Neal Flomenbaum, MD

During the summer and early fall, as the country became increasingly alarmed by the failure to contain the current Ebola outbreak in West Africa, the Centers for Disease Control and Prevention (CDC) issued statements reassuring the American people that Ebola is “unlikely…[to] spread if imported into the United States” (July 28), and that it “poses very little or no risk to the US community at large” (Aug 13). The CDC also called for vigilance and measures to ensure the US healthcare system was prepared to rapidly manage cases to avoid further transmission (Sept 17). Nowhere in these statements were there guarantees that there wouldn’t be isolated cases of Ebola in this country, but in light of subsequent events, the public perception of what was said has seriously undermined the credibility of one of the strongest and most effective public health agencies in the world.

Why were actual events seemingly at odds with the initial risk assessments? In part, it was because the statements appear to have been based on several unrealistic premises. They presumed that everyone, from airport personnel to emergency department physicians and nurses, to hospital staff and administrators, would do everything right, every time, for every patient. More importantly, hospitals underestimated the staff and resources that would actually be needed to care for Ebola patients.

The CDC statements also seem to have included a leap of faith: if the spread of Ebola among healthcare workers could be minimized in one of the most medically underserved regions of the world, surely the most advanced healthcare system in the world could do even better. This belief, however, did not take into account that any deaths among patients, close contacts, or healthcare workers would never be considered acceptable in this country, and that intravenous transfusions, hemodialysis, and other advanced treatment measures unavailable in Africa, would expose a greater number of healthcare workers here to the risk of infection.

With absolutely no margin for error in the plans to prevent the spread of Ebola, ED triage professionals, nurses, and physicians have been placed under an enormous burden to get everything right, 100% of the time—a standard that is clearly beyond human capabilities. Should EPs and nurses be blamed for the failure to diagnose the first case and the inability to subsequently prevent two nurses from becoming infected?

I am virtually certain that every EP reading this has had at least one patient encounter that he or she wishes could be done over. Sometimes no harm results from a serious or potentially fatal omission or error; sometimes we are not so fortunate. Have you ever failed to notice an important piece of information in the EMR because it was not entered into the place where you are used to finding it—especially during and after EMR “downtime” periods? Have you ever experienced the pressures resulting from too many patients and too few beds, or the federal regulations calling for reduced lengths of stay and reduced short-term admissions, or of not having all of the resources you need to treat a patient just when you need them? If not, you are indeed fortunate. But to assume that none of these factors—and others—could possibly compromise efforts to diagnose, treat, and contain Ebola is almost “magical thinking.” Afterward, when not everything goes as well as the public had believed it would, our ability to continue basing sound medical practice on scientific facts instead of unsupported fears, is undermined.

As a result of the widespread reporting of early missteps in managing the first Ebola cases in the United States, we are in a much better position now to prevent, manage, and contain new cases, and to avoid the mind-numbing effects of the huge numbers of cases we witnessed with the spread of HIV and AIDS in the 1980s and 1990s. With everyone’s full attention, and more than a small degree of luck, we can successfully prevent or limit the number of future cases—efforts that hopefully will be furthered in the next few months by at least one effective vaccine and/or antiviral agent.

But, there will always be new and emerging infections that the world has never heard of to challenge us. So now would be a very good time to think of the training and resources necessary to deal with future contagious diseases and epidemics, and to plan on avoiding the use of words that may later come back to haunt us.

—Neal Flomenbaum, MD, New York

During the summer and early fall, as the country became increasingly alarmed by the failure to contain the current Ebola outbreak in West Africa, the Centers for Disease Control and Prevention (CDC) issued statements reassuring the American people that Ebola is “unlikely…[to] spread if imported into the United States” (July 28), and that it “poses very little or no risk to the US community at large” (Aug 13). The CDC also called for vigilance and measures to ensure the US healthcare system was prepared to rapidly manage cases to avoid further transmission (Sept 17). Nowhere in these statements were there guarantees that there wouldn’t be isolated cases of Ebola in this country, but in light of subsequent events, the public perception of what was said has seriously undermined the credibility of one of the strongest and most effective public health agencies in the world.

Why were actual events seemingly at odds with the initial risk assessments? In part, it was because the statements appear to have been based on several unrealistic premises. They presumed that everyone, from airport personnel to emergency department physicians and nurses, to hospital staff and administrators, would do everything right, every time, for every patient. More importantly, hospitals underestimated the staff and resources that would actually be needed to care for Ebola patients.

The CDC statements also seem to have included a leap of faith: if the spread of Ebola among healthcare workers could be minimized in one of the most medically underserved regions of the world, surely the most advanced healthcare system in the world could do even better. This belief, however, did not take into account that any deaths among patients, close contacts, or healthcare workers would never be considered acceptable in this country, and that intravenous transfusions, hemodialysis, and other advanced treatment measures unavailable in Africa, would expose a greater number of healthcare workers here to the risk of infection.

With absolutely no margin for error in the plans to prevent the spread of Ebola, ED triage professionals, nurses, and physicians have been placed under an enormous burden to get everything right, 100% of the time—a standard that is clearly beyond human capabilities. Should EPs and nurses be blamed for the failure to diagnose the first case and the inability to subsequently prevent two nurses from becoming infected?

I am virtually certain that every EP reading this has had at least one patient encounter that he or she wishes could be done over. Sometimes no harm results from a serious or potentially fatal omission or error; sometimes we are not so fortunate. Have you ever failed to notice an important piece of information in the EMR because it was not entered into the place where you are used to finding it—especially during and after EMR “downtime” periods? Have you ever experienced the pressures resulting from too many patients and too few beds, or the federal regulations calling for reduced lengths of stay and reduced short-term admissions, or of not having all of the resources you need to treat a patient just when you need them? If not, you are indeed fortunate. But to assume that none of these factors—and others—could possibly compromise efforts to diagnose, treat, and contain Ebola is almost “magical thinking.” Afterward, when not everything goes as well as the public had believed it would, our ability to continue basing sound medical practice on scientific facts instead of unsupported fears, is undermined.

As a result of the widespread reporting of early missteps in managing the first Ebola cases in the United States, we are in a much better position now to prevent, manage, and contain new cases, and to avoid the mind-numbing effects of the huge numbers of cases we witnessed with the spread of HIV and AIDS in the 1980s and 1990s. With everyone’s full attention, and more than a small degree of luck, we can successfully prevent or limit the number of future cases—efforts that hopefully will be furthered in the next few months by at least one effective vaccine and/or antiviral agent.

But, there will always be new and emerging infections that the world has never heard of to challenge us. So now would be a very good time to think of the training and resources necessary to deal with future contagious diseases and epidemics, and to plan on avoiding the use of words that may later come back to haunt us.

—Neal Flomenbaum, MD, New York

During the summer and early fall, as the country became increasingly alarmed by the failure to contain the current Ebola outbreak in West Africa, the Centers for Disease Control and Prevention (CDC) issued statements reassuring the American people that Ebola is “unlikely…[to] spread if imported into the United States” (July 28), and that it “poses very little or no risk to the US community at large” (Aug 13). The CDC also called for vigilance and measures to ensure the US healthcare system was prepared to rapidly manage cases to avoid further transmission (Sept 17). Nowhere in these statements were there guarantees that there wouldn’t be isolated cases of Ebola in this country, but in light of subsequent events, the public perception of what was said has seriously undermined the credibility of one of the strongest and most effective public health agencies in the world.

Why were actual events seemingly at odds with the initial risk assessments? In part, it was because the statements appear to have been based on several unrealistic premises. They presumed that everyone, from airport personnel to emergency department physicians and nurses, to hospital staff and administrators, would do everything right, every time, for every patient. More importantly, hospitals underestimated the staff and resources that would actually be needed to care for Ebola patients.

The CDC statements also seem to have included a leap of faith: if the spread of Ebola among healthcare workers could be minimized in one of the most medically underserved regions of the world, surely the most advanced healthcare system in the world could do even better. This belief, however, did not take into account that any deaths among patients, close contacts, or healthcare workers would never be considered acceptable in this country, and that intravenous transfusions, hemodialysis, and other advanced treatment measures unavailable in Africa, would expose a greater number of healthcare workers here to the risk of infection.

With absolutely no margin for error in the plans to prevent the spread of Ebola, ED triage professionals, nurses, and physicians have been placed under an enormous burden to get everything right, 100% of the time—a standard that is clearly beyond human capabilities. Should EPs and nurses be blamed for the failure to diagnose the first case and the inability to subsequently prevent two nurses from becoming infected?

I am virtually certain that every EP reading this has had at least one patient encounter that he or she wishes could be done over. Sometimes no harm results from a serious or potentially fatal omission or error; sometimes we are not so fortunate. Have you ever failed to notice an important piece of information in the EMR because it was not entered into the place where you are used to finding it—especially during and after EMR “downtime” periods? Have you ever experienced the pressures resulting from too many patients and too few beds, or the federal regulations calling for reduced lengths of stay and reduced short-term admissions, or of not having all of the resources you need to treat a patient just when you need them? If not, you are indeed fortunate. But to assume that none of these factors—and others—could possibly compromise efforts to diagnose, treat, and contain Ebola is almost “magical thinking.” Afterward, when not everything goes as well as the public had believed it would, our ability to continue basing sound medical practice on scientific facts instead of unsupported fears, is undermined.

As a result of the widespread reporting of early missteps in managing the first Ebola cases in the United States, we are in a much better position now to prevent, manage, and contain new cases, and to avoid the mind-numbing effects of the huge numbers of cases we witnessed with the spread of HIV and AIDS in the 1980s and 1990s. With everyone’s full attention, and more than a small degree of luck, we can successfully prevent or limit the number of future cases—efforts that hopefully will be furthered in the next few months by at least one effective vaccine and/or antiviral agent.

But, there will always be new and emerging infections that the world has never heard of to challenge us. So now would be a very good time to think of the training and resources necessary to deal with future contagious diseases and epidemics, and to plan on avoiding the use of words that may later come back to haunt us.

—Neal Flomenbaum, MD, New York

This month marks the 100th consecutive month of EM editorials. The accompanying editorial was written for EM way back in 1986, when, as a member of EM’s editorial board, I was asked to inaugurate a series of editorial/viewpoints by board members on the issues that “boiled to the surface” at the time. I chose to write about the relatively new and frightening epidemic of HIV infections and AIDS overwhelming EDs across the country. At that time, AIDS was a lethal illness accompanied by fears that it could accidentally spread to health care workers by needle sticks etc.

Predicting the future is a risky exercise but, young and undaunted, I wondered if we would have a vaccine in 3 to 5 years, a cure in 5 to 10 years, and by the latter, “cure cancer.” Though none of these possibilities actually occurred, by the beginning of the 21^st century AIDS had been transformed into a chronic and mostly manageable illness—at least in the compliant patient. But in the years since 1986, we have indeed seen rapid scientific advances in identification of causative agents, followed by accurate tests for infection, and effective treatments or vaccines—all of which helped prevent the spread of SARS and other potentially lethal infections. In terms of outcome, not a bad forecast for 1986, though it would be more than 20 years before EM asked me to write another editorial!

Next month, the October issue of EM will be devoted to current ED infectious disease concerns, including the alarming spread of Ebola, a deadly Clostridia perfringins infection, and the current state of HIV and AIDs in the ED.

Also next month, readers will be introduced to several new EM Advisory Board members who have achieved national recognition for their work in newer EM disciplines such as prehospital care, critical care, geriatric emergency medicine, wilderness medicine, and bedside ultrasonography.

Emergency Medicine, the first and oldest publication devoted to our specialty since 1969, continues to be the newest!

We live in a time when the meanings of words often change dramatically—when bad sometimes means good and “cutting up” more often refers to a way of attempting suicide rather than to clowning around. In the 1982 edition of The American Heritage Dictionary you’ll find the entry: “aid (ad) v. aid-ed, aid-ing, aids. –intr. To help: assist. –tr. To give help or assistance to. –n.  1. The act or result of helping; assistance 2. One that helps; an assistant or helper …” But who among us will ever again be comforted by the prospect of assistance upon hearing the word “aids”? Today, we immediately think of AIDS, the acronym for acquired immunodeficiency syndrome.

Until very recently, AIDS was neither a word nor a recognized disease. Then—as noted in the article “AIDS on the Frontline” [June 1981 issue of EM], the CDC’s Morbidity and mortality Weekly Report described a cluster of cases of Pneumocystis carinii pneumonia, candidiasis, and cytomegalovirus infections occurring in young homosexual men. In November of [1981], the first of many articles on various aspects of AIDS appeared in EM and was entitled “The Riddle of Kaposi’s Sarcoma.”

Those initial reports proved to be the tip of the iceberg. Since 1981, both the tip and the iceberg have become much larger. One current estimate suggests that half of the approximately 2,550,000 intravenous drug users in the Northeast may now have a positive HTLV-III (HIV) antibody blood test, indicating exposure to the virus. Another estimate suggests that 5% or more of those with positive blood tests will eventually be stricken with AIDS, while even more may be afflicted with AIDS-related complex, or ARC—another word that used to mean something else.

If one were asked to choose the half-dozen most significant events of [the 20^th] century, along with the world at war, the theory of relativity and development of nuclear weapons, the use of antibiotics and vaccines, and the widespread employment of effective birth control methods, one would now have to include the phenomenon of AIDS—“phenomenon” because it remains to be seen whether by the end of the century it will be listed as “the AIDS epidemic and cure.” Whatever the outcome, AIDS is the scientific, clinical, and bioethical challenge to the medical profession in the last quarter of the 20^th century.

The challenge is enormous. During our medical school training and clinical practice did we have any real understanding of what is was like to be physicians during an epidemic such as plague, the catastrophic influenza of 1918-19, or smallpox? We will probably learn. Did we consider how to negotiate the impossible demands by the public for the absolute truth—including our admission of vast areas of scientific ignorance—on the one hand, and their equally insistent demands for guarantees and reassurance beyond the limits of current scientific knowledge on the other? We do every day, now.

 

The ironies of AIDS are incredible. Until a few years ago, we were struggling along “just” trying to come up with a cure (cures) for cancer, when suddenly the struggle became a science-fiction nightmare no one would have believed possible: an infectious disease that causes cancer, spread both sexually and intravenously. And yet while the problem itself has grown, the scientific advances toward a solution have also been progressing in an incredibly short period of time—identification of an etiologic organism followed by a blood test indicating exposure in just a few years.

If we could consider the scientific advances alone, we could all stand around and justifiably congratulate ourselves. But of course, the advances are overshadowed by the disease itself. Will a vaccine be available in 3 to 5 years? A cure in 5 to 10? Will we ultimately cure cancer in curing AIDS? Or will we see a new “Darwinian selection” of the biologically fittest?

To get to the year 2000, we will have to continue to set aside nuclear weapons, effectively balance the world population with the world food supply, and cure or control AIDS and any similar new disease that may develop. To get to 1987, those of us who deal with medical emergencies daily will have to treat the complications of AIDS with the medications and antibiotics available, counsel our patients as best we can, reassure the public to the limits of current scientific knowledge, and neither panic ourselves nor become complacent in handling the needles and biological material that are part of everyday patient care.

It almost makes one long for the “good old days” of the 1970s, when aids were aids and the practice of medicine seemed so much simpler.

—Neal Flomenbaum, MD, New York

This month marks the 100th consecutive month of EM editorials. The accompanying editorial was written for EM way back in 1986, when, as a member of EM’s editorial board, I was asked to inaugurate a series of editorial/viewpoints by board members on the issues that “boiled to the surface” at the time. I chose to write about the relatively new and frightening epidemic of HIV infections and AIDS overwhelming EDs across the country. At that time, AIDS was a lethal illness accompanied by fears that it could accidentally spread to health care workers by needle sticks etc.

Predicting the future is a risky exercise but, young and undaunted, I wondered if we would have a vaccine in 3 to 5 years, a cure in 5 to 10 years, and by the latter, “cure cancer.” Though none of these possibilities actually occurred, by the beginning of the 21^st century AIDS had been transformed into a chronic and mostly manageable illness—at least in the compliant patient. But in the years since 1986, we have indeed seen rapid scientific advances in identification of causative agents, followed by accurate tests for infection, and effective treatments or vaccines—all of which helped prevent the spread of SARS and other potentially lethal infections. In terms of outcome, not a bad forecast for 1986, though it would be more than 20 years before EM asked me to write another editorial!

Next month, the October issue of EM will be devoted to current ED infectious disease concerns, including the alarming spread of Ebola, a deadly Clostridia perfringins infection, and the current state of HIV and AIDs in the ED.

Also next month, readers will be introduced to several new EM Advisory Board members who have achieved national recognition for their work in newer EM disciplines such as prehospital care, critical care, geriatric emergency medicine, wilderness medicine, and bedside ultrasonography.

Emergency Medicine, the first and oldest publication devoted to our specialty since 1969, continues to be the newest!

We live in a time when the meanings of words often change dramatically—when bad sometimes means good and “cutting up” more often refers to a way of attempting suicide rather than to clowning around. In the 1982 edition of The American Heritage Dictionary you’ll find the entry: “aid (ad) v. aid-ed, aid-ing, aids. –intr. To help: assist. –tr. To give help or assistance to. –n.  1. The act or result of helping; assistance 2. One that helps; an assistant or helper …” But who among us will ever again be comforted by the prospect of assistance upon hearing the word “aids”? Today, we immediately think of AIDS, the acronym for acquired immunodeficiency syndrome.

Until very recently, AIDS was neither a word nor a recognized disease. Then—as noted in the article “AIDS on the Frontline” [June 1981 issue of EM], the CDC’s Morbidity and mortality Weekly Report described a cluster of cases of Pneumocystis carinii pneumonia, candidiasis, and cytomegalovirus infections occurring in young homosexual men. In November of [1981], the first of many articles on various aspects of AIDS appeared in EM and was entitled “The Riddle of Kaposi’s Sarcoma.”

Those initial reports proved to be the tip of the iceberg. Since 1981, both the tip and the iceberg have become much larger. One current estimate suggests that half of the approximately 2,550,000 intravenous drug users in the Northeast may now have a positive HTLV-III (HIV) antibody blood test, indicating exposure to the virus. Another estimate suggests that 5% or more of those with positive blood tests will eventually be stricken with AIDS, while even more may be afflicted with AIDS-related complex, or ARC—another word that used to mean something else.

If one were asked to choose the half-dozen most significant events of [the 20^th] century, along with the world at war, the theory of relativity and development of nuclear weapons, the use of antibiotics and vaccines, and the widespread employment of effective birth control methods, one would now have to include the phenomenon of AIDS—“phenomenon” because it remains to be seen whether by the end of the century it will be listed as “the AIDS epidemic and cure.” Whatever the outcome, AIDS is the scientific, clinical, and bioethical challenge to the medical profession in the last quarter of the 20^th century.

The challenge is enormous. During our medical school training and clinical practice did we have any real understanding of what is was like to be physicians during an epidemic such as plague, the catastrophic influenza of 1918-19, or smallpox? We will probably learn. Did we consider how to negotiate the impossible demands by the public for the absolute truth—including our admission of vast areas of scientific ignorance—on the one hand, and their equally insistent demands for guarantees and reassurance beyond the limits of current scientific knowledge on the other? We do every day, now.

 

The ironies of AIDS are incredible. Until a few years ago, we were struggling along “just” trying to come up with a cure (cures) for cancer, when suddenly the struggle became a science-fiction nightmare no one would have believed possible: an infectious disease that causes cancer, spread both sexually and intravenously. And yet while the problem itself has grown, the scientific advances toward a solution have also been progressing in an incredibly short period of time—identification of an etiologic organism followed by a blood test indicating exposure in just a few years.

If we could consider the scientific advances alone, we could all stand around and justifiably congratulate ourselves. But of course, the advances are overshadowed by the disease itself. Will a vaccine be available in 3 to 5 years? A cure in 5 to 10? Will we ultimately cure cancer in curing AIDS? Or will we see a new “Darwinian selection” of the biologically fittest?

To get to the year 2000, we will have to continue to set aside nuclear weapons, effectively balance the world population with the world food supply, and cure or control AIDS and any similar new disease that may develop. To get to 1987, those of us who deal with medical emergencies daily will have to treat the complications of AIDS with the medications and antibiotics available, counsel our patients as best we can, reassure the public to the limits of current scientific knowledge, and neither panic ourselves nor become complacent in handling the needles and biological material that are part of everyday patient care.

It almost makes one long for the “good old days” of the 1970s, when aids were aids and the practice of medicine seemed so much simpler.

—Neal Flomenbaum, MD, New York

This month marks the 100th consecutive month of EM editorials. The accompanying editorial was written for EM way back in 1986, when, as a member of EM’s editorial board, I was asked to inaugurate a series of editorial/viewpoints by board members on the issues that “boiled to the surface” at the time. I chose to write about the relatively new and frightening epidemic of HIV infections and AIDS overwhelming EDs across the country. At that time, AIDS was a lethal illness accompanied by fears that it could accidentally spread to health care workers by needle sticks etc.

Predicting the future is a risky exercise but, young and undaunted, I wondered if we would have a vaccine in 3 to 5 years, a cure in 5 to 10 years, and by the latter, “cure cancer.” Though none of these possibilities actually occurred, by the beginning of the 21^st century AIDS had been transformed into a chronic and mostly manageable illness—at least in the compliant patient. But in the years since 1986, we have indeed seen rapid scientific advances in identification of causative agents, followed by accurate tests for infection, and effective treatments or vaccines—all of which helped prevent the spread of SARS and other potentially lethal infections. In terms of outcome, not a bad forecast for 1986, though it would be more than 20 years before EM asked me to write another editorial!

Next month, the October issue of EM will be devoted to current ED infectious disease concerns, including the alarming spread of Ebola, a deadly Clostridia perfringins infection, and the current state of HIV and AIDs in the ED.

Also next month, readers will be introduced to several new EM Advisory Board members who have achieved national recognition for their work in newer EM disciplines such as prehospital care, critical care, geriatric emergency medicine, wilderness medicine, and bedside ultrasonography.

Emergency Medicine, the first and oldest publication devoted to our specialty since 1969, continues to be the newest!

We live in a time when the meanings of words often change dramatically—when bad sometimes means good and “cutting up” more often refers to a way of attempting suicide rather than to clowning around. In the 1982 edition of The American Heritage Dictionary you’ll find the entry: “aid (ad) v. aid-ed, aid-ing, aids. –intr. To help: assist. –tr. To give help or assistance to. –n.  1. The act or result of helping; assistance 2. One that helps; an assistant or helper …” But who among us will ever again be comforted by the prospect of assistance upon hearing the word “aids”? Today, we immediately think of AIDS, the acronym for acquired immunodeficiency syndrome.

Until very recently, AIDS was neither a word nor a recognized disease. Then—as noted in the article “AIDS on the Frontline” [June 1981 issue of EM], the CDC’s Morbidity and mortality Weekly Report described a cluster of cases of Pneumocystis carinii pneumonia, candidiasis, and cytomegalovirus infections occurring in young homosexual men. In November of [1981], the first of many articles on various aspects of AIDS appeared in EM and was entitled “The Riddle of Kaposi’s Sarcoma.”

Those initial reports proved to be the tip of the iceberg. Since 1981, both the tip and the iceberg have become much larger. One current estimate suggests that half of the approximately 2,550,000 intravenous drug users in the Northeast may now have a positive HTLV-III (HIV) antibody blood test, indicating exposure to the virus. Another estimate suggests that 5% or more of those with positive blood tests will eventually be stricken with AIDS, while even more may be afflicted with AIDS-related complex, or ARC—another word that used to mean something else.

If one were asked to choose the half-dozen most significant events of [the 20^th] century, along with the world at war, the theory of relativity and development of nuclear weapons, the use of antibiotics and vaccines, and the widespread employment of effective birth control methods, one would now have to include the phenomenon of AIDS—“phenomenon” because it remains to be seen whether by the end of the century it will be listed as “the AIDS epidemic and cure.” Whatever the outcome, AIDS is the scientific, clinical, and bioethical challenge to the medical profession in the last quarter of the 20^th century.

The challenge is enormous. During our medical school training and clinical practice did we have any real understanding of what is was like to be physicians during an epidemic such as plague, the catastrophic influenza of 1918-19, or smallpox? We will probably learn. Did we consider how to negotiate the impossible demands by the public for the absolute truth—including our admission of vast areas of scientific ignorance—on the one hand, and their equally insistent demands for guarantees and reassurance beyond the limits of current scientific knowledge on the other? We do every day, now.

 

The ironies of AIDS are incredible. Until a few years ago, we were struggling along “just” trying to come up with a cure (cures) for cancer, when suddenly the struggle became a science-fiction nightmare no one would have believed possible: an infectious disease that causes cancer, spread both sexually and intravenously. And yet while the problem itself has grown, the scientific advances toward a solution have also been progressing in an incredibly short period of time—identification of an etiologic organism followed by a blood test indicating exposure in just a few years.

If we could consider the scientific advances alone, we could all stand around and justifiably congratulate ourselves. But of course, the advances are overshadowed by the disease itself. Will a vaccine be available in 3 to 5 years? A cure in 5 to 10? Will we ultimately cure cancer in curing AIDS? Or will we see a new “Darwinian selection” of the biologically fittest?

To get to the year 2000, we will have to continue to set aside nuclear weapons, effectively balance the world population with the world food supply, and cure or control AIDS and any similar new disease that may develop. To get to 1987, those of us who deal with medical emergencies daily will have to treat the complications of AIDS with the medications and antibiotics available, counsel our patients as best we can, reassure the public to the limits of current scientific knowledge, and neither panic ourselves nor become complacent in handling the needles and biological material that are part of everyday patient care.

It almost makes one long for the “good old days” of the 1970s, when aids were aids and the practice of medicine seemed so much simpler.

—Neal Flomenbaum, MD, New York

The title of last month’s editorial, “A Night (and Week) to Remember!”, is an allusion to a famous book and movie about the sinking of the Titanic; the editorial that followed recounts the experiences of distinguished EP Charlotte Yeh, MD, after she had been struck by a car and became a patient in a busy Washington DC Level I trauma center. In Dr Yeh’s June 2014 article for Health Affairs she characterized her care as uneven and neglectful of her overall well-being. The care also appeared to be fragmented, sloppy, callous, and uncoordinated.

We did not comment last month on one aspect of her experience: after her radiologic studies were completed, Dr Yeh was brought back to the ED on a stretcher and parked in an ED hallway where she remained through the night, admitted but “boarding” in the ED waiting for an inpatient bed to become available. When the day crew that arrived 15 hours later recognized Dr Yeh as an EP, she was moved from the hallway to a private room. For Dr Yeh, being in an ED hallway was not the most significant problem associated with her ED care, but for most ED patients, being a hallway patient for many hours frequently overshadows all of the efforts of the many dedicated, hardworking EPs and nurses to provide our patients with the best care possible. Too often nowadays, the ED hallway has become the intersection of clinical care, comfort, length of stay, and patient satisfaction.

Ironically, Dr Yeh wrote that she “took comfort in being left in the hallway,” because to her “it meant that [she] was okay, that the hospital staff wasn’t so worried” about her and, conversely, after being moved to a darkened room with the door shut so that she could sleep, she felt abandoned.

Most patients in the overcrowded, urban, academic medical center EDs throughout the country prefer rooms—not hallways—until they are either discharged or admitted to an inpatient bed. Factoring in the constant noise and light, the uncomfortable ED stretchers, and the sometimes many hours spent in a hallway, is it any wonder that, nationwide, inpatient satisfaction scores of patients admitted through the ED are about 2 to 2.5 points lower than are those of patients admitted directly to an inpatient service? For many EPs and ED nurses, the hardest and most frequent decision they must make is whether to move a previously evaluated patient out of a room to a hallway, or to evaluate and treat a new patient outside of the room. Many factors contribute to this deplorable situation: ED overcrowding from other hospital closings, an increasing number of patients coming or sent to EDs because of the lack of primary care providers, and the growing number of patients waiting in EDs for inpatient isolation rooms. In fairness, the care of a patient on a hallway bed is not necessarily compromised. A 2012 Archives of Internal Medicine article questioned the assumption that favorable patient satisfaction scores correlate with quality of care; and bringing newly arrived patients into the ED as soon as possible, rather than making them wait in the waiting room for a room or cubicle to become available, certainly advances their care. But all that being said, why should so many patients have to spend time on hallway stretchers? If activities in EDs are closely integrated with activities in the rest of the hospital, the ED boarding situation can only improve significantly.

The title of last month’s editorial, “A Night (and Week) to Remember!”, is an allusion to a famous book and movie about the sinking of the Titanic; the editorial that followed recounts the experiences of distinguished EP Charlotte Yeh, MD, after she had been struck by a car and became a patient in a busy Washington DC Level I trauma center. In Dr Yeh’s June 2014 article for Health Affairs she characterized her care as uneven and neglectful of her overall well-being. The care also appeared to be fragmented, sloppy, callous, and uncoordinated.

We did not comment last month on one aspect of her experience: after her radiologic studies were completed, Dr Yeh was brought back to the ED on a stretcher and parked in an ED hallway where she remained through the night, admitted but “boarding” in the ED waiting for an inpatient bed to become available. When the day crew that arrived 15 hours later recognized Dr Yeh as an EP, she was moved from the hallway to a private room. For Dr Yeh, being in an ED hallway was not the most significant problem associated with her ED care, but for most ED patients, being a hallway patient for many hours frequently overshadows all of the efforts of the many dedicated, hardworking EPs and nurses to provide our patients with the best care possible. Too often nowadays, the ED hallway has become the intersection of clinical care, comfort, length of stay, and patient satisfaction.

Ironically, Dr Yeh wrote that she “took comfort in being left in the hallway,” because to her “it meant that [she] was okay, that the hospital staff wasn’t so worried” about her and, conversely, after being moved to a darkened room with the door shut so that she could sleep, she felt abandoned.

Most patients in the overcrowded, urban, academic medical center EDs throughout the country prefer rooms—not hallways—until they are either discharged or admitted to an inpatient bed. Factoring in the constant noise and light, the uncomfortable ED stretchers, and the sometimes many hours spent in a hallway, is it any wonder that, nationwide, inpatient satisfaction scores of patients admitted through the ED are about 2 to 2.5 points lower than are those of patients admitted directly to an inpatient service? For many EPs and ED nurses, the hardest and most frequent decision they must make is whether to move a previously evaluated patient out of a room to a hallway, or to evaluate and treat a new patient outside of the room. Many factors contribute to this deplorable situation: ED overcrowding from other hospital closings, an increasing number of patients coming or sent to EDs because of the lack of primary care providers, and the growing number of patients waiting in EDs for inpatient isolation rooms. In fairness, the care of a patient on a hallway bed is not necessarily compromised. A 2012 Archives of Internal Medicine article questioned the assumption that favorable patient satisfaction scores correlate with quality of care; and bringing newly arrived patients into the ED as soon as possible, rather than making them wait in the waiting room for a room or cubicle to become available, certainly advances their care. But all that being said, why should so many patients have to spend time on hallway stretchers? If activities in EDs are closely integrated with activities in the rest of the hospital, the ED boarding situation can only improve significantly.

The title of last month’s editorial, “A Night (and Week) to Remember!”, is an allusion to a famous book and movie about the sinking of the Titanic; the editorial that followed recounts the experiences of distinguished EP Charlotte Yeh, MD, after she had been struck by a car and became a patient in a busy Washington DC Level I trauma center. In Dr Yeh’s June 2014 article for Health Affairs she characterized her care as uneven and neglectful of her overall well-being. The care also appeared to be fragmented, sloppy, callous, and uncoordinated.

We did not comment last month on one aspect of her experience: after her radiologic studies were completed, Dr Yeh was brought back to the ED on a stretcher and parked in an ED hallway where she remained through the night, admitted but “boarding” in the ED waiting for an inpatient bed to become available. When the day crew that arrived 15 hours later recognized Dr Yeh as an EP, she was moved from the hallway to a private room. For Dr Yeh, being in an ED hallway was not the most significant problem associated with her ED care, but for most ED patients, being a hallway patient for many hours frequently overshadows all of the efforts of the many dedicated, hardworking EPs and nurses to provide our patients with the best care possible. Too often nowadays, the ED hallway has become the intersection of clinical care, comfort, length of stay, and patient satisfaction.

Ironically, Dr Yeh wrote that she “took comfort in being left in the hallway,” because to her “it meant that [she] was okay, that the hospital staff wasn’t so worried” about her and, conversely, after being moved to a darkened room with the door shut so that she could sleep, she felt abandoned.

Most patients in the overcrowded, urban, academic medical center EDs throughout the country prefer rooms—not hallways—until they are either discharged or admitted to an inpatient bed. Factoring in the constant noise and light, the uncomfortable ED stretchers, and the sometimes many hours spent in a hallway, is it any wonder that, nationwide, inpatient satisfaction scores of patients admitted through the ED are about 2 to 2.5 points lower than are those of patients admitted directly to an inpatient service? For many EPs and ED nurses, the hardest and most frequent decision they must make is whether to move a previously evaluated patient out of a room to a hallway, or to evaluate and treat a new patient outside of the room. Many factors contribute to this deplorable situation: ED overcrowding from other hospital closings, an increasing number of patients coming or sent to EDs because of the lack of primary care providers, and the growing number of patients waiting in EDs for inpatient isolation rooms. In fairness, the care of a patient on a hallway bed is not necessarily compromised. A 2012 Archives of Internal Medicine article questioned the assumption that favorable patient satisfaction scores correlate with quality of care; and bringing newly arrived patients into the ED as soon as possible, rather than making them wait in the waiting room for a room or cubicle to become available, certainly advances their care. But all that being said, why should so many patients have to spend time on hallway stretchers? If activities in EDs are closely integrated with activities in the rest of the hospital, the ED boarding situation can only improve significantly.

When a distinguished emergency physician writes about her experiences as a trauma patient in an ED, her account deserves the full attention of all EPs concerned with the effective delivery of emergency care and the comprehensive treatment of our patients.

Charlotte Yeh, MD, former chief of emergency medicine at Newton Wellesley Hospital and at Tufts Medical Center in Massachusetts before becoming Regional Administrator for CMS in Boston, is currently the chief medical officer for AARP Services. On a dark, rainy night in December 2011, Dr Yeh was struck by a car while crossing an intersection in Washington, DC.

After being placed on a backboard and C-collar, she was transported by ambulance to a Level I trauma center where, without identifying herself as an EP, she became another injured patient in a crowded ED.

The experiences Dr Yeh relates in the June 2014 issue of Health Affairs (http://content.healthaffairs.org/content/33/6/1094.full), which were also excerpted in the June 9, 2014 edition of the Washington Post (Go to washingtonpost.com and search for “Yeh.”), sound all too familiar, and none too comforting.

The triage nurse repeatedly asked Dr Yeh where in the car she was sitting despite her responses that she was not in a car but hit by a car—a “pedestrian struck” as they say in NYC. After triage, her pain was addressed, primary and secondary surveys were completed, and focused exams were conducted to enable safe removal of the C-collar and backboard. So far so good.

But over the next 2 days, Dr Yeh’s repeated complaints about knee and gluteal region pain went unaddressed, even as CT scans of the abdomen and pelvis, and X-rays of the chest were ordered and completed. When she returned to the ED from Radiology, Dr Yeh was “parked in a hallway” where she remained through the night after being informed by a new group of clinicians that she was going to be admitted, but “boarded” in the ED until an inpatient bed became available. After 15 hours, the day crew arrived and, recognizing that Dr Yeh was an EP, moved her from the hallway to a private ED room.

Later in the day, the trauma team informed Dr Yeh that with nothing broken, and no major injuries turning up since she arrived, she could go home—despite her excruciating pain and still unexamined knee and hip. After a physical therapy team realized that she could not stand up, the surgical resident told her “there’s no medical reason to admit you…but if you can’t walk, we’ll just have to.”

Upstairs in the first available bed (on the maternity ward!), she repeatedly requested a knee examination before an orthopedic consultant determined that Dr Yeh had a medial collateral ligament tear requiring splinting until an MRI could be obtained. Other lapses in care included a failure to identify early-on the sciatic and gluteal nerve contusions causing leg and hip numbness and tingling, and not noticing until the third hospital day that no admission history and physical exam had been performed by the admitting team. As soon as Dr Yeh was able to ambulate with assistance on day 4, she insisted on being transferred to a rehabilitation facility near her home.

Looking back at her experiences, Dr Yeh characterized the nature of her care as “uneven” and “marked by an over reliance on testing at the expense of [her] overall well-being.”

Uneven to be sure, also fragmented, episodic, sloppy, and, as she noted elsewhere, delivered with a callous attitude on the part of the trauma resident. But the picture that Dr Yeh draws is disturbing for another reason: a trauma patient in an overcrowded ED, with many different “providers” addressing specific issues, but no one coordinating all of these efforts, or looking for omissions, or caring for her as a patient. Where was the EP who should have been the captain of this ED ship ensuring the overall safety and well-being of his or her passengers? Isn’t that what an emergency physician is supposed to be doing?

Scan the QR code to read Editor in Chief Dr Neal Flomenbaum’s commentary on the documentary film “Code Black.” Our Q&A interview with “Code Black” director Dr. Ryan McGarry begins on page 318.

When a distinguished emergency physician writes about her experiences as a trauma patient in an ED, her account deserves the full attention of all EPs concerned with the effective delivery of emergency care and the comprehensive treatment of our patients.

Charlotte Yeh, MD, former chief of emergency medicine at Newton Wellesley Hospital and at Tufts Medical Center in Massachusetts before becoming Regional Administrator for CMS in Boston, is currently the chief medical officer for AARP Services. On a dark, rainy night in December 2011, Dr Yeh was struck by a car while crossing an intersection in Washington, DC.

After being placed on a backboard and C-collar, she was transported by ambulance to a Level I trauma center where, without identifying herself as an EP, she became another injured patient in a crowded ED.

The experiences Dr Yeh relates in the June 2014 issue of Health Affairs (http://content.healthaffairs.org/content/33/6/1094.full), which were also excerpted in the June 9, 2014 edition of the Washington Post (Go to washingtonpost.com and search for “Yeh.”), sound all too familiar, and none too comforting.

The triage nurse repeatedly asked Dr Yeh where in the car she was sitting despite her responses that she was not in a car but hit by a car—a “pedestrian struck” as they say in NYC. After triage, her pain was addressed, primary and secondary surveys were completed, and focused exams were conducted to enable safe removal of the C-collar and backboard. So far so good.

But over the next 2 days, Dr Yeh’s repeated complaints about knee and gluteal region pain went unaddressed, even as CT scans of the abdomen and pelvis, and X-rays of the chest were ordered and completed. When she returned to the ED from Radiology, Dr Yeh was “parked in a hallway” where she remained through the night after being informed by a new group of clinicians that she was going to be admitted, but “boarded” in the ED until an inpatient bed became available. After 15 hours, the day crew arrived and, recognizing that Dr Yeh was an EP, moved her from the hallway to a private ED room.

Later in the day, the trauma team informed Dr Yeh that with nothing broken, and no major injuries turning up since she arrived, she could go home—despite her excruciating pain and still unexamined knee and hip. After a physical therapy team realized that she could not stand up, the surgical resident told her “there’s no medical reason to admit you…but if you can’t walk, we’ll just have to.”

Upstairs in the first available bed (on the maternity ward!), she repeatedly requested a knee examination before an orthopedic consultant determined that Dr Yeh had a medial collateral ligament tear requiring splinting until an MRI could be obtained. Other lapses in care included a failure to identify early-on the sciatic and gluteal nerve contusions causing leg and hip numbness and tingling, and not noticing until the third hospital day that no admission history and physical exam had been performed by the admitting team. As soon as Dr Yeh was able to ambulate with assistance on day 4, she insisted on being transferred to a rehabilitation facility near her home.

Looking back at her experiences, Dr Yeh characterized the nature of her care as “uneven” and “marked by an over reliance on testing at the expense of [her] overall well-being.”

Uneven to be sure, also fragmented, episodic, sloppy, and, as she noted elsewhere, delivered with a callous attitude on the part of the trauma resident. But the picture that Dr Yeh draws is disturbing for another reason: a trauma patient in an overcrowded ED, with many different “providers” addressing specific issues, but no one coordinating all of these efforts, or looking for omissions, or caring for her as a patient. Where was the EP who should have been the captain of this ED ship ensuring the overall safety and well-being of his or her passengers? Isn’t that what an emergency physician is supposed to be doing?

Scan the QR code to read Editor in Chief Dr Neal Flomenbaum’s commentary on the documentary film “Code Black.” Our Q&A interview with “Code Black” director Dr. Ryan McGarry begins on page 318.

When a distinguished emergency physician writes about her experiences as a trauma patient in an ED, her account deserves the full attention of all EPs concerned with the effective delivery of emergency care and the comprehensive treatment of our patients.

Charlotte Yeh, MD, former chief of emergency medicine at Newton Wellesley Hospital and at Tufts Medical Center in Massachusetts before becoming Regional Administrator for CMS in Boston, is currently the chief medical officer for AARP Services. On a dark, rainy night in December 2011, Dr Yeh was struck by a car while crossing an intersection in Washington, DC.

After being placed on a backboard and C-collar, she was transported by ambulance to a Level I trauma center where, without identifying herself as an EP, she became another injured patient in a crowded ED.

The experiences Dr Yeh relates in the June 2014 issue of Health Affairs (http://content.healthaffairs.org/content/33/6/1094.full), which were also excerpted in the June 9, 2014 edition of the Washington Post (Go to washingtonpost.com and search for “Yeh.”), sound all too familiar, and none too comforting.

The triage nurse repeatedly asked Dr Yeh where in the car she was sitting despite her responses that she was not in a car but hit by a car—a “pedestrian struck” as they say in NYC. After triage, her pain was addressed, primary and secondary surveys were completed, and focused exams were conducted to enable safe removal of the C-collar and backboard. So far so good.

But over the next 2 days, Dr Yeh’s repeated complaints about knee and gluteal region pain went unaddressed, even as CT scans of the abdomen and pelvis, and X-rays of the chest were ordered and completed. When she returned to the ED from Radiology, Dr Yeh was “parked in a hallway” where she remained through the night after being informed by a new group of clinicians that she was going to be admitted, but “boarded” in the ED until an inpatient bed became available. After 15 hours, the day crew arrived and, recognizing that Dr Yeh was an EP, moved her from the hallway to a private ED room.

Later in the day, the trauma team informed Dr Yeh that with nothing broken, and no major injuries turning up since she arrived, she could go home—despite her excruciating pain and still unexamined knee and hip. After a physical therapy team realized that she could not stand up, the surgical resident told her “there’s no medical reason to admit you…but if you can’t walk, we’ll just have to.”

Upstairs in the first available bed (on the maternity ward!), she repeatedly requested a knee examination before an orthopedic consultant determined that Dr Yeh had a medial collateral ligament tear requiring splinting until an MRI could be obtained. Other lapses in care included a failure to identify early-on the sciatic and gluteal nerve contusions causing leg and hip numbness and tingling, and not noticing until the third hospital day that no admission history and physical exam had been performed by the admitting team. As soon as Dr Yeh was able to ambulate with assistance on day 4, she insisted on being transferred to a rehabilitation facility near her home.

Looking back at her experiences, Dr Yeh characterized the nature of her care as “uneven” and “marked by an over reliance on testing at the expense of [her] overall well-being.”

Uneven to be sure, also fragmented, episodic, sloppy, and, as she noted elsewhere, delivered with a callous attitude on the part of the trauma resident. But the picture that Dr Yeh draws is disturbing for another reason: a trauma patient in an overcrowded ED, with many different “providers” addressing specific issues, but no one coordinating all of these efforts, or looking for omissions, or caring for her as a patient. Where was the EP who should have been the captain of this ED ship ensuring the overall safety and well-being of his or her passengers? Isn’t that what an emergency physician is supposed to be doing?

Scan the QR code to read Editor in Chief Dr Neal Flomenbaum’s commentary on the documentary film “Code Black.” Our Q&A interview with “Code Black” director Dr. Ryan McGarry begins on page 318.

Last month’s editorial “Pre” Prehospital Care described a new era of making very potent lifesaving medications (epinephrine, naloxone) and devices (AEDs) available to the public without prescription, to be used on anyone in dire need of such lifesaving treatment.

So, if we are making some of our most potent tools available to the public, how are we repurposing the 21^st-century ED to treat other conditions and patients? As noted in the 2013 Rand Report on the Evolving Role of EDs in the United States (http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf), for many people, the ED has become the place to go—or be sent—for CT scans, MRIs, additional blood work, observation and treatment, or admission to the hospital. Increased patient volume, prolonged stays, and newer, complex patient needs are making the large, urban ED a more difficult environment in which to ensure that each patient receives the correct dose of the correct medication, at the correct time. This is especially true for pain meds. The 21^st-century ED is also increasingly the place where the emergent diagnostic and therapeutic needs specific to an aging population are appropriately addressed.   

In this issue of EM, Michael Stern, MD, and Mary Mulcare, MD, consider the advantages of treating elderly patients with emergencies in a purpose-built geriatric emergency department (GED), utilizing specific bedside clinical protocols designed to rapidly diagnose and treat the elderly without causing iatrogenic problems and prolonged hospital stays. Also in this issue, Peter Byers, MD, and Associate Editor in Chief, Francis Counselman, MD, take EM readers through a grand tour of modern pain management for the most common painful conditions typically presenting to an ED, while avoiding both undertreatment and the overprescribing that leads to dependency and abuse.

Prescribing the correct medications and doses for older adults and younger children, and choosing and correctly dosing pain meds—along with a myriad of other prescribing needs required of multitasking, overworked, EPs—all can be substantially aided by a pharmacist stationed in the ED 24/7. An ED pharmacist can help guide the choices and doses of meds administered in the ED, and also provide help with outpatient prescriptions. Alerting the EP to possibly dangerous drug interactions and helping with medication reconciliation are but two of the many important patient care and patient safety services ED pharmacists can provide.

A recent story about ED pharmacists on National Public Radio (NPR) noted that at Children’s Medical Center in Dallas, 10 full-time ED pharmacists are assigned to the pediatric ED where they provide 24-hour review of every one of the almost 20,000 weekly prescriptions and medication orders in real time (http://www.npr.org/blogs/health/2014/06/09/318567633/hospitals-put-pharmacists-in-the-er-to-cut-medication-errors. June 9, 2014.). Also noted in the NPR story was a February 2013 Annals of Emergency Medicine study by Cesarz et al (2013;61[2]:209-214) finding that EM pharmacists intervened in 8.5% of adult prescriptions and 23.6% of pediatric prescriptions.

The issues related to pain meds alone could probably keep an ED pharmacist busy for an entire shift, and hospitals are now beginning to pilot pain-management teams in the ED. Though some may bemoan the evolution toward specialty teams à la football instead of baseball, a team consisting of as few as one NP or PA, working together with EPs to assess, reassess, and manage their ED patients’ pain, will not only improve an ED’s record of compliance with the CMS ED core measure of “door-to-pain treatment time,” but will help address the concerns raised by Drs Byers and Counselman, and Drs Stern and Mulcare about the under- and overtreatment of pain.

In the 21st century, EPs can look forward to a very different ED than the one in which we worked in the 1970s and 1980s. The large urban 21st-century ED will have discrete areas for pediatric, adult, elderly, and psychiatric patients, while ED pharmacists and pain management providers will aid EPs, NPs, PAs, and RNs in delivering state-of-the-art care for our patients.

Last month’s editorial “Pre” Prehospital Care described a new era of making very potent lifesaving medications (epinephrine, naloxone) and devices (AEDs) available to the public without prescription, to be used on anyone in dire need of such lifesaving treatment.

So, if we are making some of our most potent tools available to the public, how are we repurposing the 21^st-century ED to treat other conditions and patients? As noted in the 2013 Rand Report on the Evolving Role of EDs in the United States (http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf), for many people, the ED has become the place to go—or be sent—for CT scans, MRIs, additional blood work, observation and treatment, or admission to the hospital. Increased patient volume, prolonged stays, and newer, complex patient needs are making the large, urban ED a more difficult environment in which to ensure that each patient receives the correct dose of the correct medication, at the correct time. This is especially true for pain meds. The 21^st-century ED is also increasingly the place where the emergent diagnostic and therapeutic needs specific to an aging population are appropriately addressed.   

In this issue of EM, Michael Stern, MD, and Mary Mulcare, MD, consider the advantages of treating elderly patients with emergencies in a purpose-built geriatric emergency department (GED), utilizing specific bedside clinical protocols designed to rapidly diagnose and treat the elderly without causing iatrogenic problems and prolonged hospital stays. Also in this issue, Peter Byers, MD, and Associate Editor in Chief, Francis Counselman, MD, take EM readers through a grand tour of modern pain management for the most common painful conditions typically presenting to an ED, while avoiding both undertreatment and the overprescribing that leads to dependency and abuse.

Prescribing the correct medications and doses for older adults and younger children, and choosing and correctly dosing pain meds—along with a myriad of other prescribing needs required of multitasking, overworked, EPs—all can be substantially aided by a pharmacist stationed in the ED 24/7. An ED pharmacist can help guide the choices and doses of meds administered in the ED, and also provide help with outpatient prescriptions. Alerting the EP to possibly dangerous drug interactions and helping with medication reconciliation are but two of the many important patient care and patient safety services ED pharmacists can provide.

A recent story about ED pharmacists on National Public Radio (NPR) noted that at Children’s Medical Center in Dallas, 10 full-time ED pharmacists are assigned to the pediatric ED where they provide 24-hour review of every one of the almost 20,000 weekly prescriptions and medication orders in real time (http://www.npr.org/blogs/health/2014/06/09/318567633/hospitals-put-pharmacists-in-the-er-to-cut-medication-errors. June 9, 2014.). Also noted in the NPR story was a February 2013 Annals of Emergency Medicine study by Cesarz et al (2013;61[2]:209-214) finding that EM pharmacists intervened in 8.5% of adult prescriptions and 23.6% of pediatric prescriptions.

The issues related to pain meds alone could probably keep an ED pharmacist busy for an entire shift, and hospitals are now beginning to pilot pain-management teams in the ED. Though some may bemoan the evolution toward specialty teams à la football instead of baseball, a team consisting of as few as one NP or PA, working together with EPs to assess, reassess, and manage their ED patients’ pain, will not only improve an ED’s record of compliance with the CMS ED core measure of “door-to-pain treatment time,” but will help address the concerns raised by Drs Byers and Counselman, and Drs Stern and Mulcare about the under- and overtreatment of pain.

In the 21st century, EPs can look forward to a very different ED than the one in which we worked in the 1970s and 1980s. The large urban 21st-century ED will have discrete areas for pediatric, adult, elderly, and psychiatric patients, while ED pharmacists and pain management providers will aid EPs, NPs, PAs, and RNs in delivering state-of-the-art care for our patients.

Last month’s editorial “Pre” Prehospital Care described a new era of making very potent lifesaving medications (epinephrine, naloxone) and devices (AEDs) available to the public without prescription, to be used on anyone in dire need of such lifesaving treatment.

So, if we are making some of our most potent tools available to the public, how are we repurposing the 21^st-century ED to treat other conditions and patients? As noted in the 2013 Rand Report on the Evolving Role of EDs in the United States (http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf), for many people, the ED has become the place to go—or be sent—for CT scans, MRIs, additional blood work, observation and treatment, or admission to the hospital. Increased patient volume, prolonged stays, and newer, complex patient needs are making the large, urban ED a more difficult environment in which to ensure that each patient receives the correct dose of the correct medication, at the correct time. This is especially true for pain meds. The 21^st-century ED is also increasingly the place where the emergent diagnostic and therapeutic needs specific to an aging population are appropriately addressed.   

In this issue of EM, Michael Stern, MD, and Mary Mulcare, MD, consider the advantages of treating elderly patients with emergencies in a purpose-built geriatric emergency department (GED), utilizing specific bedside clinical protocols designed to rapidly diagnose and treat the elderly without causing iatrogenic problems and prolonged hospital stays. Also in this issue, Peter Byers, MD, and Associate Editor in Chief, Francis Counselman, MD, take EM readers through a grand tour of modern pain management for the most common painful conditions typically presenting to an ED, while avoiding both undertreatment and the overprescribing that leads to dependency and abuse.

Prescribing the correct medications and doses for older adults and younger children, and choosing and correctly dosing pain meds—along with a myriad of other prescribing needs required of multitasking, overworked, EPs—all can be substantially aided by a pharmacist stationed in the ED 24/7. An ED pharmacist can help guide the choices and doses of meds administered in the ED, and also provide help with outpatient prescriptions. Alerting the EP to possibly dangerous drug interactions and helping with medication reconciliation are but two of the many important patient care and patient safety services ED pharmacists can provide.

A recent story about ED pharmacists on National Public Radio (NPR) noted that at Children’s Medical Center in Dallas, 10 full-time ED pharmacists are assigned to the pediatric ED where they provide 24-hour review of every one of the almost 20,000 weekly prescriptions and medication orders in real time (http://www.npr.org/blogs/health/2014/06/09/318567633/hospitals-put-pharmacists-in-the-er-to-cut-medication-errors. June 9, 2014.). Also noted in the NPR story was a February 2013 Annals of Emergency Medicine study by Cesarz et al (2013;61[2]:209-214) finding that EM pharmacists intervened in 8.5% of adult prescriptions and 23.6% of pediatric prescriptions.

The issues related to pain meds alone could probably keep an ED pharmacist busy for an entire shift, and hospitals are now beginning to pilot pain-management teams in the ED. Though some may bemoan the evolution toward specialty teams à la football instead of baseball, a team consisting of as few as one NP or PA, working together with EPs to assess, reassess, and manage their ED patients’ pain, will not only improve an ED’s record of compliance with the CMS ED core measure of “door-to-pain treatment time,” but will help address the concerns raised by Drs Byers and Counselman, and Drs Stern and Mulcare about the under- and overtreatment of pain.

In the 21st century, EPs can look forward to a very different ED than the one in which we worked in the 1970s and 1980s. The large urban 21st-century ED will have discrete areas for pediatric, adult, elderly, and psychiatric patients, while ED pharmacists and pain management providers will aid EPs, NPs, PAs, and RNs in delivering state-of-the-art care for our patients.

In recent months, state and federal legislation has been enacted to place lifesaving prescription medications and devices in the hands of nonhealthcare providers present at the scenes of medical emergencies. In 1973, the Emergency Medical Services Development Act ushered in the modern era of advanced prehospital care; current legislation may initiate a new era of advanced “pre-prehospital care.”

The 1970s
The origins of prehospital care can be traced to the years immediately following the Civil War when the horse-drawn wagons used to rapidly evacuate battlefield casualties were quickly adapted to civilian life—sometimes with a physician on board to administer care at the scene. But it wasn’t until the 1970s—more than 100 years later—that the most potent lifesaving medications and powerful electronic devices available to physicians would also be made available to paramedics operating at the scene with written protocols and online medical control.

The success in providing advanced treatment at the scene to those who might not survive transport to an ED led to the realization that in order to survive, patients with ventricular fibrillation (VF) and tachycardia, (VT), respiratory arrest from opioid overdoses, and anaphylaxis, required interventions even before paramedics could get to them.

The 1990s
A new era of “pre-prehospital care” began when the first automatic external defibrillators (AEDs) were placed in public spaces for use on any person who might be in cardiac arrest from VF or VT. The advances in computer programing of the 1990s made it possible to build compact defibrillators capable of delivering jolts of electricity only when indicated and at precisely the right time, without causing harm from inappropriate application or timing. Though initial deployment of AEDs was accompanied by an emphasis on training nonhealthcare workers in their use, many untrained people have since successfully defibrillated dying victims. In 2010, Weisfeldt et al (J Am Coll Cardiol. 55(16):1713-1720.) published the results of a study on survival after AED application prior to the arrival of EMS; of 13,769 out-of-hospital cardiac arrests, application of an AED in 259 cases was associated with a nearly doubling of survival, and the success rate of 40% by lay persons using the devices suggested that speed is more important than training.

Current Efforts
Though spring-loaded epinephrine syringes have been available for many years to individuals (and their families) at risk for anaphylaxis or severe asthma attacks, recent concerns have focused on the need to stock these devices in classrooms and other locations where they could be used on any child in need, with or without a prior history of severe allergic reactions.

At present, over 30 states permit or mandate stocking epi syringes in schools, and on November 13, 2013 President Obama signed into law the School Access to Emergency Epinephrine Act authorizing the Department of Health and Human Services to preferentially fund asthma treatment applications of states that both maintain emergency supplies of epi pens, and insure the availability of trained personnel to administer them throughout the school day.

Adding to the “pre-prehospital care” armamentarium, the FDA last month approved, by prescription, spring-loaded autoinjectors containing doses of naloxone for family members or care providers to rapidly administer to a person overdosed on a legal or illicit opioid. Also available, though not yet FDA approved, are intranasal doses of naloxone for use by nonhealthcare providers.

Emergency physicians should give all of these new developments our full support. Just as we frequently keep seriously traumatized patients alive until surgeons can arrive and operate, these newly available, lifesaving, “pre-prehospital care” measures will help patients survive until they can get to an ED. EPs can play an extremely important role in educating the public on their proper use, encouraging those who might be reluctant to apply them when needed, while decreasing any possible adverse effects from their use.

In recent months, state and federal legislation has been enacted to place lifesaving prescription medications and devices in the hands of nonhealthcare providers present at the scenes of medical emergencies. In 1973, the Emergency Medical Services Development Act ushered in the modern era of advanced prehospital care; current legislation may initiate a new era of advanced “pre-prehospital care.”

The 1970s
The origins of prehospital care can be traced to the years immediately following the Civil War when the horse-drawn wagons used to rapidly evacuate battlefield casualties were quickly adapted to civilian life—sometimes with a physician on board to administer care at the scene. But it wasn’t until the 1970s—more than 100 years later—that the most potent lifesaving medications and powerful electronic devices available to physicians would also be made available to paramedics operating at the scene with written protocols and online medical control.

The success in providing advanced treatment at the scene to those who might not survive transport to an ED led to the realization that in order to survive, patients with ventricular fibrillation (VF) and tachycardia, (VT), respiratory arrest from opioid overdoses, and anaphylaxis, required interventions even before paramedics could get to them.

The 1990s
A new era of “pre-prehospital care” began when the first automatic external defibrillators (AEDs) were placed in public spaces for use on any person who might be in cardiac arrest from VF or VT. The advances in computer programing of the 1990s made it possible to build compact defibrillators capable of delivering jolts of electricity only when indicated and at precisely the right time, without causing harm from inappropriate application or timing. Though initial deployment of AEDs was accompanied by an emphasis on training nonhealthcare workers in their use, many untrained people have since successfully defibrillated dying victims. In 2010, Weisfeldt et al (J Am Coll Cardiol. 55(16):1713-1720.) published the results of a study on survival after AED application prior to the arrival of EMS; of 13,769 out-of-hospital cardiac arrests, application of an AED in 259 cases was associated with a nearly doubling of survival, and the success rate of 40% by lay persons using the devices suggested that speed is more important than training.

Current Efforts
Though spring-loaded epinephrine syringes have been available for many years to individuals (and their families) at risk for anaphylaxis or severe asthma attacks, recent concerns have focused on the need to stock these devices in classrooms and other locations where they could be used on any child in need, with or without a prior history of severe allergic reactions.

At present, over 30 states permit or mandate stocking epi syringes in schools, and on November 13, 2013 President Obama signed into law the School Access to Emergency Epinephrine Act authorizing the Department of Health and Human Services to preferentially fund asthma treatment applications of states that both maintain emergency supplies of epi pens, and insure the availability of trained personnel to administer them throughout the school day.

Adding to the “pre-prehospital care” armamentarium, the FDA last month approved, by prescription, spring-loaded autoinjectors containing doses of naloxone for family members or care providers to rapidly administer to a person overdosed on a legal or illicit opioid. Also available, though not yet FDA approved, are intranasal doses of naloxone for use by nonhealthcare providers.

Emergency physicians should give all of these new developments our full support. Just as we frequently keep seriously traumatized patients alive until surgeons can arrive and operate, these newly available, lifesaving, “pre-prehospital care” measures will help patients survive until they can get to an ED. EPs can play an extremely important role in educating the public on their proper use, encouraging those who might be reluctant to apply them when needed, while decreasing any possible adverse effects from their use.

In recent months, state and federal legislation has been enacted to place lifesaving prescription medications and devices in the hands of nonhealthcare providers present at the scenes of medical emergencies. In 1973, the Emergency Medical Services Development Act ushered in the modern era of advanced prehospital care; current legislation may initiate a new era of advanced “pre-prehospital care.”

The 1970s
The origins of prehospital care can be traced to the years immediately following the Civil War when the horse-drawn wagons used to rapidly evacuate battlefield casualties were quickly adapted to civilian life—sometimes with a physician on board to administer care at the scene. But it wasn’t until the 1970s—more than 100 years later—that the most potent lifesaving medications and powerful electronic devices available to physicians would also be made available to paramedics operating at the scene with written protocols and online medical control.

The success in providing advanced treatment at the scene to those who might not survive transport to an ED led to the realization that in order to survive, patients with ventricular fibrillation (VF) and tachycardia, (VT), respiratory arrest from opioid overdoses, and anaphylaxis, required interventions even before paramedics could get to them.

The 1990s
A new era of “pre-prehospital care” began when the first automatic external defibrillators (AEDs) were placed in public spaces for use on any person who might be in cardiac arrest from VF or VT. The advances in computer programing of the 1990s made it possible to build compact defibrillators capable of delivering jolts of electricity only when indicated and at precisely the right time, without causing harm from inappropriate application or timing. Though initial deployment of AEDs was accompanied by an emphasis on training nonhealthcare workers in their use, many untrained people have since successfully defibrillated dying victims. In 2010, Weisfeldt et al (J Am Coll Cardiol. 55(16):1713-1720.) published the results of a study on survival after AED application prior to the arrival of EMS; of 13,769 out-of-hospital cardiac arrests, application of an AED in 259 cases was associated with a nearly doubling of survival, and the success rate of 40% by lay persons using the devices suggested that speed is more important than training.

Current Efforts
Though spring-loaded epinephrine syringes have been available for many years to individuals (and their families) at risk for anaphylaxis or severe asthma attacks, recent concerns have focused on the need to stock these devices in classrooms and other locations where they could be used on any child in need, with or without a prior history of severe allergic reactions.

At present, over 30 states permit or mandate stocking epi syringes in schools, and on November 13, 2013 President Obama signed into law the School Access to Emergency Epinephrine Act authorizing the Department of Health and Human Services to preferentially fund asthma treatment applications of states that both maintain emergency supplies of epi pens, and insure the availability of trained personnel to administer them throughout the school day.

Adding to the “pre-prehospital care” armamentarium, the FDA last month approved, by prescription, spring-loaded autoinjectors containing doses of naloxone for family members or care providers to rapidly administer to a person overdosed on a legal or illicit opioid. Also available, though not yet FDA approved, are intranasal doses of naloxone for use by nonhealthcare providers.

Emergency physicians should give all of these new developments our full support. Just as we frequently keep seriously traumatized patients alive until surgeons can arrive and operate, these newly available, lifesaving, “pre-prehospital care” measures will help patients survive until they can get to an ED. EPs can play an extremely important role in educating the public on their proper use, encouraging those who might be reluctant to apply them when needed, while decreasing any possible adverse effects from their use.

Years ago, when asked to describe the difference between internal medicine and emergency medicine, I said that it was a little bit like the difference between Occam’s razor and Gillette’s Trac II. Let me explain.

William of Occam, the 14th-century English logician, is credited with advancing the idea that “plurality should not be posited without necessity.” Also known as the “Law of Parsimony,” it was adapted to the practice of medicine some 500 years later by Sir William Osler, who postulated (loosely) that “a single explanation that can account for all of a patient’s signs and symptoms usually is correct.” The 19th-century diseases that best exemplified this principle were tuberculosis, bacterial endocarditis, and diabetes, none of which could be cured or effectively treated at that time.

The deductive reasoning required to identify the underlying cause of a patient’s problems is one of the most intellectually stimulating exercises associated with the practice of internal medicine. If you have never seen a master internist arrive at a correct diagnosis by reasoning based on the history, physical examination, and laboratory evidence, you may want to watch a rerun of “House” on television.

Enter emergency medicine, where time and extensive diagnostic testing are severely limited. It seems obvious that deductive-reasoning skills would be valuable, if not essential, to quickly diagnose and treat serious acute or life-threatening illnesses.

But, with the notable exception of diagnosing toxicologic syndromes, it never really turned out that way. On the contrary, it seems there is hardly ever a single explanation for anything. A sign or symptom, such as loss of consciousness, frequently is the result of two or more etiologies—for example, a depressant drug precipitating trauma, which in turn results in a subdural hematoma. The unfortunate EP who identifies only one of several causes and stops there will inevitably hear later from an esteemed medical or (worse) pathology colleague about the diagnoses that were missed.

In 1971, what was originally the Gillette Safety Razor Company introduced a product that seemed to serve as a better paradigm than Occam’s razor for our newly evolving specialty—the Trac II. This razor, with its tightly spaced twin blades, promised the closest shave ever: the hairs that the first blade missed would surely be sliced off by the second. With this paradigm in mind, the clinician can avoid the risk of (with apologies to the Lovin’ Spoonful) “picking up on one and leaving the other behind.”

Medical decision-making is the subject of the 2007 New York Times best-seller How Doctors Think, by Jerome Groopman, MD, chair of medicine at Harvard Medical School. In one chapter, Groopman examines the problems faced by EPs who must make decisions under time constraints and without the benefits of knowing the patient for more than a few minutes or having sufficient information.

To prevent the diagnostic errors resulting from thinking inside the box—committing prematurely to a wrong or inadequate diagnosis—Groopman cites the example of an endocrinologist who, even when dealing with a patient with an apparently obvious diagnosis, always asks, “What else could this be?” A version of this question that has served many EPs well over the years is “What is the worst thing this patient could have?”

The skilled clinician must be able to apply whichever paradigm is most appropriate for a particular patient. Pattern and syndrome recognition must immediately come to mind when applicable, while the possibility of more than one cause should not be overlooked just because Osler may have suggested otherwise. Added to this decision-making responsibility must be some sense of how far to go in pursuing different diagnoses in the ED without breaking the bank or overtaxing limited resources.

These days, Gillette is offering as many as six blades, promising the closest shave ever. But in the critical area of diagnostic decision-making, I believe our specialty has made even more progress.

An earlier version of this editorial appeared in the June 2007 issue of Emergency Medicine.

Years ago, when asked to describe the difference between internal medicine and emergency medicine, I said that it was a little bit like the difference between Occam’s razor and Gillette’s Trac II. Let me explain.

William of Occam, the 14th-century English logician, is credited with advancing the idea that “plurality should not be posited without necessity.” Also known as the “Law of Parsimony,” it was adapted to the practice of medicine some 500 years later by Sir William Osler, who postulated (loosely) that “a single explanation that can account for all of a patient’s signs and symptoms usually is correct.” The 19th-century diseases that best exemplified this principle were tuberculosis, bacterial endocarditis, and diabetes, none of which could be cured or effectively treated at that time.

The deductive reasoning required to identify the underlying cause of a patient’s problems is one of the most intellectually stimulating exercises associated with the practice of internal medicine. If you have never seen a master internist arrive at a correct diagnosis by reasoning based on the history, physical examination, and laboratory evidence, you may want to watch a rerun of “House” on television.

Enter emergency medicine, where time and extensive diagnostic testing are severely limited. It seems obvious that deductive-reasoning skills would be valuable, if not essential, to quickly diagnose and treat serious acute or life-threatening illnesses.

But, with the notable exception of diagnosing toxicologic syndromes, it never really turned out that way. On the contrary, it seems there is hardly ever a single explanation for anything. A sign or symptom, such as loss of consciousness, frequently is the result of two or more etiologies—for example, a depressant drug precipitating trauma, which in turn results in a subdural hematoma. The unfortunate EP who identifies only one of several causes and stops there will inevitably hear later from an esteemed medical or (worse) pathology colleague about the diagnoses that were missed.

In 1971, what was originally the Gillette Safety Razor Company introduced a product that seemed to serve as a better paradigm than Occam’s razor for our newly evolving specialty—the Trac II. This razor, with its tightly spaced twin blades, promised the closest shave ever: the hairs that the first blade missed would surely be sliced off by the second. With this paradigm in mind, the clinician can avoid the risk of (with apologies to the Lovin’ Spoonful) “picking up on one and leaving the other behind.”

Medical decision-making is the subject of the 2007 New York Times best-seller How Doctors Think, by Jerome Groopman, MD, chair of medicine at Harvard Medical School. In one chapter, Groopman examines the problems faced by EPs who must make decisions under time constraints and without the benefits of knowing the patient for more than a few minutes or having sufficient information.

To prevent the diagnostic errors resulting from thinking inside the box—committing prematurely to a wrong or inadequate diagnosis—Groopman cites the example of an endocrinologist who, even when dealing with a patient with an apparently obvious diagnosis, always asks, “What else could this be?” A version of this question that has served many EPs well over the years is “What is the worst thing this patient could have?”

The skilled clinician must be able to apply whichever paradigm is most appropriate for a particular patient. Pattern and syndrome recognition must immediately come to mind when applicable, while the possibility of more than one cause should not be overlooked just because Osler may have suggested otherwise. Added to this decision-making responsibility must be some sense of how far to go in pursuing different diagnoses in the ED without breaking the bank or overtaxing limited resources.

These days, Gillette is offering as many as six blades, promising the closest shave ever. But in the critical area of diagnostic decision-making, I believe our specialty has made even more progress.

An earlier version of this editorial appeared in the June 2007 issue of Emergency Medicine.

Years ago, when asked to describe the difference between internal medicine and emergency medicine, I said that it was a little bit like the difference between Occam’s razor and Gillette’s Trac II. Let me explain.

William of Occam, the 14th-century English logician, is credited with advancing the idea that “plurality should not be posited without necessity.” Also known as the “Law of Parsimony,” it was adapted to the practice of medicine some 500 years later by Sir William Osler, who postulated (loosely) that “a single explanation that can account for all of a patient’s signs and symptoms usually is correct.” The 19th-century diseases that best exemplified this principle were tuberculosis, bacterial endocarditis, and diabetes, none of which could be cured or effectively treated at that time.

The deductive reasoning required to identify the underlying cause of a patient’s problems is one of the most intellectually stimulating exercises associated with the practice of internal medicine. If you have never seen a master internist arrive at a correct diagnosis by reasoning based on the history, physical examination, and laboratory evidence, you may want to watch a rerun of “House” on television.

Enter emergency medicine, where time and extensive diagnostic testing are severely limited. It seems obvious that deductive-reasoning skills would be valuable, if not essential, to quickly diagnose and treat serious acute or life-threatening illnesses.

But, with the notable exception of diagnosing toxicologic syndromes, it never really turned out that way. On the contrary, it seems there is hardly ever a single explanation for anything. A sign or symptom, such as loss of consciousness, frequently is the result of two or more etiologies—for example, a depressant drug precipitating trauma, which in turn results in a subdural hematoma. The unfortunate EP who identifies only one of several causes and stops there will inevitably hear later from an esteemed medical or (worse) pathology colleague about the diagnoses that were missed.

In 1971, what was originally the Gillette Safety Razor Company introduced a product that seemed to serve as a better paradigm than Occam’s razor for our newly evolving specialty—the Trac II. This razor, with its tightly spaced twin blades, promised the closest shave ever: the hairs that the first blade missed would surely be sliced off by the second. With this paradigm in mind, the clinician can avoid the risk of (with apologies to the Lovin’ Spoonful) “picking up on one and leaving the other behind.”

Medical decision-making is the subject of the 2007 New York Times best-seller How Doctors Think, by Jerome Groopman, MD, chair of medicine at Harvard Medical School. In one chapter, Groopman examines the problems faced by EPs who must make decisions under time constraints and without the benefits of knowing the patient for more than a few minutes or having sufficient information.

To prevent the diagnostic errors resulting from thinking inside the box—committing prematurely to a wrong or inadequate diagnosis—Groopman cites the example of an endocrinologist who, even when dealing with a patient with an apparently obvious diagnosis, always asks, “What else could this be?” A version of this question that has served many EPs well over the years is “What is the worst thing this patient could have?”

The skilled clinician must be able to apply whichever paradigm is most appropriate for a particular patient. Pattern and syndrome recognition must immediately come to mind when applicable, while the possibility of more than one cause should not be overlooked just because Osler may have suggested otherwise. Added to this decision-making responsibility must be some sense of how far to go in pursuing different diagnoses in the ED without breaking the bank or overtaxing limited resources.

These days, Gillette is offering as many as six blades, promising the closest shave ever. But in the critical area of diagnostic decision-making, I believe our specialty has made even more progress.

An earlier version of this editorial appeared in the June 2007 issue of Emergency Medicine.

A February 2014 study by the Insurance Institute for Highway Safety on trends in older driver crash rates and fragility contains some surprising statistics with important implications for emergency medicine (http://www.iihs.org/frontend/iihs/documents/masterfiledocs.ashx?id=2059). The new study, an update of previously published age-related crash data, reaffirms that, as licensed driver fatality rates have declined across all age groups—even though drivers 70 and older remain more likely to die in car crashes than those aged 35 to 54—the rate of decline has been much more pronounced for the elderly than for middle-aged drivers.

According to police-reported crash data from 20 states, between 1997 and 2012, fatal crash rates declined by 42% for older drivers and 30% for middle-aged drivers; data between 1995 and 2008 indicate that the crash fatality rate per miles driven fell 39% for older drivers compared with 26% for middle-aged drivers. Most recently, the declines in fatality rates per licensed drivers were 18% for both age groups during 2007 through 2012, though the number of miles driven by the elderly continued to steadily increase during the study period.

The substantial declines in car crash fatalities for elderly drivers probably result from a combination of drivers remaining healthier longer, better postaccident emergency care, and cars made safer by side air bags, stabilizer and rollover-reduction systems, and automatic braking to avoid collisions. Regardless of the reason or reasons, decreasing automobile-related mortality will increase the number of the elderly who may subsequently visit EDs for (unrelated) health issues.

But the dramatic improvement in elderly safe-driving statistics should also dispel the idea that in other areas, including illnesses, injuries, and treatments, older patients will always remain less able to function adequately or be able to adapt to new conditions than will younger people. For example, a powerful new antibiotic may reduce the fatality rate in all adults, but much more so in the elderly. With respect to the evaluation and treatment of closed-head injuries, aging may allow the elderly to tolerate some expanding lesions better than younger adults thereby avoiding sudden life-threatening conditions—though after falls that may not be significant in younger adults, uncontrollable hemorrhaging may result from blood vessels that are more vulnerable in the elderly.

The point is that in many instances, elderly patients who present to EDs are not just sicker versions of younger adults, but different—sometimes sicker, to be sure, but often not as sick or sick in a different way, with fewer or different signs and symptoms associated with a particular illness. Often-cited, an acutely confused elderly patient, with little or no temperature elevation, no abnormal breath sounds, and no chest X-ray indication of consolidation, may nevertheless have pneumonia causing hypoxia that results in confusion. Another example is the dough-like abdomen of an elderly patient with nondescript gastrointestinal distress, instead of the expected board-like rigidity in a younger adult that accompanies a perforated bowel.

In the years to come, technology will make it possible for older people to function at higher levels, as they live longer. Can’t remember an important person or event? “Google” anything you can think of associated with the person or event, and the information you are seeking becomes an easy multiple choice exercise on the screen. But newer and better medications that can enable people to live longer and better, will only work when emergency physicians know how to recognize the different patterns and choose the best medications and treatments for conditions in that age group.

This is what Geriatric Emergency Medicine is all about.

A February 2014 study by the Insurance Institute for Highway Safety on trends in older driver crash rates and fragility contains some surprising statistics with important implications for emergency medicine (http://www.iihs.org/frontend/iihs/documents/masterfiledocs.ashx?id=2059). The new study, an update of previously published age-related crash data, reaffirms that, as licensed driver fatality rates have declined across all age groups—even though drivers 70 and older remain more likely to die in car crashes than those aged 35 to 54—the rate of decline has been much more pronounced for the elderly than for middle-aged drivers.

According to police-reported crash data from 20 states, between 1997 and 2012, fatal crash rates declined by 42% for older drivers and 30% for middle-aged drivers; data between 1995 and 2008 indicate that the crash fatality rate per miles driven fell 39% for older drivers compared with 26% for middle-aged drivers. Most recently, the declines in fatality rates per licensed drivers were 18% for both age groups during 2007 through 2012, though the number of miles driven by the elderly continued to steadily increase during the study period.

The substantial declines in car crash fatalities for elderly drivers probably result from a combination of drivers remaining healthier longer, better postaccident emergency care, and cars made safer by side air bags, stabilizer and rollover-reduction systems, and automatic braking to avoid collisions. Regardless of the reason or reasons, decreasing automobile-related mortality will increase the number of the elderly who may subsequently visit EDs for (unrelated) health issues.

But the dramatic improvement in elderly safe-driving statistics should also dispel the idea that in other areas, including illnesses, injuries, and treatments, older patients will always remain less able to function adequately or be able to adapt to new conditions than will younger people. For example, a powerful new antibiotic may reduce the fatality rate in all adults, but much more so in the elderly. With respect to the evaluation and treatment of closed-head injuries, aging may allow the elderly to tolerate some expanding lesions better than younger adults thereby avoiding sudden life-threatening conditions—though after falls that may not be significant in younger adults, uncontrollable hemorrhaging may result from blood vessels that are more vulnerable in the elderly.

The point is that in many instances, elderly patients who present to EDs are not just sicker versions of younger adults, but different—sometimes sicker, to be sure, but often not as sick or sick in a different way, with fewer or different signs and symptoms associated with a particular illness. Often-cited, an acutely confused elderly patient, with little or no temperature elevation, no abnormal breath sounds, and no chest X-ray indication of consolidation, may nevertheless have pneumonia causing hypoxia that results in confusion. Another example is the dough-like abdomen of an elderly patient with nondescript gastrointestinal distress, instead of the expected board-like rigidity in a younger adult that accompanies a perforated bowel.

In the years to come, technology will make it possible for older people to function at higher levels, as they live longer. Can’t remember an important person or event? “Google” anything you can think of associated with the person or event, and the information you are seeking becomes an easy multiple choice exercise on the screen. But newer and better medications that can enable people to live longer and better, will only work when emergency physicians know how to recognize the different patterns and choose the best medications and treatments for conditions in that age group.

This is what Geriatric Emergency Medicine is all about.

A February 2014 study by the Insurance Institute for Highway Safety on trends in older driver crash rates and fragility contains some surprising statistics with important implications for emergency medicine (http://www.iihs.org/frontend/iihs/documents/masterfiledocs.ashx?id=2059). The new study, an update of previously published age-related crash data, reaffirms that, as licensed driver fatality rates have declined across all age groups—even though drivers 70 and older remain more likely to die in car crashes than those aged 35 to 54—the rate of decline has been much more pronounced for the elderly than for middle-aged drivers.

According to police-reported crash data from 20 states, between 1997 and 2012, fatal crash rates declined by 42% for older drivers and 30% for middle-aged drivers; data between 1995 and 2008 indicate that the crash fatality rate per miles driven fell 39% for older drivers compared with 26% for middle-aged drivers. Most recently, the declines in fatality rates per licensed drivers were 18% for both age groups during 2007 through 2012, though the number of miles driven by the elderly continued to steadily increase during the study period.

The substantial declines in car crash fatalities for elderly drivers probably result from a combination of drivers remaining healthier longer, better postaccident emergency care, and cars made safer by side air bags, stabilizer and rollover-reduction systems, and automatic braking to avoid collisions. Regardless of the reason or reasons, decreasing automobile-related mortality will increase the number of the elderly who may subsequently visit EDs for (unrelated) health issues.

But the dramatic improvement in elderly safe-driving statistics should also dispel the idea that in other areas, including illnesses, injuries, and treatments, older patients will always remain less able to function adequately or be able to adapt to new conditions than will younger people. For example, a powerful new antibiotic may reduce the fatality rate in all adults, but much more so in the elderly. With respect to the evaluation and treatment of closed-head injuries, aging may allow the elderly to tolerate some expanding lesions better than younger adults thereby avoiding sudden life-threatening conditions—though after falls that may not be significant in younger adults, uncontrollable hemorrhaging may result from blood vessels that are more vulnerable in the elderly.

The point is that in many instances, elderly patients who present to EDs are not just sicker versions of younger adults, but different—sometimes sicker, to be sure, but often not as sick or sick in a different way, with fewer or different signs and symptoms associated with a particular illness. Often-cited, an acutely confused elderly patient, with little or no temperature elevation, no abnormal breath sounds, and no chest X-ray indication of consolidation, may nevertheless have pneumonia causing hypoxia that results in confusion. Another example is the dough-like abdomen of an elderly patient with nondescript gastrointestinal distress, instead of the expected board-like rigidity in a younger adult that accompanies a perforated bowel.

In the years to come, technology will make it possible for older people to function at higher levels, as they live longer. Can’t remember an important person or event? “Google” anything you can think of associated with the person or event, and the information you are seeking becomes an easy multiple choice exercise on the screen. But newer and better medications that can enable people to live longer and better, will only work when emergency physicians know how to recognize the different patterns and choose the best medications and treatments for conditions in that age group.

This is what Geriatric Emergency Medicine is all about.