A part from yelling, “We are sinking!” from the deck of the ED, how will we practice emergency medicine in 2022 without nurses and other essential staff? I offer these suggestions with terrifying trepidation, understanding that the difference between malpractice and lifeboat ethics may depend on the situation in which your ED is at the moment.
Scare the Community, Shame the Corporation: There is value in telling the truth for truth's sake. Solving problems correctly depends on seeing the problems correctly and using language that focuses on the proper goals. Saying that “we don't have staff” instead of “we are waiting for a bed” is essential honesty. Investigative reporting to find out where the federal money given to hospitals landed and why it is not being used to raise salaries to at least maintain staffing is essential honesty.
Americans, it seems, are stubborn and resistant to change until they are alarmed and impassioned. They need to be frightened by what is happening in emergency care. Corporations need to be shamed into generously raising salaries to reinforce critical links in the emergency medical human resources chain. But loud sirens and big financial incentives, while necessary, won't change our shifts this month or next.
Offload Low-Acuity Volume: This has been tried in various ways for many years with screening and diverting to another facility, often presenting legal and transportation barriers. The only thing different now is the boom in telemedicine, but if your ED is not already doing this, getting minor care by telemedicine is a tall order, and may not actually offload the patients coming to your front door.
Diverting all stable psychiatric patients off-site would be momentous, but all of the available psychiatric hospitals are full, and no one I know of has an off-site psych-hold ED. Can we find a way for a physician to see and dismiss a patient without him seeing a nurse or tech (just registration)? I admit I am not clear on the hospital's liability with this approach.
Use Less Fluids and Labs: Treat healthy adults under age 50 like pediatric patients (including OB) when they present with vomiting or diarrhea without tachycardia. No electrolyte checks (and certainly no other lab). No IV fluids. Do Zofran ODT and an oral fluid challenge as an initial routine. Quit doing automatic troponins twice.
The second troponin has been proven effective only for high-risk chest discomfort patients, not all comers. For lacerations, fractures, and sprains, can we scan the materials we need and put on dressings and splints without involving a nurse or tech?
Avoiding Ultrasound at Night: Consider a loading dose of a novel oral anticoagulant or a shot of enoxaparin for DVT rule-outs, and develop a system for them to be scheduled during daytime hours for a sonogram the next day.
Don't do FAST exams in low-level trauma. The FAST is used for its positive predictive value to go straight to the OR, not for its negative predictive value to go home. You need a CT, not a FAST, to rule out a bleed if you are that worried. Skip the ultrasound for pediatric appendicitis at night. Its positive yield is poor, and its negative reading is not sufficient. Do a good exam, with blood work if you wish, and have a patient with a MANTRELS (Alvarado score) above 6 examined by a pediatric surgeon. Send home patients with MANTRELS scores below 7 with advice to return if symptoms persist in six to eight hours.
Consider CT with contrast to rule out appendicitis for patients with low-level right adnexal discomfort to evaluate for an ovarian cyst rupture or mass and as a decent evaluation to rule out torsion in the low pre-test probability. Can you do a CT to look for gallstones in patients with low probability and normal or near-normal labs and have an outpatient plan to schedule for a sonogram the next day if they're normal?
The key to all of these is to get your trauma surgeons, pediatric surgeons, OB/Gyn surgeons, and general surgeons to accept this approach and promote it with the understanding that you can't get an ultrasound in a timely manner and that continuing to push for ultrasound emergently at night will run the risk of never being able to get nighttime ultrasound.
Also get a commitment and payment from the hospital to teach ultrasound to all ED staff in real time while you are on deck working with the ultrasound machine to determine first trimester intrauterine pregnancy, which is one condition (along with testicular pain) for which there is no workaround. That could save a lot of nighttime sonograms by the tech if every emergency physician received ongoing daytime training to identify an intrauterine pregnancy in the first trimester.
The Titanic is creaking. You can believe it will not sink, but I think you will see it bulging and dripping already if you look closer at your ED's hull. You may take the position that it's not our fault, that the company should have done it differently. You will continue to be the captain of the ship, following the manual, steering as long as you are able, and even going down with the ship. Or you can offload into a skully before age 65.
Or you can warn passengers of the impending disaster. You can find the courage to speak and act instead of just accepting fate. You can be innovative, understanding that a MacGyver approach to building a lifeboat engages a certain amount of lifeboat ethics for which one risks a bad outcome. We may need to strive in 2022 for the greater good for the greatest number of people. The rules may need to be broken to save human lives when your ship is sinking.
Read part 1 of this article, “The Titanic is Sinking Without Nurses,” in the March issue:https://bit.ly/EMNPastIssues.
Dr. Mosleyis an emergency physician in Wichita, KS.