Thursday, December 21, 2006

American College of Emergency Physicians ought to help forestall death

In reaction to comments made by the President of the American College of Emergency Physicians in an article in Emergency Medicine News (posted about 2 days ago) and in a press release from the “College”, I sent a letter to him today.

In particular the media release is irritating:

One paragraph begins: "Second, we don't know the facts about what happened in Illinois, so it's impossible to speculate…” and then his other comments are based on speculation
He states: "All emergency departments use a triage process, which means the most critically ill or injured patients are seen first. So a person with chest pains, stroke symptoms, or any other symptoms of a life- or limb-threatening emergency will go to the front of the line.” (which is a large part of what did NOT happen in Ms Vance’s case)
And: "However, sometimes a patient will come in with mild symptoms, and while they are waiting, their medical condition worsens. It's very important for emergency patients in waiting rooms to notify the triage nurse if they are in pain or if they start to feel worse. If they are still concerned, they should ask to speak to an emergency physician or a patient advocate.”

As I wrote him:

“Sometimes a patient will come in with mild symptoms…” Ms Vance presented with complaint of 10 out of 10 chest pain, shortness of breath, diaphoresis, and nausea (documented in triage notes). Her symptoms persisted without diminution throughout her 2 hour stay in the waiting room. Her daughter talked with the triage nurse 5 times reiterating her mother’s complaints and what appeared to be her worsening condition (weakening and changing mental status). Her daughter pleaded for her mother to be taken into the Emergency Department and asked to speak with other staff (this did not occur). Ms Vance ultimately laid down on a couch in the waiting room and suffered a cardiopulmonary arrest. That condition was noted by ED staff when they finally came for her in the waiting room. What part of your admonition and ACEP’s press release suggestions did the patient and her daughter “miss”?

I/we (the jury) do not seek criminal charges against either the doctor or nurses in the ED that night, but hope for a clarion call to improve the system. Overcrowded or not, no one should present with the classic symptoms of an acute MI and die in the ED waiting room. The system should be designed and function so that does not happen (see also the “Quality Matters column in the same EMN issue). Ms Vance’s autopsy demonstrated an acute thrombus as the cause of her MI, likely very amenable to thrombolytic treatment.

I have 17 years experience as an Emergency Medicine physician (former ACEP member and Fellow) and 8 years prior to that as an ED tech, so I do have a grounding in EM and ED function. The Coroner’s Office is in fact a public health duty and my goal is to forestall preventable death whether by violence, suicide, substance use or medical misadventure. I take my job seriously and my jury that day took their job seriously.

I agree with Dr Welch in her column (Quality Matters) that we must “…build a health care system that is safe and reliable.” I know that is also the goal of ACEP. Let’s all work toward that, using every opportunity, and not cloud the discussion with comments about how this will drive physicians from the practice of EM or noncontributory hypotheticals. There will always be dedicated physicians practicing EM and hospitals will always have EDs. Lets work to make them both the best they can be

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