Chapter 1. The Emergency Department Intensivist

A small, but growing number of emergency physicians (EPs) have pursued fellowship training in critical care (CC).1,2 Many of these dual-trained physicians now practice in intensive care units (ICU) or in a practice split between standard emergency department (ED) shifts and the ICU.3 However, there is a unique role for these Emergency Medicine Critical Care (EMCC)–trained physicians: the Emergency Department Intensivist (EDI).

EPs are masters of the art of resuscitation. Resuscitation generally encompasses the diagnosis and stabilization of a critically ill patient in the first approximately 30 minutes of the ED stay. After this time period, the ED system is predicated on the patient rapidly moving upstairs to a CC unit. However, overcrowding in almost all hospitals has led to a situation in which it may be hours or, unfortunately in some cases, days before a patient may get an ICU bed. Most EDs are not designed or staffed to provide care beyond the initial resuscitation, and yet patients remain in the ED, sometimes languishing without optimal care. Even with ample staffing, the meticulous management requirements and the necessity for obsessive attention to detail in the care of the critically ill are sometimes unappealing to EPs.4

However, it is desirable for patients to receive the same evidence-based aggressive care regardless of their geography in the hospital. It does not make sense for there to be one standard in the ICU and a different standard for the hours spent in the ED. The EDI can bring “Upstairs Care, Downstairs©.” By bringing the intensive therapies of the ICU to the bedside in the ED, the EDI can mitigate the negative effects of hospital overcrowding on the critically ill patient.

The nascent field of EMCC has outpaced the terms needed to describe it. The following is a list of definitions:

• EMCC—A subspecialty of EM dealing with the care of the critically ill both in the ED and in the rest of the hospital.
• Emergency Physician Intensivist (EPI)—A physician who has completed a residency in EM and a fellowship in CC.
• Emergency Department Critical Care (EDCC)—EMCC practiced specifically in the ED.
• Emergency Department Intensivist (EDI)—An EPI who practices EDCC as a portion of clinical time.
• Emergency Department Intensive Care Unit (ED-ICU)—A patient care unit within an ED with the same or similar staffing, monitoring, and capability for therapies as an ICU.

Any sick patient will benefit from the presence of an EDI, but certain specific clinical scenarios are uniquely suited to their skill set.

Airway Management

Although advanced airway techniques are the sine qua non of any EP, the EDI brings even more options to the ED. Experience with fiberoptic bronchoscope-aided intubations is possessed by only a fraction of EM programs, but most EDIs are skilled with this procedure. Many EDIs also have experience with percutaneous and open tracheostomies. ...