Episode 19: Emergency medicine with Seth Trueger

A few rapid-fire cases from the emergency department, with Dr. Seth Trueger (@mdaware), emergency physician at Northwestern University and digital media editor for JAMA Network Open. [Sorry for the shotty audio quality in this one!–eds.] Takeaway lessons * Many decisions in the ED are less about what to do, and more about when to do it. Time and location are key considerations for efficient care.* Goals of care starts in the ED, and not with lip service. Yes, temporize with supportive care while you go through the process, but do the work—find a legitimate representative or documentation of the patient’s wishes to determine what they’d want before you commit them to lengthy, aggressive life support. Aggressive but non-invasive medical care may also strike a good balance, keep everyone happy, and often avoid the need for invasive measures.* Over 1/3 of patients 65+ in the ED (excluding trauma and cardiac arrest) will die during that admission within 3 days.* The best ED provider intubates the “right” number of patients, while bad ones may intubate either too few or too many.* While ethically, extubating and withholding intubation should be equivalent, in practice the former feels more difficult.* Emergency staff have limited bandwidth. Evaluate the opportunity cost of everything you do. It’s not about whether it’s valuable or indicated; is it more valuable than whatever you or the nurses could be doing instead?* “Where is this patient going?” is always, ultimately, the main question of the EM provider. This differs from the main questions of many of their consulting and admitting specialties.* ICU time and ED time are different. In the ED, the ability to limit the amount of work is itself limited, so the judicious provider needs to jealously protect that time. In the ICU, we have a useful (albeit sometimes flexible) cap: our total number of beds.* Remember that nobody sees anyone else’s denominator. How many patients the ED sends home, how many consults don’t get called, how many floor patients are managed there instead of coming to the unit; these blind spots tend to promote small-mindedness and inter-disciplinary judgment. References Patel KK, Young L, Howell EH, et al. Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting. JAMA Intern Med. 2016;176(7):981–988. doi:10.1001/jamainternmed.2016.1509