Current Emergency Diagnosis

WHAT IS EMERGENCY MEDICINE?

An emergency is commonly defined as any condition perceived by the prudent layperson—or someone on his or her behalf—as requiring immediate medical or surgical evaluation and treatment. Based on that definition, the American College of Emergency Physicians (ACEP) states that the practice of emergency medicine has the primary mission of evaluating, managing, and providing treatment to these patients with unexpected injury and illness.

So what does an emergency physician do? This specialist routinely provides care and makes medical treatment decisions based on real-time evaluation of a patient's history; physical findings; and many diagnostic studies, including multiple imaging modalities, laboratory tests, and electrocardiograms. The emergency physician needs an amalgam of skills to treat a wide variety of injuries and illnesses—ranging from the diagnosis of an upper respiratory infection or dermatologic condition to resuscitation and stabilization of the multiple trauma patient. Furthermore, these physicians must be able to practice emergency medicine on patients of all ages and not just in urban tertiary-care facilities. Clinical emergency medicine may be practiced in emergency departments, both rural and urban; urgent care clinics; and other settings such as at mass gathering incidents, through emergency medical services (EMS), and in hazardous material and bioterrorism situations.

Emergency medicine serves as the United States's health care safety net. It provides valuable clinical and administrative services to the health care delivery system, including care for the indigent and others who lack access to health care, and has evolved as the most visible and vital component of a patchwork of health care providers and facilities. These emergency departments have become the routine, and often the only, source of care for many of the uninsured, thereby acting as a critical safety net for our fragmented health care delivery system.

Finally, emergency departments are the only element of the health care system whose function has been delineated by federal law. Initially authorized in 1986, the Emergency Medical Treatment and Active Labor Act mandates that all emergency departments provide screening, stabilization, and appropriate transfer to all patients with any medical condition. Emergency medicine is often the last resort for many patients and frequently the access point for competent, comprehensive, and efficient medical care.

BIRTH & GROWTH OF EMERGENCY MEDICINE

By current popular opinion based on reality and dramatic television productions, emergency medicine appears to be at the forefront of medicine, providing compassionate and competent care by residency-trained emergency physicians. Unfortunately, this has not always been the case. The profession of emergency medicine is still quite young and continues to grow and mature. A brief timeline of emergency medicine growth is shown in Table 1-1. Since the first emergency medicine residency program began in 1970, the number of approved residency programs has increased dramatically (Table 1-2). Despite the rapid growth in emergency medicine residencies, a significant number of practitioners of emergency medicine are not residency trained or board certified (Table 1-3).

SCOPE OF PRACTICE

Emergency medicine physicians are faced with an ever-growing patient volume, decreasing inpatient bed availability, decreasing reimbursement, and increased litigation. However, these same physicians have the unique responsibility for being prudent stewards of a finite amount of health care resources. Based on that responsibility, the ACEP in 2002 endorsed the following:

• The best medical interest of the patient should be foremost in any clinical decision making process.

Criteria for appropriate use of finite resources should include:

1. Urgency of the patient's medical condition

2. Likelihood, magnitude, and duration of medical benefit to the patient

3. Burdens and cost of care to the patient

4. Cost to society

• Emergency physicians should not allocate health care resources on the basis of a patient's ability to pay, contribution to society, past use of resources, or responsibility for their medical condition.

In 2001, the ACEP Core Content Task Force II published its Model of Clinical Practice of Emergency Medicine. In this publication, the scope of practice of an emergency physician is well defined and yet quite expansive, to include care from the prehospital environment to prevention and education. Listed below are the tasks of the emergency physician as agreed upon by the task force.

Prehospital Care

Participate actively in prehospital care and education, provide direct patient care or on-line or off-line medical direction or interact with prehospital medical providers, and assimilate information from prehospital care into patient assessment and management.

Emergency Stabilization

Conduct primary assessment, and take appropriate steps to stabilize and provide treatment to patients.

Performance of Focused History & Physical Examination

Communicate effectively to interpret and evaluate the patient's symptoms and history; identify pertinent risk factors in the patient's history; provide a focused evaluation; interpret the patient's appearance, vital signs, and condition; recognize pertinent physical findings; and perform techniques required for conducting the exam.

Modifying Factors

Recognize age, gender, ethnicity, barriers to communication, socioeconomic status, underlying disease, and other factors that may affect patient management.

Professional & Legal Issues

Understand and apply principles of professionalism, ethics, and legal concepts pertinent to patient management.

Diagnostic Studies

Select and perform the most appropriate diagnostic studies, and interpret the results.

Diagnosis

Develop a differential diagnosis and establish the most likely diagnoses in light of the history, physical examination, interventions, and test results.

Therapeutic Interventions

Perform procedures and nonpharmacologic therapies, and counsel patients.

Pharmacotherapy

Select appropriate pharmacotherapy, recognize pharmacokinetic properties, and anticipate drug interactions and adverse effects.

Observation & Reassessment

Evaluate and reevaluate the effectiveness of a patient's treatment or therapy, including addressing complications and potential errors; and monitor, observe, manage, and maintain the stability of one or more patients who are at different stages in their workups.

Consultation & Disposition

Collaborate with physicians and other professionals to evaluate and provide treatment to patients; arrange appropriate placement and transfer if necessary; formulate a follow-up plan; and communicate effectively with patients, family, and involved health care members.

Prevention & Education

Apply epidemiologic information to patients at risk; conduct patient education; and select appropriate disease and injury prevention techniques.

Documentation

Communicate patient care information in a concise manner that facilitates quality care and coding.

Multitasking & Team Management

Prioritize multiple patients in the emergency department in order to provide optimal patient care; interact, coordinate, educate, and supervise all members of the patient management team; utilize appropriate hospital resources; and have familiarity with disaster management procedures.

Other "Tasks"

Emergency medicine has evolved to include much more than the above-mentioned "tasks." For the profession of emergency medicine to continue to progress, physicians must embrace the following responsibilities:

• Basic and clinical research

• Multidisciplinary and continuous medical education

• Injury prevention

• Disaster management and mass-gathering medicine

• Toxicology and regional Poison Control Center direction

• Hazardous material and bioterrorism management

• Hospital and EMS systems administration

PRINCIPLES OF EMERGENCY MEDICINE

It is often said that emergency department patients "don't read the textbook," meaning that their presentations do not fit nicely into specific textbook diagnoses or classical presentations of illness. However, a cornerstone of an emergency physician's practice is the recognition of patterns in a patient's presentation; therefore, the prudent physician must be a detective and scientist to muddle through the muck of vague signs and symptoms to find the pattern.

The principles of emergency medicine are simply questions that must be answered to provide effective care to patients who have entrusted emergency physicians with their care. The questions are not to be used as a cookbook approach to the management of these often complex medical and psychosocial issues but are a simple method to guide the prudent emergency physician through the quagmire of clinical emergency medicine.

A. Is the Patient About to Die?
Obviously, this is the first and most important question to answer. Every patient's presentation is quickly prioritized to one of the following acuities:

1. Critical—Patient has symptoms consistent with a life-threatening illness or injury with a high probability of death if immediate intervention is not begun.

2. Emergent—Patient has symptoms of illness or injury that may progress in severity if treatment is not begun quickly.

3. Nonurgent—Patient has symptoms that have a low probability of progression to a more serious condition.

Look for symptoms of a life-threatening emergency, not a specific disease entity. Anticipate impending life-threatening emergencies in the apparently stable patient.

B. What Steps Must Be Undertaken to Stabilize the Patient?
Act quickly to stabilize the critically ill or injured patient. Focus on the primary survey (airway, breathing, circulation, and neurologic deficits), and make necessary interventions as each issue is identified. Do not delay necessary primary interventions while awaiting completion of ancillary testing.

C. What Are the Most Potentially Serious Causes of the Patient's Presentation?
Thinking of the worst-case scenario, develop a mental list of the most deadly causes of the patient's presentation by asking, "What will kill my patient the fastest?" Once the list has been developed, the vital signs, history, physical examination, and ancillary assessments should identify or confirm those causes highest on the list.

D. Could There Be Multiple Causes of the Patient's Presentation?
In addition to constant reevaluation and reprioritization of the differential diagnosis, continually ask, "Is this all there is?" For example, is the new-onset seizure and hypoglycemia in an older diabetic patient from intentional or accidental medication overdose or perhaps worsening renal insufficiency? Is the near-syncope and abdominal pain in an apparently intoxicated college coed from a ruptured ectopic pregnancy or perhaps a ruptured spleen secondary to undisclosed physical abuse by her boyfriend? Frequent reassessment and thoughtful inquiry as to the multiple possibilities responsible for each patient's condition are imperative.

E. Can a Treatment Assist in the Diagnosis in an Otherwise Undifferentiated Illness?
Often in emergency medicine, treatment response foretells a diagnosis. A case in point is the unconscious patient with no available collateral history. The patient's response to empiric administration of naloxone will include or exclude narcotic overdose as a contributor to the obtundation. Referred to as the "diagnostic-therapeutic" concept, it underscores the emergency medicine philosophy that an established diagnosis is not a prerequisite to initiating appropriate treatment. Pitfalls can exist. For example, sublingual nitroglycerin and so-called GI cocktails can relieve symptoms of chest pain resulting from the same cause.

F. Is a Diagnosis Mandatory or Even Possible?
After emergent issues have been addressed, the patient and emergency physician are often left with an undifferentiated symptom complex. This frequently elicits an uncomfortable response by non-emergency-medicine-trained physicians. Become accustomed to and comfortable with the notion of determining the disposition for a nonemergent patient—having treated their symptoms and excluding emergency conditions-without a specific diagnosis.

G. Does This Patient Need To Be Admitted to the Hospital?
Having appropriately answered the preceding questions, make the bottom-line disposition decision. Once assessments and treatments are under way, decide whether an emergent condition exists. Consider other subtleties. Does the patient have timely, accessible follow-up? How far away from a medical facility does the patient live? Are unresolved abuse or self-care issues involved? Are you, as the emergency physician, comfortable discharging the patient?

H. If the Patient Is Not Being Admitted, Is the Disposition Safe and Adequate for the Patient?
More frequently than not, patients are discharged home from the emergency department. However, many patients do not receive a specific diagnosis, and some symptoms may persist. Recommend appropriate follow-up, and provide written discharge instructions. Invite the patient back. Instruct the patient when to return for further evaluation should symptoms change or worsen. Provide the patient with information regarding treatment and diagnosis as well.

CONCLUSION

Since 1970, emergency medicine has seen a tremendous growth and increase in awareness of the unique aspects of the profession. It remains a challenging and fulfilling experience for many physicians and an appealing choice of specialties for medical students. As emergency medicine matures as a specialty, its importance as the United States's health care safety net and its integral status as front-line medicine will continue to expand and grow.

American College of Emergency Physicians: Definition of emergency medicine, as approved by the ACEP Board of Directors, April 2001. http://www.acep.org/3,411,0.html

American College of Emergency Physicians: Emergency medicine training, competency and professional practice principles position statement, as approved by the ACEP Board of Directors, November 2001. http://www.acep.org/3,5141,0.html

American College of Emergency Physicians: Emergency physician stewardship of finite resources, as approved by the ACEP Board of Directors, January 1997. http://www.acep.org/ 3,4245,0.html

American College of Emergency Physicians Core Content Task Force II: The Model of the Clinical Practice of Emergency Medicine. American College of Emergency Physicians, 2001.

Asplin BR, Sosnow PL, Yeh CS: "The Safety Net and Current Federal Health Care Policy." Defending America's Safety Net. American College of Emergency Physicians, 1999.