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Extended Role of Private
Emergency Physician
Hospitalist in Surgical Care
SSEM26 Oct 2019
Dr. Pak Chuen YUEN
Consultant in Emergency
Medicine
Union Hospital
Extended Care in Emergency Medicine
Rationale - to address the challenges of escalating
health care costs, mismatched resource utilization,
concern over avoidable admissions and overcrowding in
wards
Emergency medicine ward or emergency department
observation units are thus developed with emphasis on the
training in extended care in emergency medicine
In private sector, the patient would be admitted as
inpatient for further observation, stabilization, symptoms
relief , diagnostic evaluation and continued treatment of
acute care
Era of Hospitalist
Hospitalists, known as physicians, are an emerging group in the
medical field that is focused on the general medical care of
hospitalized patients
Add value to the health-care system by reducing costs, streamlining
administrative processes, and contributing to improved health-care
outcomes
Numerous evidence-based studies support the benefits of patient-
centric care over standard care, resulting in the emergence of the
‘hospitalist’
Hospitalists reduce the overuse and overtreatment in health-care
systems, decrease costs, and improve both health-care quality and
outcomes for patients and higher patient satisfaction
According to research, higher hospitalist employment levels have
been associated with lower hospital readmission rates and decrease in
length of stay
Scope of Private EP Hospitalist in
Surgical Care
Acute abdominal pain
Gross hematuria
Acute retention of urine
Uncomplicated upper GI bleeding and per-rectal bleeding +/- recent
change in bowel habit
Minor head injury
Thoracic injury with fractured ribs +/- pneumohemothorax
Traumatic wounds for surgical repair under GA
Soft tissue infection/cellulitis including abscess
Orthopedic conditions or injuries with severe pain and symptoms
Acute Abdominal Pain
Acute abdomen – defined as any sudden non-traumatic
disorder whose chief manifestation is in abdominal area
and for which urgent operation may be necessary
Pain < 1 week’s duration
Common (5-10% ED visits)
Challenging
Trivial to life-threatening
Broad overlap / nonspecific symptoms
Acute Abdominal Pain
Considerations:
Intraabdominal vs extraabdominal causes
Organ specific
Surgical vs gynaecological vs medical
Sex
Age
Pathologic process: haemorrhage, ischaemia, obstruction, infection
High risk gps: elderly, alcoholics, immunocompromised, IVDA
Acute Abdominal Pain
Management Aims
Immediate recognition + resuscitation (ABC) of life-threatening conditions e.g. peritonitis in shock, leaking AAA, acute MI, haemoperitoneum
R/O “surgical abdomen” - Consult surgeon urgently x operative intervention
For stable patients - symptomatic relief for pain and other symptoms + IV fluid rehydration +/- antibiotics
After stabilization – more investigations to arrive a definitive diagnosis and initiate appropriate treatment +/-in patient consultation / referral upon discharge
Acute Abdominal Pain
Relevant Investigations
Detailed history and proper P/E most important (85-90% Dx based on Hx alone)
Focused ancillary studies to help or confirm the clinical Dx but not substitute for clinical Hx and P/E
Urinalysis (+ pregnancy test)
Blood x CBP / WBC count, amylase level, LFT, RFT, CRP, PCT, TnT, ABG
ECG
CXR erect (including diaphragm) + AXR – bowel obstruction, nephrolithiasis, perforated hollow viscus (PPU)
Endoscopy ( Upper endoscopy +/- Colonoscopy )
USG – more useful for RUQ pain and pelvic pain
Biliary tract disease, liver abscess, AAA, renal colic +/- hydronephrosis, appendicitis in Paed, ectopic pregnancy / IUP, torsion of ovarian cyst
CT scan whole abd + IV contrast +/- oral contrast – most useful
Excellent visualization of intra-abd masses, solid viscera & retroperitoneal organs, for stable patients with suspected leaking AAA, mesenteric ischaemia, pancreatitis, perforated viscus, malignancy, retroperitoneal & pelvic pathology, appendicitis, diverticulitis, acute pyelonephritis and ureteric stone
Acute Abdominal Pain
Acute Abdominal Pain
Acute Abdominal Pain
Acute Abdominal Pain
Management
Conservative /medical treatment for uncomplicated diverticulitis/colitis/ cholecystitis / pancreatitis, mesenteric adenitis, terminal ileitis, epiploic appendagitis (appendicitis epiploica), peptic ulcer disease
IV fluid rehydration + symptomatic relief + stabilization + close monitoring of vital signs/fever/abdominal S/S
Adequate pain relief
Early judicious use of narcotic analgesia is safe and will not mask abdominal signs
Antispasmodic e.g. Buscopan injection for abdominal colic in benign conditions e.g. GE, NSAP
NSAIDS e.g. Toradol injection for relief of renal/ureteric colic, not advisable in peritonitis
Intravenous antibiotics for intra-abdominal infection/pyelonephritis
Acute Abdominal Pain
Management
Early surgical consultation if “ surgical abdomen “ that
need operative treatment or acute abdominal pain with
unstable vital signs , complication arise or failed medical
treatment or patient’s preference
Consult Urologist for ureteric stone with obstruction for
the options of expectant treatment or medical expulsive
therapy or ESWL or URS + lithotripsy + forceps stone
removal depending on the size and site of impaction of
the stone and expertise
Gastrointestinal Endoscopy
Indications
Upper endoscopy ( Oesophago-Gastro-Duodenoscopy/OGD ) + Colonoscopy
Abdominal pain/ Epigastric pain/ GERD symptoms
Uncomplicated upper GI bleeding
Per-rectal bleeding
Recent change in bowel habit
Persistent GI symptoms like vomiting , chronic diarrhoea/constipation
Iron deficiency anemia
Screening and surveillance of colorectal polyps and cancers
Acute Med Surg. 2018 Jul; 5(3): 230–235.
Potential role for emergency physicians with endoscopy training in the treatment of upper gastrointestinal hemorrhage: a retrospective observational study
Yoshiro Kobe, 1 , Takehiko Oami, 2 Tomoaki Hashida, 3 and Yoshihisa Tateishi 4
Compared the management and clinical outcomes of GI bleeding cases between those treated by an emergency physician (EP) and those treated by a non‐emergency physician (NEP; e.g., gastroenterologist or general surgeon).
Conclusion
Short‐term outcomes in GI bleeding cases managed by emergency physicians with endoscopy training were comparable to those by NEP . However, the extent of endoscopic training and experience emergency physicians should have remains unclear.
Acute Med Surg. 2018 Jul; 5(3): 230–235.
The results showed no significant difference in rebleeding rates and
adverse events. Blood transfusion requirements, length of hospital
stay, and in‐hospital mortality rates were favorable in the EP group.
The favorable outcomes in the EP group could be attributed to the
shorter time to endoscopy and intervention for bleeding.
The extent of training in endoscopy an EP should receive and the
number of patients an EP should treat to acquire endoscopic skills for
treating GI bleeding need to be determined.
This study suggests that an EP with endoscopy training could treat GI
bleeding in collaboration with endoscopic specialists.
Gastric Polyps
Gastric polyp
Gastric Polyp
Gastric Polyp
Gastric Polyp
Gastric Polyp – post-polypectomy + retrieval
Colonic Polyp
Colonic Polyp
Colonic Polyp
Colonic Polyp – post-polypectomy
Colonic Polyp – post-polypectomy and
clipping for haemostasis
Anal Polyp
Anal Polyp
Anal Polyp – post-polypectomy
Haemorrhoids
Suction Haemorrhoid Ligator
Suction Haemorrhoid Ligator
Suction Haemorrhoid Ligator
RBL of Haemorrhoid
Gross Haematuria
Alarming and scary symptom to patient and relatives
A common symptom with a multitude of differentials. It can often be a diagnostic dilemma
Common urological causes of haematuria include urinary tract infection and ureteric and renal stones, but concurrent pathology should be suspected if haematuria is significant or persistent
Ureteric and renal stones typically present with pain and microscopic haematuria
Other benign causes include BPH, nephropathy/GN, trauma, iatrogenic like irradiation/post-procedure, bleeding disorders or anticoagulant therapy above therapeutic range
Gross Haematuria
If benign conditions excluded and the haematuria
continues, further investigation advised to rule out an
underlying genitourinary malignancy especially for
painless haematuria and risk factors ( male , age > 50yrs,
smoking, irritative voiding symptoms, pelvic irradiation)
Prevalence of urinary tract carcinomas among patients
with macroscopic haematuria has been reported to be as
high as 19%, but usually ranges from 3–6%
Recommended investigations include computed
tomography intravenous pyelogram, urine cytology, urine
microscopy and culture +/- AFB and blood tests (full blood
examination, renal function and, in men, prostate-specific
antigen) +/- refer to Urologist for flexible cystoscopy
Gross Haematuria
Management Approach
Gross Haematuria
Management Key Points
Look for the complication of AROU due to blood clots ( clot retention) and treat by insertion of 3 ways Foley + bladder irrigation
Treat underlying causes accordingly
Urinary tract infection should be ruled out before any further investigations for haematuria are undertaken
Ureteric and renal stones can cause episodes of haematuria, however it is important to consider other causes if this does not settle or if there are risk factors for urinary tract malignancy.
Initial investigations for haematuria should include CT-IVP, urine cytology, full blood examination, renal function, and PSA in men.
A urological referral is recommended in patients presenting with macroscopic haematuria , persistent microscopic haematuria, abnormal urine cytology, irritative lower urinary tract symptoms or recurrent urinary tract infections.
Acute Retention of Urine
Urinary retention is a common, distressing, and dangerous medical
problem. Acute urinary retention is defined by the painful inability to
void a full bladder
Medical emergency as very painful and distressing and can have
complications like bladder damage, renal failure and urinary sepsis
Incidence dramatically increases with age so that a man in his 70s has
a 10 % chance and a man in his 80s has a more than 30% chance [but]
the incidence in women is not well documented , 13:1 male to female
ratio
Numerous causes that can be classified as obstructive, infectious and
inflammatory, pharmacologic, neurologic, or other. Although the most
common cause is benign prostatic hyperplasia (BPH), other frequent
causes of urinary retention are prostatitis, cystitis, urethritis, and
vulvovaginitis; use of anticholinergic and alpha-adrenergic agonist
drugs; and cortical, spinal, or peripheral nerve lesions. In women,
obstructive causes often involve the pelvic organs.
Acute Retention of Urine
Etiologies
Obstructive – BPH, bladder tumour, urethral /bladder stone, urethral
stricture, genital prolapse like cystocele and pelvic mass in women,
faecal impaction
Infectious – acute prostatitis, cystitis, urethritis, vulvovaginitis
Neurological – Neurogenic bladder from stroke, brain tumour, spinal
cord compression/cauda equina syndrome ( tumour, PID, trauma ),
diabetes, multiple sclerosis
Medications - anticholinergics/antihistamine, such as tricyclic
antidepressants, cause urinary retention by decreasing bladder
detrusor muscle contraction, Sympathomimetic drugs (e.g., oral
decongestants) cause urinary retention by increasing alpha-adrenergic
tone in the prostate and bladder neck. . . . NSAID [nonsteroidal anti-
inflammatory drug]-induced urinary retention is thought to occur by
inhibition of prostaglandin-mediated detrusor muscle contraction
Acute Retention of Urine
Management
Initial management includes bladder catheterization for prompt and
complete decompression- urethral or supra-pubic .If treatment with
alpha-blockers is started at the time of catheterization, men with
acute urinary retention from BPH are more likely to be able to return
to normal voiding.
Bladder scan to document bladder urine volume retention and
postvoid residual urine
Urine / blood tests/ USG /CT scan abdomen + pelvis/TRUS prostate /
MRI brain /spines/ cystoscopy
Urological consultation if failed / difficult Foley insertion , clots
retention, bladder tumour, bladder /urethral stone ,urethral stricture,
significant BPH ,suspected CA prostate
Acute Retention of Urine
Management
Men who receive a urethral catheter for BPH and acute urinary
retention are more likely to have a successful trial of voiding if they
receive an alpha-adrenergic blocker for 3 days
5 alpha reductase inhibitor- initiate in men with prostate vol > 40ml
or baseline PSA >1.5ng/ml, long term Rx ( 4-6 yrs) can reduce AROU
risk again
Removal of any provocative factors- treat UTI, relieve fecal impaction
, avoid provoking drugs
Trial of void – optimal at 3-5 days following initial catheterization
after alpha blockers started
Surgical intervention like TURP if failed void trial / bothersome LUTS/
failed medical therapy
CIC – reasonable alternative to long term indwelling catheter
Acute Retention of Urine
Management
Decision to proceed with surgery :
considerations
Patient treatment goals – willingness to incur surgical risk to be
catheter free
Patient pre-morbid conditions
Ability to perform CIC
Satisfaction/dissatisfaction with indwelling catheter
Advantages of EP Hospitalist
Continuing care of the acute condition of the patient by the same doctor
More focused and timely investigations and interventions
Save time to call or consult the appropriate surgeon or specialist to admit the patient
Avoid the potential pitfalls in patient handover to other admitting doctor
Better doctor-patient relationship with good rapport
Improve the EDs efficiency and enhance cost-effectiveness
Conclusion
With appropriate and proper surgical training , the
extended role of private EP hospitalist in surgical care is
feasible and efficient
Study showed that this model of EP hospitalist care is safe
with good outcome and better patient satisfaction
Reduce the length of hospital stay
Allow a lower hospital cost and thus less insurance claims
of the patient
More cost-effective
Would A Dream
Come True ?