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. In the ED, this experience allows the performance of emergent surgical airways and the management of emergencies in patients with existing tracheostomy. In some hospitals, the EDI may be an ideal practitioner to place elective bedside tracheostomies as well.

Respiratory Failure

A large portion of CC fellowship training is spent gaining experience with the management of acute and chronic respiratory failure. This education gives the EDI knowledge of advanced modes of ventilation, salvage of acute respiratory distress syndrome (ARDS) patients, and increased exposure to noninvasive ventilation. EM offers little training in the extubation of patients, but the EDI can comfortably extubate patients who have resolved the condition that necessitated intubation.5

Shock and Sepsis

The early goal-directed therapy (EGDT) study by Rivers et al may have been the gateway for CC in the ED.6 In addition to elucidating a bundle of therapies to manage the septic patient early in the hospital course, this study demonstrated that CC in the ED is possible and life-saving. EDIs possess a broader knowledge on antibiotic choices, source control, and advanced monitoring than most other EPs. An extensive knowledge of hemodynamic monitoring, vasoactive agents, and the ramifications of alterations of oxygen delivery and the microcirculation gives the EDI a unique perspective on how early actions in the ED can affect the patient's long-term outcome.

Post–Cardiac Arrest Care and Therapeutic Hypothermia

Aggressive treatment of the postarrest syndrome, especially with an emphasis on early and consistent maintenance of induced hypothermia, is critical for good outcome in patients after cardiac arrest.7 This level of care is beyond the resources of many conventional EDs for longer than the first hour of care. The EDI can spearhead a hospital postarrest program or be a primary clinician in the actual clinical management of these patients.

Trauma

EDIs who have received their CC training in a surgical/trauma fellowship are uniquely suited to organize a trauma resuscitation program. Mastery of all aspects of the early management of the critically ill trauma patient including blood component transfusion, conservative versus operative management, timing of angiographic interventions, surgical airways, and the lethal triad of hemorrhage (acidosis, hypothermia, and coagulopathy) is in the purview of a trauma-trained EDI.

The EDI is the ideal ED proceduralist, by nature of the training and experience with management of complications. While the placement of emergent central venous catheters may be routine during residency training, EDIs have a much greater appreciation for sterile technique and the value of infection control after a CC fellowship. During training in CC, EPIs learn the long-term consequences and morbidity of infectious complications.

EDIs are trained to be aggressive in their care. However, this aggressive care can be directed toward a curative or a palliative path. EDIs also receive training and have experienced the intricacies of advanced directives and family discussions on palliation and withdrawal of care. All of the advanced therapies and monitoring modalities an EDI brings to the ED must be balanced with a zealous approach to palliation and end-of-life care. Training in the long-term management of the critically ill patient allows the EDI to have better insight into the outcome of resuscitating the terminally ill. Although not as glamorous as high-profile treatments, this role is another powerful reason to bring CC to the ED.

ED intensive care is best performed in a dedicated area of the ED. This allows for beds with comprehensive hemodynamic monitors, a nursing staff with additional training, and the equipment necessary for advanced diagnosis and treatment. While the ideal setting may be an ED-ICU, the resuscitation area present in many EDs works well as space for EDCC.

While some EDs can support a number of EDIs, many academic departments will benefit from a single EDI. Just as one toxicologist can elevate the toxicology-related care for an entire academic program, the addition of an EDI can allow for the development of an EDCC program. At least at the beginning stages of bringing CC to the ED, the EDI may be the only health professional having experience with certain advanced treatment and diagnostic modalities.

In the ICU, bedside nurses may handle all of the hands-on equipment, for example, setting up pressure transduction to allow arterial line pressure monitoring. In the ED, it may be the EDI who is performing this setup in the beginnings of an EDCC program. Eventually the nursing staff may own this advanced practice, or in some EDs, CC nurses are integrated into the ED staff.

A residency program with an EDI on faculty will naturally graduate residents with a greater knowledge and appreciation of the role of CC in the ED. In my own program, both a dedicated EDCC lecture series and trauma lecture series are taught by an EDI.

The EDI is well suited to provide quality improvement for ED mortalities and any discrepancies in the care of the critically ill patient. At the hospital level, he or she can act as champion for initiatives such as sepsis care, induced hypothermia, deep sedation, and advanced airway management.

In conclusion, the EDI is a tremendous asset to an EM program. The gratifying training path to a career as an EDI obviates any uncertainty over certification in EMCC. The EDI facilitates ED patients getting comparable care in the ED and the ICU. Through direct clinical care and program development, the EDI can bring the level of care of an entire ED up to a level beyond initial resuscitation and equivalent to an ICU.