Emergency physicians, nurses, and residents writing on KevinMD from the emergency department: acute care, the realities of the ER, boarding and overcrowding, violence against staff, and medicine practiced under pressure. Most contributors work in emergency departments. For what emergency physicians and nurses have said about being assaulted at work and told it was part of the job, see Violence against health care workers: what physicians and nurses say, in their own words. For what emergency physicians wrote in the first weeks and months of the pandemic, see COVID-19: what physicians wrote as it happened. For what emergency physicians and pain patients have said about opioid prescribing, see Opioids: what physicians and pain patients say, in their own words. For what physicians in the highest-burnout specialty have said about burnout since 2009, see Physician burnout: what physicians say, in their own words.

The Night Shift: Real life in the heart of the ER, an excerpt

Physician
September 21, 2010

An excerpt from The Night Shift: Real Life In The Heart of The E.R. ©2010 by Dr. Brian Goldman. Published with permission from HarperCollins Publishers Ltd. All rights reserved.

Fear and Loathing

12:47 a.m.

Two police detectives were waiting for me near the main triage desk; one was a tall male in a sleek black suit, probably in his early forties. He was ruggedly handsome in the manner of Jean-Paul Belmondo, the French …

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The Night Shift: Real life in the heart of the ER, an excerpt

Emergency department utilization and its impact on health care reform

Health Policy
September 15, 2010

by James P. Davison, DO

Emergency department utilization and its impact on health care reform legislation has been a hot topic of conversation in healthcare journals and the blogosphere. It is a tenet of the currant legislation that ER visits and cost growth will go down, contributing to a decreased health cost growth curve.

Opponents state the newly insured will flock to the nation’s emergency rooms. Proponents …

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Emergency department utilization and its impact on health care reform

Moments of internal struggle in the ER

Patient
September 5, 2010

I walked into Room 22 to find a very interesting patient who presented to our ER with complaints of abdominal pain and associated nausea and vomiting.

The patient sat on her cot with her pant legs rolled up above her knees, refusing, according to her nurse, Gwen, to put on a treatment gown. Her left leg hung in the air, her ankle crossed over the knee of her right leg. Her …

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Moments of internal struggle in the ER

The TPA time limit for acute stroke causes mass chaos in the ER

Conditions and Diseases
September 1, 2010

I hate acute strokes. There are several reasons for it. Most of them are logistical. First, everyone gets into a tizzy because of the 3 (or 4.5) hour time limit after the onset of symptoms that which TPA can be given and hopefully improve the patient’s outcome. Unfortunately, this time limit (and the data for TPA’s efficacy is only OK at best) causes mass chaos and annoyance.

First, one has to …

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The TPA time limit for acute stroke causes mass chaos in the ER

Metastatic cancer and the matching walkers

Patient
August 5, 2010

They made a regal couple, the elderly man and woman sitting in Room 19. She was the patient, he the supportive husband. She sat in the treatment cot while he sat in a chair pulled near her bedside. Together, they greeted me with their warm smiles as I walked into their room.

They both had full heads of healthy, silvery hair that shimmered from the overhead fluorescent bulbs. Their eyes were …

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Metastatic cancer and the matching walkers

The difficulty of regulating x-ray radiation in the ER

Conditions and Diseases
August 2, 2010

A recent article in the New England Journal of Medicine touched off another salvo about how non-clinicians have no problems judging the abilities of clinicians in the world of medicine.

The article begins by presenting the case of a woman who awoke with facial paralysis and then went to the emergency department. On arrival, she received CT scans and MRI scans of her brain. When those were normal, she was diagnosed …

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The difficulty of regulating x-ray radiation in the ER

ER visits rise because of prescription drug abuse

Medications
July 17, 2010

by Michael Smith

The number of emergency room visits for nonmedical use of prescription painkillers more than doubled between 2004 and 2008, according to a CDC estimate.

The increase was part of a trend that saw emergency room visits for nonmedical use of all prescription and over-the-counter medications reach the same level as those for abuse of illicit drugs, the agency said in the June 18 issue of Morbidity and Mortality Weekly …

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ER visits rise because of prescription drug abuse

When the doctor is the patient, humanism and competency matter

Patient
July 13, 2010

Over the past few weeks I’ve had ample opportunity to be on the other side. Not like some parents with chronically ill children or those with children who have suffered tragic illness. No, not like that; I am fortunate that hospitals aren’t a part of my family’s everyday (except for work). My children have had amazing fortune and I remain in awe of good health. Lately though, we’ve had some …

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When the doctor is the patient, humanism and competency matter

Not all pain patients in the ER are drug seekers

Physician
July 12, 2010

by Melissa Velez-Avrach

About eight years ago, I was in an accident that left me with chronic lower back pain and muscle spasms.

Then, about a year and half ago, I was in a car accident. Bad combo for the pain. I’ve been to chiropractors, orthopedic spine specialists, had MRIs, the works and am following my doctor’s recommendations, doing yoga, deep breathing and physical therapy when needed. It has all helped me …

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Not all pain patients in the ER are drug seekers

Emergency room waits grow as more people become insured

Health Policy
July 8, 2010

Remember when I wrote, way back when, that expanding health coverage without a concurrent increase in primary care access will only worsen emergency room waits?

For instance, consider this, from CNN.com:

What good is having health insurance if you can’t find a doctor to see you? …

… The Massachusetts Medical Society reported that the average wait time for a new patient looking for a primary care doctor ranged from 36 to …

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Emergency room waits grow as more people become insured

Kidney stone pain, as experienced by a man and a woman

Conditions and Diseases
July 5, 2010

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As a typical guy, there are several painful illnesses that can hit our brotherhood in an instant. No warning was given. No “Get out of jail free” pass, either. Just cruising along, having another fine, healthy day, and bam! — suddenly, you are lying on the floor in severe distress.

The most feared? A testicular torsion. It can happen spontaneously. It can …

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Kidney stone pain, as experienced by a man and a woman

Social media in crisis management and public health emergencies

Social Media in Medicine
June 24, 2010

In Boston we took the availability and quality of our tap water for granted until May 1, 2010, when a major water pipe break interrupted water service to two million Greater Boston residents.

Information spread quickly to citizens about the problem and what to do, all the more notable because the water main break occurred on a Saturday. In this age of consumer paranoia about withheld information, the Massachusetts Water Resources …

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Social media in crisis management and public health emergencies

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Why the medical chart may not improve patient care

Physician
June 15, 2010

Why do we physicians chart the way we do? Hopefully, you do it perfectly well and have no concerns at all. But where I practice emergency medicine, we are approaching maximum inefficiency in charting.

It all became much clearer when we started using our new EMR system. Let me make it clear, I’m not against EMR. In fact, typing and templates work better for me than dictating. My dictations were usually …

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Why the medical chart may not improve patient care

Can chest pain patients be evaluated in the ER waiting room?

Physician
June 12, 2010

by John Gever

Emergency department patients with chest pain may safely be evaluated in the waiting room when necessary, researchers said.

Among 303 patients triaged to waiting-room evaluation in a prospective study, no acute coronary syndromes were missed and adverse event rates overall were lower than among 804 patients who were assessed in conventional monitored beds, reported Frank Scheuermeyer, MD, of St. Paul’s Hospital in Vancouver, British Columbia, and colleagues online in …

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Can chest pain patients be evaluated in the ER waiting room?

Treating a child with fever and leukemia

Conditions and Diseases
June 10, 2010

I walked into Room 35 to find a three year-old lying on the hospital cot. Her father sat alongside her bed, whispering softly to her. The patient appeared quite tired, wiped-out even, and if it weren’t for her complacent eyes tracking my every move, I would have thought she might be sleeping.

She was visiting our ER because, after a few days of cough and congestion, she had developed a fever. …

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Treating a child with fever and leukemia

Interruptions in the emergency department can lead to errors

Physician
June 8, 2010

by Nancy Walsh

Busy clinicians in the emergency department reduce the time they spend on clinical tasks when interrupted, working faster and possibly cutting corners, a prospective observational study found.

Overall, clinicians were interrupted 6.6 times per hour, and 11% of all tasks were interrupted, according to Johanna I. Westbrook, PhD, of the University of Sydney, in Australia, and colleagues.

The mean “time on task” for uninterrupted tasks was 1 minute and 26 …

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Interruptions in the emergency department can lead to errors

Father of a patient with a sudden brain hemorrhage

Conditions and Diseases
May 20, 2010

She was 50. Prior to being transported to our ER, her only complaint had been for non-traumatic elbow pain over the past two weeks. She was on no medications and had no significant medical history.

She was at home, preparing to visit her doctor for a scheduled visit, when she collapsed. Because she didn’t drive, her elderly father had planned on swinging by to pick her up. He had just called …

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Father of a patient with a sudden brain hemorrhage

Defensive medicine starts early in residency training

Physician
May 19, 2010

Part of a resident’s job is to learn the ropes in preparing for independent practice. While you’re a resident, you get the benefit of having someone looking over your shoulder to critique you as you determine how you are going to manage patients.

I frequently tell residents that different attending physicians practice medicine in different ways. Some practice defensive medicine more than others, some prescribe antibiotics more than others and some …

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Defensive medicine starts early in residency training

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