Structure and function of the emergency department: matching emergency department choices to the emergency department mission

Emergency caregivers experience considerable new challenges to the provision of competent, compassionate care. The good news is there are ample new approaches and new technologies to meet those new challenges.ED leaders who understand the ED mission and the resources available today and who engage vigorously in the change process will turn that mission into immensely beneficial action.     

Pneumonia in the emergency department

Pneumonia remains one of the most common reasons for admission of emergency department (ED) patients to the hospital. Pneumonia also remains one of the most common causes of death in our patients. As with many emergent conditions, the ED management of these patients initiated by ED physicians contributes greatly to the survival and successful management of these patients. Specifically, the recognition of severe pneumonias, precise choice of diagnostic tests, and appropriate antibiotics can have an impact on the outcome.     

Re-attendance to the emergency department

The re-attendance of patients to emergency departments is becoming an increasingly common problem and yet there is not much research available on this subject. This report describes an audit carried out in the emergency department of this hospital, specifically looking at the issue of re-attendance and if there is anything that can be done to prevent it. Traditionally, emergency departments in the United Kingdom have been staffed at junior doctor level by senior house officers (SHO); however, with the advent of modernising medical careers in the United Kingdom, departments are being staffed at this level by foundation year 2 doctors (FY2). Whereas SHO range in experience from a year post-qualification to a possible 5-6 years post-qualification, all FY2 doctors have only one year post-qualification clinical experience. In this audit, FY2 doctors, despite seeing fewer patients per head than the middle-grade tier, had a higher level of re-attendance and it is hypothesised whether this is due to the impact of modernising medical careers on their training.     

Dentistry in the emergency department

Dental problems are commonly seen in the emergency department. Although most emergency physicians have had little formal training in dentistry, the majority of these problems can be diagnosed and treated without the need for emergent dental consultation. The necessary procedures may require initial instruction by a cooperative consultant but are easily learned and well within the scope of practice of the emergency physician. Time invested in familiarization with the diagnosis and treatment of the more common dental problems will be rewarded with patient satisfaction.     

Hyperpyrexia in the emergency department

The differential diagnosis of the hyperpyrexic patient in the emergency department is extensive. It includes sepsis, heat illness including heat stroke, neuroleptic malignant syndrome, malignant hyperthermia, serotonin syndrome and thyroid storm. Each of these possible diagnoses has distinguishing features that may help to differentiate one from another. However, establishing the correct diagnosis is a challenge in the setting of the obtunded emergency patient who gives no history and where there may be limited access to any past medical or drug history. This paper presents such a case and reviews the features of the differential diagnoses and management of the hyperpyrexic patient.     

Headache in the emergency department

Non-traumatic headache is an unusual presenting complaint in emergency medicine, representing only 1.4% of all patients seen over 45 consecutive days at the Royal Hobart Hospital Department of Emergency Medicine. Computerised tomographic (CT) scanning was used to assist diagnosis in 28% of cases, with nearly half (47%) of CT scans positive. Twenty three percent of patients were admitted to hospital. Emergency physicians are reminded that patients with headache commonly have serious underlying pathology.     

Urolithiasis in the emergency department

Urolithiasis commonly presents to the emergency department with acute, severe, unilateral flank pain. Patients with a suspected first-time stone or atypical presentation should be evaluated with a noncontrast computed tomography scan to confirm the diagnosis and rule out alternative diagnoses. Narcotics remain the mainstay of pain management but in select patients, nonsteroidal anti-inflammatories alone or in combination with narcotics provide safe and effective analgesia in the emergency department. Whereas most kidney stones can be managed with pain control and expectant management, obstructing kidney stones with a suspected proximal urinary tract infection are urological emergencies requiring emergent decompression, antibiotics, and resuscitation.     

Hypnosis in the emergency department

Five cases are presented wherein hypnosis was used by the emergency physician either as the primary mode of treatment or as an adjuvant to standard medical care. Common hypnotic phenomena (eg, anesthesia, analgesia), as well as novel effects, are reported. The technique used for trance induction and utilization is briefly outlined, and criteria are set forth for the bedside recognition of hypnotic trance.     

Triage in the emergency department

Accurate patient triage to provide early identification of potentially seriously ill or high-risk infants and children is an important part of any emergency care system. Use of the SAVE-A-CHILD mnemonic in a busy ED setting provides systematic organization of important clinical observations that may serve as markers of serious disease. Early recognition of the high-risk patient will reduce morbidity and mortality. The discussion included may be helpful to emergency physicians in training their staff to provide a safe triage environment.     

Hyponatremia in the emergency department

Hyponatremia is a clinical manifestation of a wide variety of diseases, some of which have high mortality rates. To assess the prevalence, cause, and prognosis of hyponatremia encountered in the emergency department, we conducted a prospective study at a major hospital in southern Taiwan. We included all adult internal medicine patients treated in the emergency department during a 2-month period. Hyponatremia was defined as a serum sodium level below 134 mEq/L, and cases patients were followed till being discharged. Among the 3,784 patients included, 166 case patients were identified. Most (65%) case patients were hypovolemic, and the overall mortality rate was 17.9%. The mortality rate increased as the sodium level decreased, but was not related to gender, age, cause, or serum potassium level. When 21 hyperglycemic patients whose serum sodium levels went beyond 134 mEq/L after the adjustment for blood sugar levels were excluded, the prevalence of true hyponatremia was 3.83%. The most common underlying diseases were those of the gastrointestinal system. It is concluded that hyponatremia is a common condition encountered in the emergency department. The mortality is correlated with the serum sodium level, and adjustment of the level is required in hyperglycemic patients to make a correct diagnosis. Unlike the cases in some other clinical settings, almost all cases of hyponatremia encountered in the emergency department were not iatrogenic and had recognizable underlying diseases. Therefore, more effort is generally required to identify the cause of hyponatremia cases in the emergency department.