Chapter 1. Approach to the Emergency Department Patient

An emergency is commonly defined as any condition perceived by the prudent layperson—or someone on his or her behalf—as requiring immediate medical or surgical evaluation and treatment. On the basis of this definition, the American College of Emergency Physicians states that the practice of emergency medicine has the primary mission of evaluating, managing, and providing treatment to these patients with unexpected injury and illness.

So what does an emergency physician (EP) do? He or she routinely provides care and makes medical treatment decisions based on real-time evaluation of a patient's history; physical findings; and many diagnostic studies, including multiple imaging modalities, laboratory tests, and electrocardiograms. The EP needs an amalgam of skills to treat a wide variety of injuries and illnesses, ranging from the diagnosis of an upper respiratory infection or dermatologic condition to resuscitation and stabilization of the multiple trauma patient. Furthermore, these physicians must be able to practice emergency medicine on patients of all ages. It has been said that EPs are masters and mistresses of negotiation, creativity, and disposition. Clinical emergency medicine may be practiced in emergency departments (EDs), both rural and urban; urgent care clinics; and other settings such as at mass gathering incidents, through emergency medical services (EMS), and in hazardous material and bioterrorism situations.

Emergency medicine serves as the US health care safety net. It provides valuable clinical and administrative services to the health care delivery system, including care for the indigent and others who lack access to health care, and has evolved as the most visible and vital component of a patchwork of health care providers and facilities. EDs have become the routine, and often the only, source of care for many of the uninsured, thereby acting as a critical safety net for our fragmented health care delivery system.

Finally, EDs are the only element of the health care system whose function has been delineated by federal law. Initially authorized in 1986, the Emergency Medical Treatment and Active Labor Act mandates that all EDs provide screening, stabilization, and appropriate transfer to all patients with any medical condition. Emergency medicine is often the last resort for many patients and frequently the access point for competent, comprehensive, and efficient medical care.

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 he or she needs 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 will increase. This leads to patient dissatisfaction and an increased risk of litigation, not to mention the potential that the patient is leaving with a potential life threat that has not been identified.

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 patients 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 patients 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 clichés 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 EPs 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.

It is often said that ED patients “don't read the textbook,” meaning that their presentations do not fit nicely into specific textbook diagnoses or classical presentations of illness. However, a cornerstone of an EP's practice is the recognition of patterns in a patient's presentation; therefore, the prudent physician must be a detective and scientist to muddle through the muck of vague signs and symptoms to find the pattern.

The principles of emergency medicine are simply questions that must be answered to provide effective care to patients who have entrusted EPs with their care. The questions are not to be used as a cookbook approach to the management of these often complex medical and psychosocial issues but are to be used as a simple method to guide the prudent EP through the quagmire of clinical emergency medicine.

Is the Patient About to Die?

Obviously, this is the first and most important question to answer. Every patient's presentation is quickly prioritized to one of the following acuities:

Critical

Patient has symptoms consistent with a life-threatening illness or injury with a high probability of death if immediate intervention is not begun.

Emergent

Patient has symptoms of illness or injury that may progress in severity if treatment is not begun quickly.

Nonurgent

Patient has symptoms that have a low probability of progression to a more serious condition.

Look for symptoms of a life-threatening emergency, not a specific disease entity. Anticipate impending life-threatening emergencies in the apparently stable patient.

What Steps Must Be Undertaken to Stabilize the Patient?

Act quickly to stabilize the critically ill or injured patient. Focus on the primary survey (airway, breathing, circulation, and neurologic deficits), and make necessary interventions as each issue is identified. Do not delay necessary primary interventions while awaiting completion of ancillary testing.

What Are the Most Potential Serious Causes of the Patient's Presentation?

Thinking of the worst-case scenario, develop a mental list of the most deadly causes of the patient's presentation by asking, “What will kill this patient the fastest?” Once the list has been developed, the vital signs, history, physical examination, and ancillary assessments should identify or confirm those causes highest on the list.

Could There Be Multiple Causes of the Patient's Presentation?

In addition to constant reevaluation and reprioritization of the differential diagnosis, continually ask, “Is this all there is?” For example, is the new-onset seizure and hypoglycemia in an older diabetic patient from intentional or accidental medication overdose or perhaps worsening renal insufficiency? Is the near-syncope and abdominal pain in an apparently intoxicated college coed from a ruptured ectopic pregnancy or perhaps a ruptured spleen secondary to undisclosed physical abuse by her boyfriend? Frequent reassessment and thoughtful inquiry as to the multiple possibilities responsible for each patient's condition is imperative.

Can a Treatment Assist in the Diagnosis in an Otherwise Undifferentiated Illness?

Often, in emergency medicine, treatment response foretells a diagnosis. A case in point is the unconscious patient with no available collateral history. The patient's response to empiric administration of naloxone will include or exclude narcotic overdose as a contributor to the obtundation. Referred to as the “diagnostic–therapeutic” concept, it underscores the emergency medicine philosophy that an established diagnosis is not a prerequisite to initiating appropriate treatment. Pitfalls can exist. For example, sublingual nitroglycerin and so-called GI cocktails can relieve symptoms of chest pain resulting from the same cause.

Is a Diagnosis Mandatory or Even Possible?

After the emergency issues have been addressed, the patient and EP are often left with an undifferentiated symptom complex. This frequently elicits an uncomfortable response by nonemergency medicine trained physicians. The EP should become accustomed to and comfortable with the notion of determining the disposition for nonemergency patients—having treated their symptoms and excluding emergency conditions—without a specific diagnosis.

Does This Patient Need to Be Admitted to the Hospital?

Having appropriately answered the preceding questions, make the bottom-line disposition decision. Once assessments and treatments are under way, decide whether an emergency condition exists. Consider other subtleties. Does the patient have timely, accessible follow-up? How far away from a medical facility does the patient live? Are unresolved abuse or self-care issues involved? Are you, as the EP, comfortable discharging the patient?

If the Patient Is Not Being Admitted, Is the Disposition Safe and Adequate for the Patient?

More frequently than not, patients are discharged home from the ED. However, many patients do not receive a specific diagnosis, and some symptoms may persist. Recommend appropriate follow-up, and provide written discharge instructions. Instruct the patient when to return for further evaluation should symptoms change or worsen. Provide the patient with information regarding treatment and diagnosis as well. In patients who choose to leave against medical advice, the EP must make it clear that there are no hard feelings and the patient is welcome to return at any time.

Emergency medicine has seen a tremendous growth and increase in awareness of the unique aspects of the profession. It remains a challenging and fulfilling experience for many physicians and an appealing choice of specialties for medical students. As emergency medicine matures as a specialty, its importance as the US health care safety net and its integral status as front-line medicine will continue to expand and grow.