Critically Sick/Emergent

[Rialaigh]

After reading some other posts in other threads I find myself interested at the lines drawn by EMS for what we consider an emergency. Especially compared to the term critically sick (or very sick) in a hospital setting. After reading through Veneficus thread "Life and Death" I realized in part, we are looking at some of this through the wrong lens.

His question was posed "Patient required immediate surgery or direct ICU admit?" in relation to lights and sirens use for what people consider critical.



I would like to offer that critical, and emergent, are two completely different often completely unrelated things.

Sometimes patients that are what I would consider "emergencies" are critically ill. However most of the time they are not.

The patients that I consider critically ill are often not what I would consider emergencies.

Vene asked about critical care direct admits (basically). My question is, are most of those patients, really emergencies, or are they very sick. Because I believe that is two completely different things.


I think it is something not thought about or taught on enough is the HUGE difference in the care required and the urgency of a situation when the patient is critically ill, compared with an emergency.




Any thoughts on the differences between these two, the way they are viewed in hospital settings or in EMS. The way they "should be viewed?


I will add more thoughts later but this post is long enough...

 

[JPINFV]

There's a difference between a patient who needs critical care and has not yet received it, and one who needs critical care and just needs it continued.

 

[Veneficus]

After reading some other posts in other threads I find myself interested at the lines drawn by EMS for what we consider an emergency. Especially compared to the term critically sick (or very sick) in a hospital setting. After reading through Veneficus thread "Life and Death" I realized in part, we are looking at some of this through the wrong lens.

His question was posed "Patient required immediate surgery or direct ICU admit?" in relation to lights and sirens use for what people consider critical.

Actually, I didn't post it to relate to lights and siren transport. I posted it to compare to my in hospital experience to see if there is a difference between what EMS providers view as critically ill or emergent vs. what by a very broad definition, actually is.

In EMS, there is a very limited education and knowledge base on what constitutes both emergent and critically ill as you describe. As a consequence, any patient that providers do not have knowledge of or understand is considered emergent on the "what if" principle.

That was reasonable in 197x, but some 40+ years later, isn't really valuable.

I agree that overtriage is probably a best practice in emergency medicine, but I think it needs to be constantly refined in order to minimize it.

One of the ways to do this is to first identify how many "emergent" patients we see vs. how many we perceive we see.

I would like to offer that critical, and emergent, are two completely different often completely unrelated things.

I think it is splitting hairs. Whether a person is "emergent" as you say, or "critically ill" as I say, they both require immediate and sustained care. The only thing that really differs is that there are phases of such care and where a given provider is in them.

The patients that I consider critically ill are often not what I would consider emergencies.

I would offer that a person requiring emergent care is the same as a critical patient. The early intensive intervention simply reduces the amount of sustained intervention required. Urgency is not the same as emergency.

If you cut yourself, you may benefit from urgent application of sutures, but you are not likely to die without them. Though you may become worse. This is an easy example, but not the only one.

The lack of urgent treatment can have an effect on quality of life, both short and long term, but as a rule, not on the very survival of the organism.

Vene asked about critical care direct admits (basically). My question is, are most of those patients, really emergencies, or are they very sick. Because I believe that is two completely different things.

From the long term perspective, I see no difference. An "emergency" based on an unknown is different than an emergency based on what is actually known.

Use for example an asthma attack. People are prescribed and self administer medication for these without the medical system ever being activated or aware. many asthma attacks, whether medicated or not, will not progress to a life and death "emergency." But when they do, it will then cross the line into the need for immediate and sustained care.

We prescribe seizure medication, Nitro, and a host of other meds for self treatment of exacerbations of all systemic etiologies. It doesn't make all of them emergencies.

I think it is something not thought about or taught on enough is the HUGE difference in the care required and the urgency of a situation when the patient is critically ill, compared with an emergency

I have found the more a provider knows, the less "emergencies" they see. At the very least, the less urgency they see.

Take for example the dehydrated "sick" person. You may find them in Class I shock. Are they emergent? They are in shock right?

But how often have you been this sick and never sought medical attention? I would bet more often than you think. Certainly you or this patient would benefit from immediate medical care. But it hardly qualifies as "emergent." If you doubt, go look at people in the waiting area of a busy hospital. Many of them will sit within reach of medical care and recieve neither care nor re-evaluation for hours. At the same time, EMS providers may feel the need to initiate treatment immediately, thus it is the provider and not the pathology which elevates the patient status to an "emergency," preecluding them from being "critical."

Any thoughts on the differences between these two, the way they are viewed in hospital settings or in EMS. The way they "should be viewed?

I detailed the differences above.

Generally I think that EMS considers patients an emergency much more than hospitals do. Both because of lack of knowledge and lack of treatment options.

As is commonly said, "when all you have is a hammer, everything becomes a nail."

I think the first step in how things should be viewed is asking:
Would the patient benefit from immediate medical care now, or will they be in mortal peril without it?

Next I would offer:

If the patient would benefit from care, is it beyond the ability of EMS because of the seriousness of the condition or because of the limited scope of EMS intervention?

For example, a fever. Most EMS agencies do not have protocols or medication to treat fever.(in a range where treatment is indicated)

Again dehydration, ALS agencies usually only have protocol for IV therapy for this, and not oral rehydration. Most BLS agencies have no ability to treat this at all.

But these therapies are readily avialable to nonmedical providers, from parents to sports coaches and used with great effect. The same with heat and cold "emergencies" not in extremis.

How many people self adminiister prescription nitro at home when they have chest pain and never recieve any workup at all? Surely cardiac chest pain is an emergency is it not?

(as you can see, perhaps not)

 

[bonesaw]

Again dehydration, ALS agencies usually only have protocol for IV therapy for this, and not oral rehydration. Most BLS agencies have no ability to treat this at all.

But htese therapies are readily avialable to nonmedical providers, from parents to sports coaches and used with great effect. The same with heat and cold "emergencies" not in extremis.

(as you can see, perhaps not)

+1 Great example