A Creative Approach By Neal E. Flomenbaum, MD, Editor-in-Chief

One way to characterize emergency medicine is that it is among the most creative of specialties. By the late 1960s, the practice of medicine had become completely specialized and was rapidly becoming subspecialized into unique disciplines based on approaches—medical or surgical—and organ systems. But it soon became evident that a few distinct patient populations had been left out of this scheme. The need for a “generalist” to care for all members of a family over extended periods of time was one such gap that gave rise to the specialty of family practice. Another glaring omission was the need to competently care for the increasing numbers of patients with acute problems going to emergency departments at inconvenient times, which led to the creation of emergency medicine as a specialty.

We defined ourselves in a way never previously included in a specialty definition: by time, and the need to act quickly—or, in some cases, the need to determine how much additional time can safely be allowed before an intervention is required. So unique is the element of time to emergency medicine that its board adopted the hourglass as its symbol.

As emergency medicine became a recognized specialty over the next two decades, several other time-related clinical disciplines emerged as subspecialties, such as toxicology, sports medicine, and pediatric emergency medicine. There was a sense then that finally every patient’s needs were being addressed. But little in life remains the same for long, and needs change, while change creates new needs. Managed care imposed additional requirements of demonstrating medical necessity prior to approving inpatient admissions, the population began to age, and the destructive forces of manmade and natural disasters increased in frequency and magnitude as patients began piling up in ED waiting rooms. The need for the type of creativity that gave rise to emergency medicine in the first place became more apparent.

Here are a few creative solutions currently being field-tested in busy, overcrowded urban EDs:

If you can’t solve all of the problems, at least solve the ones you can. For example, consider what can be done to reduce the lengths of stay of those who can be treated and released, even while others wait for inpatient beds. This need was initially addressed by the creation of urgent care or “fast track” units, but now patients in the main EDs, triage, and waiting rooms must be included as well. Providers, mid-level or higher, joining triage teams is one way to more rapidly initiate diagnosis and treatment.

Identify patients with time-limited special needs and provide what they need before it is too late. Life-threatening cardiac and pulmonary problems always go to the head of the line, but patients who have acute surgical abdomens can’t be relegated to waiting rooms for any but the briefest times. Fever and leukopenia, along with systemic or serious bacterial infections such as pneumonia, require rapid diagnosis and antibiotics. Addressing only these specific needs may be full-time jobs in many urban EDs, but by doing so, mid-level providers may actually enable more timely treatment of others.

Should these considerations be managed by creating new subspecialties, such as geriatric emergency medicine and wilderness/preparedness medicine, or by formally designating associate directors for “operations,” “outpatient emergencies,” or “off-hour services”? The recognition of those who are willing and able to take up these challenges may be useful, and we already have “hospitalists,” “nocturnalists,” and “nighthawk radiologists” in other specialties. But officially designated or not, the need is real, and emergency medicine should not hesitate to once more creatively address the emergent needs of the 21st century.

Emerg Med 40(5):4, 2008