What actually What actually happens in an happens in an

Emergency Emergency Department?Department?Jeremy AckermanJeremy Ackerman

“Emergency medicine is the medical

specialty dedicated to the diagnosis and treatment of unforeseen illness or injury. It encompasses a unique body of knowledge as set forth in the “Model of the Clinical Practice of Emergency Medicine.” The practice of emergency medicine includes the initial evaluation, diagnosis, treatment, and disposition of any patient requiring expeditious medical, surgical, or psychiatric care…”

American College of Emergency Physicians “Definition of Emergency Medicine”

ERER

NBC's second longest-running drama NBC's second longest-running drama the longest-running American the longest-running American

primetime medical drama of all time.primetime medical drama of all time. It premiered on September 19, 1994 It premiered on September 19, 1994 It has been aired on Thursday nights It has been aired on Thursday nights

at 10:00 for its entire run.at 10:00 for its entire run. This season will be the last and will This season will be the last and will

end in February 2009end in February 2009

Is it accurate?Is it accurate?

The script of the 1994 pilot was The script of the 1994 pilot was essential unchanged from the movie essential unchanged from the movie script written in the early 70s…script written in the early 70s…

Many of the leaders of emergency Many of the leaders of emergency medicine have made cameos…medicine have made cameos…

Regularly cite recent articles and Regularly cite recent articles and update patient management to update patient management to reflect current standard of care…reflect current standard of care…

““Cardiopulmonary Resuscitation on Television — Miracles and Misinformation”Cardiopulmonary Resuscitation on Television — Miracles and Misinformation”Susan J. Diem, M.D., M.P.H., John D. Lantos, M.D., and James A. Tulsky, M.D.Susan J. Diem, M.D., M.P.H., John D. Lantos, M.D., and James A. Tulsky, M.D. NEJM NEJM Volume 334:1578-1582Volume 334:1578-1582 June 13, 1996June 13, 1996 Number 24 Number 24

ABSTRACTABSTRACT BackgroundBackground Responsible, shared decision making on the part of physicians and patients about Responsible, shared decision making on the part of physicians and patients about

the potential use of cardiopulmonary resuscitation (CPR) requires patients who are the potential use of cardiopulmonary resuscitation (CPR) requires patients who are educated about the procedure's risks and benefits. Television is an important source of educated about the procedure's risks and benefits. Television is an important source of information about CPR for patients. We analyzed how three popular television programs information about CPR for patients. We analyzed how three popular television programs depict CPR. depict CPR.

MethodsMethods We watched all the episodes of the television programs We watched all the episodes of the television programs ERER and and Chicago HopeChicago Hope during during the 1994–1995 viewing season and 50 consecutive episodes of the 1994–1995 viewing season and 50 consecutive episodes of Rescue 911Rescue 911 broadcast over broadcast over a three-month period in 1995. We identified all occurrences of CPR in each episode and a three-month period in 1995. We identified all occurrences of CPR in each episode and recorded the causes of cardiac arrest, the identifiable demographic characteristics of the recorded the causes of cardiac arrest, the identifiable demographic characteristics of the patients, the underlying illnesses, and the outcomes. patients, the underlying illnesses, and the outcomes.

ResultsResults There were 60 occurrences of CPR in the 97 television episodes — 31 on There were 60 occurrences of CPR in the 97 television episodes — 31 on ER,ER, 11 on 11 on Chicago Hope,Chicago Hope, and 18 on and 18 on Rescue 911.Rescue 911. In the majority of cases, cardiac arrest was caused In the majority of cases, cardiac arrest was caused by trauma; only 28 percent were due to primary cardiac causes. Sixty-five percent of the by trauma; only 28 percent were due to primary cardiac causes. Sixty-five percent of the cardiac arrests occurred in children, teenagers, or young adults. Seventy-five percent of cardiac arrests occurred in children, teenagers, or young adults. Seventy-five percent of the patients survived the immediate arrest, and 67 percent appeared to have survived to the patients survived the immediate arrest, and 67 percent appeared to have survived to hospital discharge. hospital discharge.

ConclusionsConclusions The survival rates in our study are significantly higher than the most optimistic The survival rates in our study are significantly higher than the most optimistic survival rates in the medical literature, and the portrayal of CPR on television may lead survival rates in the medical literature, and the portrayal of CPR on television may lead the viewing public to have an unrealistic impression of CPR and its chances for success. the viewing public to have an unrealistic impression of CPR and its chances for success. Physicians discussing the use of CPR with patients and families should be aware of the Physicians discussing the use of CPR with patients and families should be aware of the images of CPR depicted on television and the misperceptions these images may foster. images of CPR depicted on television and the misperceptions these images may foster.

Some of what we do:Some of what we do: Emergency stabilization of critically ill patientsEmergency stabilization of critically ill patients Ongoing management of critically ill patientsOngoing management of critically ill patients Screen for psychiatric illnessScreen for psychiatric illness Obstetrics and gynecologyObstetrics and gynecology PediatricsPediatrics Minor surgical procedures – wound repair, central lines, I&DMinor surgical procedures – wound repair, central lines, I&D Major surgical procedures – chest tubes, thoracotomyMajor surgical procedures – chest tubes, thoracotomy Orthopedics – reducing fractures and dislocations, splintingOrthopedics – reducing fractures and dislocations, splinting Cardiology – EKG interpretation, management of arrhythmias Cardiology – EKG interpretation, management of arrhythmias Ophthalmology – eye trauma, eye infectionsOphthalmology – eye trauma, eye infections Infectious diseaseInfectious disease Screen for child abuse and domestic violenceScreen for child abuse and domestic violence Interpret radiographic studiesInterpret radiographic studies Perform radiographic studies – ultrasoundPerform radiographic studies – ultrasound Routine medical careRoutine medical care

If someone in the hospital does it, we probably do it too!

(or at least we have to know when to call them)

Other important facts:Other important facts:

Nationally:Nationally: The admission rate from the ED is between 15 and The admission rate from the ED is between 15 and

20%20% The ED accounts for a growing percentage of all The ED accounts for a growing percentage of all

hospital admissions (>50%)hospital admissions (>50%) Emergency Departments are the only place everyone Emergency Departments are the only place everyone

is guaranteed access to medical care under federal is guaranteed access to medical care under federal lawlaw

In smaller hospitals, the Emergency physician may In smaller hospitals, the Emergency physician may be the only physician physically in the hospitalbe the only physician physically in the hospital

Many EDs see all ages from neonates to 100+Many EDs see all ages from neonates to 100+““ER Diversion” does not stop the patients from ER Diversion” does not stop the patients from

comingcoming

““When I come to work, as I When I come to work, as I get ready to leave my get ready to leave my driveway, I say, ‘Dear Lord, driveway, I say, ‘Dear Lord, help me not to make a help me not to make a mistake tonight,’ and when I mistake tonight,’ and when I leave the hospital, I say, leave the hospital, I say, ‘Dear God, thank you for ‘Dear God, thank you for getting me and my patients getting me and my patients through another night.’” through another night.’”

– Arthur D. Kellerman, – Arthur D. Kellerman, MDMD

AGE61302242432351706820443048665121404037254328545342608924212760862683

CHIEF COMPLAINTBladder infectionabdominal pain for 2 weekssickle cell, abdominal pain for 2 weeksflank pain for 2 weeks (pulmonary embolism)nausea, vomiting, dehydration, abdominal pain abdominal pain RUQ x1 week, acutely worsefever (renal transplant with UTI)fever, history of prostate and stomach cancerdyspnea x3 weeks, jfever, nausea, vomiting, pyleonephritiscut on upper armback painabdominal pain for 5 monthsfatigue and weight loss for six months, can't walkAsthma attackvomiting bloodAsthma attackeye pain and blurred visionflank/hip painitching and rashnausea, vomiting, dehydration, abdominal pain, vaginal discharge, multiple othersconstipation, aneuriafevernausea, vomiting, abdominal painchest painswollen finger and dyspneabuttock pain, malaiseChest pain, non-Hodgkin's lymphomaabdominal pain, nausea, vomitingsevere low back painrespiratory distressChest paincombative behavoir and twitching

DISPOD/CD/CD/CadmitD/CD/CadmitD/CadmitD/CD/CadmitD/CadmitD/CadmitadmitD/CD/CD/CD/CD/CD/CadmitadmitadmitD/CD/CD/CCDUD/CICUD/Ctransfer

ACTIONSlab, transfuse, antibioticultrasound, lablab, CTCT, lab, EKG, CXRlab, IVFlab, ultrasoundlab, antibiotics, IVF, CXR, EKGlab, antibiotics, CXREKG, CXR, labIVF, lab, antibioticssuture and hemostasislab, medsCT, lab, medslab, CXR, EKGCXR, medslab, IVFlab, CXR, medsopthamologymed, securitymedicationIVF, meds, labslabsxrlab, CXR, antibioticslab, meds, CT, IVFlab, EKG, CXR, medslab, XR, EKG, medslab, CT, med, I&Dlab, XR, EKG, medslab, meds, IVFlab, meds, EKG, CTlab, XR, intubation, central line, ventilator, antibioticsCXR, EKGlab, CT, XR, EKG

DIAGNOSISbladder cancer, anemia, urinary obstructionpelvic pain uncertain causesickle cell pain, abdominal pain uncertain causepulmonary embolismabdominal pain uncertain causecholelithiasis with colicUTI vs. rejectionlikely UTIcongestive heart failure exacerbation, acute renal failurepyleonephritislacerationlumbar disk disease, chronic painabdominal pain, unknown causeUTI, hyponatremia, likely cancerasthma exacerbation with bronchitispost tonsilectomy hemorragepneumoniacorneal abraision and conjunctivitisopiate dependence, opiate abuse, chronic painallergic reactiongastroenteritisUTI, BV, bipolarconstipation, severe dementiaUTI, renal transplantmany operations, intractable vomiting and abdominal painacute MIcongestive heart failure, ainflammatory arthritis vs. infectiousabcess, UTIpleural effusion, chest pain, possible recurrance of lymphoma after BMTabdominal pain uncertain , possibly ulcerkidney stone, chronic pain, hemipeligia, s/p strokepneumonia, CHF, respiratory failure, s/p strokeanxietydementia, anemia

Two overnight eight-hour shifts:

The statistics:The statistics:

Total patients: 34 in 16 hours Total patients: 34 in 16 hours =2.125/hr=2.125/hr

Admit*:Admit*: n=11n=11 35%35% DischargeDischarge n=23n=23 65%65%

Admissions include:Admissions include: TransferTransfer n=1n=1 3%3% ICUICU n=1n=1 3%3% ObservationObservation n=1n=1 3%3%