Miguel Andrei C.

Medina 2016-00448
VLE Forum Discussion Answers

Module 1: Have you ever been a patient in the ED? Or have you ever brought a patient
in ED? Describe how you felt and your experience.

I have been an ED patient twice. Once when I was in high school, for anaphylaxis, and another
when I was in LU3, for severe dehydration and acute gastroenteritis. Needless to say, both
times, I was apprehensive about going to the emergency room. I kept trying to convince myself
that I was overreacting and need not seek urgent care. Thankfully however, I decided to go, as
after some point, I realized I was dying (for the anaphylaxis, my difficulty in breathing worsened,
and for the acute AGE episode, I was beginning to feel numbness in my extremities and
become confused). I remember seeing a single person in a desk for the latter visit, who I now
know to be the triage nurse, who took my VS and also got a basic rundown of why I was in the
ER. I remember being treated with utmost care and urgency, especially for the visit for my
anaphylaxis – for that visit, I walked in, told the triage officer (who was a student in the PGH ER)
that I needed epinephrine, and she immediately passed me over for resuscitation. Both times, I
remember being greeted by emergency physicians, who calmed me down, and told me that I
was already in the ER and wasn’t going to die. I really appreciated that they took the time to
make me feel like I was going to be okay. They also had appropriate bedside manner – when
they had to give me fluids for AGE, they were joking about how hard it was to find a suitable
vein as all my veins had collapsed, instead of complaining and making a fuss, they tried their
best to keep their cool. Even before they had given me an epinephrine injection for my
anaphylaxis, they warned me that it would probably be the most painful injection of my life (it
was), but it immediately made me feel fine because of its fast-acting effects, to which the ED
physician also joked with me about. All in all, I can confidently say that going to the ER saved
my life, and I have nothing but respect for the ED physicians and other ED HCWs.

Ambulansyang de Paa - “What is the importance of pre-hospital care in improving

outcomes for patients especially for those with acute life-threatening conditions and in
improving access to health care”

Proper pre-hospital care is very important in improving outcomes for patients because patients
could easily deteriorate or worsen on the way to the hospital. This is especially true for patients
with acute life-threatening conditions - these patients need immediate care, and delaying basic
interventions in favor of waiting for them to reach the hospital may lead to their demise. Access
to proper health care is not synonymous with access to hospitals - it includes everything else,
such as proper access to primary health care clinics, nutrition, sanitation, and yes, proper pre-
hospital care. As shown in the documentary Ambulansyang-de-Paa, because of limitations in
infrastructure there is difficulty in bringing patients to see health professionals. While the resilience
of the communities shown in the documentary is praiseworthy, this is not ideal at all. Many
complications can happen in the 3-4 hour trek down to the municipal health center, and that time
delay will still increase while they are being transported to the hospital, at which time patients
would already be in a much worse state than they had began with. It doesn't help that those
volunteering to help bring the ill down to the healthcare centers do not know how to manage these
conditions. Proper pre-hospital care would thus be able to prevent these complications, but this
would also entail fixing many other related socioeconomic issues such as the rampant poverty,
lack of proper governance, lack of funding, lack of medicines, lack of electricity and proper
infrastructure, lack of doctors and other HCWs, etc.

Module 2: Recall your first clinical experience in the ED, how are patients prioritized?

Because there are limited personnel and resources in the ED, and because some patients may
require more urgent care than others, a triage system is in place to ensure the most efficient
and effective distribution of resources. There are many kinds of triage systems, but the one I am
most familiar with is the emergency severity index triage system, which ranks patients from 1-5,
with 1 being patients who needed the most urgent care (immediate life-saving interventions).
Patients ranked 2 in this system would be those who are at high-risk for deterioration and would
need care within minutes; while patients ranked 3, 4, and 5, are those who may wait for longer
and need many, one, or no resource/s, respectively. I have never been on duty in the ED, but
based on my ER visits in the past as a patient, I have seen the triage system at play. For
example, when I had arrived due to my anaphylaxis, I needed immediate IM epinephrine.
However, as I could still talk, I was probably still at ESI 2 at this point. Meanwhile, another
patient had a grand mal tonic-clonic seizure in front of me. This patient was definitely ESI 1, and
had higher priority than me, as seizures of that type can cause airway obstruction and
immediate death. However, once the seizure patient was brought in, I was seen in 5 minutes
and given my life-saving shot. This is just one example of the triage system working to ensure
that patients get the best care possible given our limited resources and time.

Module 3: How different is an approach to an emergency patient from an OPD patient?

The approach to an ED patient is different from an OPD patient from the very start. With ED
patients, we seek to rule out life-threatening causes FIRST and FOREMOST. We do not even
have a focus on getting the diagnosis right, we just need to make sure that the patient lives, and
is stable, before we make the proper decision on disposition. ER management may thus take on
many roles, but is primarily for stabilization and addressing emergent issues, rather than being
definitive for a particular disease. For OPD patients, there is a focus on taking a detailed history
and targeted physical exam, in order to generate a working impression, to which initial
management can be directed towards. For OPD patients, we might think in terms of
epidemiology more: our patients may come to us with a constellation of signs and symptoms,
but we may rank a particular differential higher because it is more common. For ER patients, we
still need to consider less-common diseases if there is even a slight chance that it could be
lethal. Ruling these out is the priority. We always think of the worst in the ED. A “tummy ache”
could be acute appendicitis, needing urgent care, or it could just be GERD, in the OPD. While
both differentials should be considered by both OPD and ED physicians, the focus is still
different: OPD – curative, definitive; versus ED – life-saving, stabilization, disposition.

Module 4: Reflect on how decision-making happens in the ED, what are barriers to good
decision-making; what important characteristics must emergency care personnel
possess?

Decision-making in the ED should be based on a team-effort along with other HCWs on duty.
Patient stability and life should always be at the forefront. Algorithms for managing emergent
cases should always be kept in mind. There is no room for ego or experimentation in the ED,
especially when patients lives are at stake. Some barriers to good decision-making are as
follows: poor communication, panic, poor teamwork, being overworked, and lack of manpower.
Poor communication would lead to wrong decisions, from as early as the triaging stage to the
management stage. Panic has no place in the ER, as ED personnel must learn how to stay
calm under pressure – they are the patient’s lifeline. Poor teamwork is also a potential problem
in the ED; personnel must always learn to work together as it could maximize their limited
manpower. Being overworked and having limited manpower is another potential problem, as the
amount of patients going to the ED because of a poor healthcare system may overload the ED,
which are at the frontlines. Needless to say, ED personnel must be able to be calm under
pressure, have good teamwork, know how to communicate effectively and rapidly, know how to
follow directions, be technically knowledgeable and skilled, and need to be able to think quickly.