Decision Making in Emergency Critical Care


Scott Weingart


Emergency medicine in the United States is at a crossroads. The purpose of the emergency physician is being determined as we speak by legislators and hospital administrators. Our role in the hospital is slowly being forced to evolve to that of a provider of primary care, available without appointment, 24 hours a day. This is laudable and a boon for patients; it is, however, very different than the original purpose of our specialty.

Many of the founders of our specialty envisioned emergency physicians as the ideal managers of critically ill patients during their initial resuscitation. In the time between caring for these sick patients, the department could also see patients with non–life-threatening complaints. It was understood that these latter patients could wait for care if a critically ill patient arrived, thereby maximizing treatment to the group whose lives depended on our interventions.

During the past decade, this system has been turned around. Now, in many departments, it is the noncrashing patient who takes priority. The wait time of patients with primary care complaints has become a rubric by which an emergency physician is judged. This year, the postvisit reviews of the patients discharged from the emergency department (ED) will be a pay-for-performance measure; not the reviews of patients we admitted to the hospital and not the reviews of the patients we brought back from near-death and sent to the intensive care unit (ICU) markedly improved due to our resuscitation.1This is a clear message from the shapers of health care policy: the ED must prioritize the noncrashing patient over the crashing one.

Despite these pressures, we will still always manage airway, breathing, and circulation for the first 10 to 20 minutes of a patient's ED course, but after that, the feeling in some departments is that these high-risk patients should become someone else's problem. The ICU doctors should take these patients upstairs or come manage them in the ED. Unfortunately, waits of 24 to 48 hours for an ICU bed are not uncommon, and a dire shortage of intensivists makes their caring for critical patients in the ED untenable in most hospitals.

But someone must take care of critically ill patients in the ED. These patients must not be left to languish with anything less than the equivalent care they will receive when their ICU bed becomes available. That someone could be an inpatient intensivist, an ED intensivist, or an emergency physician. All three are capable, but if the emergency physician cedes this role, then our profession has become very different than the specialty I hoped for when I was a medical student choosing my future career.

This handbook offers the knowledge and techniques necessary to care for the critically ill patient in the ED. It will guide you through the initial resuscitation and the continued management of these patients during their first 24 hours of intensive care. A wealth of experience is encompassed in the pages of this monograph. It extends the already strong foundations of resuscitation that are the core of our specialty. Please seize the knowledge contained here and use it.

Use it to take back the role of the emergency physician as the ultimate resuscitationist. Use it to care for patients during their most vulnerable moments. Use it to heal and to relieve suffering when we cannot heal. Just because the intubated patients cannot verbalize their complaints and misery, do not let their needs be drowned out by a patient who needs a medication refill. All patients deserve rapid, optimal care, but the purpose of an emergency physician is to provide maximally aggressive care to patients at their sickest. Everything else fills the time until the next crashing patient arrives.