The overwhelmed emergency physician

From Kevin MD:

I see it time and time again. Overwhelming numbers of patients with increasingly complex medical and social problems, versus inadequate physician coverage at all hours of the day, and especially the night. We’ve all done it. Already fatigued, we have five chest pains yet to see, as well as a trauma on the way into the department. Two more patients have fever but don’t speak English, and we’re waiting to make the translation line work. And there’s a large facial laceration yet to be repaired. And that’s just the first nine patients. It’s not even three hours into the shift. (And the EMR backup is in process.)

Why Low-Acuity Patients Often Complain

From Emergency Medicine News (hat tip: Dr. Menadue):

Patients, just like everyone else, experience cognitive dissonance. Sometimes they feel it in the ED when two ideas conflict. The decision to seek care is not an easy one. When they realize they’ve misjudged their emergency, they experience cognitive dissonance about their acuity, or more specifically, acuity dissonance.

Low-acuity patients still have nonmedical needs, even though their medical needs are easy to meet. But these nonmedical needs are legitimate. Rushing them through their encounter is a disservice to everyone. Inexperienced doctors make the mistake of ignoring acuity dissonance at their peril.


Let’s understand something about the American healthcare system: The problem is not the emergency department nor emergency physicians

From Becker’s:

Our emergency physicians and their departments have been described as the safety net of our healthcare system. They are available 24/7/365 to everyone. They represent the healing edge of our system today, in many ways far more than a safety net. Emergency physicians are positioned within our healthcare system as both master diagnosticians and masters in knowing all of the strategic nuances of care alternatives, follow up sub-specialists and downstream care options within their hospital systems for their patients.

Rural Hospitals Across Tennessee At Risk Of Closing

From News Channel 5:

Decatur County General is hardly alone in the struggle to stay open. Nationwide 81 rural hospitals have closed since 2010. Nine of those closures have happened in Tennessee, county run hospitals from the eastern mountains to the Mississippi River have disappeared. The only state with more rural hospital closures than Tennessee is Texas, where in 2013 an 18-month old died after being rushed to an emergency room that her parents didn’t realize had closed.

Surprise! You Have Medical Coverage Gaps

From the Huffington Post (Dr. Bose):

Surprise coverage gaps occur when an ED patient reasonably believes that they are having an emergency, are treated by the ED and then discover after the fact that their health plan does not provide fair coverage for the services that were provided to them or their family member. One common coverage gap is that the patient’s health plan will reimburse the physician at or about Medicare levels—leaving a large “balance”, or difference, between that “allowable charge or rate” and the clinician’s charges or the “balance bill”, particularly where the clinicians were “out of network” (OON), which of course the patient has no control over.

Controversial psychiatric hospital, first of its kind in Iowa, approved for Quad Cities

From the Des Moines Register:

State regulators on Thursday approved a proposal to build Iowa’s first private, free-standing psychiatric hospital.

A national company, Strategic Behavioral Health, plans to build the $15 million, 72-bed hospital in Bettendorf. The project was opposed by the Quad Cities’ two main health-care systems, which testified that they already offer sufficient services and would be harmed by a new facility built by the for-profit company.

The Iowa Health Facilities Council, which had twice previously deadlocked 2-2 on the proposal, voted 4-1 in favor of it Thursday. This was the first time the full council considered the matter.

Autopsy interrogation of emergency medicine dispute cases: how often are clinical diagnoses incorrect?

From the BMJ:

Aims Emergency medicine is a ‘high risk’ specialty. Some diseases develop suddenly and progress rapidly, and sudden unexpected deaths in the emergency department (ED) may cause medical disputes. We aimed to assess discrepancies between antemortem clinical diagnoses and postmortem autopsy findings concerning emergency medicine dispute cases and to figure out the most common major missed diagnoses.

Methods Clinical files and autopsy reports were retrospectively analysed and interpreted. Discrepancies between clinical diagnoses and autopsy diagnoses were evaluated using modified Goldman classification as major and minor discrepancy. The difference between diagnosis groups was compared with Pearson χ2 test.’

Results Of the 117 cases included in this study, 71 of cases (58 class I and 13 class II diagnostic errors) were revealed as major discrepancies (60.7%). The most common major diagnoses were cardiovascular diseases (54 cases), followed by pulmonary diseases, infectious diseases and so on. The difference of major discrepancy between the diagnoses groups was significant (p<0.001). Aortic dissection and myocardial infarction were the most common cause of death (15 cases for each disease) and the most common missed class I diagnoses (80% and 66.7% for each), higher than the average 49.6% of all class I errors of the study patients.

Conclusions High major disparities between clinical diagnoses and postmortem examinations exist in emergency medical disputes cases; acute aortic dissection and myocardial infarction are the most frequently major missed diagnoses that ED clinicians should pay special attention to in practice. This study reaffirmed the necessity and usefulness of autopsy in auditing death in EDs.