Emergency Departments: Primary Care of the New Century?

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Author: Kenneth K. Chang, MS III
Western University of Health Sciences
AAEM/RSA Education Committee

As aspiring emergency medicine (EM) physicians, what is it that motivates us? Perhaps it was from working as a first responder or in emergency medical services? Or maybe even from shadowing at a busy trauma center or watching a TV show come to life as the ED team rush to diagnose a complex pediatric poisoning? Or maybe, it was a poignant personal experience with serious disease or injury? While these challenging and adrenaline-rush cases provide variety and excitement to the profession, one must always remember that the core of EM is often times primary care medicine. According to the 2014 CDC data, while there were 141.4 million ED visits in the year, only 7.9% of those were critical cases requiring hospital admission.[3] As many as one-third of ED visits are thought to be for primary care complaints.[5] Although there is not a set definition, most of these are defined as non-urgent ED visits, conditions in which a delay of several hours of care would not increase the likelihood of adverse outcomes. In retrospective medical record reviews, non-urgent visits were defined by diagnoses, whether hospital admission was an endpoint, symptoms, and vital signs to name a few. However perceived seriousness of condition by the patient may also be a subjective factor. With changing healthcare policies of our new era, it is inevitable that access to healthcare, especially primary care, will be a significant concern for the younger uninsured and Medicaid population.[4] It is evident that the greatest increase in ED visits between 2006 and 2014 were from the Medicaid population. In that time period, with the exception of injury as the first-listed diagnosis, there has been an increased percentage in medical, mental health/substance abuse, and maternal/neonatal conditions that were managed on an outpatient disposition. From the EM profession’s standpoint, the questions arises: should there be more policy changes and interventions to decrease use of the already overextended ED’s? Or should the EM profession embrace this inevitable change and adapt to care for primary care issues?

EKG Case Study: Is There More to This Chest Pain?

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Author: Ashley Grigsby, DO, PGY-4
Combined Emergency Medicine/Pediatrics
Indiana University

Case
A 32-year-old previously healthy African American male presents via emergency medical services (EMS) for evaluation of chest pain. An ST elevation myocardial infarction (STEMI) code had been activated by EMS based on pre-hospital electrocardiogram (EKG) that had been interpreted as ST elevation in the anterior leads with reciprocal ST depression in the lateral leads. On arrival to the emergency department (ED), the patient appears ill and reports severe crushing chest pain radiating to the arm and down into the abdomen. He is diaphoretic and clutching his chest. His heart rate is 123 beats per minutes, respiratory rate 16 breaths per minute, and blood pressure 210/110 mmHg. He is afebrile. Initial ED EKG is shown below.

Just a Nick?: Mitigating and Identifying Paracentesis Complications

Image Credit: Wikimedia

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Author: Mitchell Zekhtser, MS III
Western University of Health Sciences
AAEM/RSA Vice-Chair of Education Committee

Case
A 60-year-old female with a past medical history of alcoholic cirrhosis presented to the emergency department (ED) with abdominal pain and distension seven hours after undergoing a paracentesis. The patient noted that she routinely had the procedure done at her primary care office, but today she started feeling distended again at an accelerated rate. On exam, the patient was hypotensive with a pressure of 98/57, tachycardic with a heart rate of 110, and had diffuse abdominal tenderness worst in the left lower quadrant (LLQ). A computed tomography (CT) scan revealed blood between the abdominal wall and parietal peritoneum, and complete blood count (CBC) showed an acute drop in hemoglobin. Several hours after presentation, the patient underwent an emergent exploratory laparotomy, which revealed a lacerated left inferior epigastric artery (IEA), likely a result of her recent paracentesis. The patient lost four liters of blood throughout the operation. During her stay, she received a total of five units of packed red blood cells and three units of fresh frozen plasma. While the patient survived the surgery, unfortunately, she passed away two weeks later due to exacerbation of her chronic conditions.

Resident Journal Review: Inflammatory Bowel Disease

Authors: Erica Bates, MD and Adeolu Ogunbodede, MD
Editors: Michael Bond, MD FAAEM and Kelly Maurelus, MD FAAEM
Originally Published: Common Sense March/April 2018

Introduction
Inflammatory bowel disease (IBD), which includes both Crohn’s disease (CD) and ulcerative colitis (UC), is a potentially debilitating chronic inflammatory condition of the digestive tract that affects over one million Americans.[1] Individuals with IBD are at risk for a number of potentially serious complications which emergency physicians must be able to recognize and manage. Here we review several articles relevant to the care of this patient population.

Top Ten Things I Have Learned Along the Interview Trail

Author: Chris Ryba, MS4
Loyola Stritch School of Medicine
AAEM/RSA Medical Student Council President

As my interview season comes to a close and Match Day now awaits on the horizon, I thought now would be the perfect opportunity to list the top ten things I have learned along the interview trail:

1. The Interview Trail is TIRING
Long days, long travel times across the country, early morning starts, and the constant goal of always trying to look your best during months of interviews can take a major toll on the body.

My advice: Rest up and keep a good sleep schedule, maintain a healthy lifestyle, pack meals for road trips, and take advantage of hotel perks.

Chief Complaint: I Feel Like I’m About to Have a Seizure

Image Source: Pixabay

Author: Elaine Holtzman Brown, MD
University of Mississippi Medical Center
Board Liaison to the RSA Social Media Committee
Originally Published: Common Sense March/April 2018

Your patient is a 69-year-old female with a past medical history significant for seizure disorder, hypothyroidism, anxiety, and frequent urinary tract infections. She presents with a four-day history of generalized weakness to the point where she can no longer walk without assistance. Additionally, she has shortness of breath that worsens with exertion. She is anxious, and feels like she is about to have a seizure. You hear her say, “I have this feeling of impending doom.” And there it is. This lady has a PE. You nailed it!