LOCAL FRONTIERS: When ED Care is Clearly the Best Option

Jeffrey “Jim” Dietz, MD

In the last issue of Marin Medicine, Dr. Dustin Ballard wrote a fascinating article about the “Frequent Fred” phenomenon and discussed how a community might manage patients who overuse emergency departments. But what about the other side of the coin? What are the time-critical situations for which ED care is clearly advantageous?

It goes without saying that a patient suffering cardiac arrest should be brought immediately to an ED, when field resuscitation has been successful or if there is any further chance for resuscitation. It is also obvious that patients with any degree of respiratory distress should access 911 or be immediately referred to the ED. Physicians in the ED have advance airway skills and the equipment needed to stabilize these situations and initiate diagnostic modalities, as well as therapeutic interventions specific to the underlying etiology.

ED intervention is also clearly indicated for some other clinical situations, as detailed below.

STEMI

The standard of care for ST elevation myocardial infarction (STEMI) is emergent direct percutaneous angioplasty, which restores perfusion to injured and threatened myocardium. EDs in Marin County have fortunately had the capability to perform this procedure for the past 20 years. Community education efforts have led to early recognition of STEMI warning symptoms by patients and families. People with diabetes or other neuropathic conditions may present with atypical symptoms, as may a higher percentage of women.

Patients with any suspicion for acute coronary syndrome should have immediate EKGs, which are often performed by paramedics. Should the EKG demonstrate STEMI, the patient should be referred or transported to Kaiser San Rafael or Marin General Hospital, the two STEMI treatment centers in Marin. Furthermore, private physicians or paramedics who detect STEMI should contact the treatment center and whenever possible either fax or otherwise transmit the EKG prior to the patient’s arrival. This contact will initiate mobilization of the cath lab team while the patient is en route, reducing time to reperfusion. Times to catheterization in Marin County are excellent--much better than national benchmarks.

Stroke

Just as occlusion of a coronary artery will result in subsequent destruction of cardiac tissue, occlusion of a cerebrovascular artery (stroke) will result in further destruction of brain tissue or failure of less-damaged brain tissue to recover (the “penumbra effect”). Though the indications for stroke intervention are more controversial than for STEMI, early revascularization may result in better outcomes.

The key factor for stroke treatment is time from onset of symptoms, generally defined as when the patient was last seen to be normal. This critical piece of data should be investigated by referring doctors or paramedics who may have access to family members prior to the patient’s arrival in the ED. In cases where the patient wakes up with stroke symptoms, the last “normal” time is defined as when they went to sleep. Patients who slept for several hours prior to discovery of stroke symptoms may be excluded from certain time-restricted interventions.

For acute cerebrovascular accidents that meet time and clinical criteria, the primary intervention is intravenous tissue plasminogen activator (tPA). After initial studies of risk and benefit, the use of tPA was recommended for cases where the treatment could be administered within the first three hours after onset of symptoms. Given that tight time frame, many patients were excluded by virtue of time considerations alone. Recently the time window for consideration of intravenous tPA has been extended to 4.5 hours.

Other techniques to restore perfusion (intra-arterial interventions) may be considered even later. The most critical issues are that the patient be identified immediately, CT obtained rapidly, and a determination made expeditiously as to whether the patient meets criteria for either intravenous tPA or other procedures. The public has also been educated about warning signs of stroke and the need to seek treatment immediately at one of the three EDs in the county (Kaiser, Marin General, Sutter), each of which is capable of administering IV tPA for stroke.

Other Vascular Emergencies

The admonition that “time is tissue” applies to other organs as well. Patients with the potential for other vascular emergencies should be seen immediately in an ED for evaluation and treatment. Examples include suspected thoracic dissections, abdominal aortic aneurysms, thrombosis of the arterial supply to bowel or extremities, and testicular or ovarian torsion. Local EDs are well prepared to organize the workup and acute interventions for such immediate threats to life and limb.

Trauma

Ten years ago, the County of Marin, with input from local hospitals and the community at large, developed a county trauma system. Marin General was designated as a level III trauma center and is unique among such centers in that it has 24/7 neurosurgical capabilities. Experience has shown repeatedly that victims of major trauma have better outcomes when treated at a trauma center. Paramedics are directed by county EMS policy to take trauma patients who meet established criteria to Marin General. As part of the county plan, Kaiser San Rafael is designated as an EDAT (emergency department approved for trauma) and as such has a greater level of capability than a typical ED.

Sepsis

In recent years, the approach to patients with serious infections has rapidly evolved. Early recognition of patients with the more severe manifestations of systemic infection (severe sepsis and septic shock) benefit from aggressive fluid management, early antibiotics, and other “goal-directed therapy,” which may include the use of a central venous catheter-based monitoring. One goal is to provide intensive interventions to patients who are approaching severe sepsis but have not yet fallen off the cliff. The challenge is to identify patients who qualify for such therapy, which is relatively aggressive, as compared with what is usually provided for the typical “flu” patient (and yet may appear quite similar at presentation). ED physicians attempt to make this determination rapidly by assessing vital signs and other clinical findings, along with laboratory and radiologic testing.

Acute Abdomen

The differential diagnosis for acute abdominal pain is extensive. Patients with such pain often require parenteral analgesia plus immediate laboratory and often imaging studies. The results of those studies may lead to emergent or urgent operative intervention. EDs within our hospitals are capable of providing all these services.

Conclusion

In summary, the emergency departments in Marin County will keep taking care of “Frequent Fred” until we find another way to manage his needs. In the meantime, we are well prepared to handle the clinical entities that are truly emergent.

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Dr. Dietz chairs the Department of Emergency Medicine at Marin General Hospital.