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UNIQUE ASPECTS OF EMERGENCY MEDICINE PRACTICE

An EP faces numerous challenges. The first and most distinctive challenge is that of limited time. Time constraints occur because of the severity and acuity of the illness and also because of the ever-present worry that someone else will need the physician's attention. The second challenge for the EP is that they need to quickly assess and make therapeutic decisions on the basis of limited information. The EP may also be providing medical control for patients in the prehospital environment. In addition, the EP also will need to determine what care was given prior to arrival and what impact the intervention made. History may be provided from bystanders or EMS providers and given to the physician second hand.

The EP has a different mindset than other specialties. The main concern of the EP is not necessarily the diagnosis, but a process of thinking aimed at ruling in or out serious pathology that is life- or limb-threatening. The classic model of history taking followed by a physical examination and then diagnostic testing must often be compressed and conducted simultaneously when time is of the essence and the patient's life is threatened.

The evaluation of patients should proceed in a parallel fashion rather than the time-honored serial method. The mindset that patients must be triaged and registered in the waiting room when there are beds available must be abandoned. Patients should be taken straight away to any available room where the physician and nurse assess the patient and get the history while the patient is simultaneously having an intravenous line with blood work drawn and registration occurring in the room. The single intervention of in-room registration can decrease the length of stay of the patient by an average of 15 minutes.

The ED is a unique environment in that hospital EDs are required by federal law to evaluate patients without regard to ability to pay. In 2005, there were an estimated 45-48 million Americans without health insurance. This puts financial strains on both hospitals and physicians. In addition, patients with nonurgent health problems use the ED for a variety of reasons. Studies have found that the majority of patients were not aware of other places to go for their care. When an ED reaches 140% of its capacity, the number of patients leaving without being seen increases. This leads to patient dissatisfaction and an increased risk of litigation.

Because of a number of factors it may be difficult to get on-call physicians to care for patients seen in the ED. In a recent study conducted in California it was found that the lack of insurance had a negative impact on the availability to obtain specialty physician assistance. The seven specialties noted to have the greatest difficulty in obtaining specialty consultations were plastic surgery, ENT, dentistry, psychiatry, neurosurgery, ophthalmology, and orthopedics. This was found despite the medical staff bylaws that required on-call ED coverage. It is up to the EP to be the patient advocate, even when that means holding a patient in the department until they can get the care they need or the appropriate laboratory or specialty evaluation to let them safely go home.

It is imperative that the EP be informed about the resources that are available to the patients after discharge. It is a simple matter to send a patient to see a physician that they already have a relationship with. It may not be such an easy matter for the uninsured or indigent patient. Various clinics in the community can assist patients with needs such as prenatal care or those with diabetes or HIV. In addition, the physician must inquire about domestic violence and elderly abuse and remain vigilant about the potential of child abuse.

EPs work in an environment in which patients die. Despite the circumstances surrounding the patient's death, the EP needs to get answers to a myriad of questions: Why the person died, will the illness have an impact on survivors, does the illness put health-care workers and society at risk, should an autopsy be performed for medical or legal reasons, and does the family desire organ donation? In interacting with survivors, the EP should avoid cliches that can be misleading and let the survivors know that the patient has died, in whatever language is appropriate. The EP needs to be on guard for the occasional violent reaction by survivors, so doors need to be open and security may need to be in close proximity. It behooves the EP to find positive ways to take care of themselves and the ED staff from emotionally traumatic events through techniques such as stress debriefing or counseling. - source: McgrawHill Textbook on Medicine

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