Future of Emergency Medicine

[Dock1234]

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I was watching talk by Eric Topol and he mentioned that we are close to having wearable tech to monitor body 24/7, lab on a chip devices to allow patients monitor themselfs and even nanosensors in blood stream that would monitor proteins, antibodies etc and predict cardiac arrest etc. He even said that he have worked with some Caltech researcher to create these nanosensors.

That made me think that these technologies could be bad for the job outlook of EM physicians. If in future we can diagnose conditions before they develop and prevent them, there won't be any need for acute care. For example if nanosensors in blood stream can predict cardiac arrest days before it happens, patients can just go to cardiologist and they will never end up in ER.

Of course there will always be traumas etc but these technologies could still greatly reduce need for EM docs. What do you think? Is this just scifi or will this happen in the next 10-20 years?

 

[Apollyon]

People are lazy and/or stupid, and also psychopathology plays into things. As such, many people won't wear the things you mentioned, and will come to the ED looking for the handout, instead of being a partner in their own care. Even the ones who do have such things will have a number of people that will still come in, directly due to the results from their devices.

Combine that with, as you mention, people getting drunk, punching walls, and beating on their wives (and husbands), and, if anything, EM will be one of the last bastions of live bodies seeing patients, instead of a computer.

 

[SoyMilk]

For example if nanosensors in blood stream can predict cardiac arrest days before it happens, patients can just go to cardiologist and they will never end up in ER.

Of course there will always be traumas etc but these technologies could still greatly reduce need for EM docs. What do you think? Is this just scifi or will this happen in the next 10-20 years?

Explain the pathophys there.

Also, there are a million acute/subacute/nonemergent reasons for an abn lab value or study. Sometimes an abn value is not significant in the context of the symptomatology or history. For example, There are several reasons someone might have a troponin leak, a rapid workup is required because the underlying etiology may be critical though is more commonly boring. Where will this rapid initial differentiation occur, in the clinic?!?! Hah!!! An abn lab value is a very common reason to come to the ED. Nothing will change. If anything, this may increase business in the ED. Pigs shall fly the day our medical system can bear the cost of high fidelity continuous monitoring of all patients, vetting of data, interpretation of data in context of the symptomatology, and capacity to CYA for all these patients. Also, more testing isn't always better nor does it always result in better outcomes.

 

[SoyMilk]

I was watching talk by Eric Topol and he mentioned that we are close to having wearable tech to monitor body 24/7, lab on a chip devices to allow patients monitor themselfs and even nanosensors in blood stream that would monitor proteins, antibodies etc and predict cardiac arrest etc. He even said that he have worked with some Caltech researcher to create these nanosensors.

That made me think that these technologies could be bad for the job outlook of EM physicians. If in future we can diagnose conditions before they develop and prevent them, there won't be any need for acute care. For example if nanosensors in blood stream can predict cardiac arrest days before it happens, patients can just go to cardiologist and they will never end up in ER.

Of course there will always be traumas etc but these technologies could still greatly reduce need for EM docs. What do you think? Is this just scifi or will this happen in the next 10-20 years?

Based on your posting history I think I can safely conclude that you are a premed

 

[Doctor Bob]

If in future we can diagnose conditions before they develop and prevent them, there won't be any need for acute care. For example if nanosensors in blood stream can predict cardiac arrest days before it happens, patients can just go to cardiologist and they will never end up in ER.

"Hello? ... What Mr. Smith? Your heart/blood sensor said you're likely to have a heart attack in a few days? ... An appointment? No, Dr. Heart is all booked. Just go to the ER and they'll be able to see you."

 

[SoyMilk]

"Hello? ... What Mr. Smith? Your heart/blood sensor said you're likely to have a heart attack in a few days? ... An appointment? No, Dr. Heart is all booked. Just go to the ER and they'll be able to see you."

 

[Dock1234]

Explain the pathophys there.

http://www.qmed.com/mpmn/medtechpulse/eric-topol-how-prevent-heart-attacks-nanosensors

 

[Birdstrike]

There's only only technology that could decrease the flood of patients to your ED, profoundly enough to affect Emergency Physician job security. It's the "TTM." I happen to have some insider knowledge on it, though I can't really disclose details, yet. Have you heard of it?

It's the: The Triage Time Machine

(start wacky infomercial-guy voice): "If you think our 105 minute wait times are quick, don't bother with this ED right now, choose door 1 and be seen LAST WEEK!"

"Or, choose door 2 if you think healthcare in the future is much better. Here at DingleSchlitz General, we assure you it will be better than here. That's if we ever get to you!"

"Or, choose nothing and we assure you, you'll wait so long you'll eventually be seen in the future. The distant, distant future! Would you like a complementary coffee and some hand sanitizer to reduce the spread of disease, Sir? "

No, but seriously, the reasons people to to the ER are so vast, there is no technology in your lifetime that will decrease patient visits enough to negatively impact your job security. ED overcrowding is much more likely to remain the norm in all of our lifetimes. The next time you hear bold claims by someone promising they have a drug or device, your first question should not be, "Is this going to radically alter the course of medical history and mess up my career?" It should be, "Is this guy making this bold statements a paid consultant for the company selling the drug/device?"

9 out of 10 times the answer will be, "Yes." Keep in mind, the same thing could have been said for pacemakers and defibrillators and AICDs decades ago. But people get sick and die eventually anyways, and everyone else seems to conveniently be too busy to deal with it, except.... "you know who."

EP job security is rock-solid looking into the future. And trust me, if it wasn't, I'd be the first one to blow the warning whistle about it.

 

[Zebra Hunter]

I don't understand the thought process here. Even if all the tech mentioned in the OP worked as well as stated, does the OP think that early detection would drastically change patient outcomes without reliance on the emergency department? More than likely the "pre-MI" patient would get sent to the ED by their cardiologist or PCP for cath vs obs/stress test or coronary CTA. Its not like they could do much outside of prescribing some aspirin in the outpatient setting which likely wouldn't change outcomes for the majority of patients. So likely, what this would do is increase the number of individuals that present to the ED from clinic. And that is ignoring the fact that many people are lazy or don't have a cardiologist or even a PCP.

 

[link2swim06]

People vastly overestimate technology in medicine; especially the timeline.

The lay public and 'futurist' like to describe medicine as simple math. There is a problem and all we have to do is to determine the solution and the problem is solved. However, little in medicine can be described with simple math. We have sensitivities, specificity, penetrance, etc, etc, etc. We live in a world of partial solutions.

If it was so simple it wouldn't have cost billions of dollars to come up with "simple" things like statins. Now how much time and money would it have taken to make all those statin molecules actually be functioning computers?

 

[Birdstrike]

If it was so simple it wouldn't have cost billions of dollars to come up with "simple" things like statins. Now how much time and money would it have taken to make all those statin molecules actually be functioning computers?

And further more, if it was so simple, those billion dollar statins would have been made so that they actually prevent people without heart disease from dying from it. But they don't.

http://www.epmonthly.com/features/c...or-healthy-people-a-cocktail-party-manifesto/

Yeah, we doctors all continue to have jobs.

 

[TooMuchResearch]

And further more, if it was so simple, those billion dollar statins would have been made so that they actually prevent people without heart disease from dying from it. But they don't.

http://www.epmonthly.com/features/c...or-healthy-people-a-cocktail-party-manifesto/

Yeah, we doctors all continue to have jobs.

I didn't win any friends in our Cardiology department when I mentioned that topic.

 

[SoyMilk]

The futurist crowd likes to talk like these technologies are within grasp (5-10 years). But they are not. Even our most sensitive and important assays rarely reach 99% Sensitivity.The other day we did a CTA and diagnosed PE in a lady who was PERC negative, nl DDimer, nl Vitals, no risk factors all because of a admittedly unimpressive shadow on her xray and CLINICAL GESTALT.

Unless these MAGICAL nanites will somehow suddenly have assays that don't yet exist which are significantly more sensitive than what we have presently, have xray/CT/MRI imaging techniques that normally require a room to house the machine, are cost effective enough to put in all people, and have AI then I don't see this being a tenable solution. Maybe one day it will be possible. But not today, tomorrow, or in the next couple decades.

 

[Zebra Hunter]

The futurist crowd likes to talk like these technologies are within grasp (5-10 years). But they are not. Even our most sensitive and important assays rarely reach 99% Sensitivity.The other day we did a CTA and diagnosed PE in a lady who was PERC negative, nl DDimer, nl Vitals, no risk factors all because of a admittedly unimpressive shadow on her xray and CLINICAL GESTALT.

Why would you D-dimer a patient or PERC them if you had a high clinical suspicion of a PE?

 

[RustedFox]

Why would you D-dimer a patient or PERC them if you had a high clinical suspicion of a PE?

I do it all the time; but I also end up scanning them. Reason being: there are several flavors of D-dimer test out there. Make sure that you know which one your facility uses and its Sn/Sp.
Also, I've seen cases wherein the D-dimer is sky high, but the CTA is stone cold negative... and I wonder to myself : "Hmm... why the dimer level?" Then I look elsewhere for other sources of hypercoaguable states (cancer, hereditary disease, etc).

Before anyone out there says - "No you don't. That's crazy and a waste of time." - ... yes, yes I do. I've caught some things that might make you go "hmm". Its the remaining internist in me.

 

[link2swim06]

Why would you D-dimer a patient or PERC them if you had a high clinical suspicion of a PE?

If they were PERC negative, normal vitals, and no risk factors I'd saw you should have a low clinical suspicion.

 

[Birdstrike]

I didn't win any friends in our Cardiology department when I mentioned that topic.

They all looked at you like you had a big **** sticking out of your forehead, didn't they?

 

[Zebra Hunter]

If they were PERC negative, normal vitals, and no risk factors I'd saw you should have a low clinical suspicion.

I agree, but he was talking about sensitivities and stated that his resident or attending's clinical gestalt led them to getting a CTPA anyway. The negative predictive value of PERC and D-dimer are significantly reduced if the physician's clinical suspicion is intermediate to high for PE, which means that PERC rule for that patient no longer has a negative predictive value of 98.2% which means there is no point in even PERCing them to begin with.

As for what you said, rustedfox, that's good to know. I was just trained that unless the pre-test probability is low, don't even bother with PERC or D-dimers.

 

[Druggernaut]

That made me think that these technologies could be bad for the job outlook of EM physicians. If in future we can diagnose conditions before they develop and prevent them, there won't be any need for acute care. For example if nanosensors in blood stream can predict cardiac arrest days before it happens, patients can just go to cardiologist and they will never end up in ER.

Of course there will always be traumas etc but these technologies could still greatly reduce need for EM docs. What do you think? Is this just scifi or will this happen in the next 10-20 years?

Probably close to half of my patients my last two shifts weren't taking some or any of their medications. Big ticket items like their blood pressure meds (accompanied by 220/120 BPs), their Plavix after a stent, and Xarelto. Some because they couldn't afford them, some because they couldn't get a ride to see their PCP for a new prescription, some because they'd just forget. You can never eliminate the human element of disease.

Meanwhile, I'm still waiting for portable ultrasounds to make my stethoscope obsolete, though they've been saying that's just around the corner for some time now. Or for the radiologists to be made obsolete by a computer, despite the fact that computers still can't read an EKG worth a damn.

And there's still a frighteningly large number of people who believe Ebola was created by the US government and was inoculated into Africans, and that they're now hiding information about how it's spread and crafting policy to intentionally bring it into the US, where it will spread like wildfire for some nefarious, ultra-super-classified plot that will somehow benefit some tiny sect of people who are pulling all the strings around the world from behind the scenes. You really think they're going to allow "the establishment" to install tiny microchips into their bodies?

Sci-fi, pure and simple.

 

[WilcoWorld]

Re: post #16 above

39 yo pregnant woman who had pleuritic chest pain last week and now has dyspnea. HR = 98 and O2 = 96% as long as she's breathing 24/min.

PERC negative, but not low risk.

D-dimer is released at the time of clot formation, since her clot formed over a week ago, the d dimer might be negative.

I'd CT her (after looking for a DVT on US first).

 

[WilcoWorld]

Oh yeah, fat is a health food and statins are poison.

I'm serious.

 

[Zebra Hunter]

Re: post #16 above

39 yo pregnant woman who had pleuritic chest pain last week and now has dyspnea. HR = 98 and O2 = 96% as long as she's breathing 24/min.

PERC negative, but not low risk.

D-dimer is released at the time of clot formation, since her clot formed over a week ago, the d dimer might be negative.

I'd CT her (after looking for a DVT on US first).

PERC rule and even D-dimer, at least based on what I've been taught and the research I've seen*, should not be used for pregnant women given their increased risk of developing a PE and increase in baseline D-dimer levels.

*although I did see a recent article in EMJ stating a negative D-dimer for a low risk pregnant woman was potentially enough for rule out.

 

[RustedFox]

Re: post #16 above

39 yo pregnant woman who had pleuritic chest pain last week and now has dyspnea. HR = 98 and O2 = 96% as long as she's breathing 24/min.

PERC negative, but not low risk.

D-dimer is released at the time of clot formation, since her clot formed over a week ago, the d dimer might be negative.

I'd CT her (after looking for a DVT on US first).

"Just CT her"... unless you're committed to looking in all four extremities for DVT.

15-20% of PEs are from upper extremity DVTs.

 

[Birdstrike]

In regards to y'all's decision rules:

Decision rules are good for one thing, only. To know when to ignore them. Know the risk factors that go in to making the rule. Know their sensitivity and specificity (rarely every close enough to 100%). Know the study patient inclusion/exclusion criteria (usually bleached of confounders) because study populations rarely if ever mimic your patient population exactly. Know all this so you can promptly ignore them in favor of your, hopefully superior, clinical judgement.

If decision rules supplanted clinical judgement, trust me, your hospital would be happy to fire you and have a certified medical assistant armed with a tablet full of protocol-driven check-box decision rules to take your place.

 

[Zebra Hunter]

Decision rules are good for one thing: To know when to ignore them. Know the risk factors that go in to making the rule. Know their sensitivity and specificity (rarely every close enough to 100%). Know the study patient inclusion/exclusion criteria because study populations rarely if ever mimic your patient population exactly. All this is so that you know exactly when to ignore and override them with your clinical judgement.

If decision rules supplanted clinical judgement, trust me, your hospital would be happy to fire you and have a certified medical assistant armed with a tablet full of check-box decision rules to take your place.

Well duh, but for n00bs such as myself, clinical decision rules help make up for my poor clinical gestalt (at least compared to old fogeys such as yourself ).

 

[Birdstrike]

Well duh, but for n00bs such as myself, clinical decision rules help make up for my poor clinical gestalt (at least compared to old fogeys such as yourself ).

I know. I am super old. I was around when people had these things called "CDs." They were really cool. If you stared into them long enough, you might see a rainbow. Seriously.

 

[WilcoWorld]

oh never mind...

 

[WilcoWorld]

"Just CT her"... unless you're committed to looking in all four extremities for DVT.

15-20% of PEs are from upper extremity DVTs.

My point was that I'd stop testing at a +US and just treat as a presumed PE, thereby sparing her the CT.

 

[Birdstrike]

oh nevermind...

I liked your post better before you edited it.

 

[WilcoWorld]

I liked your post better before you edited it.

Thanks, but I decided I'd already picked on enough students this week.

 

[Birdstrike]

Thanks, but I decided I'd already picked on enough students this week.

Lol. I know. I wonder too, if there's any purpose to me even being on this forum at this point, or am I just purely trolling pre-meds and med students by my mere presence. Or are some truths just better left unsaid. I don't know.

 

[RustedFox]

My point was that I'd stop testing at a +US and just treat as a presumed PE, thereby sparing her the CT.

Good thinking, but I'd rather just get the quick and easy study done, rather than send a "potentially?" unstable patient for a long US exam, where the tech could knock loose more emboli.

 

[SoyMilk]

Re: post #16 above

39 yo pregnant woman who had pleuritic chest pain last week and now has dyspnea. HR = 98 and O2 = 96% as long as she's breathing 24/min.

Minus the pregnant and tachypneic part this is almost exactly the patient I had.

Anyways, the discussion generated illustrates an important point
A computer based diagnostic and triage system that aims to decrease ED visits would necessarily rely on clinical decision rules that are limited and may harm people if applied without real medical decision making.

 

[TooMuchResearch]

They all looked at you like you had a big **** sticking out of your forehead, didn't they?

Indeed they did, Dr. Birdstrike. Indeed they did.

 

[TooMuchResearch]

And there's still a frighteningly large number of people who believe Ebola was created by the US government and was inoculated into Africans, and that they're now hiding information about how it's spread and crafting policy to intentionally bring it into the US, where it will spread like wildfire for some nefarious, ultra-super-classified plot that will somehow benefit some tiny sect of people who are pulling all the strings around the world from behind the scenes. You really think they're going to allow "the establishment" to install tiny microchips into their bodies?

That all sounds quite reasonable.

 

[Birdstrike]

Indeed they did, Dr. Birdstrike. Indeed they did.

Why are you calling me, "Doctor"?

 

[gman33]

Why are you calling me, "Doctor"?

Since you were the only one in the room not wearing a white coat, he figured you must be a doctor.

 

[jw3600]

Good thinking, but I'd rather just get the quick and easy study done, rather than send a "potentially?" unstable patient for a long US exam, where the tech could knock loose more emboli.

My understanding was that the whole Homan's test/US exam thing can be contraindicated with regards to releasing emboli was kind of debunked. What are people's thoughts?

 

[Arcan57]

Listening to an US guy doing a lecture at ACEP that related a patient with + LE DVT that had multiple students examining the leg. The last student goes and finds the vein is compressible now and the pt starts complaining of chest pain. I'm pretty sure there is no randomized data and I wouldn't change my practice (which doesn't involve teaching currently) based on that anecdote. To the poster crowing about picking up a PE, where was the PE and was there anything else on history that lead you towards PE? Because if it's your practice to routinely CTPA patients with low pre-test prob, nl VS, and a negative dimer you're going to cause significantly more harm to your patients then just leaving them alone.

 

[EctopicFetus]

Will the anti-vaxxers allow these nano particles into their bodies?

 

[RustedFox]

My understanding was that the whole Homan's test/US exam thing can be contraindicated with regards to releasing emboli was kind of debunked. What are people's thoughts?

Emboli gotta come knocked loose somehow...

 

[TooMuchResearch]

Emboli gotta come knocked loose somehow...

Eboli? Where?!?

 

[The White Coat Investor]

Or for the radiologists to be made obsolete by a computer, despite the fact that computers still can't read an EKG worth a damn.

That explains a lot about your hospital- the radiologists are reading the EKGs!