In addition to shouting: “We are sinking!” from the bridge of the ED, how are we going to practice emergency medicine in 2022 without nurses and other essential personnel? I offer these suggestions with terrifying trepidation, knowing that the difference between malpractice and lifeboat ethics may depend on the situation your ED finds itself in at the moment.
Scare the community, shame the society: There is value in speaking the truth for the truth’s sake. Correctly solving problems depends on viewing problems correctly and using language that focuses on the appropriate goals. Saying “we don’t have staff” instead of “we’re expecting a bed” is essential honesty. Investigative reports about where federal money given to hospitals landed and why it’s not being used to raise salaries to at least maintain staff is essential honesty.
Americans, it seems, are stubborn and resist change until they are alarmed and passionate. They must be scared of what’s going on in emergency care. Companies should be ashamed of themselves for generously increasing salaries to strengthen the essential links in the chain of emergency medical human resources. But loud sirens and big financial incentives, while necessary, won’t change our shifts this month or next.
Unload Low Sharpness Volume: This has been tried in various ways for many years with screening and diversion to another facility, often presenting legal and transportation hurdles. The only thing different now is the boom in telemedicine, but if your emergency department isn’t already doing it, getting minor care via telemedicine is a tall order and may not offload patients who show up at your doorstep. ‘Entrance.
Diverting all stable psychiatric patients offsite would be critical, but all available psychiatric hospitals are full, and no one I know of has an offsite psychiatric emergency ward. Can we find a way for a doctor to see and discharge a patient without them seeing a nurse or technician (just recording)? I confess that I am not clear on the responsibility of the hospital with this approach.
Use less fluids and labs: Treat healthy adults less than 50 years of age as pediatric patients (including OB) when they present with vomiting or diarrhea without tachycardia. No electrolyte checks (and certainly no other labs). No IV fluids. Do Zofran ODT and an oral fluid challenge as your initial routine. Stop doing automatic troponins twice.
The second troponin was found to be effective only for patients with high-risk chest discomfort, not for all patients. For lacerations, fractures and sprains, can we scan the materials we need and put on dressings and splints without involving a nurse or technician?
Avoid ultrasound at night: Consider a loading dose of a new oral anticoagulant or a dose of enoxaparin for DVT exclusions, and develop a system to have them scheduled during daytime hours for ultrasound the next day.
Don’t do low-level trauma FAST exams. The FAST is used for its positive predictive value for going straight to the operating room, not for its negative predictive value for going home. You need a CT, not a FAST, to rule out bleeding if you’re so worried. Skip ultrasound for pediatric appendicitis at night. Its positive return is low and its negative reading is not enough. Do a good examination, with a blood test if you wish, and have a patient with a MANTRELS (Alvarado score) greater than 6 examined by a pediatric surgeon. Send patients with MANTRELS scores below 7 home with advice to return if symptoms persist within six to eight hours.
Consider CT scan with contrast to rule out appendicitis in patients with low grade right adnexal discomfort to assess rupture or ovarian cyst mass and as a decent assessment to rule out torsion in the low pretest probability . Can you do a CT scan to check for gallstones in patients with low probability and normal or nearly normal labs and have an outpatient plan to schedule an ultrasound the next day if they are normal?
The key to all of this is to get your trauma surgeons, pediatric surgeons, obstetrician/gynecologist surgeons, and general surgeons to accept this approach and promote it knowing that you cannot get an ultrasound in a timely manner and that to continue Pushing for an emergency ultrasound at night will run the risk of never being able to get a nighttime ultrasound.
Also get a commitment and payment from the hospital to teach ultrasound to all ER staff in real time as you work on deck with the ultrasound to determine first trimester intrauterine pregnancy, which is a condition (with testicular pain) for which there is no workaround. It could save a lot of nighttime ultrasound scans by technology if every emergency physician received ongoing daytime training to identify intrauterine pregnancy in the first trimester.
the Titanic creaks. You may believe it won’t sink, but I think you’ll already see it bulging and dripping if you take a closer look at your ED’s shell. You can take the position that it’s not our fault, that the company should have done things differently. You will continue to be the captain of the ship, following the manual, leading for as long as you can, and even going down with the ship. Or you can unload in a skully before 65.
Or you can warn passengers of impending disaster. You can find the courage to speak up and act instead of just accepting fate. You can be innovative, understanding that a MacGyver approach to building a lifeboat engages a certain lifeboat ethic for which one risks a poor outcome. We may have to strive in 2022 for the greatest good of the greatest number of people. Rules may have to be broken to save human lives when your ship sinks.
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.