Some things are likely to ever remain the same - for example, the predictable unpredictability of the kind of cases that will roll into an ambulance bay on a Saturday night, as anyone who has done a rotation in emergency medicine can tell you. However, an emergency department (ED) is also where the forces of change are often most visible.
Many of those changes are for the better, with advances in care saving lives that might have been lost only a few years ago. Others, in the crucible of a medical crisis, become vivid examples of the challenging effects of a changing economic, social, demographic and political environment.
On the front lines of both sides of change, UAB’s ED is the state’s only level one trauma center. It has the honor of being one of the few centers selected to participate in the 10-city Resuscitation Outcomes Consortium (ROC) network to gather real-world clinical data on the most effective ways to save the lives of survivors of cardiac arrest and traumatic injuries.
As better approaches are identified, the people of Birmingham are among the first to benefit as those best practices are put into place as the standard of care.
Changes That Challenge
Worldwide economic changes have added to the number of low income families in Alabama. Lost jobs have been difficult to replace with part time jobs that pay less and have fewer benefits. The effects on health are now becoming apparent in the ED.
“We’re seeing more people and sicker people, and we’re hearing the same from other emergency departments across the country,” Henry Wang, MD, said. Vice Chairman for Research in Emergency Medicine, Wang said the increase in volume isn’t simply people coming to the emergency room when they should be going to a doctor’s office.
“People are putting off preventive care until the delay turns into a real medical emergency. We’re also seeing patients with chronic health problems who have run out of insulin or blood pressure medication and don’t have the money to buy more, and they are coming in with full blown complications.”
Janyce Sanford, MD, Chair of the Department of Emergency Medicine, says changing demographics are also adding to the volume and acuity of incoming patients.
“Our aging population is having more health problems, and that trend will continue as boomers reach a time in their lives when they are more likely to need emergency care. We’ve set up our department to make it more accessible for older people. We have a staff trained in managing geriatric emergencies, and we may involve a social worker in after-care to help patients follow up with appointments, see that they get their medication, and have a safe place to go with a caregiver if needed.” Sanford said.
“In addition to more procedures being done in an outpatient setting, which may need follow up if there are complications, another factor likely to add to our patient load in the years ahead is the shortage of primary care physicians,” Sanford said. “The shortage will probably grow worse with more patients looking for doctors as the Affordable Care Act takes effect. If people can’t find a doctor accepting new patients, an ED is likely to be the safety net they turn to next.”
Changes for the Better
Fortunately, most changes you’ll see in an ED these days are advances in care that are saving lives and improving outcomes.
One encouraging example is the doubling of survival rates in cardiac arrest patients using therapeutic hypothermia, a technique tested in a ROC clinical trial at UAB.
“Therapeutic hypothermia seems to have a protective effect on the brain,” Wang said. “When the heart resumes pumping, the change in blood flow can increase the damage. We cool patients to 90 degrees for 24 hours and then gradually warm them, which seems to allow a gentler restart to body systems. The improvements we’re seeing in brain function and survival rates have been significant enough that we’re using therapeutic hypothermia for all patients revived from a cardiac arrest.”
Although the chances of surviving a cardiac arrest are still slim, especially in rural areas, at least those who make it to an ED now have better odds for a second chance at life.
Another ROC study that could improve survival in heart attack patients is research that has changed recommendations for CPR.
“When we equipped EMS units with a monitor that records every compression, we noticed gaps,” Wang said. “The EMS teams explained that there were times they had to stop compressions to move patients or load them into the ambulance. Each time they stopped, it was as if a pump lost its priming. It would take 20 to 30 more compressions to get blood circulating to essential organs.
“Taking that knowledge and applying it to CPR recommendations, we realized that telling people doing CPR alone to alternate 30 compressions with 2 breaths might not be the most effective way to go. We tested the two approaches and found the best advice for CPR is to keep those compressions coming.”
As with most wars of the last century, at least one positive byproduct of the conflicts is an increased understanding of trauma and the best ways to treat it. UAB participated in research comparing the effectiveness of standard and concentrated saline solution in head trauma and other injuries. It found that outcomes are essentially the same.
Current research is looking at the most effective combination of blood cells to use in patients needing massive transfusions.
“Sometimes we have to replace a patient’s entire blood volume one, two or even three times using multiple IV’s and rapid infusers. We know that in addition to red cells, they need white cells and platelets, but the most effective proportion of each component is unknown. We’re randomizing two “recipes” in clinical trials to determine whether one is associated with better outcomes,” Wang said.
Using Technology
Both Sanford and Wang say that one particular piece of technology has been especially helpful in the ED, and community hospitals may want to consider acquiring it for the same advantages.
“The capabilities of portable ultrasound have revolutionized treatment,” Sanford said. “We have two ultrasound specialists, and all of us are learning to use it.”
Wang said, “It looks like a laptop computer and it helps us see life-threatening injuries like bleeds in the abdomen, and it also helps in placing large IV lines. It also helped us quickly spot a ruptured aortic aneurysm.”
Another advance that should be making its way into emergency departments soon is personalized medicine using rapid genetic sequencing. Now that genetic sequencing is faster and more affordable, the segments of genes that affect variations in response to medication can be mapped from medical files. If a patient needs a drug like warfarin, a physician will be able to use the patient’s own unique genetic profile to more accurately predict the correct dosage to prevent clots without risking a dangerous bleed.
Unmasking Stealth Killers
“It’s a ninja disease—and one of the most common problems we see in an ED,” Wang said. “Sepsis can be subtle at first, and easy to miss, like a cigarette smoldering in a wastebasket, ready to flare up and become an inferno. It kills, and here in the south, mortality is twice as high as it is in the rest of the US.”
Wang had long been interested in sepsis, but it wasn’t until he moved to Alabama that he noticed a sharp increase in the number of cases he was seeing in the ED. He started plotting statistics geographically and saw a sepsis belt that is a close match to the stroke belt.
“Sepsis is an exaggerated response to infection—a cellular level disaster that dumps inflammatory chemicals into the bloodstream that can damage tissues and kill. It’s how infections commonly kill people,” Wang said. “Anyone with an infection can be at risk, and some individuals seem to be more prone to an exaggerated response.”
Wang is now involved in research trying to identify why sepsis mortality is higher here than elsewhere.
“Does the heat and humidity here breed more fierce infections? Does air quality and pollution have a role? Is it the genetics of the people who live here and how we respond to infection?” Wang said.
As he followed data from the REWARDS cohort in the overlapping stroke belt, Wang started noticing a spider web of disorders including several that have links to inflammation.
“Sepsis mortality seems to be highest in people with other health issues. The correlation is highest with lung disease, and people with kidney disorders seem very susceptible. There seem to be links to diabetes and obesity. Inflammation is the smoke of the fire, and fat fans the flames.
“In the ED, we’re accustomed to looking for unusual things that may be contributing to a case, and we’re getting better at spotting it early. When a patient presents in a doctor’s office with just a little fever, perhaps with the blood pressure down a bit and the heart rate slightly elevated, it may not seem like much. However, possibility of sepsis should be considered and watched closely,” Wang said.
When early stages of septic shock are identified by emergency medicine physicians at UAB, they respond aggressively.
“We treat with fluids, antibiotics and oxygen, typically using two to three times as much IV fluid as most physicians to support blood pressure. Dopamine has typically been used in the past, but we’re seeing some indications that Levophed may offer better results.”
In addition to sepsis, emergency departments screen for HIV and other stealth diseases. UAB’s ED is participating in a CDC study offering Hepatitis C screenings to patients in the baby boomer generation. Findings thus far indicate that Hepatitis C is significantly under diagnosed in the 46 to 64 age group.
Emergencies Natural and Man-Made
The recent history of killer tornadoes, massive hurricanes and industrial disasters, along with the lethal potential of terrorism, have increased awareness of the role of emergency medicine in responding to mass casualty situations. As past disasters have taught us, the need for maintaining preparedness is too important to be left to chance.
BREMS, the Birmingham Regional Emergency Medical Services system, coordinates emergency services, hospitals and volunteers. Regular drills help those who deal with disasters prepare for the real thing.
“We recently participated in a drill that let us test our triage and transport response in a mass shooting simulation. The drill was a UAB-wide event, and we were pleased with how well our people performed,” Sanford said.
Wang added, “We learn lessons from every incident. In major events like the tornadoes a couple of years ago, we learned that we need to take care of care givers and to anticipate needs. When a situation is likely to be of long duration, we need to deploy people sequentially rather than everyone at once, so we will have people to relieve those who are exhausted.”
In an age when air travel can bring an epidemic from the other side of the globe to your door in a matter of hours, preparation for outbreaks of infectious diseases is also a priority.
“The SARS outbreak taught the world a lot about managing an infectious threat,” Sanford said. “We have worked with difficult flu seasons in the past and have procedures in place for dealing with epidemics. We limit exposure by keeping those who might be infected in a limited area. We keep plenty of staff in reserve to handle our regular flow of emergencies so those patients won’t come in contact with the infection.”
More Changes Ahead
With population growth in outlying areas, and traffic congestion increasing between city centers and suburbs, freestanding emergency rooms are a growing national trend that is being echoed with three certificates of need for new facilities in the Birmingham area.
“The idea is to take emergency care where the people are,” said Sanford.
On the subject of change, Sanford and Wang agreed on the one change most likely to reduce the number of people coming to their door, and to reduce our individual chances of being among them.
“We as a society and as individuals need to take better care of our health,” Wang said. “People don’t seem to be doing a good job of that. We can do better.”
