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Emergentology: The Graying Elephant in the Room

Walker, Graham MD

doi: 10.1097/01.EEM.0000419520.65973.46

Dr. Walkeris a fellow in simulation medicine in the Stanford/Kaiser Emergency Medicine Residency Program. He has been blogging since medical school, first at Over My Med Body, and now as the developer and co-creator of MDCalc, a medical calculator for clinical scores, equations, and risk stratifications (, and The NNT, a number-needed-to-treat tool to communicate benefit and harm (






That was going to be the introduction to my column this month, until it turned out that it is not true. The elderly are not going to ruin health care after all. We are already doing that ourselves.

I had planned to spend the next 1,105 words going all Chicken Little on you, dear readers, but according to a number of articles I recently perused from Health Affairs, the elderly probably will not chew through our health care dollars after all. Technology spending and cancer care probably will. So look on the bright side!

Other countries are further ahead in the graying of their populations. Western Europe has been at this longer than we have (we will not reach their levels until about 2020) so hopefully we will have learned from them by the time we get there.

The other exciting news is that it appears we are moving toward a “compression of morbidity,” or in other words, less morbidity than mortality in the future. We are living longer and we are living with more years of high-quality life. More years without disability. Go, us!

But emergency medicine is still going to be affected just like all of health care. The elderly frequently need a workup compared with a younger patient with the same complaint; they also frequently require some period of observation. Often we are also trying to track down information on these patients: what exactly happened when the patient “was confused for five minutes” that prompted the nursing home to call 911? What is the patient's baseline? What is his code status? Who is the health care proxy? The durable power of attorney? Do we have the paperwork to confirm this?

All of this will mean a change to our specialty, as it will to everyone's practice. A sign of the times of our ability to adapt or grow or mature?

We will need more of us. Our abilities (diagnostics, intubation, procedural sedation, ultrasound, regional anesthesia, fracture management) will allow us to take a larger piece of the medical pie, with the ability to staff ourselves at better levels. Many conditions require close inpatient observation and fewer multiday stays, and we will take over more short stay care as well. Add to the mix a number of hospital administrators realizing how efficient emergency physicians are compared with our internal medicine colleagues, and no question, emergency medicine (“acute care medicine?”) will be leading the way.

We will also need to develop better communication strategies with consultants, family members, and new team members with whom we will be working even closer, such as palliative care, case management, social work, and physical and occupational therapy. Twenty-five percent of patients over 65 have some degree of disability (problems with their ADLs or iADLs), and we need to be part of the chain that keeps them well and living independently. Maybe technology could help with some of these communication pieces as well. How nice would it be to have video chats with family members at the bedside? Or video consultations instead of talking over the phone? Or a YouTube database of nursing home patients' baseline mental status and functional ability?

All of this means change, at which physicians and health care systems are notoriously terrible — and slow. One of the hardest areas to address — possibly the hardest — is what to do about death and dying.

We are clearly the specialty most focused on “saving” lives. Emergency medicine views death as a failure. We are trained to save people, to do everything. And I think our specialty will have to navigate the rough waters of when that is not the right thing to do. As Dr. Ira Byock, the director of Palliative Care Medicine at Dartmouth writes in his recent book on death and dying, “They could not imagine that there was anything worse than their dear mother … dying. And yet, they found out — as so many of our patients eventually do — that there are worse things than having someone you love so much die. There's having them die badly, suffering as they die.”

We have all seen this. We all know this feeling.

What is the right thing to do with the patient in front of you? That is never going to be an easy question, as I was reminded on shift last night. I think, however, that we in emergency medicine need to add one more simple step to our usual algorithms before we immediately jump into action, just before we push that “Big Workup, Do Everything, Go, Go, Go” button we so frequently love to push: “Is this in line with the patient's wishes or goals of care?”

Let's be honest. It can be pretty easy to dispo elderly patients: “I don't know why they are altered. I will order a bunch of tests, cover them for infection, and admit them to the hospital.” “If I need to intubate them, I will just intubate them.” Slam dunk. Turn off brain, admit. But the more difficult and frequently more time-consuming, emotionally draining, less-reimbursed and often right thing to do (when there is time to do it, of course) is to first figure out if the patient would have wanted all this stuff done in the first place.

We are not going to do this on our own. We are not going to decide a patient is not an operative candidate for his small bowel obstruction. But we can lead the way by discussing these things openly with our colleagues and getting their input as well. Lead by example: “If emergency medicine is asking about this and they do not even see the patient after admission, maybe we should be asking about this, too.”

Hell, let's pay our colleagues to do this! Or how about patients themselves? Reimburse highly for goals-of-care discussions. Pay people to fill out a code status and health care proxy worksheet. Full code? DNR/DNI? Either way, great! Here is 50 bucks!”

One fewer month-long ICU stay per hospital would easily start to pay for the program. (I once sarcastically suggested that if we just assumed everyone on arrival to a hospital was DNR/DNI unless otherwise stated, everyone would have a documented code status in 24 hours. I kid, but one study showed that only 20 percent of patients with metastatic cancer admitted to an academic hospital had a code status.)

So, Henny Penny, Chicken Little, Goosey Loosey, and Foxy Loxy, it is not the end of the world. The elderly apocalypse is not coming. We will have to make changes. We will have to acclimate and adjust. But who thrives under pressure and adapts to the situation better than emergency physicians?

*I really do not want to make it seem like all I think about older people (my parents, soon me) is that they are all really sick, disabled, and terminal, but we do not see a whole lot of well elderly patients in the ED. They usually come to the ED because they are sick. (Really not trying to be ageist.)

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