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Dr. Mike Smith (Host):  Emergency Medicine is advancing very quickly. Lots of research going on and we’re going to talk about some of that today. Welcome to The GW HealthCast. I’m Dr. Mike Smith. and today’s topic:  Emergency Care Innovations. My guest is Dr. Andrew Meltzer. Dr. Meltzer is Associate Professor of Emergency Medicine at the GW School of Medicine and Health Sciences and is affiliated with The George Washington University Hospital. Dr. Meltzer, welcome to the show.

Andrew Meltzer, MD, MS (Guest):  Thanks so much for having. I’m so excited to be here.

Host:  So, before we get into the innovations, I want to talk a little bit about Emergency Medicine and a common question that I get from family members and friends. When do I need to go to the Emergency Room versus Urgency Care? Can you clear that up a little bit for us?

Dr. Meltzer:  Yeah, I mean I don’t know if I can clear it up, but I can sort of tell you our thought process. I mean essentially, it’s really hard to tell. I think if you are worried about a life threatening condition or if you have pain or feel like you need rapid diagnostic tests; then there is really no substitute for the Emergency Department. This is where acute, unscheduled care is provided. And that’s no to say everybody who comes through our doors is dying or everybody has a life threatening disease but almost everybody and I’ll put that at 85-90% is somewhat concerned that that is what’s going on. That they have something that could hurt them or kill them and if they have to wait to schedule an appointment or have to wait to go through some process that they maybe don’t understand of how to see a doctor; this could be dangerous to them.

So, we are the only place in the whole medical system where the front door never locks. So, we’re always open and people can come anytime, and we have the privilege to take care of people 24/7.

Host:  So, I had a friend of mine that went to the Emergency Room about maybe a couple of weeks ago and not important why she went. But she went and she was there for a while waiting in the waiting room. She calls me and she’s upset. She’s wondering why she has to wait so long, and some people are rushed right back to the back and I had to explain to her why. Could you let the audience know why some people wait a little longer and why some people are seen more quickly?

Dr. Meltzer:  Yeah well ideally, nobody waits. And as soon as you sort of get checked in, you get seen by that front nurse and they do your vitals and take your complaint; ideally there is a place to put the patient and be evaluated by the physician. In reality, that does not happen throughout the day. We have surges throughout the day typically, it depends on the ER, but typically in the evenings, weekdays, especially at our ER. The place fills up and the beds are filled, and we go through sort of a triage process up front.

So, the nurses who are sort of our specially trained triage nurses up front are supposed to evaluate the patient quickly and make a decision if this person needs to be seen right away or if this person can potentially wait for the bed to open. So, it doesn’t necessarily come as first come first served once the beds are filled. It comes basically as what we think is the most serious, the most life threatening or potentially the person who is in the most discomfort gets seen first and a lot of times, other patients unfortunately depending on the day and depending on the ER, will have to wait.

So, I wish it wasn’t that case, but that’s just the way it is. When you do go to like an Urgent Care or your primary care, it is first come first served because the idea is that most of the complaints are pretty much the same and that everybody could wait. It’s not going to be life threatening if they had to.

Host:  So, Dr. Meltzer, as an Emergency Room physician, tell us a little bit about the training that you went through.

Dr. Meltzer:  Yeah. The training, I mean I’m now over ten years out, but the training really hasn’t changed a whole lot. When Emergency Medicine sort of first came into being as its own specialty; that was probably in the early 80s so almost 40 years ago and before that, it was sort of general doctors or maybe moonlighting surgeons or moonlighting internal medicine doctors would staff the Emergency Department. Often it was trainees and there wasn’t any specialized training for Emergency Department doctors and some of them got good at it and some of them really didn’t know exactly what the mission of the Emergency Department is.

So, our training is a really broad based training where we are basically being taught to take care of all sorts of conditions that are time dependent and life threatening. So, whether it’s a pediatric patient, whether it’s an overdose, whether it’s a trauma, whether it’s an OB patient, GYN complaints, neurological complaints, ear, nose and throat complaints. All of those things we are experts at sort of that first hour of that subset of conditions that are the life threatening conditions.

And I think ER doctors really play not to lose. So, we play to pick up on all the serious life threatening diseases and we not always get the diagnosis perfectly right; but I think we rarely miss the serious diagnoses, the ones that will kill you or are potentially life threatening or limb threatening.

Host:  So, Dr. Meltzer, I know that you are interested in a few research aspects of emergency care and I know that of course, a lot of the innovations come initially from that research of Emergency Room physicians. So, tell us a little bit about what are some of the innovations that you’ve seen? What are some of the things that you’re researching, that’s taking emergency care to just another level?

Dr. Meltzer:  Yeah, I think, I mean I’m an Associate Professor and academic, so I spend about half my time at the University at GW working with students and residents and researchers across the university and then the other half, I work clinically. So, the research that I do, at least the way I try to focus it is what can we do to sort of speed up the diagnosis of acute diseases, diseases that we really can’t wait for.

So, a lot of our conditions that we see, we can’t figure it out in the Emergency Department. So, sometimes we have to bring them into the hospital, sometimes there’s a series of tests, sometimes they’ll be pretty invasive, sometimes they require extra specialty training to figure out what’s going on. So, the things that I try to do are how can we bring that stuff to the ER. How can we bring it into that first hour, two hours, three hours, where we can really figure out what’s going on?

So, to give you an example. One of the research topics that I work on is patients who come in with an upper GI bleed. So, those are patients that most likely have let’s say a bleeding stomach ulcer. And they come in and maybe they have weakness, maybe they vomited some blood or maybe there is blood in their stool, maybe they just have severe belly pain. And we don’t have a great way to look inside the stomach in the ER and sort of see what’s going on with that person who is bleeding.

So, the typical patient who comes in with that kind of condition is going to need to come into the hospital, going to need to be put to sleep, going to need to have an anesthesiologist and a gastroenterologist come in from home and they will put a tube down their mouth and take a look inside the stomach. And that can’t be done right away. It’s just not logistically possible.

So, we’ve worked on ways to how can we expedite that diagnostic workup and what technologies out there that maybe we can use to figure out what’s going on in the ER to either send patients home if they are not that sick or speed up care if they are sick.

So, one of the things we’re using is something called a video capsule endoscopy. So, basically, we use a product that is – looks like a pharmaceutical pill but it’s got lights on either end. It’s got a camera. It’s got a radio transmitter and the patient swallows the camera and it take pictures as it goes down and we set up the monitor right at the bedside that we can sort of do real time evaluation of what’s going on with that person who maybe has a serious bleed or maybe has a benign bleed and really doesn’t need further invasive workup.

So, that’s one way I think that we can bring sort of rapid diagnosis to the Emergency Department.

Host:  Yeah, and that’s very interesting. So, in a sense, if I could summarize for the audience here. In some cases, maybe using the bleeding ulcer or GI bleed as the example. You may know the patient is bleeding from somewhere. You can get them stabilized but at some point, a further workup is needed. What you’re saying is you’re trying to bring some of that technology into the ER where you can find some of those answers upfront as they are being admitted or maybe they don’t even need to be admitted, so it’s saving time, saving money even possibly and of course saving more lives because of the quick diagnosis. Does that kind of sum up what that innovation brings?

Dr. Meltzer:  Yeah, I think so. It’s more of a rapid risk stratification of what’s going on. It’s more accurate. It makes it so we can better tell patients that this is something that’s real serious and you need to come to the hospital, or this is something that’s not that serious and you can go home.

Host:  Right, right. Now Dr. Meltzer, when you talk about a pill with a camera that could look at a patient’s bowels; many of my listeners are thinking right now, well maybe I don’t need the colonoscopy, can I just take this pill? Or is it really just for emergency care?

Dr. Meltzer:  No, it’s being studied in a variety of conditions. There is an FDA approval for a type of this pill as an alternative to a colonoscopy. I think most gastroenterologists don’t recommend that, but it is still an option for some people if they don’t want to be put to sleep or have the more invasive colonoscopy. So, that’s something that people could do, but that’s not typically like the standard colonoscopy cancer screening which you get when you’re 50 or 45. It’s not something that we typically do in the Emergency Department. But evaluating somebody who might have let’s say bleeding from that cancer is something we would do.

Host:  Right. So, Dr. Meltzer, just in summary, I know the work that you do is fascinating. Obviously, Emergency Departments across the nation really do save lots of lives. What would you like the audience to know, in summary, about care?

Dr. Meltzer:  I think I would like people to know that we are there as a safety net, that we are there as a resource. And we are always open. And we don’t feel like patients who come in and don’t have a life threatening condition are wasting our time. We feel like that’s our job to rule out those life threatening conditions and we know that we’re not treating diseases. We are treating symptoms. So, if you have chest pain; we are treating chest pain. We are not necessarily treating the heart attack. We’re treating the symptom that you feel, and we are trying to determine if that chest pain is a heart attack or maybe it’s something more benign. Maybe you strained your muscle lifting weights.

Host:  Yeah, so that’s really – the work that you do is fascinating. I love the fact that you are interested in bringing some of the technologies for that more rapid triage and diagnosis. So, Dr. Meltzer, I want to thank you again for coming on the show today. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Meltzer or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment.. I’m Dr. Mike Smith. Thanks for listening.