What does 2021 hold for EM?

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Predicting the latest challenges and pitfalls for the New Year.

While no one could have predicted what was in store on a global front as the world was challenged with COVID-19, some of the EPM editorial board did accurately predict even without knowing exactly how prophetic their thoughts would play out in 2020.


“The demand for telemedicine will continue” and “Telehealth will gain mainstream adoption” might have been safe bets, but the level of which those predictions were true was startling. Patients and physicians alike adapted while the world is still in the midst of a pandemic. As 2021 gets underway, the Emergency Physicians Monthly board brought back their predictive technology and crystal balls to predict what’s in store for the New Year.

Salim Rezaie:

Well, 2020 has been a difficult year for many of us with the focus mostly being on COVID-19. This will most likely continue into 2021, but I want to talk about something other than COVID-19:  Changes in patient care based on research from 2020…


  1. More advanced imaging will be used in stroke care (i.e. Perfusion based imaging) although we will still debate on whether thrombolysis is useful in stroke.
  2.  We will define cath lab activation based on occlusion myocardial infarction (OMI) and non-occlusion myocardial infarction (NOMI) to be better predictors instead of traditional STEMI/NSTEMI criteria.
  3.  TXA will no longer be a darling medication for everything that bleeds.
  4.  D-dimer thresholds will be increased based on clinical probability of VTE.
  5.  The modified Valsalva maneuver will be the go-to maneuver in hemodynamically stable SVT (i.e. Not Adenosine).
  6.  CT scans can be performed with IV contrast at higher creatinine thresholds.
  7.  HFNC will become more commonly used in the ED.
  8.  Mild- to moderate-sized pneumothoraces will be managed with conservative watching instead of large bore chest tubes.
  9.  US-guided peripheral IVs will decrease the number of CVCs needed.
  10. Droperidol and Haloperidol will continue to gain use for just about everything.

Judith E. Tintinalli, MD, MS:

  1. TXA will be used more by EM clinicians for serious conditions besides trauma  such as pulmonary hemorrhage — and think angioedema
  2. We’ll convince more EM residency graduates to study   Health Care Economics and Information Technology
  3. We’ll get EDs involved in research trials on covid antigens and antibodies, and become partners with public health in influenza and COVID vaccination
  4. We’ll use ketamine for  just about everything
  5. tPA administration for stroke will be changing fast- keep our eyes on the clinical literature
  6. hsT won’t be the instant magic bullet for chest pain we’re hoping for. We’ll still have to be careful.
  7. ED overcrowding will be here to stay
  8. More EDs will have institutional support for expanded ED mental health units

Mark Plaster, MD, JD:

As bad as 2020 has been, I see 2021 only improving marginally. I suspect that the benefits of vaccination programs will reach the wider population very slowly and will probably not result in social relaxation of tensions for quite some time. Moreover the political rancor is not likely to subside any time soon. The actors playing the ‘resistance’ role might change, maybe not. But the animosity and the ‘take no prisoners’ rhetoric will not. Science itself has been under a microscope in 2020 with the long held assumptions of objectivity being brought into question.

I’ve been deeply disappointed to see social media threads that were established by emergency physicians for the purpose of discussing cases descend into political name calling. That’s why I hope that open forums like Emergency Physicians Monthly will play a role as a platform for open, honest, vigorous, but civil debate on a variety of topics that affect our personal as well as professional lives. This magazine, after all, is for and about us. We have a long tradition of presenting the pro vs. con on many topics, even some with deep sensitivities. And we will continue that. But it will remain to be seen if we can do so with a sense of camaraderie and mutual respect. I certainly hope so.


Aditi Joshi, MD, MSC:

  1. Use of remote consults will increase both for decreasing exposure and decreasing time to consultation within EDs
  2. There will be more institutional support for warm handoff training and resources

Andrew Kalnow, DO:

The ET3 model for EMS transport “Emergency Triage, Treat and Transport” will gain traction and provide a possible Emergency Medicine Telehealth opportunites for EM physicians to triage field patients while better addressing patient needs by diverting patients that will not directly benefit from an ED visit.

Zyprexa (Olanzapine) will become the new Haldol for non-agitated patients… abdominal pain, nausea including cyclic vomiting, refractory headaches and more.

We will get wider recognition of the need for multidisciplinary support in the ED, ie ED pharmacy, respiratory therapy, behavioral health, case, management, etc. and we are further recognized as the hospital hub and intersection of inpatient and outpatient care. (I might be dreaming this one…)

Mike Silverman, MD:

Unfortunately, I think COVID will continue to be a major story in emergency medicine throughout 2021.

On the plus side, I have a good excuse not to wear a tie at work, even at meetings. Masks, goggles, scrubs and disposable stethoscopes will continue to dominate our wardrobe.

ED volumes are still considerably down compared to baseline. While volumes may creep up, I can’t see them returning to normal until everything is back to normal. Historically, about 10% of the volume at my ED is tourists. I can’t remember the last time I saw a tourist.

Telemedicine may have finally hit its tipping point and will impact how we do business. The infrastructure primary care offices have built for telemedicine access for their patients will keep some lower acuity patients out of the ED, which may not be good for our business model, but likely beneficial when viewed from the medical utilization perspective. Some ED groups have and will enter this space and will adapt their own business model throughout 2021.

The decreased volume has led to staffing issues with many EDs being overstaffed. This has changed for the job market. It’s hard to get a job and harder to get a job at your first choice hospital or even in your first choice city. This has impacted experienced docs as well as recent residency grads and next summer’s grads. Jobs still exist, but the openings in bigger cities just aren’t there.

Evie Marcolini, MD, FAAEM, FACEP, FCCM:

We will continue to find ways to treat more stroke patients using advanced technology.  EMS will perfect the digital apps to determine the most efficient way to get the patient with LVO to advanced imaging and interventional treatment for an increasing number of patients.  We will get closer to saying goodbye to thrombolytic infusions for acute ischemic stroke in favor of bolus dosing thrombolytics or none at all if the patient is close enough to an angio suite — following in the footsteps of our cardiology colleagues treating acute STEMI.

We will see more patients requesting telehealth for their medical needs.  We (and our patients) have resorted to telemedicine because of dire need, but along the way have found that it’s actually very reasonable in many situations.  In that sense we also have recognized the benefits (economic, environmental, productivity) of working from home. (https://hiddenbrain.org/podcast/when-you-start-to-miss-tony-from-accounting/) When we are able to loosen the shackles of physical distancing, many will hang on to some of the virtual components that work just as well.

Looking forward to bidding adieu to 2020 and better times ahead!

William Sullivan, DO, JD:

The catchphrase for 2020 was “social distancing.” The catchphrase for 2021 will be “COVID passport.” Corporations will increasingly restrict travel and other important services unless people can produce proof of COVID vaccination or that they are otherwise immune to infection. Because of this, antibody testing will come into vogue.

Once the mechanism of mRNA vaccines becomes more widely known, concerns about what is *really* in the vaccines and what the vaccines are *really* doing to our bodies will cause significant resistance to COVID vaccination. Isolated social media reports of outlandish alleged vaccination side effects will fuel this resistance. Social media may or may not block such information from being disseminated.

COVID-19 will mutate or new strains will be discovered. Whether the vaccines will be effective against those new strains is a coin flip. No public health official will dare to say when it is “safe” for the public to cease using masks. Masks are here to stay.

ED volumes will wax and wane depending on local and regional severity of virus outbreaks, but overall will not approach pre-pandemic volumes for the next year. Many more rural hospitals will close due to financial pressures.

More medical professionals will become burned out or frustrated and will leave the profession. While some larger hospitals are overstaffed and are laying off staff, other smaller/rural hospitals will have difficulty finding adequate staffing.

Use of midlevel providers will increase not just in the emergency departments, but throughout medicine. More states will allow independent practice while more hospitals will staff emergency departments solely with midlevel providers.

Telemedicine use will continue increasing. Insurance companies will limit payments for telemedicine visits.

Social isolation will cause or exacerbate mental health issues in an increasing number of patients. Telepsychiatry will flourish.

Unfortunately, the medical “cancel culture” will worsen. Rather than allowing medical professionals to engage in scholarly discussion about opposing views, journals will retract studies that are questioned in the media. Fear of negative public sentiment will cause journals to refuse to publish studies that don’t fit in with the current narratives.

Random wild prediction… stock markets dive at some point in 2021, drop by at least 33%

Andy Little, DO

– Due to declining volumes with COVID, added to the increase in EM grads, the dream of the Board Certified EM physician moving to practice in rural America will become a reality.

– Despite literature proving otherwise, there will be a large public concern for the safety of the COVID vaccines and we will see many Americans opt-out of receiving the vaccine, leading to a prolonged COVID-19 pandemic.

– Due to the continued COVID pandemic we will see an expansion of groups providing EM conferences. With most (if not all) going virtual, many will try their hand at putting on a conference.

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