What's really going on behind the scenes at your local Emergency Department? A peek under the hood.

I have been working in Emergency Medicine for the last 29 years.

During that time, I have worked in EDs small and large; I've worked in leadership roles as well as worker bee roles. I've worked on the wards, in operating theatres and in EDs themselves of course. I have also worked in austere environments a long way from help. The Bering Sea was a highlight. In fact, at this stage of my career it's easier to remember where I haven't worked rather than where I have.

But do you want to know a secret? Most people don't understand what's really happening inside an ED, and in some cases that includes the clinicians themselves.

Here's my framework of what is really happening, and it's happening in every ED all day long:

Emergency medicine #101: Diagnose and treat time urgent problems.

There are some patient presentations where speed is of the essence. In some instances, such as patients having a heart attack or significant stroke, that care is provided outside the ED - care is frequently delayed at points of transition and these patients are on the clock for urgent intervention. Delays cost lives. In other instances, such as the patient who has stopped breathing following a drug ingestion, definitive care lies within the ED itself. These diagnoses are, for the most part, not hard to make. Sometimes this will involve moving the patient to a hospital better suited to their clinical condition - not all hospitals are created equal.

These patients need the acute care system to have discussed the approach to their specific problem in advance, and to have agreed on the appropriate care pathway. In summary:

• Avoid recreating the wheel each and every time these patient groups present
• Instead, get everyone on the same page beforehand; and monitor system performance post hoc to make sure it is working as intended.
• When the patient is in front of you, avoid fussing and performing tasks that delay access to care so that the patient maintains momentum towards that care, safely, as the number 1 priority. Do that, and you'll unlock great outcomes for the patient.

Easy, right?

Emergency medicine #102: The search for low frequency high consequence illness.

Some acute illnesses and injuries are not hard to spot - a fracture dislocation of the ankle does not usually present a diagnostic dilemma for the ED team. There are, however, some diagnoses that are notoriously difficult to make, such as:

• Pulmonary embolism (blood clots in the lungs)
• Meningococcal disease
• Thoracic aortic dissection (tearing of the wall of the major blood vessel in the chest)

There are many other examples, but if we just focus on these three they have a couple of things in common: they can be difficult to diagnose, are treatable when diagnosed early, and have a significant risk of dying when diagnosis is delayed.

The other thing patients with these diagnoses have in common - the presentation is often non specific - which is to say patients with similar symptoms often have no serious underlying problem to be found - or may have a serious diagnosis present - such as pulmonary embolism. It can be very hard to tell without blood work and imaging tests, and even then some uncertainty often remains.

As a consequence, there are a lot of imaging tests done to "exclude" aortic dissection, for instance, that end up being normal and the patient goes home - or another, less serious diagnosis is identified.

Emergency medicine #103: Have the right patients in hospital and the right patients out of hospital.

Some clinical conditions are poorly matched to an outpatient approach. A broken hip that needs an operation is a good example. Other patient groups can go either way - there are in hospital and out of hospital approaches to some infections for instance. And then there are patients who, at the end of their ED evaluation, clearly have no need to be in hospital - for example the patient who thought their ankle was broken, but after x-ray it just turns out to be badly sprained.

Getting the answer to this simple question right - who should be in hospital and who should not - well it's more important to your average ED Doc tha getting the diagnosis right. Which is not to say that the diagnosis is unimportant, but sometimes the right move is to get the smart subspecialty doctors involved and let them do the heavy lifting.

Get this wrong - patients in the community who should be in hospital - and it's a recipe for misery.

Quick note: Don't put patients in hospital that don't need to be there. That's a huge mistake too. The system runs out of capacity sooner than it should.

Emergency medicine #104: Relief of significant symptoms

This one is really important, and in particular very important to patients. Pain is one of the most frequent presenting symptoms in our EDs, and quite separate from the underlying cause of the pain, there is a need for good pain relief which comes in many guises. EDs are often surprisingly bad at this - time to analgesia is measured within our EDs and the results are often longer than anyone would like.

That’s it!

I hope this cooks tour through the metagame of Emergency Medicine has been interesting - I'm happy to answer any comments or questions below.