The emergency department serves as the gateway for medical care for the preponderance of acutely ill patients. Whether due to medical, surgical, pediatric, obstetric, neurologic, or psychiatric conditions, patients presenting with acute ailments expect that the emergency department and emergency physicians in particular will be able to diagnose and initiate management of critical conditions.
Experts worldwide have recognized the need for quality emergency care, and progress has been seen in nations as diverse as India, Turkey, and Argentina, which have all acknowledged emergency medicine as a specialty. With this explosive growth in emergency care, it is increasingly common for patients to view the emergency department as the entry into the health care system when confronted with unexpected and severe medical complaints, as 117 million annual ED visits in 2007 testify. (National Ambulatory Medical Survey: 2007 emergency deparment summary; http://www.cdc.gov/nchs/data/nhsr/nhsr026.pdf.)
While recognition of the emergency department is well warranted, it does create a dilemma for emergency physicians who must be aware of the vast complexities of ailments that cause patients to present for emergency care. While emergency physicians are clearly well trained to deal with the most common diseases that require emergency interventions, such as cardiovascular disease and trauma, emergency providers must be facile with managing patients whose disease entities are only now being recognized or whose therapies have only recently developed.
During a typical clinical shift, an emergency physician may have to manage acute issues in patients whose comorbidities may include transplantation, congenital heart disease, end-stage renal disease, or cancer. Without awareness of the new treatments and procedures in these areas, not to mention the implications of increased longevity in patients who previously may have never required emergency care, it is easy to understand why emergency physicians may not correctly diagnose and initiate treatment in conditions that require acute intervention — with detriment to the patient.
The emergency medicine literature and educational process has understandably focused on patients who present most commonly for emergency department care. Research in emergency medicine largely, though not exclusively, focuses on the most prevalent conditions, such as acute coronary syndromes, pulmonary embolism, stroke, trauma, and sepsis, and textbooks in emergency medicine are comprehensive surveys of the entire gamut of diseases that can present to the ED. Similarly, the core curriculum in emergency medicine residency training attempts to cover the entire range of conditions but does not allow more in-depth consideration of patients on the horizon or whose therapies are quickly evolving to result in increased longevity and changed pathophysiology.
Faced with this changing environment for emergency care, three themes emerge that underline the challenge facing emergency physicians over the next five years and beyond.
Evolving medical care and understanding the pathophysiology of disease have resulted in a vast improvement in the life expectancy of patients who previously did not survive to adulthood or whose survival to late adulthood resulted in their exposure to illnesses that now require emergency department care. Whether considering congenital heart disease, geriatric trauma, cystic fibrosis, intellectual disability, sickle cell disease, or pediatric intestinal failure, emergency physicians are currently, and will continue treating patients whose disease processes in the past would have led to markedly shortened life expectancy.
For emergency physicians, this increased longevity will result in the need to reconsider the pathologic processes that can result in illness and new complications of late-stage disease. Survival to adulthood of patients with congenital heart disease, for instance, means emergency physicians will have to recognize complications of surgical procedures used to correct defects in infancy as well as late cardiovascular and pulmonary issues that may not arise until adulthood.
The aging population means emergency physicians will have to understand the more complex pathophysiology of trauma when presenting with other age-related illnesses. Children with intestinal failure may now survive for longer periods of time and present with complications previously only seen in specialized centers shortly after birth. Emergency physicians have to recognize how patients may present with novel complications not seen in the past.
Novel Treatment Modalities
Changing medical and surgical care for patients who previously had different or ineffective treatment modalities has resulted in emergency complications that require recognition by emergency department providers. From bariatric surgical procedures and highly active antiretroviral therapy for HIV patients to new chemotherapeutic regimens and post-cardiac arrest therapy, novel treatments have often provided benefits to patient populations in quality of life and longevity, but have made the emergency department the venue in which acute diagnosis of treatment failures or complications will take place.
The astronomic growth of bariatric surgical procedures, for example, requires emergency physicians to be aware of the anatomic and physiological changes that take place post-operatively as well as the side effects and treatment issues that arise. The increased longevity of HIV-positive adults on antiretroviral therapy has resulted in completely new disease processes. Hypothermia treatment after cardiac arrest requires emergency physicians to manage patients previously thought to be neurologically devastated. For all of these patient populations, new and evolving therapies have created a novel set of disease processes and treatments with which emergency physicians must become familiar.
The emergency department also serves as the canary in the coal mine for pathologies that often extend beyond the medical realm. (“Health insurance: canary in the mine.” Cincinnati Enquirer, July 1, 2004; http://bit.ly/CanaryInED.) This may be the dark side of the emergency department being the gateway to the health care system. Emergency physicians must contend with the consequences of failures in our medical system and complexities that result from the breakdown in family relationships or societal forces.
The growth in the number of patients with conditions that cause chronic pain, the lack of medical training in pain management, and a shortage of pain management physicians, for instance, have left the emergency department as the last resort for patients who require analgesia perhaps best managed in the outpatient setting. Increased recognition of child abuse and intimate partner violence has also imposed a burden on emergency physicians to treat the medical and social dangers imposed by these conditions. And obesity has profound implications for the diagnostic assessment and therapeutic management of ED patients. These emerging patient populations represent a profound challenge for emergency care in the 21st century.
Emergency physicians' central strength is our ability to care for the undifferentiated, acutely ill patient. For better or worse, the emergency department is now the gateway for acute care for the vast majority of patients in the health care system, and will remain so for the foreseeable future. The challenge for emergency medicine will be to expand the knowledge base of how to assess and manage patients with emerging conditions only now being recognized. That knowledge will help our patients negotiate their way through the rapidly changing health care system where the emergency department is often the only feasible port-of-entry.
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Dr. Venkatthe director of research in the department of emergency medicine and an ethics consultant at Allegheny General Hospital in Pittsburgh. He is also an associate professor of emergency medicine at Drexel University College of Medicine and Temple University School of Medicine in Philadelphia. He adapted this essay for Emergency Medicine News from his book, Challenging and Emerging Conditions in Emergency Medicine (Wiley-Blackwell).© 2011 Lippincott Williams & Wilkins, Inc.