got public health?

Public health and emergency medicine—are these really two separate entities?

Some might say that the emergency department acts as the safety net for the United States healthcare system. After all, there is no question that many patients use the emergency room as their source of primary care medicine. However, does this place emergency medicine as a facet of public health? Or do the services provided within the emergency department actually link these two specialties together?  The answer to this question lies in the practice and perception of individuals who work in either emergency medicine or public health and on those that use both systems and value their worth.

The list of public health related services that exist through emergency departments is immense.  Some services are required by law, such as EMTALA, which stands for the Emergency Medical Treatment and Active Labor Act. It mandates a medical screening exam to all comers to the emergency room that are legally eligible to receive care regardless of ability to pay or of medical complaint. The reporting and treating of communicable diseases such as chlamydia, gonorrhea, HIV, measles, or lyme disease, are also the role of the emergency physician. Emergency rooms are likely to be the first to identify outbreaks or epidemics of food borne illnesses by noting an increased number of GI complaints, and are key to helping prevent and control the spread of illness. Hospital and state policies may require screening for HIV or obtaining routine testing of syphilis and hepatitis B on any newly diagnosed pregnant females.

The emergency room physician is often the first to generate suspicion or question patients regarding child or elder abuse, or domestic violence. In addition to documentation and providing patient education, we are mandated to report all cases of concern. The emergency room is no stranger to patients with mental health issues, including homicidal and suicidal ideation. Part of our assessment includes inquiring about homicidal/suicidal ideations, plans of attack, screening for depression, and observing them in the ER until can be seen by a professional mental health care worker. The role of preventing disease and promoting safety is seen when assessing eligibility for pneumonia and influenza vaccines in older adults, and updating tetanus immunity among trauma patients. The promotion of safety amongst the pediatric population is seen with asking questions regarding seat belt usage, working smoke detectors at home house, use of bike helmets, immunization status, and lead exposure.

So unbeknownst to them, a patient is not only entering the emergency department to seek care, but they have now entered the world of public health. As they are being registered into the hospital system, getting their vital signs collected, and as we start to delve into their medical history, they are providing information regarding their own public health: use to tobacco, alcohol and illicit drug use, counseling (or lecturing) regarding cessation of such products, last time they obtained routine screening tests such as mammograms or colonoscopies, or if they have ever been tested for diabetes. Often times, we are the first to diagnose asymptomatic hypertension or new onset diabetes, educate about sexually transmitted diseases and pregnancy prevention, start them on prenatal vitamins, or inform them that their out of control high blood pressure or diabetes is starting to affect their kidneys.

In addition to providing the care for patients on an individual basis, emergency departments and staff are relied upon by local, national, and international communities to provide medical care at city wide events, be the leaders behind disaster preparedness and mass casualty efforts, and be the first to respond in national and international natural disasters. The local poison control centers are act as a liaison and information source between families and the emergency departments.

So, is there a line between public health and emergency medicine based practice?  Do EM practitioners focus primarily on the individual, providing treatment and education without thinking about the larger realm of public health?

How conscious is the thought process of providing public health based initiatives in the emergency department?  As residents we are being trained to focus on learning about disease processes, patient management, time management, all while trying to keep our heads above water.

Your time as a resident passes by quickly and you become more skilled in your management of individual patients and on a huge variety of medical issues.  However, you must keep in mind your role as an emergency medicine physician is not limited to the immediate care you are providing, but the long term care you can provide as you address public health aspects for an individual patient. You serve a more valuable role than you think….patients are seeking care in a time of need or because they are limited on who they can turn to. Take advantage of the opportunity….you never know how much of a difference you can make.

Authored by Claire Pearson, MD

Dr. Claire Pearson is a third year emergency resident at Detroit Receiving Hospital/Wayne State University.  She is the EMRA representative for the ACEP Committee – Emergency Medicine Practice Group. Her academic and research interests include public health and health policy, prehospital medicine, and anthropology.

Case 3.1

Prepared by Dr Julie Nguyen

Case presentation:
An 18-year-old African-American woman with no significant past medical history, presented to the ED complaining of cough, fever, generalized weakness, and worsening dyspnea for a week.  The patient was tachycardic, tachypneic and hypothermic.  Her labs showed leukocytosis, thrombocytosis, and coagulopathy. She had an anion gap of 21 and lactic acid of 6.7.  Her d-dimer was elevated and troponin level was 5.86. CT scan of her chest showed a massive bilateral PE in the main pulmonary arteries.  Lower extremity duplex did not show presence of DVTs.  The patient was admitted to the MICU where she was intubated secondary to persistent hypoxia (pulse ox 70-80%) despite receiving supplemental oxygen therapy.  TEE was done and showed a thrombus in the right ventricle.  Patient was treated with a bolus dose of TPA, as well as heparin drip.  She also was transfused with FFP in order to correct her coagulopathy and hypofibrinogenemia.

The patient deteriorated while in the MICU.  She was transferred to Children’s hospital the following day as a possible candidate for ECMO therapy.  A cardiac catheterization was performed, but was unsuccessful in removing the thrombus.  Local TPA infusion was done instead and the patient was continued on a heparin drip.  ECMO was not started because it was felt that the patient would not benefit from it at this time due to prolong hypoxia and multi-organ system failure.  Patient subsequently expired on hospital day #4.

Fibrinolytic therapy in Pulmonary Embolism
Thrombolytic agents activate plasminogen to form plasmin, resulting in accelerated lysis of thrombi. Common thrombolytic regimens include tPA, streptokinase, and urokinase. Streptokinase is antigenic and can cause immunologic sensitization and allergic reaction; tPA was associated with more rapid clot lysis and fever bleeding complications. Thrombolytic agents have been used in STEMI, stroke, phlegmasia cerula dolens  and central venous catheter clearance.

Indications:
•    Persistent hypotension (SBP<90mmHg or drop in SBP>40mmHg from baseline)
•    Severe hypoxemia
•    Substantial perfusion defect
•    Right ventricular dysfunction
•    Free floating right atrial or ventricular thrombus
•    Patent foramen ovale
Thrombolytic therapy accelerates clot lysis and is associated with short-term physiologic benefits, but has not been shown to improve mortality. Despite the lack of demonstrable mortality benefit, most clinicians accept massive PE as an indication for thrombolysis because successful therapy can be life saving. The risk versus benefits of thrombolysis should always be weighted on a case-by-case basis.

ECMO in the treatment of PE in adults
ECMO (extracorporeal membrane oxygenation) was first developed by Dr. Gibbon Jr. in 1953.  The idea is to remove deoxygenated blood from the body, oxygenate it, and return it back to the body.  This is similar to the idea of cardiopulmonary bypass but there are subtle differences.  The goal of ECMO is to allow the heart and lungs to rest from the high levels of oxygen and airway pressures that are required for ventilation and oxygenation.  It is a bridge to definitive therapy.

The use of ECMO has been mainly utilized in the pediatric population, especially in neonates.  Most of the studies and data on ECMO are within the pediatric population.  It has not been well studied in the adult population and the success rate varies.

Here are the indications and contraindications/exclusions for the use of ECMO in adults.

Indications:

• Cardiac or lung diseases that are acute, life threatening, unresponsive to standard conventional therapy, and are thought to be reversible.
• It has been mainly used for ARDS in adults
• No clear indications for PE

Contraindications/Exclusions:

• More than 10 days on mechanical ventilation
• Age > 65 years old
• Contraindications to anticoagulation
• Necrotizing pneumonia
• Multiple system organ failure
• Terminal underlying disease
• Major or irreversible CNS injury

Sherwin’s Critical Care is an education module that focuses on various aspects of critical care relevant to the practice of Emergency Medicine.   These are real cases as managed in the ED.  All postings are HIPAA compliant.

Tracings Vol 3.1 Answer

HPI

A 15 y.o. girl was transported by EMS to the ED. She had just experienced her second syncopal episode in 8 days. This morning while in the bathroom at her family’s home getting ready for school, she felt nauseous and then passed out. When she awoke, EMS was on the scene. She had had a previous syncopal episode 8 days prior while at school. On that occasion she had gone into the girls’ bathroom and then woke up lying on the floor. “Possible” seizure activity was observed. Since that time she has had a throbbing headache involving the entire head. Neither episode had associated chest pain, shortness of breath, faintness or focal neurologic symptoms. Her last menstrual period had been 3 weeks prior.

Past medical history was significant for a congenital single kidney and appendectomy. She was taking no medications. There was no history of drug, alcohol or tobacco use.

Physical Exam

On exam the patient appeared alert and generally well. BP was 116/66, pulse 73, respirations 20, and temperature 36.5C. General, cardiopulmonary, neurologic and extremity exams were all normal. Pulse oximetry registered a 100% saturation on room air.

Review of the EMR revealed that a brain CT performed during the ED visit 8 days prior had been normal. UDS and SDS had both been negative. The patient had been discharged from the ED and referred to her primary care physician. He had obtained a neurology consult which found no abnormalities and an EEG which was normal.

During the present visit, a 12-lead ECG was normal and initial laboratory evaluation was unremarkable. After conferring with the patient’s physician, a decision was made to obtain an echocardiogram.

While the patient was awaiting this study, the cardiac monitor alarm activated and a rhythm strip was recorded. The patient remained asymptomatic and the abnormality which had triggered the alarm resolved before any action could be contemplated.

Repeat VS and a directed exam were unremarkable.

Questions

1.  What rhythm does this strip reflect?

2.  What should be done next?

Discussion

The rhythm strip reveals what appears to be a wide-complex QRS rhythm with a rate of around 215 bpm. On the surface this seems highly suspicious for ventricular tachycardia. Another possibility might be a supraventricular re-entrant or atrial tachycardia with aberrant conduction.

However, there are narrow QRS complexes running through and apparently dissociated from the wide-complex QRS rhythm (see arrows) and at a rate that is identical to the sinus rhythm at the beginning of the strip.

What’s going on?

Since you can’t have simultaneous and concurrent ventricular depolarizations of the ventricle triggered by both the sinus impulse and an ectopic ventciular pacemaker (note that some of the narrow beats land on the wider deflections and some land in between), the only explanation is that  the wide-complex QRS rhythm is artifact, most likely electrical in origin.

In this case, a consulting cardiologist determined that the rhythm was artifact. Further workup failed to reveal a cause for this patient’s recurrent syncope.

Lesson: look for this phenomenon when apparent wide complex rhythms are recorded by cardiac monitors, especially when the patient remains asymptomatic (although a patient can certainly remain asymptomatic during runs of VT).

Tracings is a learning module involving actual cases of patients and their ECGs that present to the Emergency Department.  Topics chosesn are dervied from the EM Model for Resident Education. Cases are prepared by Dr. William Berk.

Tracings Vol 3.1

HPI

A 15 y.o. girl was transported by EMS to the ED. She had just experienced her second syncopal episode in 8 days. This morning while in the bathroom at her family’s home getting ready for school, she felt nauseous and then passed out. When she awoke, EMS was on the scene. She had had a previous syncopal episode 8 days prior while at school. On that occasion she had gone into the girls’ bathroom and then woke up lying on the floor. “Possible” seizure activity was observed. Since that time she has had a throbbing headache involving the entire head. Neither episode had associated chest pain, shortness of breath, faintness or focal neurologic symptoms. Her last menstrual period had been 3 weeks prior.

Past medical history was significant for a congenital single kidney and appendectomy. She was taking no medications. There was no history of drug, alcohol or tobacco use.

Physical Exam

On exam the patient appeared alert and generally well. BP was 116/66, pulse 73, respirations 20, and temperature 36.5C. General, cardiopulmonary, neurologic and extremity exams were all normal. Pulse oximetry registered a 100% saturation on room air.

Review of the EMR revealed that a brain CT performed during the ED visit 8 days prior had been normal. UDS and SDS had both been negative. The patient had been discharged from the ED and referred to her primary care physician. He had obtained a neurology consult which found no abnormalities and an EEG which was normal.

During the present visit, a 12-lead ECG was normal and initial laboratory evaluation was unremarkable. After conferring with the patient’s physician, a decision was made to obtain an echocardiogram.

While the patient was awaiting this study, the cardiac monitor alarm activated and a rhythm strip was recorded. The patient remained asymptomatic and the abnormality which had triggered the alarm resolved before any action could be contemplated.

Repeat VS and a directed exam were unremarkable.

Questions

1.  What rhythm does this strip reflect?

2.  What should be done next?

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

Tracings is a learning module involving actual cases of patients and their ECGs that present to the Emergency Department.  Topics are derived from the EM Model for Resident Education. Cases are prepared by Dr. William Berk.

Answer VizD Vol 3.1

Winners

Marjan Siadat                 Kyle Perry                        Katie Ohlendorf

Katie Dobratz                  Brian Junnila                 Matt Steimle

Sam Lee                           Devon Moore                  Donnell Newman

Shereaf Walid                 Dan Seitz                         Eric Tosh

Case 2.2

A 7-year-old boy is brought to the ED by his mother after she noticed the rash below on his body.  The mom states that the rash first appeared on her son’s face  and then rapidly spread to his neck, back, chest, and legs.  Mom states that her son complained of a sore throat for the last couple of days and he had a low-grade fever.  Mom states that her son is vaccinated with all vaccines except those that have live viruses.  On exam, you note postauricular and posterior lymphadenopathy.  The rash is pink to red and maculopapular.

1. What is the diagnosis?

Rubella (German Measles) – caused by infection with Rubivirus

Click here for a Lancet review on Rubella

2. What vaccine could have prevented this condition?

Mumps, Measles, Rubella – a live-attenuated virus

3. What is the most concerning complication of this condition?

-Congenital rubella syndrome (exposure occurs during the first trimester of pregnancy)

Click here for a review on Congenital Rubella Syndrome

-Subacute sclerosing panencephalitis

Thank you to everyone who submitted their answer.  Stay tuned for next week’s VizD

VizD is a weekly contest of an interesting or pathognomonic image from emergency medicine. Its goal is to integrate learning into a fun and relaxed environment. All images are original and are posted with the consent of the patient.

Visual Diagnosis Vol 3.1

Case 3.1

A 7-year-old boy is brought to the ED by his mother after she noticed the rash below on his body.  The mom states that the rash first appeared on her son’s face  and then rapidly spread to his neck, back, chest, and legs.  Mom states that her son complained of a sore throat for the last couple of days and he had a low-grade fever.  Mom states that her son is vaccinated with all vaccines except those that have live viruses.  On exam, you note postauricular and posterior lymphadenopathy.  The rash is pink to red and maculopapular.

1. What is the diagnosis?

2. What vaccine could have prevented this condition?

3. What is the most concerning complication of this condition?

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

VizD is a weekly contest of an interesting or pathognomonic image from emergency medicine. Its goal is to integrate learning into a fun and relaxed environment. All images are original and are posted with the consent of the patient.

Conf

2009-2010 Reading Curriculum

__

2009 Schedule

__

Resident Lecture Assignments

PGY2

PGY3