Neal Flomenbaum, MD, Editor

According to a February 18, 2016 CDC report (http://www.cdc.gov/nchs/data/nhsr/nhsr090.pdf) that utilized data from the 2013 and 2014 National Health Statistics Reports, “approximately 20% of US adults [ages 18–64 years] seek care at the emergency room (ER) each year, a percentage that has remained largely unchanged in the last decade.” The report also found “few changes in ER use…between 2013 and 2014.” The January 2014 Emergency Medicine editorial predicted both of these findings, as well as the reasons adults seek care in our EDs.

One of the stated goals of the Affordable Care Act (ACA) signed into law by President Obama in March 2010 was to decrease ED visits by providing more access to primary care. We predicted at the time that ED visits would instead increase, as “Demographic data for the past decade indicate[d] that many more people [were] now choosing EDs for their care…including significant numbers with the means or insurance coverage to obtain at least some of that care elsewhere” (Emerg Med. 2010;42[4]:5). We further noted that “this [could] only be the result of two considerations operating in concert: faith in the quality of emergency department care and convenience or need to obtain that care when other providers are not available. With millions more Americans now gaining access to care that was previously unavailable to them, the desire or need for timely care may further increase the numbers of people choosing EDs for their care.”

Though still too early to determine how successful ACA will be in achieving all of its goals, a study of a pre-ACA limited expansion of Medicaid coverage in Oregon, published in Science on January 2, 2014 (http://www.sciencemag.org/content/early/2014/01/02/science.1246183) found that a study group among the approximately 30,000 low-income people randomly selected by lottery to receive Medicaid in Oregon in 2008 made 40% more ED visits during the first 18 months, compared to a similar group among the 60,000 who entered the lottery but remained uninsured. As the New York Times noted, “the pattern was so strong it held true across most demographic groups, times of day and types of visits, including those for conditions that were treatable in primary care settings” (http://www.nytimes.com/2014/01/03/health/access-to-health-care-may-increase-er-visits-study-suggests.html).

Should EPs celebrate this latest affirmation of the strength and continuing growth of emergency medicine (EM)  as a health care provider of choice? Yes, and no.

Every new health care plan since managed care was first aggressively promoted in the 1980s has failed in its promise to decrease ED visits; compounding these miscalculations, none of the plans included adequate provisions to pay for the increased ED visits they failed to predict.

If ACA does result in long-term increases in ED visits, neither the current economic model for delivering emergency care nor the financial viability of EDs may be sustainable. Further exacerbations of ED overcrowding by Medicaid and/or inadequately insured patients may incentivize patients with the best insurance to seek alternative forms of care initially, though many will subsequently be referred to EDs nevertheless. It is almost certainly no coincidence that urgent care centers are suddenly springing up in the best neighborhoods of many cities; freed of federal requirements of EDs to screen and stabilize all regardless of their ability to pay, urgent care centers can be selective in who they treat.

Why have so many health care plans miscalculated the continuing and expanding role of EM? All have failed to recognize that modern emergency care is unique, valuable, and cannot be replaced by other types of primary care. Primary care providers increasingly send patients to EDs to complete their diagnostic evaluations and to treat, observe, or admit them to inpatient services when indicated. Additionally, few other providers—including many urgent care centers—are available 24/7.

According to a February 18, 2016 CDC report (http://www.cdc.gov/nchs/data/nhsr/nhsr090.pdf) that utilized data from the 2013 and 2014 National Health Statistics Reports, “approximately 20% of US adults [ages 18–64 years] seek care at the emergency room (ER) each year, a percentage that has remained largely unchanged in the last decade.” The report also found “few changes in ER use…between 2013 and 2014.” The January 2014 Emergency Medicine editorial predicted both of these findings, as well as the reasons adults seek care in our EDs.

One of the stated goals of the Affordable Care Act (ACA) signed into law by President Obama in March 2010 was to decrease ED visits by providing more access to primary care. We predicted at the time that ED visits would instead increase, as “Demographic data for the past decade indicate[d] that many more people [were] now choosing EDs for their care…including significant numbers with the means or insurance coverage to obtain at least some of that care elsewhere” (Emerg Med. 2010;42[4]:5). We further noted that “this [could] only be the result of two considerations operating in concert: faith in the quality of emergency department care and convenience or need to obtain that care when other providers are not available. With millions more Americans now gaining access to care that was previously unavailable to them, the desire or need for timely care may further increase the numbers of people choosing EDs for their care.”

Though still too early to determine how successful ACA will be in achieving all of its goals, a study of a pre-ACA limited expansion of Medicaid coverage in Oregon, published in Science on January 2, 2014 (http://www.sciencemag.org/content/early/2014/01/02/science.1246183) found that a study group among the approximately 30,000 low-income people randomly selected by lottery to receive Medicaid in Oregon in 2008 made 40% more ED visits during the first 18 months, compared to a similar group among the 60,000 who entered the lottery but remained uninsured. As the New York Times noted, “the pattern was so strong it held true across most demographic groups, times of day and types of visits, including those for conditions that were treatable in primary care settings” (http://www.nytimes.com/2014/01/03/health/access-to-health-care-may-increase-er-visits-study-suggests.html).

Should EPs celebrate this latest affirmation of the strength and continuing growth of emergency medicine (EM)  as a health care provider of choice? Yes, and no.

Every new health care plan since managed care was first aggressively promoted in the 1980s has failed in its promise to decrease ED visits; compounding these miscalculations, none of the plans included adequate provisions to pay for the increased ED visits they failed to predict.

If ACA does result in long-term increases in ED visits, neither the current economic model for delivering emergency care nor the financial viability of EDs may be sustainable. Further exacerbations of ED overcrowding by Medicaid and/or inadequately insured patients may incentivize patients with the best insurance to seek alternative forms of care initially, though many will subsequently be referred to EDs nevertheless. It is almost certainly no coincidence that urgent care centers are suddenly springing up in the best neighborhoods of many cities; freed of federal requirements of EDs to screen and stabilize all regardless of their ability to pay, urgent care centers can be selective in who they treat.

Why have so many health care plans miscalculated the continuing and expanding role of EM? All have failed to recognize that modern emergency care is unique, valuable, and cannot be replaced by other types of primary care. Primary care providers increasingly send patients to EDs to complete their diagnostic evaluations and to treat, observe, or admit them to inpatient services when indicated. Additionally, few other providers—including many urgent care centers—are available 24/7.

According to a February 18, 2016 CDC report (http://www.cdc.gov/nchs/data/nhsr/nhsr090.pdf) that utilized data from the 2013 and 2014 National Health Statistics Reports, “approximately 20% of US adults [ages 18–64 years] seek care at the emergency room (ER) each year, a percentage that has remained largely unchanged in the last decade.” The report also found “few changes in ER use…between 2013 and 2014.” The January 2014 Emergency Medicine editorial predicted both of these findings, as well as the reasons adults seek care in our EDs.

One of the stated goals of the Affordable Care Act (ACA) signed into law by President Obama in March 2010 was to decrease ED visits by providing more access to primary care. We predicted at the time that ED visits would instead increase, as “Demographic data for the past decade indicate[d] that many more people [were] now choosing EDs for their care…including significant numbers with the means or insurance coverage to obtain at least some of that care elsewhere” (Emerg Med. 2010;42[4]:5). We further noted that “this [could] only be the result of two considerations operating in concert: faith in the quality of emergency department care and convenience or need to obtain that care when other providers are not available. With millions more Americans now gaining access to care that was previously unavailable to them, the desire or need for timely care may further increase the numbers of people choosing EDs for their care.”

Though still too early to determine how successful ACA will be in achieving all of its goals, a study of a pre-ACA limited expansion of Medicaid coverage in Oregon, published in Science on January 2, 2014 (http://www.sciencemag.org/content/early/2014/01/02/science.1246183) found that a study group among the approximately 30,000 low-income people randomly selected by lottery to receive Medicaid in Oregon in 2008 made 40% more ED visits during the first 18 months, compared to a similar group among the 60,000 who entered the lottery but remained uninsured. As the New York Times noted, “the pattern was so strong it held true across most demographic groups, times of day and types of visits, including those for conditions that were treatable in primary care settings” (http://www.nytimes.com/2014/01/03/health/access-to-health-care-may-increase-er-visits-study-suggests.html).

Should EPs celebrate this latest affirmation of the strength and continuing growth of emergency medicine (EM)  as a health care provider of choice? Yes, and no.

Every new health care plan since managed care was first aggressively promoted in the 1980s has failed in its promise to decrease ED visits; compounding these miscalculations, none of the plans included adequate provisions to pay for the increased ED visits they failed to predict.

If ACA does result in long-term increases in ED visits, neither the current economic model for delivering emergency care nor the financial viability of EDs may be sustainable. Further exacerbations of ED overcrowding by Medicaid and/or inadequately insured patients may incentivize patients with the best insurance to seek alternative forms of care initially, though many will subsequently be referred to EDs nevertheless. It is almost certainly no coincidence that urgent care centers are suddenly springing up in the best neighborhoods of many cities; freed of federal requirements of EDs to screen and stabilize all regardless of their ability to pay, urgent care centers can be selective in who they treat.

Why have so many health care plans miscalculated the continuing and expanding role of EM? All have failed to recognize that modern emergency care is unique, valuable, and cannot be replaced by other types of primary care. Primary care providers increasingly send patients to EDs to complete their diagnostic evaluations and to treat, observe, or admit them to inpatient services when indicated. Additionally, few other providers—including many urgent care centers—are available 24/7.

A February 16, 2016 study in JAMA on in-hospital outcomes and costs among patients hospitalized during a return visit to the ED by Sabbatini et al (2016;315[7]:663-671) provides compelling evidence that the number of unscheduled return visits to an ED within 30 days should not be considered a quality measure of ED care. Though the findings of this important study should provide reassurance that emergency physicians (EPs) and EDs provide quality care, the way the paper’s conclusion was framed makes one wonder whether we EPs tend to judge ourselves too harshly.

Sabbatini et al analyzed Healthcare Cost and Utilization Project data on 9,036,483 patients ages 18 years or older who visited 424 hospital EDs in Florida and New York from February through November 2013, and found that of the 7,278,124 patients who were initially discharged, 1,205,865 returned to the ED within 30 days. Of the returning patients, the 86,012 who were admitted to the hospital within 7 days of the initial visit had significantly lower rates of in-hospital mortality, ICU admissions, and mean costs of hospitalization, but slightly higher inpatient lengths of stay, compared with the 1,609,145 patients who had been admitted on their initial ED visits. Similar outcomes were observed for patients who returned to the ED and were admitted within 14 and 30 days of their initial ED visits. In contrast, patients readmitted upon return to the ED after hospital discharge had higher rates of inpatient mortality and ICU admissions, longer lengths of stay, and higher costs during their repeat hospitalizations compared with the hospitalizations of patients admitted during their initial ED visit with no return ED visits after discharge.

To James Adams, MD, in an editorial accompanying the study (JAMA. 2016;315[7]:659-660), these numbers suggest that neither misdiagnosis nor inadequate treatment on an initial ED visit appear to be the primary causes of return visits to EDs that result in admissions and do not indicate a failure of ED care. However, the authors of the paper—mostly EPs—framed their conclusion somewhat differently, writing “these findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit,” implying, perhaps, that there are ED quality-of-care deficits but that the number of return ED visits followed by admissions does not capture them. An alternatively worded, accurate conclusion about the findings might be “hospitalizations associated with return visits to an ED do not appear to indicate a quality-of-care deficit.”

An unfortunate choice of words or an overly critical view of EP performance? In this issue of Emergency Medicine, there are other examples suggesting that EPs’ perception of their performance—and perhaps by extension, satisfaction with their roles—may be problematic.

In “Allegations: Current Trends in Medical Malpractice, Part 2” (pages 158-162), McCammon and Jennings note that EP’s perception of their malpractice risk ranks higher than that of other physicians’ perception of their risks, despite the findings of a 1991-2005 review of malpractice claims ranking EM in the middle of all specialties with respect to annual risk of claims. “What’s Hot and What’s Not in Our National Organizations: an Emergency Medicine Panel” reports on the most important issues facing emergency medicine (pages 163-166). ACEP President Jay Kaplan, MD, begins by noting that “EM leads all specialties in the frequency of physician burnout.”

Why the pessimism, the unfounded concerns over malpractice risk, the acceptance of possible deficits in the quality of emergency care we provide that may or may not actually exist? After years of listening to unsubstantiated concerns about malpractice suits and quality issues from administrators and regulators, along with dire warnings about EM burnout from other specialists, are we actually beginning to believe them? Doing so would only perpetuate these myths and possibly even discourage the type of high-quality study demonstrated by the efforts of Sabbatini et al. Emergency physicians fulfill an increasingly important central role in health care and have much to be proud of, so let’s insist on evidence-based findings and not accept half-truths or less from anyone. As an essential specialty practiced by highly valued specialists, we deserve better!

A February 16, 2016 study in JAMA on in-hospital outcomes and costs among patients hospitalized during a return visit to the ED by Sabbatini et al (2016;315[7]:663-671) provides compelling evidence that the number of unscheduled return visits to an ED within 30 days should not be considered a quality measure of ED care. Though the findings of this important study should provide reassurance that emergency physicians (EPs) and EDs provide quality care, the way the paper’s conclusion was framed makes one wonder whether we EPs tend to judge ourselves too harshly.

Sabbatini et al analyzed Healthcare Cost and Utilization Project data on 9,036,483 patients ages 18 years or older who visited 424 hospital EDs in Florida and New York from February through November 2013, and found that of the 7,278,124 patients who were initially discharged, 1,205,865 returned to the ED within 30 days. Of the returning patients, the 86,012 who were admitted to the hospital within 7 days of the initial visit had significantly lower rates of in-hospital mortality, ICU admissions, and mean costs of hospitalization, but slightly higher inpatient lengths of stay, compared with the 1,609,145 patients who had been admitted on their initial ED visits. Similar outcomes were observed for patients who returned to the ED and were admitted within 14 and 30 days of their initial ED visits. In contrast, patients readmitted upon return to the ED after hospital discharge had higher rates of inpatient mortality and ICU admissions, longer lengths of stay, and higher costs during their repeat hospitalizations compared with the hospitalizations of patients admitted during their initial ED visit with no return ED visits after discharge.

To James Adams, MD, in an editorial accompanying the study (JAMA. 2016;315[7]:659-660), these numbers suggest that neither misdiagnosis nor inadequate treatment on an initial ED visit appear to be the primary causes of return visits to EDs that result in admissions and do not indicate a failure of ED care. However, the authors of the paper—mostly EPs—framed their conclusion somewhat differently, writing “these findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit,” implying, perhaps, that there are ED quality-of-care deficits but that the number of return ED visits followed by admissions does not capture them. An alternatively worded, accurate conclusion about the findings might be “hospitalizations associated with return visits to an ED do not appear to indicate a quality-of-care deficit.”

An unfortunate choice of words or an overly critical view of EP performance? In this issue of Emergency Medicine, there are other examples suggesting that EPs’ perception of their performance—and perhaps by extension, satisfaction with their roles—may be problematic.

In “Allegations: Current Trends in Medical Malpractice, Part 2” (pages 158-162), McCammon and Jennings note that EP’s perception of their malpractice risk ranks higher than that of other physicians’ perception of their risks, despite the findings of a 1991-2005 review of malpractice claims ranking EM in the middle of all specialties with respect to annual risk of claims. “What’s Hot and What’s Not in Our National Organizations: an Emergency Medicine Panel” reports on the most important issues facing emergency medicine (pages 163-166). ACEP President Jay Kaplan, MD, begins by noting that “EM leads all specialties in the frequency of physician burnout.”

Why the pessimism, the unfounded concerns over malpractice risk, the acceptance of possible deficits in the quality of emergency care we provide that may or may not actually exist? After years of listening to unsubstantiated concerns about malpractice suits and quality issues from administrators and regulators, along with dire warnings about EM burnout from other specialists, are we actually beginning to believe them? Doing so would only perpetuate these myths and possibly even discourage the type of high-quality study demonstrated by the efforts of Sabbatini et al. Emergency physicians fulfill an increasingly important central role in health care and have much to be proud of, so let’s insist on evidence-based findings and not accept half-truths or less from anyone. As an essential specialty practiced by highly valued specialists, we deserve better!

A February 16, 2016 study in JAMA on in-hospital outcomes and costs among patients hospitalized during a return visit to the ED by Sabbatini et al (2016;315[7]:663-671) provides compelling evidence that the number of unscheduled return visits to an ED within 30 days should not be considered a quality measure of ED care. Though the findings of this important study should provide reassurance that emergency physicians (EPs) and EDs provide quality care, the way the paper’s conclusion was framed makes one wonder whether we EPs tend to judge ourselves too harshly.

Sabbatini et al analyzed Healthcare Cost and Utilization Project data on 9,036,483 patients ages 18 years or older who visited 424 hospital EDs in Florida and New York from February through November 2013, and found that of the 7,278,124 patients who were initially discharged, 1,205,865 returned to the ED within 30 days. Of the returning patients, the 86,012 who were admitted to the hospital within 7 days of the initial visit had significantly lower rates of in-hospital mortality, ICU admissions, and mean costs of hospitalization, but slightly higher inpatient lengths of stay, compared with the 1,609,145 patients who had been admitted on their initial ED visits. Similar outcomes were observed for patients who returned to the ED and were admitted within 14 and 30 days of their initial ED visits. In contrast, patients readmitted upon return to the ED after hospital discharge had higher rates of inpatient mortality and ICU admissions, longer lengths of stay, and higher costs during their repeat hospitalizations compared with the hospitalizations of patients admitted during their initial ED visit with no return ED visits after discharge.

To James Adams, MD, in an editorial accompanying the study (JAMA. 2016;315[7]:659-660), these numbers suggest that neither misdiagnosis nor inadequate treatment on an initial ED visit appear to be the primary causes of return visits to EDs that result in admissions and do not indicate a failure of ED care. However, the authors of the paper—mostly EPs—framed their conclusion somewhat differently, writing “these findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit,” implying, perhaps, that there are ED quality-of-care deficits but that the number of return ED visits followed by admissions does not capture them. An alternatively worded, accurate conclusion about the findings might be “hospitalizations associated with return visits to an ED do not appear to indicate a quality-of-care deficit.”

An unfortunate choice of words or an overly critical view of EP performance? In this issue of Emergency Medicine, there are other examples suggesting that EPs’ perception of their performance—and perhaps by extension, satisfaction with their roles—may be problematic.

In “Allegations: Current Trends in Medical Malpractice, Part 2” (pages 158-162), McCammon and Jennings note that EP’s perception of their malpractice risk ranks higher than that of other physicians’ perception of their risks, despite the findings of a 1991-2005 review of malpractice claims ranking EM in the middle of all specialties with respect to annual risk of claims. “What’s Hot and What’s Not in Our National Organizations: an Emergency Medicine Panel” reports on the most important issues facing emergency medicine (pages 163-166). ACEP President Jay Kaplan, MD, begins by noting that “EM leads all specialties in the frequency of physician burnout.”

Why the pessimism, the unfounded concerns over malpractice risk, the acceptance of possible deficits in the quality of emergency care we provide that may or may not actually exist? After years of listening to unsubstantiated concerns about malpractice suits and quality issues from administrators and regulators, along with dire warnings about EM burnout from other specialists, are we actually beginning to believe them? Doing so would only perpetuate these myths and possibly even discourage the type of high-quality study demonstrated by the efforts of Sabbatini et al. Emergency physicians fulfill an increasingly important central role in health care and have much to be proud of, so let’s insist on evidence-based findings and not accept half-truths or less from anyone. As an essential specialty practiced by highly valued specialists, we deserve better!

In the October 2006 editorial, “A Design for the 21st Century,” I suggested that the first consideration in designing a new ED should be how long it is likely to remain in service before being replaced or substantially renovated, and then to consider which conditions are most likely to continue to present or increase in importance during the first several decades of the 21^st century (Emerg Med. 2006;37[10]:7). I envisioned “increasing patient volume, an aging population, new and emerging viral infections, an even higher incidence of bacterial resistance, and more immunocompromised patients resulting from organ transplants and greater use of chemotherapy.” A decade after these predictions were made, how are they holding up?

Since 2006, there have been over 40 epidemics worldwide and although most have not affected this country, easy travel and global emergency medicine missions have brought several distant viral illnesses to US EDs as well. In 2009, EDs throughout the country had to deal with a potentially disastrous epidemic of H1N1 influenza, and in the years since we have been challenged by MERS (2012), dengue fever (2013-), Ebola (2014), and now Zika and chikungunya—not to mention outbreaks of “older” bacterial and viral illnesses such as pertussis (2012), and measles (2014-2015). Though several of the newer viruses mentioned are mosquito borne, pathogens transmitted from human to human, or human to surface to human, along with the increasing incidence of antibiotic resistance (MRSA, Clostridium difficile, Carbapenem-resistant Enterobacteriaceae, etc) make the need for greater numbers of ED negative-pressure rooms undeniable.

One important design feature not specifically considered in 2006, but made apparent by the Ebola experience in 2014, is a need for the shortest possible route between the ambulance and non-ambulance ED entry points/triage and isolation facilities. As noted in 2006, a separate entrance and air handling for a designated infection-control unit in the ED is essential if it must be sealed off from the rest of the hospital and/or main ED.

The second major ED design issue considered in 2006 was the increasing numbers of elderly patients who will present to our EDs during the first half of this century. Isolation rooms and private rooms in the ED will help manage the rapidly rising number of elderly patients with contagious diseases, along with other conditions such as dementia and delirium. Significant needs of the elderly also include measures to prevent or mitigate falls, catheter-related UTIs, and bedsores.

One epidemic in the elderly that we are already facing is a significant increase in the number of trauma cases. In some Level I trauma centers, over 34% of trauma activations are for patients 55 years old and older. The 2003-2012 Oregon Trauma Registry Report containing data on 84,099 patients from 44 trauma hospitals, notes that the rate of trauma increased from 200.7 to 244.6 per 100,000 during that period, almost exclusively occurring in patients 55 years old or older who represented 21% of cases in 2003 and 34% by 2012—a rise largely attributed to a 159% increase in trauma due to falls (http://public.health.oregon.gov/providerpartnerresources/emstraumasystems/traumasystems/documents/reports/otr-report.pdf). In another study, Hsia et al reported that 27% of 430,081 patients admitted to California acute care hospitals for trauma-related diagnoses between January 1, 1999 and December 31, 2008  were older than 65 years (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3121677/), and in Houston, Texas, 13% of 15,223 trauma patients admitted to one of its two level I trauma centers between January 2005 and December 2008 were 65 years old or older, according to Adams et al (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3836632/). The Adams paper noted that trauma centers were originally designed to care for seriously ill patients without age-specific guidelines, but in patients 65 years or older there was a negligible amount of penetrating trauma, and a marked increase in blunt trauma, especially falls, while fatality rates, organ failure, and thromboembolic complications correlated with increasing age. Clearly EDs designed for the 21^st century must be built not only to handle increasing numbers of trauma cases in the elderly, but for changing etiologies, characteristics, and comorbidities.

When I wrote “A Design for the 21^st Century” in 2006, I was in the midst of actually designing an expansion to our (circa 1997) ED to increase capacity by 1/3. Readers who would like to see how the considerations presented here (and others) shaped the unit we opened in 2009, can view the short video below.

In the October 2006 editorial, “A Design for the 21st Century,” I suggested that the first consideration in designing a new ED should be how long it is likely to remain in service before being replaced or substantially renovated, and then to consider which conditions are most likely to continue to present or increase in importance during the first several decades of the 21^st century (Emerg Med. 2006;37[10]:7). I envisioned “increasing patient volume, an aging population, new and emerging viral infections, an even higher incidence of bacterial resistance, and more immunocompromised patients resulting from organ transplants and greater use of chemotherapy.” A decade after these predictions were made, how are they holding up?

Since 2006, there have been over 40 epidemics worldwide and although most have not affected this country, easy travel and global emergency medicine missions have brought several distant viral illnesses to US EDs as well. In 2009, EDs throughout the country had to deal with a potentially disastrous epidemic of H1N1 influenza, and in the years since we have been challenged by MERS (2012), dengue fever (2013-), Ebola (2014), and now Zika and chikungunya—not to mention outbreaks of “older” bacterial and viral illnesses such as pertussis (2012), and measles (2014-2015). Though several of the newer viruses mentioned are mosquito borne, pathogens transmitted from human to human, or human to surface to human, along with the increasing incidence of antibiotic resistance (MRSA, Clostridium difficile, Carbapenem-resistant Enterobacteriaceae, etc) make the need for greater numbers of ED negative-pressure rooms undeniable.

One important design feature not specifically considered in 2006, but made apparent by the Ebola experience in 2014, is a need for the shortest possible route between the ambulance and non-ambulance ED entry points/triage and isolation facilities. As noted in 2006, a separate entrance and air handling for a designated infection-control unit in the ED is essential if it must be sealed off from the rest of the hospital and/or main ED.

The second major ED design issue considered in 2006 was the increasing numbers of elderly patients who will present to our EDs during the first half of this century. Isolation rooms and private rooms in the ED will help manage the rapidly rising number of elderly patients with contagious diseases, along with other conditions such as dementia and delirium. Significant needs of the elderly also include measures to prevent or mitigate falls, catheter-related UTIs, and bedsores.

One epidemic in the elderly that we are already facing is a significant increase in the number of trauma cases. In some Level I trauma centers, over 34% of trauma activations are for patients 55 years old and older. The 2003-2012 Oregon Trauma Registry Report containing data on 84,099 patients from 44 trauma hospitals, notes that the rate of trauma increased from 200.7 to 244.6 per 100,000 during that period, almost exclusively occurring in patients 55 years old or older who represented 21% of cases in 2003 and 34% by 2012—a rise largely attributed to a 159% increase in trauma due to falls (http://public.health.oregon.gov/providerpartnerresources/emstraumasystems/traumasystems/documents/reports/otr-report.pdf). In another study, Hsia et al reported that 27% of 430,081 patients admitted to California acute care hospitals for trauma-related diagnoses between January 1, 1999 and December 31, 2008  were older than 65 years (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3121677/), and in Houston, Texas, 13% of 15,223 trauma patients admitted to one of its two level I trauma centers between January 2005 and December 2008 were 65 years old or older, according to Adams et al (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3836632/). The Adams paper noted that trauma centers were originally designed to care for seriously ill patients without age-specific guidelines, but in patients 65 years or older there was a negligible amount of penetrating trauma, and a marked increase in blunt trauma, especially falls, while fatality rates, organ failure, and thromboembolic complications correlated with increasing age. Clearly EDs designed for the 21^st century must be built not only to handle increasing numbers of trauma cases in the elderly, but for changing etiologies, characteristics, and comorbidities.

When I wrote “A Design for the 21^st Century” in 2006, I was in the midst of actually designing an expansion to our (circa 1997) ED to increase capacity by 1/3. Readers who would like to see how the considerations presented here (and others) shaped the unit we opened in 2009, can view the short video below.

In the October 2006 editorial, “A Design for the 21st Century,” I suggested that the first consideration in designing a new ED should be how long it is likely to remain in service before being replaced or substantially renovated, and then to consider which conditions are most likely to continue to present or increase in importance during the first several decades of the 21^st century (Emerg Med. 2006;37[10]:7). I envisioned “increasing patient volume, an aging population, new and emerging viral infections, an even higher incidence of bacterial resistance, and more immunocompromised patients resulting from organ transplants and greater use of chemotherapy.” A decade after these predictions were made, how are they holding up?

Since 2006, there have been over 40 epidemics worldwide and although most have not affected this country, easy travel and global emergency medicine missions have brought several distant viral illnesses to US EDs as well. In 2009, EDs throughout the country had to deal with a potentially disastrous epidemic of H1N1 influenza, and in the years since we have been challenged by MERS (2012), dengue fever (2013-), Ebola (2014), and now Zika and chikungunya—not to mention outbreaks of “older” bacterial and viral illnesses such as pertussis (2012), and measles (2014-2015). Though several of the newer viruses mentioned are mosquito borne, pathogens transmitted from human to human, or human to surface to human, along with the increasing incidence of antibiotic resistance (MRSA, Clostridium difficile, Carbapenem-resistant Enterobacteriaceae, etc) make the need for greater numbers of ED negative-pressure rooms undeniable.

One important design feature not specifically considered in 2006, but made apparent by the Ebola experience in 2014, is a need for the shortest possible route between the ambulance and non-ambulance ED entry points/triage and isolation facilities. As noted in 2006, a separate entrance and air handling for a designated infection-control unit in the ED is essential if it must be sealed off from the rest of the hospital and/or main ED.

The second major ED design issue considered in 2006 was the increasing numbers of elderly patients who will present to our EDs during the first half of this century. Isolation rooms and private rooms in the ED will help manage the rapidly rising number of elderly patients with contagious diseases, along with other conditions such as dementia and delirium. Significant needs of the elderly also include measures to prevent or mitigate falls, catheter-related UTIs, and bedsores.

One epidemic in the elderly that we are already facing is a significant increase in the number of trauma cases. In some Level I trauma centers, over 34% of trauma activations are for patients 55 years old and older. The 2003-2012 Oregon Trauma Registry Report containing data on 84,099 patients from 44 trauma hospitals, notes that the rate of trauma increased from 200.7 to 244.6 per 100,000 during that period, almost exclusively occurring in patients 55 years old or older who represented 21% of cases in 2003 and 34% by 2012—a rise largely attributed to a 159% increase in trauma due to falls (http://public.health.oregon.gov/providerpartnerresources/emstraumasystems/traumasystems/documents/reports/otr-report.pdf). In another study, Hsia et al reported that 27% of 430,081 patients admitted to California acute care hospitals for trauma-related diagnoses between January 1, 1999 and December 31, 2008  were older than 65 years (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3121677/), and in Houston, Texas, 13% of 15,223 trauma patients admitted to one of its two level I trauma centers between January 2005 and December 2008 were 65 years old or older, according to Adams et al (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3836632/). The Adams paper noted that trauma centers were originally designed to care for seriously ill patients without age-specific guidelines, but in patients 65 years or older there was a negligible amount of penetrating trauma, and a marked increase in blunt trauma, especially falls, while fatality rates, organ failure, and thromboembolic complications correlated with increasing age. Clearly EDs designed for the 21^st century must be built not only to handle increasing numbers of trauma cases in the elderly, but for changing etiologies, characteristics, and comorbidities.

When I wrote “A Design for the 21^st Century” in 2006, I was in the midst of actually designing an expansion to our (circa 1997) ED to increase capacity by 1/3. Readers who would like to see how the considerations presented here (and others) shaped the unit we opened in 2009, can view the short video below.

The Latin dictum primum non nocere, or first cause no harm, has been applied to patient care for centuries. But first responders, health care providers, and humanitarians eager to help victims of natural and man-made disasters can also be harmed, along with those they inadvertently expose to harm afterward. The tragic consequences of attempting to help victims of the 9/11 World Trade Center destruction and, more recently, caring for patients infected with the Ebola virus are but two examples. Loss of humanitarian lives that can be anticipated and prevented or mitigated are especially tragic, considering the potential good such people could do for so many others over a long lifetime.

Toxic exposures and infectious disease transmission have long been identified as potential risks to health care providers, but other conditions can also claim lives or result in lasting disabilities.

The middle of January brought the heartbreaking news of the deaths of three Columbia University undergraduates, who were killed when their bus plummeted 250 feet down a ravine in Honduras as they were returning from a mission to provide basic health care to underserved people. We knew one of the victims, 20-year-old Daniela Moffson, since she was a child. A bright, energetic Barnard College premed student planning to be a pediatrician, Daniella spent her vacations working in an AIDS clinic in South Africa, volunteering on the pediatric service at our hospital, and serving as a counselor in a sleep-away camp for children with cancer.

A second victim, Abigail Flanagan, was a 45-year-old nurse practitioner at our Columbia University Medical Center campus and a postbac premed student at the Columbia School of General Studies. Her 19-year-old son, a Columbia College undergraduate, also planning to be a doctor, survived the bus accident and tried unsuccessfully to resuscitate his mother with CPR. The third victim, Columbia College student Olivia Erhardt, was also planning a career in health care.

All emergency physicians (EPs) are reminded daily that accidents and other forms of trauma can happen anywhere, and staying close to home does not necessarily protect from harm. But is there also a specific role for EPs in treating and preventing serious and fatal injuries around the globe?

A January 16, 2016 New York Times article titled “Universities Focus on Safety of Trips Abroad After 3 Columbia Students Die” (http://www.nytimes.com/2016/01/16/nyregion/death-of-3-columbia-students-raises-fears-over-trips-abroad.html) points out that the US State Department has had a travel warning in effect for Honduras which “…is considered a particularly dangerous country to travel in…primarily because of the high levels of crime and violence….But [also]…because of poor road conditions, a lack of enforcement of traffic laws and a large number of vehicles that are old or in disrepair.”

The many humanitarian organizations and over 40 non-ACGME International (or Global) Emergency Medicine (IEM) fellowship programs in the United States have had a stellar safety record to date, but perhaps there is an additional role for IEM fellows and faculty to monitor and disseminate State Department foreign travel information and CDC health advisories and, working with affiliated medical schools and local college campuses, provide essential safety information and advice about changing conditions around the world. The Times article also notes that some universities have responded to the increased number of students studying or volunteering abroad by creating administrative positions devoted to ensuring and monitoring their safety. Shouldn’t EPs support these efforts in a proactive way?

Volunteers for humanitarian missions—especially young people—have a tendency to ignore personal safety warnings, and there are inherently dangerous situations that clearly require skilled professionals who should be remunerated adequately for the personal risks they are taking. But EPs devoted to providing IEM may be able to take additional steps to help reduce the dangers to everyone.

As this editorial was going to press, the CDC issued a warning for pregnant women to avoid travel to countries in the Americas where a new mosquito-borne zika viral epidemic has already caused thousands of cases of microcephaly in babies born to women who were infected during pregnancy.

The Latin dictum primum non nocere, or first cause no harm, has been applied to patient care for centuries. But first responders, health care providers, and humanitarians eager to help victims of natural and man-made disasters can also be harmed, along with those they inadvertently expose to harm afterward. The tragic consequences of attempting to help victims of the 9/11 World Trade Center destruction and, more recently, caring for patients infected with the Ebola virus are but two examples. Loss of humanitarian lives that can be anticipated and prevented or mitigated are especially tragic, considering the potential good such people could do for so many others over a long lifetime.

Toxic exposures and infectious disease transmission have long been identified as potential risks to health care providers, but other conditions can also claim lives or result in lasting disabilities.

The middle of January brought the heartbreaking news of the deaths of three Columbia University undergraduates, who were killed when their bus plummeted 250 feet down a ravine in Honduras as they were returning from a mission to provide basic health care to underserved people. We knew one of the victims, 20-year-old Daniela Moffson, since she was a child. A bright, energetic Barnard College premed student planning to be a pediatrician, Daniella spent her vacations working in an AIDS clinic in South Africa, volunteering on the pediatric service at our hospital, and serving as a counselor in a sleep-away camp for children with cancer.

A second victim, Abigail Flanagan, was a 45-year-old nurse practitioner at our Columbia University Medical Center campus and a postbac premed student at the Columbia School of General Studies. Her 19-year-old son, a Columbia College undergraduate, also planning to be a doctor, survived the bus accident and tried unsuccessfully to resuscitate his mother with CPR. The third victim, Columbia College student Olivia Erhardt, was also planning a career in health care.

All emergency physicians (EPs) are reminded daily that accidents and other forms of trauma can happen anywhere, and staying close to home does not necessarily protect from harm. But is there also a specific role for EPs in treating and preventing serious and fatal injuries around the globe?

A January 16, 2016 New York Times article titled “Universities Focus on Safety of Trips Abroad After 3 Columbia Students Die” (http://www.nytimes.com/2016/01/16/nyregion/death-of-3-columbia-students-raises-fears-over-trips-abroad.html) points out that the US State Department has had a travel warning in effect for Honduras which “…is considered a particularly dangerous country to travel in…primarily because of the high levels of crime and violence….But [also]…because of poor road conditions, a lack of enforcement of traffic laws and a large number of vehicles that are old or in disrepair.”

The many humanitarian organizations and over 40 non-ACGME International (or Global) Emergency Medicine (IEM) fellowship programs in the United States have had a stellar safety record to date, but perhaps there is an additional role for IEM fellows and faculty to monitor and disseminate State Department foreign travel information and CDC health advisories and, working with affiliated medical schools and local college campuses, provide essential safety information and advice about changing conditions around the world. The Times article also notes that some universities have responded to the increased number of students studying or volunteering abroad by creating administrative positions devoted to ensuring and monitoring their safety. Shouldn’t EPs support these efforts in a proactive way?

Volunteers for humanitarian missions—especially young people—have a tendency to ignore personal safety warnings, and there are inherently dangerous situations that clearly require skilled professionals who should be remunerated adequately for the personal risks they are taking. But EPs devoted to providing IEM may be able to take additional steps to help reduce the dangers to everyone.

As this editorial was going to press, the CDC issued a warning for pregnant women to avoid travel to countries in the Americas where a new mosquito-borne zika viral epidemic has already caused thousands of cases of microcephaly in babies born to women who were infected during pregnancy.

The Latin dictum primum non nocere, or first cause no harm, has been applied to patient care for centuries. But first responders, health care providers, and humanitarians eager to help victims of natural and man-made disasters can also be harmed, along with those they inadvertently expose to harm afterward. The tragic consequences of attempting to help victims of the 9/11 World Trade Center destruction and, more recently, caring for patients infected with the Ebola virus are but two examples. Loss of humanitarian lives that can be anticipated and prevented or mitigated are especially tragic, considering the potential good such people could do for so many others over a long lifetime.

Toxic exposures and infectious disease transmission have long been identified as potential risks to health care providers, but other conditions can also claim lives or result in lasting disabilities.

The middle of January brought the heartbreaking news of the deaths of three Columbia University undergraduates, who were killed when their bus plummeted 250 feet down a ravine in Honduras as they were returning from a mission to provide basic health care to underserved people. We knew one of the victims, 20-year-old Daniela Moffson, since she was a child. A bright, energetic Barnard College premed student planning to be a pediatrician, Daniella spent her vacations working in an AIDS clinic in South Africa, volunteering on the pediatric service at our hospital, and serving as a counselor in a sleep-away camp for children with cancer.

A second victim, Abigail Flanagan, was a 45-year-old nurse practitioner at our Columbia University Medical Center campus and a postbac premed student at the Columbia School of General Studies. Her 19-year-old son, a Columbia College undergraduate, also planning to be a doctor, survived the bus accident and tried unsuccessfully to resuscitate his mother with CPR. The third victim, Columbia College student Olivia Erhardt, was also planning a career in health care.

All emergency physicians (EPs) are reminded daily that accidents and other forms of trauma can happen anywhere, and staying close to home does not necessarily protect from harm. But is there also a specific role for EPs in treating and preventing serious and fatal injuries around the globe?

A January 16, 2016 New York Times article titled “Universities Focus on Safety of Trips Abroad After 3 Columbia Students Die” (http://www.nytimes.com/2016/01/16/nyregion/death-of-3-columbia-students-raises-fears-over-trips-abroad.html) points out that the US State Department has had a travel warning in effect for Honduras which “…is considered a particularly dangerous country to travel in…primarily because of the high levels of crime and violence….But [also]…because of poor road conditions, a lack of enforcement of traffic laws and a large number of vehicles that are old or in disrepair.”

The many humanitarian organizations and over 40 non-ACGME International (or Global) Emergency Medicine (IEM) fellowship programs in the United States have had a stellar safety record to date, but perhaps there is an additional role for IEM fellows and faculty to monitor and disseminate State Department foreign travel information and CDC health advisories and, working with affiliated medical schools and local college campuses, provide essential safety information and advice about changing conditions around the world. The Times article also notes that some universities have responded to the increased number of students studying or volunteering abroad by creating administrative positions devoted to ensuring and monitoring their safety. Shouldn’t EPs support these efforts in a proactive way?

Volunteers for humanitarian missions—especially young people—have a tendency to ignore personal safety warnings, and there are inherently dangerous situations that clearly require skilled professionals who should be remunerated adequately for the personal risks they are taking. But EPs devoted to providing IEM may be able to take additional steps to help reduce the dangers to everyone.

As this editorial was going to press, the CDC issued a warning for pregnant women to avoid travel to countries in the Americas where a new mosquito-borne zika viral epidemic has already caused thousands of cases of microcephaly in babies born to women who were infected during pregnancy.

Continuing last month’s review of quotes and analogies from past editorials illustrating key points, I found similarities between a scripted exchange from a now famous aviation emergency and a fundamental principle of emergency-medicine practice and resident education. When his aircraft suddenly lost both engines to a flock of geese upon take-off, Captain Chesley Sullenberger immediately took control from his copilot by placing his hand on the controls and announcing “my aircraft.” He then safely brought the plane down on the Hudson River 4 minutes later, saving all 155 passengers and crew on board (“My Patient” Emerg Med. 2009;41[3]:5 and Emerg Med. 2013;45[4]:1). I wrote: “…for some potentially catastrophic medical occurrences, everything depends on who is operating and who is standing a few feet away, ready to take over the controls on a moment’s notice. Emergency Medicine is one of an increasing number of specialties that have found the resources to adopt the concept of “my patient” at all hours.…”

The typical first question on ED patient satisfaction questionnaires is “apart from the wait, how would you rate your overall experience?” To me, this sounded very much like asking “apart from that Mrs Lincoln, how did you enjoy the play?” (“Patient Satisfaction,” Emerg Med. 2010;42[7]:5).

Although the Affordable Care Act of 2010 promised millions of Americans access to timely care, there were no provisions to increase the number of health care providers. As a result, ED visits continued to increase, along with the risk of compromising care due to overcrowding—even in so-called “safety-net” hospitals. “[With] the large and growing number of patients vying for space to land on the safety net, it is inevitable that some will hit the rim or miss the net entirely.”

“A National Disgrace” (Emerg Med. 2012;44[8]:2 and Emerg Med. 2015;47[7]:292), referred to continuing nationwide medication shortages, recalling “cold war images of empty shelves in Russian supermarkets which still remain vivid reminders of a failed system of government. So who would have predicted that in the 21st-century the mighty United States of America… would have hospital pharmacy shelves bereft of essential medications, including many of the sterile, injectable, crash cart meds that we rely on during resuscitations?”

“A Wintry Mix of Patients” (Emerg Med. 2013;45[3]:1 and Emerg Med. 2015;47[7]:101) considered the terrible, inexcusable plight of patients who require acute psychiatric inpatient care, waiting days or weeks in EDs for beds. It ended with “as a nation, if we cannot recognize the seriousness of this problem and if we do nothing to fix it immediately, lack of bed [capacity] is not the only lack of capacity from which we suffer.”

“Will You Still Need Me, Will You Still Feed Me…?” (Emerg Med. 2013;45[5]:1) called for age-appropriate reductions in EP night shift requirements, pointing out that “the greatest professional baseball players cannot play professionally in their 50s or 60s…”, and suggested that “staffing and running attached or satellite urgent care centers could utilize the interpersonal and clinical skills EPs have acquired over years of EM practice, while allowing their ED group to maintain financial viability…”

“We Told You So! Now What?” (Emerg Med. 2014;46[1]:5 1/14) noted that published data confirmed our prediction that the Affordable Care Act would not reduce the numbers of ED visits; and asked “…why do so many people continue to go to EDs despite the overcrowding and all of the efforts to dissuade them?” The question was answered by paraphrasing … Winston Churchill on democracy as a form of government: “for many, many people and many, many problems, EDs may be the worst form of care, except for all of the others.”

Finally, in “’Tis the Season” (Emerg Med. 2014;46[12]:5), we asked readers if they “would be able to diagnose the first case of Ebola in a febrile patient who has no travel history and presents to an ED during flu season.” Referencing some famous advice to internists who must be able to recognize rare diseases, but more frequently favor more common diagnoses, we suggested that “determining when hoofbeats are caused by a horse and when they are caused by a zebra is one of the most difficult challenges of emergency medicine.”

Before you gallop off on your own horse or zebra, we once again wish you a happy and healthy New Year.  

Continuing last month’s review of quotes and analogies from past editorials illustrating key points, I found similarities between a scripted exchange from a now famous aviation emergency and a fundamental principle of emergency-medicine practice and resident education. When his aircraft suddenly lost both engines to a flock of geese upon take-off, Captain Chesley Sullenberger immediately took control from his copilot by placing his hand on the controls and announcing “my aircraft.” He then safely brought the plane down on the Hudson River 4 minutes later, saving all 155 passengers and crew on board (“My Patient” Emerg Med. 2009;41[3]:5 and Emerg Med. 2013;45[4]:1). I wrote: “…for some potentially catastrophic medical occurrences, everything depends on who is operating and who is standing a few feet away, ready to take over the controls on a moment’s notice. Emergency Medicine is one of an increasing number of specialties that have found the resources to adopt the concept of “my patient” at all hours.…”

The typical first question on ED patient satisfaction questionnaires is “apart from the wait, how would you rate your overall experience?” To me, this sounded very much like asking “apart from that Mrs Lincoln, how did you enjoy the play?” (“Patient Satisfaction,” Emerg Med. 2010;42[7]:5).

Although the Affordable Care Act of 2010 promised millions of Americans access to timely care, there were no provisions to increase the number of health care providers. As a result, ED visits continued to increase, along with the risk of compromising care due to overcrowding—even in so-called “safety-net” hospitals. “[With] the large and growing number of patients vying for space to land on the safety net, it is inevitable that some will hit the rim or miss the net entirely.”

“A National Disgrace” (Emerg Med. 2012;44[8]:2 and Emerg Med. 2015;47[7]:292), referred to continuing nationwide medication shortages, recalling “cold war images of empty shelves in Russian supermarkets which still remain vivid reminders of a failed system of government. So who would have predicted that in the 21st-century the mighty United States of America… would have hospital pharmacy shelves bereft of essential medications, including many of the sterile, injectable, crash cart meds that we rely on during resuscitations?”

“A Wintry Mix of Patients” (Emerg Med. 2013;45[3]:1 and Emerg Med. 2015;47[7]:101) considered the terrible, inexcusable plight of patients who require acute psychiatric inpatient care, waiting days or weeks in EDs for beds. It ended with “as a nation, if we cannot recognize the seriousness of this problem and if we do nothing to fix it immediately, lack of bed [capacity] is not the only lack of capacity from which we suffer.”

“Will You Still Need Me, Will You Still Feed Me…?” (Emerg Med. 2013;45[5]:1) called for age-appropriate reductions in EP night shift requirements, pointing out that “the greatest professional baseball players cannot play professionally in their 50s or 60s…”, and suggested that “staffing and running attached or satellite urgent care centers could utilize the interpersonal and clinical skills EPs have acquired over years of EM practice, while allowing their ED group to maintain financial viability…”

“We Told You So! Now What?” (Emerg Med. 2014;46[1]:5 1/14) noted that published data confirmed our prediction that the Affordable Care Act would not reduce the numbers of ED visits; and asked “…why do so many people continue to go to EDs despite the overcrowding and all of the efforts to dissuade them?” The question was answered by paraphrasing … Winston Churchill on democracy as a form of government: “for many, many people and many, many problems, EDs may be the worst form of care, except for all of the others.”

Finally, in “’Tis the Season” (Emerg Med. 2014;46[12]:5), we asked readers if they “would be able to diagnose the first case of Ebola in a febrile patient who has no travel history and presents to an ED during flu season.” Referencing some famous advice to internists who must be able to recognize rare diseases, but more frequently favor more common diagnoses, we suggested that “determining when hoofbeats are caused by a horse and when they are caused by a zebra is one of the most difficult challenges of emergency medicine.”

Before you gallop off on your own horse or zebra, we once again wish you a happy and healthy New Year.  

Continuing last month’s review of quotes and analogies from past editorials illustrating key points, I found similarities between a scripted exchange from a now famous aviation emergency and a fundamental principle of emergency-medicine practice and resident education. When his aircraft suddenly lost both engines to a flock of geese upon take-off, Captain Chesley Sullenberger immediately took control from his copilot by placing his hand on the controls and announcing “my aircraft.” He then safely brought the plane down on the Hudson River 4 minutes later, saving all 155 passengers and crew on board (“My Patient” Emerg Med. 2009;41[3]:5 and Emerg Med. 2013;45[4]:1). I wrote: “…for some potentially catastrophic medical occurrences, everything depends on who is operating and who is standing a few feet away, ready to take over the controls on a moment’s notice. Emergency Medicine is one of an increasing number of specialties that have found the resources to adopt the concept of “my patient” at all hours.…”

The typical first question on ED patient satisfaction questionnaires is “apart from the wait, how would you rate your overall experience?” To me, this sounded very much like asking “apart from that Mrs Lincoln, how did you enjoy the play?” (“Patient Satisfaction,” Emerg Med. 2010;42[7]:5).

Although the Affordable Care Act of 2010 promised millions of Americans access to timely care, there were no provisions to increase the number of health care providers. As a result, ED visits continued to increase, along with the risk of compromising care due to overcrowding—even in so-called “safety-net” hospitals. “[With] the large and growing number of patients vying for space to land on the safety net, it is inevitable that some will hit the rim or miss the net entirely.”

“A National Disgrace” (Emerg Med. 2012;44[8]:2 and Emerg Med. 2015;47[7]:292), referred to continuing nationwide medication shortages, recalling “cold war images of empty shelves in Russian supermarkets which still remain vivid reminders of a failed system of government. So who would have predicted that in the 21st-century the mighty United States of America… would have hospital pharmacy shelves bereft of essential medications, including many of the sterile, injectable, crash cart meds that we rely on during resuscitations?”

“A Wintry Mix of Patients” (Emerg Med. 2013;45[3]:1 and Emerg Med. 2015;47[7]:101) considered the terrible, inexcusable plight of patients who require acute psychiatric inpatient care, waiting days or weeks in EDs for beds. It ended with “as a nation, if we cannot recognize the seriousness of this problem and if we do nothing to fix it immediately, lack of bed [capacity] is not the only lack of capacity from which we suffer.”

“Will You Still Need Me, Will You Still Feed Me…?” (Emerg Med. 2013;45[5]:1) called for age-appropriate reductions in EP night shift requirements, pointing out that “the greatest professional baseball players cannot play professionally in their 50s or 60s…”, and suggested that “staffing and running attached or satellite urgent care centers could utilize the interpersonal and clinical skills EPs have acquired over years of EM practice, while allowing their ED group to maintain financial viability…”

“We Told You So! Now What?” (Emerg Med. 2014;46[1]:5 1/14) noted that published data confirmed our prediction that the Affordable Care Act would not reduce the numbers of ED visits; and asked “…why do so many people continue to go to EDs despite the overcrowding and all of the efforts to dissuade them?” The question was answered by paraphrasing … Winston Churchill on democracy as a form of government: “for many, many people and many, many problems, EDs may be the worst form of care, except for all of the others.”

Finally, in “’Tis the Season” (Emerg Med. 2014;46[12]:5), we asked readers if they “would be able to diagnose the first case of Ebola in a febrile patient who has no travel history and presents to an ED during flu season.” Referencing some famous advice to internists who must be able to recognize rare diseases, but more frequently favor more common diagnoses, we suggested that “determining when hoofbeats are caused by a horse and when they are caused by a zebra is one of the most difficult challenges of emergency medicine.”

Before you gallop off on your own horse or zebra, we once again wish you a happy and healthy New Year.