Emergency medicine in the Veterans Health Administration-results from a nationwide survey.

STUDY OBJECTIVE: We describe emergency physician staffing, capabilities, and academic practices in US Veterans Health Administration (VHA) emergency departments (EDs). METHODS: As part of an ongoing process improvement effort for the VHA emergency care system, VHA-wide surveys are conducted among ED medical directors every 3 years. Web-based surveys of VHA ED directors were conducted in 2013 on clinical operations and academic program development. We describe the results from the 2013 survey. When available, we compare responses with the previously administered survey from 2010. RESULTS: A total of 118 of 118 ED directors filled out the survey in 2013 (100% response rate). Respondents reported that 45.5% of VHA emergency physicians are board certified in emergency medicine, and 95% spend most their time in direct patient care. Clinical care is also provided by part-time (<0.5 full-time employee equivalent) emergency physicians in 59.3% of EDs. More than half of EDs (57%) provide on-site tissue plasminogen activator for acute ischemic stroke patients, and only 39% can administer tissue plasminogen activator 24 hours per day, 7 days per week. Less than half (48.3%) of EDs have emergency Obstetrics and Gynecology consultation availability. Most VHA EDs (78.8%) have a university affiliation, but only 21.5% participated in the respective academic emergency medicine program. CONCLUSIONS: Veterans Health Administration emergency physicians have primarily clinical responsibilities, and less than half have formal emergency medicine board certification. Despite most VHA EDs having university affiliations, traditional academic activities (eg, teaching and research) are performed in only 1 in 3 VHA EDs. Less than half of VHA EDs have availability of consulting services, including advanced stroke care and women's health.

Even 'safe' medications need to be administered with care.

A 60-year-old man with a history of hepatic cirrhosis and cardiomyopathy underwent transoesophageal echocardiogram. He received mild sedation and topical lidocaine. During the recovery period the patient developed ataxia and diplopia for about 30 mins, a result of lidocaine toxicity. The patient was administered a commonly used local anaesthetic, a combination of 2% viscous lidocaine, 4% lidocaine gargle and 5% lidocaine ointment topically to the oropharnyx. The total dose was at least 280 mg. Oral lidocaine undergoes extensive first pass metabolism and its clearance is quite dependent on rates of liver blood flow as well as other factors. The patient's central nervous system symptoms were mild and transient but remind us that to avoid adverse side effects, orally administered drugs with fairly high hepatic extraction ratio given to patients with chronic liver disease need to be given in reduced dosages. Even 'Safe' medications need to be carefully administered.