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What actually happens in an Emergency Department?

What actually happens in an Emergency Department?. Jeremy Ackerman.

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What actually happens in an Emergency Department?

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  1. What actually happens in an Emergency Department? Jeremy Ackerman

  2. “Emergency medicine is the medical specialty dedicated to the diagnosis and treatment of unforeseen illness or injury. It encompasses a unique body of knowledge as set forth in the “Model of the Clinical Practice of Emergency Medicine.” The practice of emergency medicine includes the initial evaluation, diagnosis, treatment, and disposition of any patient requiring expeditious medical, surgical, or psychiatric care…” American College of Emergency Physicians “Definition of Emergency Medicine”

  3. ER NBC's second longest-running drama • the longest-running American primetime medical drama of all time. • It premiered on September 19, 1994 • It has been aired on Thursday nights at 10:00 for its entire run. • This season will be the last and will end in February 2009

  4. Is it accurate? • The script of the 1994 pilot was essential unchanged from the movie script written in the early 70s… • Many of the leaders of emergency medicine have made cameos… • Regularly cite recent articles and update patient management to reflect current standard of care…

  5. “Cardiopulmonary Resuscitation on Television — Miracles and Misinformation”Susan J. Diem, M.D., M.P.H., John D. Lantos, M.D., and James A. Tulsky, M.D. NEJM Volume 334:1578-1582June 13, 1996Number 24 ABSTRACT Background Responsible, shared decision making on the part of physicians and patients about the potential use of cardiopulmonary resuscitation (CPR) requires patients who are educated about the procedure's risks and benefits. Television is an important source of information about CPR for patients. We analyzed how three popular television programs depict CPR. Methods We watched all the episodes of the television programs ER and Chicago Hope during the 1994–1995 viewing season and 50 consecutive episodes of Rescue 911 broadcast over a three-month period in 1995. We identified all occurrences of CPR in each episode and recorded the causes of cardiac arrest, the identifiable demographic characteristics of the patients, the underlying illnesses, and the outcomes. Results There were 60 occurrences of CPR in the 97 television episodes — 31 on ER, 11 on Chicago Hope, and 18 on Rescue 911. In the majority of cases, cardiac arrest was caused by trauma; only 28 percent were due to primary cardiac causes. Sixty-five percent of the cardiac arrests occurred in children, teenagers, or young adults. Seventy-five percent of the patients survived the immediate arrest, and 67 percent appeared to have survived to hospital discharge. Conclusions The survival rates in our study are significantly higher than the most optimistic survival rates in the medical literature, and the portrayal of CPR on television may lead the viewing public to have an unrealistic impression of CPR and its chances for success. Physicians discussing the use of CPR with patients and families should be aware of the images of CPR depicted on television and the misperceptions these images may foster.

  6. Some of what we do: • Emergency stabilization of critically ill patients • Ongoing management of critically ill patients • Screen for psychiatric illness • Obstetrics and gynecology • Pediatrics • Minor surgical procedures – wound repair, central lines, I&D • Major surgical procedures – chest tubes, thoracotomy • Orthopedics – reducing fractures and dislocations, splinting • Cardiology – EKG interpretation, management of arrhythmias • Ophthalmology – eye trauma, eye infections • Infectious disease • Screen for child abuse and domestic violence • Interpret radiographic studies • Perform radiographic studies – ultrasound • Routine medical care If someone in the hospital does it, we probably do it too! (or at least we have to know when to call them)

  7. Other important facts: Nationally: • The admission rate from the ED is between 15 and 20% • The ED accounts for a growing percentage of all hospital admissions (>50%) • Emergency Departments are the only place everyone is guaranteed access to medical care under federal law In smaller hospitals, the Emergency physician may be the only physician physically in the hospital Many EDs see all ages from neonates to 100+ “ER Diversion” does not stop the patients from coming

  8. “When I come to work, as I get ready to leave my driveway, I say, ‘Dear Lord, help me not to make a mistake tonight,’ and when I leave the hospital, I say, ‘Dear God, thank you for getting me and my patients through another night.’” – Arthur D. Kellerman, MD

  9. Two overnight eight-hour shifts: AGE 61 30 22 42 43 23 51 70 68 20 44 30 48 66 51 21 40 40 37 25 43 28 54 53 42 60 89 24 21 27 60 86 26 83 CHIEF COMPLAINT Bladder infection abdominal pain for 2 weeks sickle cell, abdominal pain for 2 weeks flank pain for 2 weeks (pulmonary embolism) nausea, vomiting, dehydration, abdominal pain abdominal pain RUQ x1 week, acutely worse fever (renal transplant with UTI) fever, history of prostate and stomach cancer dyspnea x3 weeks, j fever, nausea, vomiting, pyleonephritis cut on upper arm back pain abdominal pain for 5 months fatigue and weight loss for six months, can't walk Asthma attack vomiting blood Asthma attack eye pain and blurred vision flank/hip pain itching and rash nausea, vomiting, dehydration, abdominal pain, vaginal discharge, multiple others constipation, aneuria fever nausea, vomiting, abdominal pain chest pain swollen finger and dyspnea buttock pain, malaise Chest pain, non-Hodgkin's lymphoma abdominal pain, nausea, vomiting severe low back pain respiratory distress Chest pain combative behavoir and twitching DISPO D/C D/C D/C admit D/C D/C admit D/C admit D/C D/C admit D/C admit D/C admit admit D/C D/C D/C D/C D/C D/C admit admit admit D/C D/C D/C CDU D/C ICU D/C transfer ACTIONS lab, transfuse, antibiotic ultrasound, lab lab, CT CT, lab, EKG, CXR lab, IVF lab, ultrasound lab, antibiotics, IVF, CXR, EKG lab, antibiotics, CXR EKG, CXR, lab IVF, lab, antibiotics suture and hemostasis lab, meds CT, lab, meds lab, CXR, EKG CXR, meds lab, IVF lab, CXR, meds opthamology med, security medication IVF, meds, labs labs xr lab, CXR, antibiotics lab, meds, CT, IVF lab, EKG, CXR, meds lab, XR, EKG, meds lab, CT, med, I&D lab, XR, EKG, meds lab, meds, IVF lab, meds, EKG, CT lab, XR, intubation, central line, ventilator, antibiotics CXR, EKG lab, CT, XR, EKG DIAGNOSIS bladder cancer, anemia, urinary obstruction pelvic pain uncertain cause sickle cell pain, abdominal pain uncertain cause pulmonary embolism abdominal pain uncertain cause cholelithiasis with colic UTI vs. rejection likely UTI congestive heart failure exacerbation, acute renal failure pyleonephritis laceration lumbar disk disease, chronic pain abdominal pain, unknown cause UTI, hyponatremia, likely cancer asthma exacerbation with bronchitis post tonsilectomy hemorrage pneumonia corneal abraision and conjunctivitis opiate dependence, opiate abuse, chronic pain allergic reaction gastroenteritis UTI, BV, bipolar constipation, severe dementia UTI, renal transplant many operations, intractable vomiting and abdominal pain acute MI congestive heart failure, ainflammatory arthritis vs. infectious abcess, UTI pleural effusion, chest pain, possible recurrance of lymphoma after BMT abdominal pain uncertain , possibly ulcer kidney stone, chronic pain, hemipeligia, s/p stroke pneumonia, CHF, respiratory failure, s/p stroke anxiety dementia, anemia

  10. The statistics: • Total patients: 34 in 16 hours =2.125/hr • Admit*: n=11 35% • Discharge n=23 65% Admissions include: • Transfer n=1 3% • ICU n=1 3% • Observation n=1 3%

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