The Good, Bad & Ugly

Of Emergency Medicine

ACOEMP Fall Scientific Assembly 2016

Corey M. Slovis, M.D.

Vanderbilt University Medical Center

Metro Nashville Fire Department

Nashville International Airport

Nashville, TN

I have no conflicts of interest

Learning Objectives

• Better understand the history of emergency

medicine and appreciate the conflicts

encountered during practice

• Create a sense of pride being an emergency

physician

• Learn how to do a better Valsalva maneuver

The Ugly

The IOM Report

• ED volumes continue to rise rapidly

• EDs closing as more patients need care

• ED crowding is a hospital problem

• ED IP boarding continues to increase

• Ambulances diverted > 500,000 / yr

“With many EDs at or over capacity,

there is little surge capacity for a major

event, whether it takes the form of a

natural disaster, disease outbreak or

terrorist attack”

The IOM Report

The IOM report was over a decade ago;

released in June of 2006

The Ugly continued

So what’s happened since the

IOM Report?

ED Care 2016

• More ED patients

• More EDs closed

• More ED diversions

• Health care reform has not addressed

EDs much

“…policymakers seem to view EDs

as little more than a focus of

inefficient or unnecessary care – a

place where patients without access or

insurance seek care at great expense

to the taxpayers”

How We are Viewed

Schuur JD, Venkatesh AK.

The Growing Role of EDs in Hospital Admissions.

New Engl J Med 2012;367:391-3

High Intensity ED Visits

Have Increased

• Total ED visits went up 25%

• High acuity ED visits by 87%

Health Affairs 2013;32:1811-19

We are seeing sicker and sicker patients

in our EDs

The Good

We are doing an amazing job in the

face of adversity and need to be

proud of what EDs and ED MDs,

DOs, RNs, PAs, NPs and

Paramedics do 24/7/365 in our EDs

The Good -

And Yet The Ugly

We in the ED are

being punished• For all that is wrong with modern

healthcare

• For the lack of PCPs

• For patients who are uninsured

• For lack of preventative care

• For politicians who are so dysfunctional

We in the ED are

being punished

• Because we are always available

• Because EMTALA only applies to EDs

• Because insurers can attack us so easily

• Because we are so efficient

• Because “anyone can work in an ED”

What’s worse, EDs are closing and the

number of trauma centers are decreasing

• As drive time increases, trauma

mortality increases

• Mortality increased by 21%

• By 2 years, mortality by 29%

J Trauma 2014;76:1048-54

• As EDs close, ugly things happen

• IP-mortality 5% at contiguous EDs

• Death 15% for AMI, sepsis and CVA

• mortality still present 2 years later

Health Affairs 2014;33:323-29

And to rub salt into the wound, the

insurers are trying to avoid paying us

for rendering emergency care based on

ED non emergency chief complaints or

discharge diagnoses

More Bad

Does the chief complaint reliably predict

who has an ambulatory non ED disease

better seen by a PCP or clinic?

• 34,942 ED patients

• National Hospital Ambulatory Survey

• 6.3% of pts were ultimately deemed primary care pts

JAMA 2013;309:1145-53

The chief complaints of the patients who

ultimately had non-urgent primary care

illnesses were the same as 88.7% of all ED

patients – many of whom were quite ill

JAMA 2013;309:1145-53

• 11.1% deemed high acuity

• 12.5% required hospital admission

• 3.4% went directly to the OR

You can’t use discharge diagnosis to

say the patient did not need to come

to the ED

“non cardiac CP” does not need to be

seen in the ED

But it’s only non-cardiac after 1-2

ECGs, 1-2 troponins, maybe a CXR,

other blood work and possibly a

stress test or coronary CTA

Boarding only gets worse

• Hospitals are full, IP boarding

• Waiting rooms overflow

• Patients are angry at us

• “We should fix it”

• “We should go faster”

The longer patients board in the ED,

the worse they do

Independent Predictors of Death*

• Door to team aOR 1.13 (1.07-1.18)

• Door to wards aOR 1.07 (1.02-1.13)

*adjustment included Charlson’s index and AISS (acute illness severity score)

Waiting room medicine isn’t really a

new subspecialty!

So what’s so good about

Emergency Medicine?

Emergency Medicine 2016

• We treat almost 140 million pts / year

• And we do so cheaply – regardless of

what so many say

• Total US costs = $2,100,000,000

• ED care < 2% of US health care costs

We treat whomever presents to us

regardless of race, creed, color, point of

national origin, sexual preference,

sexual identity or how they look, smell

or curse at us

People claim we are used only by those

who don’t need us, or those without

their own physician

Yet 85% of all ED patients have some

kind of health coverage

We are so popular, so busy, so

overcrowded – because we are

so damn good

ED Work Ups

• We can do a 1-3 day inpatient workup…

in 4-12 hrs

• And have patients appreciate it

• It’s why we get so many referrals from

patients’ physicians

• “You sound really complicated – better

go to the ED, I’ll call them”

In the ED

• Immediate blood testing for anything

• CT, CTA, CCTA, CT perfusion

• MRI, MRA, MRV

• ECG, EEG, EMG

• US, Doppler flows, Nuclear studies

How popular are we?

There are now almost 50,000 ED

physicians of which 37,000 are

board certified

Emergency Medicine Residency

Matches - 2016

• 171 EM residency programs

• 1,821 residency positions offered

• EM was third most popular specialty for

graduating US medical students (behind IM

and Peds)

• EM is the most competitive, large resident

number specialty in the US (> IM or Peds)

The Good and Great of

Emergency Medicine

Look at all that we continue to

learn to do and deal with

Is there any other specialty that has

changed so much with such great success

and practice advancement

It’s time for us to be very proud

Recent changes that we take for granted…and/or

learn or master

We foam in and foam out about

100 times a shift

mostly without even thinking about it

We are ready for anthrax,

Ebola, botulism, sarin gas or

a bomb blast from terrorists

We know about Dengue,

Chikungunya and Zika

Ann Emerg Med 2010;56:27-33

We place orders before patients even

get in their ED bed

We now routinely use ultrasound to

guide CPR, resuscitations, find

veins, diagnose pulmonary edema,

assess volume status and to find

pneumothoraces

• Oxygenate and Ventilate

• Secure IV access

• Look for 3 causes

EMD - PEA

5 Step Management

– ECG– Temperature– Volume Status– Ultrasound Look

• Epi – 1 mg Q 3 min

• Review for All 5 Causes

CAUSE

4 Chamber View

Pericardial Effusion + ↓RV = Tamponade

↓RV + ↓LV = Hypovolemia

↑RV + ↑RA vs. ↓LV = PE

Poor Contractility = Cardiogenic Shock

Normal = Lung View

When the nation faced an Ebola crisis it

was the entire ED, and all who worked

in it, who geared up to be able to

evaluate potential victims

Not that many years ago, anesthesia

came to many EDs to perform advanced

invasive airway techniques or just

to intubate

Now we in the ED do RSI, apneic

oxygenation, videolaryngoscopy and

utilize state of the art check lists to

ensure expert management

Check list medicine now

exists for many emergencies

We Routinely Use Drugs Never

Before Seen in the ED

• Propofol

• Etomidate

• Ketamine

• Our own mixtures

• Paralytics

We Have Become the Experts in

• Cardiac Arrest

• Toxicology

• Chest Pain Evaluations

• Disaster Medicine

• Excited Delirium

We Use Evidence Based Protocol

• Indications to perform a D-dimer

• PE evaluation and therapy

• Chest pain R/O ACS pathways

• Ankle and knee film needs

• Head CT rules s/p trauma

We Approach Death and Dying

Rationally• Many non ED physicians don’t discuss death

& dying even in pre-terminal and terminally

ill patients

• Failed chemo patients still full code

• DNR and DNI are initials only to many

We in the ED counsel with compassion and

expertise at the most emotional times for

patients and their families

And we adapt and change as

old therapies evolve

PSVT Management

Stable Unstable

Younger Older Conscious Unconscious

PSVT Management

Stable

Younger

• Valsalva

• Carotid massage

• Both Valsalva and Carotid

• Consider ice water

• Adenosine 12 mgs IVP

Older

Valsalva

--

--

--

Adenosine 12 mgs IVP

Ann Emerg Med 2015;65:27-29

• Valsalva’s effectiveness in SVT is variable

• Works 17 - 54% of the time

• Usually 10 – 20% effective

• “Usual way” not optimal

• Article discusses way to increase efficacy

Lancet 2015;386:1747-53

Can lying the patient down and raising their

legs 45˚ for 15 seconds immediately post

Valsalva increase its effectiveness?

• 428 Patients with PSVT

• Randomized 1:1 for standard vs. modified

• Sitting vs sitting then lie back with legs raised

0

5

10

15

20

25

30

35

40

45

50

15%

Valsalva Effectiveness(n=214 each group)

Standard Lie back, Legs up

47%%

Lancet 2015;386:1747-53

p < 0.0001

or = 4.9

We in the ED have become all things

to all people

• MDs and RNs

• Social workers

• Drug and ETOH Dependence counselors

• Insurance advisors

• PCPs

• Chaplains

• Care coordinators

• Appointment secretaries

• Cheerleaders

We work each shift as

Emergency medicine is the best

specialty, with the best people, doing

the best things

Emergency physicians are becoming

leaders within medical centers and

medical schools

Our personalities, seeing every

service at their best and worst – make

many of us perfect for leadership

roles in health care

We need to be proud of who we are

We need to brag about all we do

We need to support one another

more during periods of personal

and professional stress

Responsibility

is a Heavy Responsibility

Cheech of Cheech and Chong

Kaizen

• A Way of Life

• Constant Improvement

• Constant Learning

• Looking for Systems Improvements

• Using Problems to Find Solutions

Praise More . . .

Criticize Less

Never make an enemy

when you could make a friend

Never make an enemy

when you could make a friend

Friends come and go

Enemies only accumulate

You and your enemy are one. You co-exist.

You must use your enemy’s energy against

himself in order to defeat him ( or her).

Bruce Lee

Control your emotion or it will control you(Chinese Adage)

The angry man will defeat himself in battle

as well as in life

Samurai Maxim

There are at least

two sides to every story

Softness triumphs over hardness,

feebleness over strength…What is more

malleable is always superior over that

which is immovable.

This is the principal of controlling things

by going along with them, of mastery

through adoption

Lao-Tzu

We need to cherish our

time in the ED