As I have this time of year for the past 11 years, I wish all of our readers, and all EPs everywhere, a joyous and safe holiday season and many happy and healthy new years to come. 

Between late August and early November of this year, three strong Gulf Coast and Atlantic hurricanes and several intense, fast-moving northern California forest fires claimed more than 285 lives and caused countless additional injuries and illnesses. During the same period, three unnatural disasters—in Las Vegas, New York City (NYC), and now Sutherland Springs, Texas—were responsible for a total of 84 deaths and 558 injuries. Emergency physicians (EPs) and our colleagues helped deal with the aftermath of all of these incidents, saving lives and ameliorating survivors’ pain and suffering. But ironically, preventing future deaths and injuries from natural disasters may be easier than preventing loss of life from depraved human behavior.

An October 9, 2017 Wall Street Journal (WSJ) article by Jeanne Whalen entitled “Training Ground for Military Trauma Experts: U.S. Gun Violence,” describes how military surgeons helped treat victims of the Las Vegas shooting, one of several arrangements across the United States where steady gun violence provides a training ground that experts can then use on the battlefield. The article includes a photograph of Tom Scalea, MD, Chief of the R. Adams Cowley (Maryland) Shock Trauma Center and EM board member, operating with the assistance of an Air Force surgeon “embedded” at the hospital. 

Before September 11, 2001, US hospitals looked to military surgeons experienced in treating combat injuries to direct and staff their trauma centers.  Now, the military looks to US hospitals to provide their surgeons with experience treating victims of gun violence, explosives, and high-speed vehicular injuries prior to sending them into war zones! In the week before this issue of EM went to press, a terrorist driving a rental truck down an NYC bicycle path killed 8 people and injured 11 near the site of the 1993 and 2001 World Trade Center attacks. Five days later, 26 church worshipers near Austin, Texas lost their lives and 20 more were seriously injured when a lone gunman shot them with an assault rifle.

The gun violence statistics in this country are staggering. According to the nonprofit Gun Violence Archive (GVA; http://www.gunviolencearchive.org/), from January 1 through November 8, 2017 there have been 52,719 incidents resulting in 13,245 deaths and 27,111 injuries, and the Texas church attack was the 307th mass shooting* in the United States this year!

The pervasiveness of the gun culture in this country offers little hope of eliminating such incidents in the future, which makes it especially important for all EPs to be skilled in state-of-the-art trauma management. (See parts I and II of “The changing landscape of trauma care” in the July and August 2017 issues of EM [www.mdedge.com/emed-journal]). As Baltimore trauma surgeon Tom Scalea notes in the WSJ article cited earlier, “Mass shooting? That’s every weekend.…it makes me despondent….I don’t have the ability to make that go away. I have the ability to keep as many alive as I can, and we’re pretty good at it.”

As for preventing deaths from natural disasters, more accurate weather forecasting and newer technology offer more hope. Among the 134 storm-related deaths from Hurricane Irma in September, 14 were heat-related after the storm disabled a transformer supplying power to the air conditioning system of a Hollywood, Florida nursing home. A new state law will now require all nursing homes to have adequate backup generators. But for the increasing numbers of older persons with comorbidities, taking multiple medications, and living in hot climates, air conditioning must be considered life support equipment that requires immediate repair or replacement when it fails—or transfer of the residents to a cool facility.

If only we could someday also prevent terrorism and other acts of senseless violence. 

*The GVA defines a mass shooting as a single incident resulting in 4 or more people (not including the shooter) shot and/or killed at the same general time and location.

Between late August and early November of this year, three strong Gulf Coast and Atlantic hurricanes and several intense, fast-moving northern California forest fires claimed more than 285 lives and caused countless additional injuries and illnesses. During the same period, three unnatural disasters—in Las Vegas, New York City (NYC), and now Sutherland Springs, Texas—were responsible for a total of 84 deaths and 558 injuries. Emergency physicians (EPs) and our colleagues helped deal with the aftermath of all of these incidents, saving lives and ameliorating survivors’ pain and suffering. But ironically, preventing future deaths and injuries from natural disasters may be easier than preventing loss of life from depraved human behavior.

An October 9, 2017 Wall Street Journal (WSJ) article by Jeanne Whalen entitled “Training Ground for Military Trauma Experts: U.S. Gun Violence,” describes how military surgeons helped treat victims of the Las Vegas shooting, one of several arrangements across the United States where steady gun violence provides a training ground that experts can then use on the battlefield. The article includes a photograph of Tom Scalea, MD, Chief of the R. Adams Cowley (Maryland) Shock Trauma Center and EM board member, operating with the assistance of an Air Force surgeon “embedded” at the hospital. 

Before September 11, 2001, US hospitals looked to military surgeons experienced in treating combat injuries to direct and staff their trauma centers.  Now, the military looks to US hospitals to provide their surgeons with experience treating victims of gun violence, explosives, and high-speed vehicular injuries prior to sending them into war zones! In the week before this issue of EM went to press, a terrorist driving a rental truck down an NYC bicycle path killed 8 people and injured 11 near the site of the 1993 and 2001 World Trade Center attacks. Five days later, 26 church worshipers near Austin, Texas lost their lives and 20 more were seriously injured when a lone gunman shot them with an assault rifle.

The gun violence statistics in this country are staggering. According to the nonprofit Gun Violence Archive (GVA; http://www.gunviolencearchive.org/), from January 1 through November 8, 2017 there have been 52,719 incidents resulting in 13,245 deaths and 27,111 injuries, and the Texas church attack was the 307th mass shooting* in the United States this year!

The pervasiveness of the gun culture in this country offers little hope of eliminating such incidents in the future, which makes it especially important for all EPs to be skilled in state-of-the-art trauma management. (See parts I and II of “The changing landscape of trauma care” in the July and August 2017 issues of EM [www.mdedge.com/emed-journal]). As Baltimore trauma surgeon Tom Scalea notes in the WSJ article cited earlier, “Mass shooting? That’s every weekend.…it makes me despondent….I don’t have the ability to make that go away. I have the ability to keep as many alive as I can, and we’re pretty good at it.”

As for preventing deaths from natural disasters, more accurate weather forecasting and newer technology offer more hope. Among the 134 storm-related deaths from Hurricane Irma in September, 14 were heat-related after the storm disabled a transformer supplying power to the air conditioning system of a Hollywood, Florida nursing home. A new state law will now require all nursing homes to have adequate backup generators. But for the increasing numbers of older persons with comorbidities, taking multiple medications, and living in hot climates, air conditioning must be considered life support equipment that requires immediate repair or replacement when it fails—or transfer of the residents to a cool facility.

If only we could someday also prevent terrorism and other acts of senseless violence. 

*The GVA defines a mass shooting as a single incident resulting in 4 or more people (not including the shooter) shot and/or killed at the same general time and location.

Between late August and early November of this year, three strong Gulf Coast and Atlantic hurricanes and several intense, fast-moving northern California forest fires claimed more than 285 lives and caused countless additional injuries and illnesses. During the same period, three unnatural disasters—in Las Vegas, New York City (NYC), and now Sutherland Springs, Texas—were responsible for a total of 84 deaths and 558 injuries. Emergency physicians (EPs) and our colleagues helped deal with the aftermath of all of these incidents, saving lives and ameliorating survivors’ pain and suffering. But ironically, preventing future deaths and injuries from natural disasters may be easier than preventing loss of life from depraved human behavior.

An October 9, 2017 Wall Street Journal (WSJ) article by Jeanne Whalen entitled “Training Ground for Military Trauma Experts: U.S. Gun Violence,” describes how military surgeons helped treat victims of the Las Vegas shooting, one of several arrangements across the United States where steady gun violence provides a training ground that experts can then use on the battlefield. The article includes a photograph of Tom Scalea, MD, Chief of the R. Adams Cowley (Maryland) Shock Trauma Center and EM board member, operating with the assistance of an Air Force surgeon “embedded” at the hospital. 

Before September 11, 2001, US hospitals looked to military surgeons experienced in treating combat injuries to direct and staff their trauma centers.  Now, the military looks to US hospitals to provide their surgeons with experience treating victims of gun violence, explosives, and high-speed vehicular injuries prior to sending them into war zones! In the week before this issue of EM went to press, a terrorist driving a rental truck down an NYC bicycle path killed 8 people and injured 11 near the site of the 1993 and 2001 World Trade Center attacks. Five days later, 26 church worshipers near Austin, Texas lost their lives and 20 more were seriously injured when a lone gunman shot them with an assault rifle.

The gun violence statistics in this country are staggering. According to the nonprofit Gun Violence Archive (GVA; http://www.gunviolencearchive.org/), from January 1 through November 8, 2017 there have been 52,719 incidents resulting in 13,245 deaths and 27,111 injuries, and the Texas church attack was the 307th mass shooting* in the United States this year!

The pervasiveness of the gun culture in this country offers little hope of eliminating such incidents in the future, which makes it especially important for all EPs to be skilled in state-of-the-art trauma management. (See parts I and II of “The changing landscape of trauma care” in the July and August 2017 issues of EM [www.mdedge.com/emed-journal]). As Baltimore trauma surgeon Tom Scalea notes in the WSJ article cited earlier, “Mass shooting? That’s every weekend.…it makes me despondent….I don’t have the ability to make that go away. I have the ability to keep as many alive as I can, and we’re pretty good at it.”

As for preventing deaths from natural disasters, more accurate weather forecasting and newer technology offer more hope. Among the 134 storm-related deaths from Hurricane Irma in September, 14 were heat-related after the storm disabled a transformer supplying power to the air conditioning system of a Hollywood, Florida nursing home. A new state law will now require all nursing homes to have adequate backup generators. But for the increasing numbers of older persons with comorbidities, taking multiple medications, and living in hot climates, air conditioning must be considered life support equipment that requires immediate repair or replacement when it fails—or transfer of the residents to a cool facility.

If only we could someday also prevent terrorism and other acts of senseless violence. 

*The GVA defines a mass shooting as a single incident resulting in 4 or more people (not including the shooter) shot and/or killed at the same general time and location.

Between August 30 and September 16, 2017, Hurricane Irma wreaked havoc in the Caribbean and throughout Florida. In the days after the Rehabilitation Center at Hollywood Hills, Florida, lost its transformer and air conditioning due to the storm, 12 residents ranging in age from 57 to 99 years died* with body temperatures as high as 109.9°F, even though the hospital across the street continued to have full power. The nursing home staff tried in vain several times to get Florida Power and Light to restore full power. They also called a “personal” cell phone number provided by the governor for storm victims in need of help, but their voicemail messages went unanswered. Apparently, no one called 911 or tried to have the patients moved across the street before they were in extremis or began to die.

Large numbers of casualties are not an inevitable sequela of natural disasters. In August 1973 (the second month of my internship), a late summer heat wave in New York City sent 12 patients with heat stroke and heat exhaustion from nearby non-air-conditioned nursing homes to the Albert Einstein/Jacobi Hospital emergency department in just a few hours. After being packed in ice until their temperatures dropped, all but one of the patients survived, while the 12th patient died of her underlying illnesses (see “Sheldon Jacobson, MD 1938-2009,” July 2009 EM).

On August 14, 2003, a hot (92.5°F), humid day in NYC, a power outage affecting the entire northeast and northwest United States trapped many New Yorkers in elevators, subways, and train cars. Residents were also trapped in high-rise apartments with only limited battery power for respirators and other essential electrical equipment. Within a few hours, first responders had reportedly evacuated everyone from stalled elevators in about 800 buildings, and over 600 subway and commuter train cars. Others were safely evacuated from their high-rise residences and taken to EDs powered by emergency generators. Upon arrival, their life support equipment and devices were plugged into electrical outlets, while they were examined, given medications as necessary, and later returned to their homes when power was restored.

First responders and emergency physicians have become quite adept at managing heat stroke and heat-related conditions, but only in patients who are still alive. In the aftermath of Hurricane Katrina, which devastated New Orleans on August 29, 2005, 215 bodies were found in New Orleans hospitals and nursing homes—including those from 40 post-storm deaths in one hospital alone (See Sheri Fink. Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital. New York, NY: Crown Publishers; 2013). The tragic events following Katrina should have been a wake-up call for all health facilities and regulators in the US to anticipate and adequately prepare for loss of power, water, and severe heat conditions. Instead, a 2006 Florida bill that would have required adequate generators in all nursing homes was defeated, reportedly due to industry lobbying efforts.

The number of casualties and deaths due to natural disasters in this country may be fewer than those caused by such man-made incidents as the June 12, 2016 Pulse Nightclub shooting in Orlando, FL (see “The Orlando Nightclub Shooting: Firsthand Accounts and Lessons Learned,” August 2016 EM) and now the mass shooting in Las Vegas, NV on October 1, 2017, as this issue of Emergency Medicine was going to press. But natural disasters such as hurricanes, tornadoes, earthquakes, etc, are far more predictable and will reoccur with a 100% certainty in areas prone to or previously affected by such events. In these incidents, loss of life is preventable.

To quote the famous aphorism of George Santayana, “Those who cannot remember the past are condemned to repeat it.” More inexcusably, it often seems that those who can remember the past are also condemned to repeat it. 

*As of October 11, 2017, this number rose to 14 deaths.

Between August 30 and September 16, 2017, Hurricane Irma wreaked havoc in the Caribbean and throughout Florida. In the days after the Rehabilitation Center at Hollywood Hills, Florida, lost its transformer and air conditioning due to the storm, 12 residents ranging in age from 57 to 99 years died* with body temperatures as high as 109.9°F, even though the hospital across the street continued to have full power. The nursing home staff tried in vain several times to get Florida Power and Light to restore full power. They also called a “personal” cell phone number provided by the governor for storm victims in need of help, but their voicemail messages went unanswered. Apparently, no one called 911 or tried to have the patients moved across the street before they were in extremis or began to die.

Large numbers of casualties are not an inevitable sequela of natural disasters. In August 1973 (the second month of my internship), a late summer heat wave in New York City sent 12 patients with heat stroke and heat exhaustion from nearby non-air-conditioned nursing homes to the Albert Einstein/Jacobi Hospital emergency department in just a few hours. After being packed in ice until their temperatures dropped, all but one of the patients survived, while the 12th patient died of her underlying illnesses (see “Sheldon Jacobson, MD 1938-2009,” July 2009 EM).

On August 14, 2003, a hot (92.5°F), humid day in NYC, a power outage affecting the entire northeast and northwest United States trapped many New Yorkers in elevators, subways, and train cars. Residents were also trapped in high-rise apartments with only limited battery power for respirators and other essential electrical equipment. Within a few hours, first responders had reportedly evacuated everyone from stalled elevators in about 800 buildings, and over 600 subway and commuter train cars. Others were safely evacuated from their high-rise residences and taken to EDs powered by emergency generators. Upon arrival, their life support equipment and devices were plugged into electrical outlets, while they were examined, given medications as necessary, and later returned to their homes when power was restored.

First responders and emergency physicians have become quite adept at managing heat stroke and heat-related conditions, but only in patients who are still alive. In the aftermath of Hurricane Katrina, which devastated New Orleans on August 29, 2005, 215 bodies were found in New Orleans hospitals and nursing homes—including those from 40 post-storm deaths in one hospital alone (See Sheri Fink. Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital. New York, NY: Crown Publishers; 2013). The tragic events following Katrina should have been a wake-up call for all health facilities and regulators in the US to anticipate and adequately prepare for loss of power, water, and severe heat conditions. Instead, a 2006 Florida bill that would have required adequate generators in all nursing homes was defeated, reportedly due to industry lobbying efforts.

The number of casualties and deaths due to natural disasters in this country may be fewer than those caused by such man-made incidents as the June 12, 2016 Pulse Nightclub shooting in Orlando, FL (see “The Orlando Nightclub Shooting: Firsthand Accounts and Lessons Learned,” August 2016 EM) and now the mass shooting in Las Vegas, NV on October 1, 2017, as this issue of Emergency Medicine was going to press. But natural disasters such as hurricanes, tornadoes, earthquakes, etc, are far more predictable and will reoccur with a 100% certainty in areas prone to or previously affected by such events. In these incidents, loss of life is preventable.

To quote the famous aphorism of George Santayana, “Those who cannot remember the past are condemned to repeat it.” More inexcusably, it often seems that those who can remember the past are also condemned to repeat it. 

*As of October 11, 2017, this number rose to 14 deaths.

Between August 30 and September 16, 2017, Hurricane Irma wreaked havoc in the Caribbean and throughout Florida. In the days after the Rehabilitation Center at Hollywood Hills, Florida, lost its transformer and air conditioning due to the storm, 12 residents ranging in age from 57 to 99 years died* with body temperatures as high as 109.9°F, even though the hospital across the street continued to have full power. The nursing home staff tried in vain several times to get Florida Power and Light to restore full power. They also called a “personal” cell phone number provided by the governor for storm victims in need of help, but their voicemail messages went unanswered. Apparently, no one called 911 or tried to have the patients moved across the street before they were in extremis or began to die.

Large numbers of casualties are not an inevitable sequela of natural disasters. In August 1973 (the second month of my internship), a late summer heat wave in New York City sent 12 patients with heat stroke and heat exhaustion from nearby non-air-conditioned nursing homes to the Albert Einstein/Jacobi Hospital emergency department in just a few hours. After being packed in ice until their temperatures dropped, all but one of the patients survived, while the 12th patient died of her underlying illnesses (see “Sheldon Jacobson, MD 1938-2009,” July 2009 EM).

On August 14, 2003, a hot (92.5°F), humid day in NYC, a power outage affecting the entire northeast and northwest United States trapped many New Yorkers in elevators, subways, and train cars. Residents were also trapped in high-rise apartments with only limited battery power for respirators and other essential electrical equipment. Within a few hours, first responders had reportedly evacuated everyone from stalled elevators in about 800 buildings, and over 600 subway and commuter train cars. Others were safely evacuated from their high-rise residences and taken to EDs powered by emergency generators. Upon arrival, their life support equipment and devices were plugged into electrical outlets, while they were examined, given medications as necessary, and later returned to their homes when power was restored.

First responders and emergency physicians have become quite adept at managing heat stroke and heat-related conditions, but only in patients who are still alive. In the aftermath of Hurricane Katrina, which devastated New Orleans on August 29, 2005, 215 bodies were found in New Orleans hospitals and nursing homes—including those from 40 post-storm deaths in one hospital alone (See Sheri Fink. Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital. New York, NY: Crown Publishers; 2013). The tragic events following Katrina should have been a wake-up call for all health facilities and regulators in the US to anticipate and adequately prepare for loss of power, water, and severe heat conditions. Instead, a 2006 Florida bill that would have required adequate generators in all nursing homes was defeated, reportedly due to industry lobbying efforts.

The number of casualties and deaths due to natural disasters in this country may be fewer than those caused by such man-made incidents as the June 12, 2016 Pulse Nightclub shooting in Orlando, FL (see “The Orlando Nightclub Shooting: Firsthand Accounts and Lessons Learned,” August 2016 EM) and now the mass shooting in Las Vegas, NV on October 1, 2017, as this issue of Emergency Medicine was going to press. But natural disasters such as hurricanes, tornadoes, earthquakes, etc, are far more predictable and will reoccur with a 100% certainty in areas prone to or previously affected by such events. In these incidents, loss of life is preventable.

To quote the famous aphorism of George Santayana, “Those who cannot remember the past are condemned to repeat it.” More inexcusably, it often seems that those who can remember the past are also condemned to repeat it. 

*As of October 11, 2017, this number rose to 14 deaths.

Following the successful use of ambulances during the Civil War to transport wounded soldiers from the battlefield to safer and better equipped field hospital facilities, many communities adopted the practice for their civilian populations. Between the Civil War and World War II (WWII) "teaching hospitals" sent interns on their ambulances both to improve patient care at the scene, and to further their interns’ postgraduate education. However, as described by Ryan Corbett Bell in his book The Ambulance (Jefferson, NC: McFarland; 2009), by the 1930s, relatively poor reimbursement for ambulance calls followed by the severe doctor shortage due to WWII, effectively ended this practice. Though the interns were initially replaced by "ambulance attendants" or "orderlies," since the 1960s, ambulances have been staffed by trained EMTs and (later) paramedics to provide basic and advanced prehospital care both at the scene and during transport. For almost half a century, paramedics operating with standing protocols and physician medical control have conclusively demonstrated their ability to improve care and save lives.

At present, the increased demand for access to medical care brought about by the Affordable Care Act, an aging homebound population, overcrowded EDs, and inpatient services filled to capacity, along with, in some areas, insufficient numbers of visiting nurses, NPs, and PAs to provide needed home care services, prompted many to consider expanding the role of paramedics and EMTs to provide "community paramedicine," without afterward requiring them to transport patients to hospitals.

Community paramedicine was defined in 2012 by the US Department of Health and Human Services Administration as "an emerging field in health care where EMTs and Paramedics operate in expanded roles in an effort to connect underutilized resources to underserved populations" (https://www.hrsa.gov). A standard curriculum consisting of 114 hours of education in social determinants of health, public health, and tailored learning about chronic diseases, together with 200 hours of laboratory and clinical experiences has been developed and made available free of charge to colleges and universities (https://www.ruralhealthinfo.org).

Among the many individuals and organizations weighing in on the subject of community paramedicine, the American College of Emergency Physicians 2015 policy statement supports the development of properly designed expanded scope of practice programs for EMS personnel with medical oversight, that do not compromise existing emergency response systems (https://www.acep.org/). Dr Bryan Bledsoe, an editorial board member of JEMS (Journal of Emergency Medical Services), provides a thoughtful analysis of the pros and cons of community paramedicine (http://www.jems.com), hile Iyah K. Romm and colleagues, writing in the NEJM Catalyst, offer concrete evidence of the effectiveness of one such mobile integrated healthcare and community paramedicine program (http://catalyst.nejm.org).

Properly trained, experienced paramedics with careful supervision by emergency medical control physicians and consultation with the patients’ primary care physicians, supported by telemedicine and bedside diagnostic tests, can provide essential care in a patient’s home environment. Depending on local circumstances, EMTs and paramedics can provide that care 24/7, supplementing other available home health care to support posthospital-discharge care for congestive heart failure, wound healing, etc, obviating the need for repeated ED and clinic visits or hospitalizations.

In addition to patient benefits, community paramedicine offers an opportunity for experienced paramedics to extend their years of practice similar to the way urgent care clinics have enabled experienced EPs to extend theirs. For all of these reasons, we support an expanded role for EMTs and paramedics in safe, carefully planned community paramedicine programs.

Following the successful use of ambulances during the Civil War to transport wounded soldiers from the battlefield to safer and better equipped field hospital facilities, many communities adopted the practice for their civilian populations. Between the Civil War and World War II (WWII) "teaching hospitals" sent interns on their ambulances both to improve patient care at the scene, and to further their interns’ postgraduate education. However, as described by Ryan Corbett Bell in his book The Ambulance (Jefferson, NC: McFarland; 2009), by the 1930s, relatively poor reimbursement for ambulance calls followed by the severe doctor shortage due to WWII, effectively ended this practice. Though the interns were initially replaced by "ambulance attendants" or "orderlies," since the 1960s, ambulances have been staffed by trained EMTs and (later) paramedics to provide basic and advanced prehospital care both at the scene and during transport. For almost half a century, paramedics operating with standing protocols and physician medical control have conclusively demonstrated their ability to improve care and save lives.

At present, the increased demand for access to medical care brought about by the Affordable Care Act, an aging homebound population, overcrowded EDs, and inpatient services filled to capacity, along with, in some areas, insufficient numbers of visiting nurses, NPs, and PAs to provide needed home care services, prompted many to consider expanding the role of paramedics and EMTs to provide "community paramedicine," without afterward requiring them to transport patients to hospitals.

Community paramedicine was defined in 2012 by the US Department of Health and Human Services Administration as "an emerging field in health care where EMTs and Paramedics operate in expanded roles in an effort to connect underutilized resources to underserved populations" (https://www.hrsa.gov). A standard curriculum consisting of 114 hours of education in social determinants of health, public health, and tailored learning about chronic diseases, together with 200 hours of laboratory and clinical experiences has been developed and made available free of charge to colleges and universities (https://www.ruralhealthinfo.org).

Among the many individuals and organizations weighing in on the subject of community paramedicine, the American College of Emergency Physicians 2015 policy statement supports the development of properly designed expanded scope of practice programs for EMS personnel with medical oversight, that do not compromise existing emergency response systems (https://www.acep.org/). Dr Bryan Bledsoe, an editorial board member of JEMS (Journal of Emergency Medical Services), provides a thoughtful analysis of the pros and cons of community paramedicine (http://www.jems.com), hile Iyah K. Romm and colleagues, writing in the NEJM Catalyst, offer concrete evidence of the effectiveness of one such mobile integrated healthcare and community paramedicine program (http://catalyst.nejm.org).

Properly trained, experienced paramedics with careful supervision by emergency medical control physicians and consultation with the patients’ primary care physicians, supported by telemedicine and bedside diagnostic tests, can provide essential care in a patient’s home environment. Depending on local circumstances, EMTs and paramedics can provide that care 24/7, supplementing other available home health care to support posthospital-discharge care for congestive heart failure, wound healing, etc, obviating the need for repeated ED and clinic visits or hospitalizations.

In addition to patient benefits, community paramedicine offers an opportunity for experienced paramedics to extend their years of practice similar to the way urgent care clinics have enabled experienced EPs to extend theirs. For all of these reasons, we support an expanded role for EMTs and paramedics in safe, carefully planned community paramedicine programs.

Following the successful use of ambulances during the Civil War to transport wounded soldiers from the battlefield to safer and better equipped field hospital facilities, many communities adopted the practice for their civilian populations. Between the Civil War and World War II (WWII) "teaching hospitals" sent interns on their ambulances both to improve patient care at the scene, and to further their interns’ postgraduate education. However, as described by Ryan Corbett Bell in his book The Ambulance (Jefferson, NC: McFarland; 2009), by the 1930s, relatively poor reimbursement for ambulance calls followed by the severe doctor shortage due to WWII, effectively ended this practice. Though the interns were initially replaced by "ambulance attendants" or "orderlies," since the 1960s, ambulances have been staffed by trained EMTs and (later) paramedics to provide basic and advanced prehospital care both at the scene and during transport. For almost half a century, paramedics operating with standing protocols and physician medical control have conclusively demonstrated their ability to improve care and save lives.

At present, the increased demand for access to medical care brought about by the Affordable Care Act, an aging homebound population, overcrowded EDs, and inpatient services filled to capacity, along with, in some areas, insufficient numbers of visiting nurses, NPs, and PAs to provide needed home care services, prompted many to consider expanding the role of paramedics and EMTs to provide "community paramedicine," without afterward requiring them to transport patients to hospitals.

Community paramedicine was defined in 2012 by the US Department of Health and Human Services Administration as "an emerging field in health care where EMTs and Paramedics operate in expanded roles in an effort to connect underutilized resources to underserved populations" (https://www.hrsa.gov). A standard curriculum consisting of 114 hours of education in social determinants of health, public health, and tailored learning about chronic diseases, together with 200 hours of laboratory and clinical experiences has been developed and made available free of charge to colleges and universities (https://www.ruralhealthinfo.org).

Among the many individuals and organizations weighing in on the subject of community paramedicine, the American College of Emergency Physicians 2015 policy statement supports the development of properly designed expanded scope of practice programs for EMS personnel with medical oversight, that do not compromise existing emergency response systems (https://www.acep.org/). Dr Bryan Bledsoe, an editorial board member of JEMS (Journal of Emergency Medical Services), provides a thoughtful analysis of the pros and cons of community paramedicine (http://www.jems.com), hile Iyah K. Romm and colleagues, writing in the NEJM Catalyst, offer concrete evidence of the effectiveness of one such mobile integrated healthcare and community paramedicine program (http://catalyst.nejm.org).

Properly trained, experienced paramedics with careful supervision by emergency medical control physicians and consultation with the patients’ primary care physicians, supported by telemedicine and bedside diagnostic tests, can provide essential care in a patient’s home environment. Depending on local circumstances, EMTs and paramedics can provide that care 24/7, supplementing other available home health care to support posthospital-discharge care for congestive heart failure, wound healing, etc, obviating the need for repeated ED and clinic visits or hospitalizations.

In addition to patient benefits, community paramedicine offers an opportunity for experienced paramedics to extend their years of practice similar to the way urgent care clinics have enabled experienced EPs to extend theirs. For all of these reasons, we support an expanded role for EMTs and paramedics in safe, carefully planned community paramedicine programs.

In the days before this issue of Emergency Medicine (EM) went to press, the United States Senate tried unsuccessfully, first to repeal and replace the Affordable Care Act (ACA), then to repeal key provisions of ACA without a replacement bill. Despite having a majority in both the Senate and House of Representatives as well as a Republican President, after 7 years of vowing to repeal “Obama Care,” Republicans have still not been able to fulfill that vow.

When ACA was signed into law in March 2010 (See “Springing Forward,” April 2010 EM), we wrote “though the new law will undoubtedly be challenged, tested, modified, refined, used—and probably abused—it will not be repealed. As was the case with Medicare and Medicaid previously, this will change everything in subtle and not-so-subtle ways.” (For a discussion of how the healthcare industry has managed to co-opt and abuse ACA, see the recently published book An American Sickness by Elisabeth Rosenthal, who was an emergency physician [EP] in our department before becoming a senior science and healthcare reporter for the New York Times.)

But the failure of ACA to deliver on many of its promises, its uncertain financial future, and the lack of improvements to ACA since 2010, directly or indirectly affects every American. Predictably, for those in need of care who cannot find a physician to accept their insurance or schedule a timely appointment, the ED remains the safety net for obtaining care.

After the constitutionality of ACA was upheld by the Supreme Court in June 2012 (See “Our National Pastime,” July 2012 EM), we noted that “ACA contains no provisions for increasing the number of healthcare providers [and] if 24 million more Americans now have access to affordable health insurance, but there are no new providers, who will they go to for care?” Seven years after passage of ACA, the answer to this question has been provided by published studies confirming that even more insured Americans are now seeking care in EDs than before “affordable care” became available. At the same time, urgent care centers, freestanding EDs, and “convenient care” centers, have sprung up and proliferated throughout the country, while in many states, nurse practitioners, physician assistants, and now emergency medical technicians and paramedics have sought and received authorization to evaluate and treat patients independent of physician supervision and oversight. Telemedicine or “telehealth” is the latest attempt to stretch the available supply of physicians to manage patients remotely, in the hope of obviating the need for an ED visit. 

But none of these measures completely addresses a basic weakness of ACA: There are not enough physicians, including EPs, in this country to care for everyone entitled to healthcare; at the same time, there is a generation of highly qualified, highly motivated young men and women seeking entrance to medical school who will never get the opportunity to become fine physicians because there are not enough places for them. The solution to these problems seems obvious and the funds needed to finance it would be well spent, though the benefits of increasing the number of medical school places would not be realized for 4 to 8 years after they are made available.

In the meantime, we leave you with the solution President George W. Bush offered to a Cleveland audience on July 10, 2007 (See “Dream On,” March 2008 EM): “people have access to healthcare in America. After all, you just go to an emergency room.” 

In the days before this issue of Emergency Medicine (EM) went to press, the United States Senate tried unsuccessfully, first to repeal and replace the Affordable Care Act (ACA), then to repeal key provisions of ACA without a replacement bill. Despite having a majority in both the Senate and House of Representatives as well as a Republican President, after 7 years of vowing to repeal “Obama Care,” Republicans have still not been able to fulfill that vow.

When ACA was signed into law in March 2010 (See “Springing Forward,” April 2010 EM), we wrote “though the new law will undoubtedly be challenged, tested, modified, refined, used—and probably abused—it will not be repealed. As was the case with Medicare and Medicaid previously, this will change everything in subtle and not-so-subtle ways.” (For a discussion of how the healthcare industry has managed to co-opt and abuse ACA, see the recently published book An American Sickness by Elisabeth Rosenthal, who was an emergency physician [EP] in our department before becoming a senior science and healthcare reporter for the New York Times.)

But the failure of ACA to deliver on many of its promises, its uncertain financial future, and the lack of improvements to ACA since 2010, directly or indirectly affects every American. Predictably, for those in need of care who cannot find a physician to accept their insurance or schedule a timely appointment, the ED remains the safety net for obtaining care.

After the constitutionality of ACA was upheld by the Supreme Court in June 2012 (See “Our National Pastime,” July 2012 EM), we noted that “ACA contains no provisions for increasing the number of healthcare providers [and] if 24 million more Americans now have access to affordable health insurance, but there are no new providers, who will they go to for care?” Seven years after passage of ACA, the answer to this question has been provided by published studies confirming that even more insured Americans are now seeking care in EDs than before “affordable care” became available. At the same time, urgent care centers, freestanding EDs, and “convenient care” centers, have sprung up and proliferated throughout the country, while in many states, nurse practitioners, physician assistants, and now emergency medical technicians and paramedics have sought and received authorization to evaluate and treat patients independent of physician supervision and oversight. Telemedicine or “telehealth” is the latest attempt to stretch the available supply of physicians to manage patients remotely, in the hope of obviating the need for an ED visit. 

But none of these measures completely addresses a basic weakness of ACA: There are not enough physicians, including EPs, in this country to care for everyone entitled to healthcare; at the same time, there is a generation of highly qualified, highly motivated young men and women seeking entrance to medical school who will never get the opportunity to become fine physicians because there are not enough places for them. The solution to these problems seems obvious and the funds needed to finance it would be well spent, though the benefits of increasing the number of medical school places would not be realized for 4 to 8 years after they are made available.

In the meantime, we leave you with the solution President George W. Bush offered to a Cleveland audience on July 10, 2007 (See “Dream On,” March 2008 EM): “people have access to healthcare in America. After all, you just go to an emergency room.” 

In the days before this issue of Emergency Medicine (EM) went to press, the United States Senate tried unsuccessfully, first to repeal and replace the Affordable Care Act (ACA), then to repeal key provisions of ACA without a replacement bill. Despite having a majority in both the Senate and House of Representatives as well as a Republican President, after 7 years of vowing to repeal “Obama Care,” Republicans have still not been able to fulfill that vow.

When ACA was signed into law in March 2010 (See “Springing Forward,” April 2010 EM), we wrote “though the new law will undoubtedly be challenged, tested, modified, refined, used—and probably abused—it will not be repealed. As was the case with Medicare and Medicaid previously, this will change everything in subtle and not-so-subtle ways.” (For a discussion of how the healthcare industry has managed to co-opt and abuse ACA, see the recently published book An American Sickness by Elisabeth Rosenthal, who was an emergency physician [EP] in our department before becoming a senior science and healthcare reporter for the New York Times.)

But the failure of ACA to deliver on many of its promises, its uncertain financial future, and the lack of improvements to ACA since 2010, directly or indirectly affects every American. Predictably, for those in need of care who cannot find a physician to accept their insurance or schedule a timely appointment, the ED remains the safety net for obtaining care.

After the constitutionality of ACA was upheld by the Supreme Court in June 2012 (See “Our National Pastime,” July 2012 EM), we noted that “ACA contains no provisions for increasing the number of healthcare providers [and] if 24 million more Americans now have access to affordable health insurance, but there are no new providers, who will they go to for care?” Seven years after passage of ACA, the answer to this question has been provided by published studies confirming that even more insured Americans are now seeking care in EDs than before “affordable care” became available. At the same time, urgent care centers, freestanding EDs, and “convenient care” centers, have sprung up and proliferated throughout the country, while in many states, nurse practitioners, physician assistants, and now emergency medical technicians and paramedics have sought and received authorization to evaluate and treat patients independent of physician supervision and oversight. Telemedicine or “telehealth” is the latest attempt to stretch the available supply of physicians to manage patients remotely, in the hope of obviating the need for an ED visit. 

But none of these measures completely addresses a basic weakness of ACA: There are not enough physicians, including EPs, in this country to care for everyone entitled to healthcare; at the same time, there is a generation of highly qualified, highly motivated young men and women seeking entrance to medical school who will never get the opportunity to become fine physicians because there are not enough places for them. The solution to these problems seems obvious and the funds needed to finance it would be well spent, though the benefits of increasing the number of medical school places would not be realized for 4 to 8 years after they are made available.

In the meantime, we leave you with the solution President George W. Bush offered to a Cleveland audience on July 10, 2007 (See “Dream On,” March 2008 EM): “people have access to healthcare in America. After all, you just go to an emergency room.” 

In Emergency Medicine this month and next, Drs. Tom Scalea (See “The Golden Hourglass,” EM, April 2007), Ashley Menne, Daniel Haase, and Jay Menaker of the University of Maryland’s R Adams Cowley Shock Trauma Center paint a detailed picture of the changing landscape of trauma care over the past two decades.

In his introduction, Dr. Scalea writes “Certainly, the most important change has been the ‘graying’ of trauma patients…[whose evaluation and care] may involve a number of diagnostic tests in the ED…”, and whose care must include dealing with comorbidities, and a large number of medications that might interact with the analgesics, sedatives, and anti-seizure meds needed to treat trauma. These considerations have led many Level I trauma centers to add advanced patient age as an independent determinant for both trauma activations and subsequent ICU admissions, and to include “geriatric” consultants in the initial management. 

The aging trauma patient, however, is not the only factor responsible for major changes in the management of serious trauma, as the Shock Trauma group describes the current difficulties in attempting to rapidly reverse the anticoagulation effects of the novel oral anticoagulants (NOACs) that are increasingly being prescribed instead of warfarin to manage the thromboembolic complications of atrial fibrillation, valve replacement, venous thrombosis, and pulmonary embolism in both younger and older patients. They also explain a major change in thinking regarding the optimal degree of blood pressure control in favor of “permissive hypotension” as part of “damage control resuscitation,” and in the amount and types of volume replacement, optimal blood component ratios for transfusion, monitoring, and faster and less invasive endovascular repair techniques for hemostasis. The authors also note the persistent and rising incidence of penetrating trauma from gunshot and knife wounds. 

But the increasing percentages of elderly trauma victims requiring care for devastating falls and low-speed vehicular injuries in even the busiest “knife and gun club” trauma centers mandate the attention of all health care providers. In recent months, much space in this and other journals has been devoted to the health care issues of the elderly (see “Recognizing and Managing Elder Abuse in the Emergency Department,” and “Elder Abuse: A New Old Problem,” EM, May 2017) that necessitate significantly increased resources and provider time and effort now, and for at least the first half of the 21st century.

The main reason for this seismic demographic shift, dubbed by some “the silver tsunami”, is the aging post World War II “baby boomer” generation that has commanded center stage in western society throughout their development since the late 1940s. As a member of that generation, I often wonder how subsequent generations such as “Gen X” and “Millennials” view this phenomenon. Do they resent the attention, resources, and expenditures now demanded by baby boomers? If so, there is an important lesson to be learned from the changes in trauma care described in the following pages: virtually every measure now employed to enhance recovery of an elderly trauma victim will benefit younger trauma victims, as well. At most, some of the measures may not be absolutely necessary because younger adults have greater functional reserve and are more likely to survive less precise management, even if their posttraumatic courses are longer and more difficult. But younger trauma victims with comorbidities can also benefit from a more inclusive team approach from the start, as well as measures such as permissive hypotension, vascular stents and less invasive endovascular approaches, more precise blood component replacement, more accurate monitoring, and a better approach to anticoagulation and its reversal.

Faster and better quality survival of all trauma victims—including, but not limited to, the elderly—will free up needed and expensive resources for other patients and trauma victims, including those who continue to butt heads, drive two and four wheel vehicles at excessive speeds, and engage in trauma of an “interpersonal nature.” 

In Emergency Medicine this month and next, Drs. Tom Scalea (See “The Golden Hourglass,” EM, April 2007), Ashley Menne, Daniel Haase, and Jay Menaker of the University of Maryland’s R Adams Cowley Shock Trauma Center paint a detailed picture of the changing landscape of trauma care over the past two decades.

In his introduction, Dr. Scalea writes “Certainly, the most important change has been the ‘graying’ of trauma patients…[whose evaluation and care] may involve a number of diagnostic tests in the ED…”, and whose care must include dealing with comorbidities, and a large number of medications that might interact with the analgesics, sedatives, and anti-seizure meds needed to treat trauma. These considerations have led many Level I trauma centers to add advanced patient age as an independent determinant for both trauma activations and subsequent ICU admissions, and to include “geriatric” consultants in the initial management. 

The aging trauma patient, however, is not the only factor responsible for major changes in the management of serious trauma, as the Shock Trauma group describes the current difficulties in attempting to rapidly reverse the anticoagulation effects of the novel oral anticoagulants (NOACs) that are increasingly being prescribed instead of warfarin to manage the thromboembolic complications of atrial fibrillation, valve replacement, venous thrombosis, and pulmonary embolism in both younger and older patients. They also explain a major change in thinking regarding the optimal degree of blood pressure control in favor of “permissive hypotension” as part of “damage control resuscitation,” and in the amount and types of volume replacement, optimal blood component ratios for transfusion, monitoring, and faster and less invasive endovascular repair techniques for hemostasis. The authors also note the persistent and rising incidence of penetrating trauma from gunshot and knife wounds. 

But the increasing percentages of elderly trauma victims requiring care for devastating falls and low-speed vehicular injuries in even the busiest “knife and gun club” trauma centers mandate the attention of all health care providers. In recent months, much space in this and other journals has been devoted to the health care issues of the elderly (see “Recognizing and Managing Elder Abuse in the Emergency Department,” and “Elder Abuse: A New Old Problem,” EM, May 2017) that necessitate significantly increased resources and provider time and effort now, and for at least the first half of the 21st century.

The main reason for this seismic demographic shift, dubbed by some “the silver tsunami”, is the aging post World War II “baby boomer” generation that has commanded center stage in western society throughout their development since the late 1940s. As a member of that generation, I often wonder how subsequent generations such as “Gen X” and “Millennials” view this phenomenon. Do they resent the attention, resources, and expenditures now demanded by baby boomers? If so, there is an important lesson to be learned from the changes in trauma care described in the following pages: virtually every measure now employed to enhance recovery of an elderly trauma victim will benefit younger trauma victims, as well. At most, some of the measures may not be absolutely necessary because younger adults have greater functional reserve and are more likely to survive less precise management, even if their posttraumatic courses are longer and more difficult. But younger trauma victims with comorbidities can also benefit from a more inclusive team approach from the start, as well as measures such as permissive hypotension, vascular stents and less invasive endovascular approaches, more precise blood component replacement, more accurate monitoring, and a better approach to anticoagulation and its reversal.

Faster and better quality survival of all trauma victims—including, but not limited to, the elderly—will free up needed and expensive resources for other patients and trauma victims, including those who continue to butt heads, drive two and four wheel vehicles at excessive speeds, and engage in trauma of an “interpersonal nature.” 

In Emergency Medicine this month and next, Drs. Tom Scalea (See “The Golden Hourglass,” EM, April 2007), Ashley Menne, Daniel Haase, and Jay Menaker of the University of Maryland’s R Adams Cowley Shock Trauma Center paint a detailed picture of the changing landscape of trauma care over the past two decades.

In his introduction, Dr. Scalea writes “Certainly, the most important change has been the ‘graying’ of trauma patients…[whose evaluation and care] may involve a number of diagnostic tests in the ED…”, and whose care must include dealing with comorbidities, and a large number of medications that might interact with the analgesics, sedatives, and anti-seizure meds needed to treat trauma. These considerations have led many Level I trauma centers to add advanced patient age as an independent determinant for both trauma activations and subsequent ICU admissions, and to include “geriatric” consultants in the initial management. 

The aging trauma patient, however, is not the only factor responsible for major changes in the management of serious trauma, as the Shock Trauma group describes the current difficulties in attempting to rapidly reverse the anticoagulation effects of the novel oral anticoagulants (NOACs) that are increasingly being prescribed instead of warfarin to manage the thromboembolic complications of atrial fibrillation, valve replacement, venous thrombosis, and pulmonary embolism in both younger and older patients. They also explain a major change in thinking regarding the optimal degree of blood pressure control in favor of “permissive hypotension” as part of “damage control resuscitation,” and in the amount and types of volume replacement, optimal blood component ratios for transfusion, monitoring, and faster and less invasive endovascular repair techniques for hemostasis. The authors also note the persistent and rising incidence of penetrating trauma from gunshot and knife wounds. 

But the increasing percentages of elderly trauma victims requiring care for devastating falls and low-speed vehicular injuries in even the busiest “knife and gun club” trauma centers mandate the attention of all health care providers. In recent months, much space in this and other journals has been devoted to the health care issues of the elderly (see “Recognizing and Managing Elder Abuse in the Emergency Department,” and “Elder Abuse: A New Old Problem,” EM, May 2017) that necessitate significantly increased resources and provider time and effort now, and for at least the first half of the 21st century.

The main reason for this seismic demographic shift, dubbed by some “the silver tsunami”, is the aging post World War II “baby boomer” generation that has commanded center stage in western society throughout their development since the late 1940s. As a member of that generation, I often wonder how subsequent generations such as “Gen X” and “Millennials” view this phenomenon. Do they resent the attention, resources, and expenditures now demanded by baby boomers? If so, there is an important lesson to be learned from the changes in trauma care described in the following pages: virtually every measure now employed to enhance recovery of an elderly trauma victim will benefit younger trauma victims, as well. At most, some of the measures may not be absolutely necessary because younger adults have greater functional reserve and are more likely to survive less precise management, even if their posttraumatic courses are longer and more difficult. But younger trauma victims with comorbidities can also benefit from a more inclusive team approach from the start, as well as measures such as permissive hypotension, vascular stents and less invasive endovascular approaches, more precise blood component replacement, more accurate monitoring, and a better approach to anticoagulation and its reversal.

Faster and better quality survival of all trauma victims—including, but not limited to, the elderly—will free up needed and expensive resources for other patients and trauma victims, including those who continue to butt heads, drive two and four wheel vehicles at excessive speeds, and engage in trauma of an “interpersonal nature.” 

In this issue of Emergency Medicine (EM), emergency physician (EP) Christopher Hunter, MD, and his colleagues from Orlando Regional Medical Center (ORMC) share their first-person experiences planning for and dealing with the medical issues presented by an estimated 40,000 people attending an annual outdoor electronic dance music festival on each of 2 days in November 2016. Reacting to the overwhelming burden that had been placed on their ED and hospital by the same event the year before, the ORMC EPs demonstrate how a coordinated approach to planning and execution by EPs, the local emergency medical services system, festival organizers, and disaster response groups can accurately anticipate and effectively deal with the myriad of urgent and emergent needs presented by this type of event. In recent years, the number of such events throughout the country has been increasing rapidly.

This same group of skilled and dedicated ORMC EPs authored a first-person account in the August 2016 issue of EM (The Orlando Nightclub Shooting: Firsthand Accounts and Lessons Learned. Emerg Med. 2016;48(8):348-356), describing how they handled the aftermath of the Pulse Nightclub mass casualty incident (MCI), which also occurred in close proximity to ORMC.

Tragically, as this issue of EM was going to press, the world was shocked by yet another terrorist MCI, this time at a concert venue in Manchester, England. The lethal explosives were detonated in Manchester by a suicide bomber just outside the arena as the exiting crowd was heading to the nearby railroad station. This latest MCI claimed the lives of at least 22 children, parents, and young adults, and is of great concern to all who participate in concerts and large outdoor events: We must now consider the possibility of incidents combining the problems described in both of the first-person accounts mentioned above.

The most recent wave of terrorist MCIs, including the 2016 Orlando Pulse Nightclub shootings (49 deaths, 53 injuries, all but four victims were under the age of 40 years); the November 2015 terrorist incidents in Paris, including the Bataclan theatre rock concert massacre (89 deaths); and the April 15, 2013 Boston Marathon bombing (three deaths—ages 8, 23, 29 years—and 264 injuries), have all targeted mostly children and young adults.

In contrast, the victims of previous terrorist MCIs were mostly working adults. Of the almost 3,000 people who died in the 9/11 World Trade Center (WTC) and Pentagon attacks, almost all were between 35 and 39 years old, with the youngest WTC tower victim 18 years of age and the oldest 79. Terrorist activities in trains such as the March 11, 2004 Madrid commuter train bombings (192 deaths, about 2,000 injuries), and the March 20, 1995 Tokyo subway sarin gas release (12 deaths, over 1,000 severe injuries) also appeared to have targeted adults traveling to work during rush hours.

Clearly, EPs have an important role to play in providing urgent and emergent care at large outdoor gatherings, and emergent care and resuscitation of victims after natural and man-made MCIs. But the prospect of both types of events occurring in rapid succession at the same venue underlines the importance of preserving hospital-based ED resources during large gatherings by treating and releasing the majority of patients with festival-related illnesses and minor injuries on-site, as described in this month’s cover article.

The proliferation of EP-staffed urgent care centers and freestanding EDs (FSEDs) in recent years has demonstrated the ability of EPs to provide expert, needed emergency care outside of the walls of traditional, hospital-based EDs—a healthy trend for the future of emergency medicine. Like “pop-up” seasonal retail stores, the “pop-up FSED” described here by the ORMC EPs will become an increasingly important means of delivering urgent and emergent care in the future. 

In this issue of Emergency Medicine (EM), emergency physician (EP) Christopher Hunter, MD, and his colleagues from Orlando Regional Medical Center (ORMC) share their first-person experiences planning for and dealing with the medical issues presented by an estimated 40,000 people attending an annual outdoor electronic dance music festival on each of 2 days in November 2016. Reacting to the overwhelming burden that had been placed on their ED and hospital by the same event the year before, the ORMC EPs demonstrate how a coordinated approach to planning and execution by EPs, the local emergency medical services system, festival organizers, and disaster response groups can accurately anticipate and effectively deal with the myriad of urgent and emergent needs presented by this type of event. In recent years, the number of such events throughout the country has been increasing rapidly.

This same group of skilled and dedicated ORMC EPs authored a first-person account in the August 2016 issue of EM (The Orlando Nightclub Shooting: Firsthand Accounts and Lessons Learned. Emerg Med. 2016;48(8):348-356), describing how they handled the aftermath of the Pulse Nightclub mass casualty incident (MCI), which also occurred in close proximity to ORMC.

Tragically, as this issue of EM was going to press, the world was shocked by yet another terrorist MCI, this time at a concert venue in Manchester, England. The lethal explosives were detonated in Manchester by a suicide bomber just outside the arena as the exiting crowd was heading to the nearby railroad station. This latest MCI claimed the lives of at least 22 children, parents, and young adults, and is of great concern to all who participate in concerts and large outdoor events: We must now consider the possibility of incidents combining the problems described in both of the first-person accounts mentioned above.

The most recent wave of terrorist MCIs, including the 2016 Orlando Pulse Nightclub shootings (49 deaths, 53 injuries, all but four victims were under the age of 40 years); the November 2015 terrorist incidents in Paris, including the Bataclan theatre rock concert massacre (89 deaths); and the April 15, 2013 Boston Marathon bombing (three deaths—ages 8, 23, 29 years—and 264 injuries), have all targeted mostly children and young adults.

In contrast, the victims of previous terrorist MCIs were mostly working adults. Of the almost 3,000 people who died in the 9/11 World Trade Center (WTC) and Pentagon attacks, almost all were between 35 and 39 years old, with the youngest WTC tower victim 18 years of age and the oldest 79. Terrorist activities in trains such as the March 11, 2004 Madrid commuter train bombings (192 deaths, about 2,000 injuries), and the March 20, 1995 Tokyo subway sarin gas release (12 deaths, over 1,000 severe injuries) also appeared to have targeted adults traveling to work during rush hours.

Clearly, EPs have an important role to play in providing urgent and emergent care at large outdoor gatherings, and emergent care and resuscitation of victims after natural and man-made MCIs. But the prospect of both types of events occurring in rapid succession at the same venue underlines the importance of preserving hospital-based ED resources during large gatherings by treating and releasing the majority of patients with festival-related illnesses and minor injuries on-site, as described in this month’s cover article.

The proliferation of EP-staffed urgent care centers and freestanding EDs (FSEDs) in recent years has demonstrated the ability of EPs to provide expert, needed emergency care outside of the walls of traditional, hospital-based EDs—a healthy trend for the future of emergency medicine. Like “pop-up” seasonal retail stores, the “pop-up FSED” described here by the ORMC EPs will become an increasingly important means of delivering urgent and emergent care in the future. 

In this issue of Emergency Medicine (EM), emergency physician (EP) Christopher Hunter, MD, and his colleagues from Orlando Regional Medical Center (ORMC) share their first-person experiences planning for and dealing with the medical issues presented by an estimated 40,000 people attending an annual outdoor electronic dance music festival on each of 2 days in November 2016. Reacting to the overwhelming burden that had been placed on their ED and hospital by the same event the year before, the ORMC EPs demonstrate how a coordinated approach to planning and execution by EPs, the local emergency medical services system, festival organizers, and disaster response groups can accurately anticipate and effectively deal with the myriad of urgent and emergent needs presented by this type of event. In recent years, the number of such events throughout the country has been increasing rapidly.

This same group of skilled and dedicated ORMC EPs authored a first-person account in the August 2016 issue of EM (The Orlando Nightclub Shooting: Firsthand Accounts and Lessons Learned. Emerg Med. 2016;48(8):348-356), describing how they handled the aftermath of the Pulse Nightclub mass casualty incident (MCI), which also occurred in close proximity to ORMC.

Tragically, as this issue of EM was going to press, the world was shocked by yet another terrorist MCI, this time at a concert venue in Manchester, England. The lethal explosives were detonated in Manchester by a suicide bomber just outside the arena as the exiting crowd was heading to the nearby railroad station. This latest MCI claimed the lives of at least 22 children, parents, and young adults, and is of great concern to all who participate in concerts and large outdoor events: We must now consider the possibility of incidents combining the problems described in both of the first-person accounts mentioned above.

The most recent wave of terrorist MCIs, including the 2016 Orlando Pulse Nightclub shootings (49 deaths, 53 injuries, all but four victims were under the age of 40 years); the November 2015 terrorist incidents in Paris, including the Bataclan theatre rock concert massacre (89 deaths); and the April 15, 2013 Boston Marathon bombing (three deaths—ages 8, 23, 29 years—and 264 injuries), have all targeted mostly children and young adults.

In contrast, the victims of previous terrorist MCIs were mostly working adults. Of the almost 3,000 people who died in the 9/11 World Trade Center (WTC) and Pentagon attacks, almost all were between 35 and 39 years old, with the youngest WTC tower victim 18 years of age and the oldest 79. Terrorist activities in trains such as the March 11, 2004 Madrid commuter train bombings (192 deaths, about 2,000 injuries), and the March 20, 1995 Tokyo subway sarin gas release (12 deaths, over 1,000 severe injuries) also appeared to have targeted adults traveling to work during rush hours.

Clearly, EPs have an important role to play in providing urgent and emergent care at large outdoor gatherings, and emergent care and resuscitation of victims after natural and man-made MCIs. But the prospect of both types of events occurring in rapid succession at the same venue underlines the importance of preserving hospital-based ED resources during large gatherings by treating and releasing the majority of patients with festival-related illnesses and minor injuries on-site, as described in this month’s cover article.

The proliferation of EP-staffed urgent care centers and freestanding EDs (FSEDs) in recent years has demonstrated the ability of EPs to provide expert, needed emergency care outside of the walls of traditional, hospital-based EDs—a healthy trend for the future of emergency medicine. Like “pop-up” seasonal retail stores, the “pop-up FSED” described here by the ORMC EPs will become an increasingly important means of delivering urgent and emergent care in the future. 

Emergency physicians (EPs) are trained to recognize and treat conditions that most severely affect patients at the extremes of age. For decades, the recognition and management of child neglect and abuse has been part of emergency medicine (EM) residency training and most states now require physicians to complete a child abuse course for licensing. In this issue, “Recognizing and Managing Elder Abuse in the Emergency Department” by Rosen et al describes abuse at the other age extreme. The thorough discussion following an illustrative case presentation raises serious concerns that the occurrence of elder neglect and abuse may be increasing in frequency in a rapidly aging population.

Child abuse and elder abuse share several common features along with some notable differences. When a member of either age group presents to the ED with fractures and/or soft tissue injuries, EPs must maintain a high index of suspicion for abuse, obtain a carefully directed history, and be able to recognize the characteristic patterns of injury. Hallmarks of both child abuse and elder abuse include a history provided by the caregiver that is not consistent with the actual injuries; an often-unobtainable independent history from an infant or baby not yet able to speak or an older adult with dementia; and a physical exam revealing bruises in areas that are not over bony prominences. A radiographic skeletal survey may show multiple fractures in various stages of healing, and laboratory testing may reveal nutritional evidence of neglect, medication over- or underdosing, or the presence of medications that have not been prescribed for the patient.

Patterns of abuse injuries in the two age groups differ. As noted by Colbourne and Clarke in Tintinalli’s Emergency Medicine (8^th ed, p. 1001), nonaccidental bruises in children are more common on the torso, neck, ears, cheeks, buttocks, and back; appear in clusters; are frequently symmetrical; and tend to be larger and more numerous than accidental injuries. Hand or implement patterns on the skin may be observed. Rib and metaphyseal fractures are unusual in children, as are all fractures at a very young age.

In the midst of an epidemic of elderly fall injuries, abuse injuries, as described in the pages ahead, most commonly occur on the head, neck, and upper extremities, and include large bruises on the face, lateral arm, or posterior torso. Based on preliminary results from an ongoing study, left periorbital, neck, and ulnar forearm injuries appear to be particularly indicative of abuse rather than accidental. An elderly person may be abused by an adult-child or relative living in the same household attempting to gain control over the victim’s wealth or residence.

Interventional resources required for both types of abuse, as well as for intimate partner abuse, are also similar and include safe facilities for extended treatment and separation from a suspected abuser; hospital security, legal, and administrative support; social services; law enforcement; psychiatric evaluation of adult capacity; and child or adult protective services, which, as Rosen et al note, operate very differently from one another. All states, except one, now require reporting of both child abuse and elder abuse.*

None of these comparisons of child abuse and elder abuse are meant to suggest equivalency—moral or otherwise. Children are not “little adults,” and the frail elderly are not truly “child-like.” Each incident of a child “slipping through the cracks” of the protective measures currently in place underscores the need for sufficient resources to deal with child abuse alone, and an increasing number of elder abuse cases should not compete with these needs. But implementing greater awareness, preventive measures, and physical and human resources to address these problems at both extremes of age cannot be put off for the future. 

When I started the first geriatric emergency medicine fellowship in the country in 2005, elder abuse was not even on my radar screen. Now it must be considered a serious and growing problem by all. 

*New York State alone does not require reporting of elder abuse.

Emergency physicians (EPs) are trained to recognize and treat conditions that most severely affect patients at the extremes of age. For decades, the recognition and management of child neglect and abuse has been part of emergency medicine (EM) residency training and most states now require physicians to complete a child abuse course for licensing. In this issue, “Recognizing and Managing Elder Abuse in the Emergency Department” by Rosen et al describes abuse at the other age extreme. The thorough discussion following an illustrative case presentation raises serious concerns that the occurrence of elder neglect and abuse may be increasing in frequency in a rapidly aging population.

Child abuse and elder abuse share several common features along with some notable differences. When a member of either age group presents to the ED with fractures and/or soft tissue injuries, EPs must maintain a high index of suspicion for abuse, obtain a carefully directed history, and be able to recognize the characteristic patterns of injury. Hallmarks of both child abuse and elder abuse include a history provided by the caregiver that is not consistent with the actual injuries; an often-unobtainable independent history from an infant or baby not yet able to speak or an older adult with dementia; and a physical exam revealing bruises in areas that are not over bony prominences. A radiographic skeletal survey may show multiple fractures in various stages of healing, and laboratory testing may reveal nutritional evidence of neglect, medication over- or underdosing, or the presence of medications that have not been prescribed for the patient.

Patterns of abuse injuries in the two age groups differ. As noted by Colbourne and Clarke in Tintinalli’s Emergency Medicine (8^th ed, p. 1001), nonaccidental bruises in children are more common on the torso, neck, ears, cheeks, buttocks, and back; appear in clusters; are frequently symmetrical; and tend to be larger and more numerous than accidental injuries. Hand or implement patterns on the skin may be observed. Rib and metaphyseal fractures are unusual in children, as are all fractures at a very young age.

In the midst of an epidemic of elderly fall injuries, abuse injuries, as described in the pages ahead, most commonly occur on the head, neck, and upper extremities, and include large bruises on the face, lateral arm, or posterior torso. Based on preliminary results from an ongoing study, left periorbital, neck, and ulnar forearm injuries appear to be particularly indicative of abuse rather than accidental. An elderly person may be abused by an adult-child or relative living in the same household attempting to gain control over the victim’s wealth or residence.

Interventional resources required for both types of abuse, as well as for intimate partner abuse, are also similar and include safe facilities for extended treatment and separation from a suspected abuser; hospital security, legal, and administrative support; social services; law enforcement; psychiatric evaluation of adult capacity; and child or adult protective services, which, as Rosen et al note, operate very differently from one another. All states, except one, now require reporting of both child abuse and elder abuse.*

None of these comparisons of child abuse and elder abuse are meant to suggest equivalency—moral or otherwise. Children are not “little adults,” and the frail elderly are not truly “child-like.” Each incident of a child “slipping through the cracks” of the protective measures currently in place underscores the need for sufficient resources to deal with child abuse alone, and an increasing number of elder abuse cases should not compete with these needs. But implementing greater awareness, preventive measures, and physical and human resources to address these problems at both extremes of age cannot be put off for the future. 

When I started the first geriatric emergency medicine fellowship in the country in 2005, elder abuse was not even on my radar screen. Now it must be considered a serious and growing problem by all. 

*New York State alone does not require reporting of elder abuse.

Emergency physicians (EPs) are trained to recognize and treat conditions that most severely affect patients at the extremes of age. For decades, the recognition and management of child neglect and abuse has been part of emergency medicine (EM) residency training and most states now require physicians to complete a child abuse course for licensing. In this issue, “Recognizing and Managing Elder Abuse in the Emergency Department” by Rosen et al describes abuse at the other age extreme. The thorough discussion following an illustrative case presentation raises serious concerns that the occurrence of elder neglect and abuse may be increasing in frequency in a rapidly aging population.

Child abuse and elder abuse share several common features along with some notable differences. When a member of either age group presents to the ED with fractures and/or soft tissue injuries, EPs must maintain a high index of suspicion for abuse, obtain a carefully directed history, and be able to recognize the characteristic patterns of injury. Hallmarks of both child abuse and elder abuse include a history provided by the caregiver that is not consistent with the actual injuries; an often-unobtainable independent history from an infant or baby not yet able to speak or an older adult with dementia; and a physical exam revealing bruises in areas that are not over bony prominences. A radiographic skeletal survey may show multiple fractures in various stages of healing, and laboratory testing may reveal nutritional evidence of neglect, medication over- or underdosing, or the presence of medications that have not been prescribed for the patient.

Patterns of abuse injuries in the two age groups differ. As noted by Colbourne and Clarke in Tintinalli’s Emergency Medicine (8^th ed, p. 1001), nonaccidental bruises in children are more common on the torso, neck, ears, cheeks, buttocks, and back; appear in clusters; are frequently symmetrical; and tend to be larger and more numerous than accidental injuries. Hand or implement patterns on the skin may be observed. Rib and metaphyseal fractures are unusual in children, as are all fractures at a very young age.

In the midst of an epidemic of elderly fall injuries, abuse injuries, as described in the pages ahead, most commonly occur on the head, neck, and upper extremities, and include large bruises on the face, lateral arm, or posterior torso. Based on preliminary results from an ongoing study, left periorbital, neck, and ulnar forearm injuries appear to be particularly indicative of abuse rather than accidental. An elderly person may be abused by an adult-child or relative living in the same household attempting to gain control over the victim’s wealth or residence.

Interventional resources required for both types of abuse, as well as for intimate partner abuse, are also similar and include safe facilities for extended treatment and separation from a suspected abuser; hospital security, legal, and administrative support; social services; law enforcement; psychiatric evaluation of adult capacity; and child or adult protective services, which, as Rosen et al note, operate very differently from one another. All states, except one, now require reporting of both child abuse and elder abuse.*

None of these comparisons of child abuse and elder abuse are meant to suggest equivalency—moral or otherwise. Children are not “little adults,” and the frail elderly are not truly “child-like.” Each incident of a child “slipping through the cracks” of the protective measures currently in place underscores the need for sufficient resources to deal with child abuse alone, and an increasing number of elder abuse cases should not compete with these needs. But implementing greater awareness, preventive measures, and physical and human resources to address these problems at both extremes of age cannot be put off for the future. 

When I started the first geriatric emergency medicine fellowship in the country in 2005, elder abuse was not even on my radar screen. Now it must be considered a serious and growing problem by all. 

*New York State alone does not require reporting of elder abuse.

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 monitor and supplement the care of admitted patients waiting in the ED. This arrangement provided an additional level of patient safety with no additional expense to the hospital. But flexible measures to provide patient comfort and ensure safety cannot solve the inflexible space issue, and instituting harsher regulations and core measures will only increase the pressures on ED staffs. What is required is a serious look at the national model for accruing ED costs, revenues, and third-party reimbursements, and then adjusting the formulas to address the current patient care realities before a “fasciotomy” is required. 

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 monitor and supplement the care of admitted patients waiting in the ED. This arrangement provided an additional level of patient safety with no additional expense to the hospital. But flexible measures to provide patient comfort and ensure safety cannot solve the inflexible space issue, and instituting harsher regulations and core measures will only increase the pressures on ED staffs. What is required is a serious look at the national model for accruing ED costs, revenues, and third-party reimbursements, and then adjusting the formulas to address the current patient care realities before a “fasciotomy” is required. 

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 monitor and supplement the care of admitted patients waiting in the ED. This arrangement provided an additional level of patient safety with no additional expense to the hospital. But flexible measures to provide patient comfort and ensure safety cannot solve the inflexible space issue, and instituting harsher regulations and core measures will only increase the pressures on ED staffs. What is required is a serious look at the national model for accruing ED costs, revenues, and third-party reimbursements, and then adjusting the formulas to address the current patient care realities before a “fasciotomy” is required. 

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 (http://bit.ly/2jEOHfs). We know now that prescription opioids have been driving this 15-year increase. Since 1999, both the amount of opioids prescribed and the number of opioid deaths in the US have quadrupled. Ironically, during that same period, the amount of pain reported has not changed overall (http://bit.ly/2jEOHfs). In 2015 alone, opioids were involved with 33,091 deaths, of which more than 15,000 were due to prescription opioid overdoses—most commonly methadone, oxycodone, and hydrocodone (http://bit.ly/2jZ1TfO and http://bit.ly/2iwagAI). Adding to the misery has been a sharp increase in deaths due to heroin since 2010, and a similar increase in deaths due to fentanyl, tramadol, and other synthetics since 2013. Currently, more than 1,000 people are treated in EDs each day for misusing prescription opioids (http://bit.ly/2iwagAI).

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 (http://bit.ly/2jEOHfs). We know now that prescription opioids have been driving this 15-year increase. Since 1999, both the amount of opioids prescribed and the number of opioid deaths in the US have quadrupled. Ironically, during that same period, the amount of pain reported has not changed overall (http://bit.ly/2jEOHfs). In 2015 alone, opioids were involved with 33,091 deaths, of which more than 15,000 were due to prescription opioid overdoses—most commonly methadone, oxycodone, and hydrocodone (http://bit.ly/2jZ1TfO and http://bit.ly/2iwagAI). Adding to the misery has been a sharp increase in deaths due to heroin since 2010, and a similar increase in deaths due to fentanyl, tramadol, and other synthetics since 2013. Currently, more than 1,000 people are treated in EDs each day for misusing prescription opioids (http://bit.ly/2iwagAI).

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 (http://bit.ly/2jEOHfs). We know now that prescription opioids have been driving this 15-year increase. Since 1999, both the amount of opioids prescribed and the number of opioid deaths in the US have quadrupled. Ironically, during that same period, the amount of pain reported has not changed overall (http://bit.ly/2jEOHfs). In 2015 alone, opioids were involved with 33,091 deaths, of which more than 15,000 were due to prescription opioid overdoses—most commonly methadone, oxycodone, and hydrocodone (http://bit.ly/2jZ1TfO and http://bit.ly/2iwagAI). Adding to the misery has been a sharp increase in deaths due to heroin since 2010, and a similar increase in deaths due to fentanyl, tramadol, and other synthetics since 2013. Currently, more than 1,000 people are treated in EDs each day for misusing prescription opioids (http://bit.ly/2iwagAI).

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.