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 ?