Tintinalli’s Year in Review: What We Learned in 2017

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2017 was, shall we say, complicated. Here are the issues that dominated our headlines and will continue to drive conversations in 2018.

Tragedy in Las Vegas brings out the best in emergency medicine

It took our breath away. 500+ shooting victims and 59 deaths in a massacre aimed randomly at the thousands who were celebrating the Harvest Country Music Festival. Many named and unnamed heroes from bystanders to police to EMS pushed aside their fears and did what they could to help at the scene and at the hospital. Hats off to our emergency medicine and trauma surgery heroes, whose story we told in the November issue. Drs. Kevin Menes, James Walker, Patrick Flores, Michael Tang, and Allan MacIntyre kept their wits throughout that brutal night and made us all proud of them. Their story was our most-shared and most-commented upon piece of the year for good reason. We think future mass casualty planners will study their innovations and decisions that night.
Reverse, Inverse and Perverse EMTALA

Bob Bitterman opened our eyes to new CMS and OIG interpretations of what makes for an EMTALA violation.

In June 2017 a South Carolina hospital was charged with a number of alleged violations involving ED mental health patients. Violations included failure to properly screen, stabilize, and transfer psychiatric patients, implying that this is not an OIG-accepted role for emergency physicians but rather is the domain of psychiatry. This issue stirred great antagonism, controversy, and near fisticuffs at ACEP’s 2017 Scientific Assembly and continues to stretch the definition of EMTALA well beyond its original purpose. EMTALA citations are morphing into a new channel for punishing hospitals, and EPs are consistently caught in the crossfire. If CMS and OIG do not understand that we emergency physicians are the lynchpins of acute mental health care and that we are doing the best we can amid shrinking resources, that’s a message we need to work on.

Akron City EM Residency shuttered after contract dispute

Founded in 1974, one of the oldest EM residencies in the United States lost its ACGME accreditation and closed this July, leaving 21 emergency medicine residents in the lurch. The story is well known. Summa Emergency Associates (SEA) and its 50 mature and well-trained emergency physicians provided care to Akron City/Summa Health for 40 years. Contract renewal negotiations, anticipated to succeed over last year’s holiday break, failed, and US Acute Care Solutions (USACS) took over the contract at a moment’s notice – at midnight, January 1, 2017. The response from the EM community was fast and furious. Outrage! Injustice! Shock! Corporate Medicine scuttles the Academic mission! Posts, blogs, letters poured out, as did statements from every EM organization. But it took only about 60 days for our outrage to die down. By September, Dave Seaberg, ACEP past president with an impressive career in academic leadership, became the new chairman of Akron’s Department of Emergency Medicine. So is it ‘all’s well that ends well’? Or does it mean that we are all dispensable/disposable with takeovers looming at our doors? That depends on which side of the negotiating table you find yourself. But given market forces, there’s little doubt that we’ll see these events play out again. Could this happen to you? You bet.

In The War on opioids, let’s not neglect pain management

There are two aspects to our current opium wars. The first is physician prescribing habits, which fortunately we as physicians can control. The second is the ample availability of designer opioids on the street, which makes overdose all too easy. This is a more difficult and complex problem but one that deserves more attention than I can discuss here.

The Fifth Vital Sign came into vogue in the mid-1990s, fostered by the American Pain Society and followed closely by the Joint Commission, which required monitoring and treatment of pain as a key quality care marker. The pharmaceutical industry was quick to see the economic potential for the development and marketing of a variety of opioids to treat acute and chronic pain. A new concern is the opioid redux and surge in tramadol marketing. Tramadol is a synthetic opioid that does have addictive and abuse potential and interacts with SSRIs. An increase in tramadol prescriptions is not what we want!

We need to make sure the pendulum doesn’t swing from over-prescribing to under-prescribing, and we should take care to avoid overlooking a patient’s issues with acute or chronic pain. I was recently told of one hospital where only oral oxycodone is permissible for acute sickle cell crisis treatment in the ED. However, data shows that ‘low-intensity opioid prescribers’ are less likely to start a patient on the chain of events that leads to chronic opioid use. Hence the current focus on physician interventions aimed to move to low-intensity opioid prescriptions.

Nonetheless, pain control options for us to order in the ED or prescribe upon discharge are limited. Let’s not fool ourselves – as our patients already know this – highly touted OTC meds, such as capsaicin, topical lidocaine, and topical NSAIDS are not always effective. Oral NSAIDS were great until we learned about cardiac and renal effects of chronic use and in the elderly. Recent research on the effectiveness of low-dose IV ketorolac dosing demonstrates how we’ve accepted the manufacturer’s package insert dose without question for too long.

We shouldn’t forget about cooling therapies for pain control. Maybe IV lidocaine, given in the right dose to the right patient, has potential for acute pain control.

Acupuncture is used in Australia in the ED and also for outpatient pain control, but the technique does not have a lot of advocates in the US, quality is not standardized, and may not be widely available. Chiropractic treatment is used by the non-medical community but is not well-regarded by the house of medicine. And, remember ‘Special K’? Most of us now use ketamine for acute pain control for a wide variety of painful procedures (dislocations, joint aspirations, Bartholin gland abscess drainage, etc.) and procedural sedation. We are using more regional blocks for better ED pain control. However, these modalities do not solve the issue of pain control after ED discharge.
We should all prescribe a tincture of time and non-pharmacological options: counsel our patients about ways to control pain after discharge (Broken arm? Elevate it and reduce swelling!); discuss that pain will resolve over time; provide the risks/benefits of the various analgesics; and most importantly, be clear that we have no miracle drug to make all the pain go away.

Laypersons aren’t so prudent anymore

As of May 2017, BCBS of Georgia, Kentucky and Missouri, and soon Indiana and Ohio, will no longer cover ‘unnecessary’ ED visits, defining ‘unnecessary’ as those conditions, complaints, or diagnoses that do not fit a list of prior approved ICD 10 codes. So for that chest pain patient you thought might have ACS but turned out to just be GERD… well that patient may have to foot the bill for the ED workup. While this is billed as a cost-saving and efficiency maneuver, it reverses the key principles of the Prudent Layperson Act, which is part of federal ACA legislation and state legislation in about 37 states. We thought we won the war, but another battle is brewing. Support the organizations that fight for us and our patients. We will win again.

ABOUT THE AUTHOR

EDITOR-IN-CHIEF
Dr. Tintinalli is currently a professor and Chair Emeritus of Emergency Medicine at the University of North Carolina. In addition to teaching in the emergency medicine department, she is an adjunct professor at the UNC Gillings School of Global Public, and a frequent lecturer in the School of Journalism and Mass Communication. Dr. Tintinalli is double boarded in emergency medicine and internal medicine. She was the founder and first president of the Council of Emergency Medicine Residency Directors. She is a former president of ABEM as well as the Association of Academic Chairs in Emergency Medicine. She is a past winner of ACEP's James Mills award as well as ACEP's National Education Award. And of course, she is the Editor-in-Chief of 7 editions of her eponymous textbook, which is arguably the best-known EM text in the world.

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