Why Emergency Medicine?

As you might have read in the previous post, certain personality types gravitate to certain fields in medicine. A colleague of mine composed a diagram that was published in the esteemed British Medical Journal -- it's essentially a hilarious but true algorithm to determine what type of physician you should be. Take a look at it: specialty algorithm -- page 2, it's a .pdf file. If you're in medicine, follow the algorithm and see if you ended up where you belong. I did. If you're not in medicine, you can see what kind of personality your medicine friends have.

So before I get back to more stories from the ER, I should briefly explain how I got into the field in the first place. In summation, it's because I have no attention span.

Generalizations are made about every field of medicine. In a previous post, I described how surgeons were jerks, hardworking, but still jerks; internal medicine people are smart and pontificate for hours on end, etc. Similarly, there are some generalizations about the type of person who decides on a career in emergency medicine. In no specific order, they are:

1) No attention span. On some level, ER docs have a component of ADD. We don't have the patience to spend hours with one person and concentrate on the nuances of little (but important) details like, for example, the level of sodium in someone's urine, calculating that with their cardiac output, etc. We like quick assessments and quick fixes to problems. If we can't fix it, we turf it out to someone who can, and this is a big source of problems during residency (a topic to which I'll return shortly).

2) We like having an outside life. ER docs do shift work. We know when we're coming, and we know when we're leaving. If something is not done by the time your shift is up, you pass it along to the next ER doctor taking your place. After residency (let me stress after), you work much fewer shifts, an average of 3 or 4 days a week. You don't carry a pager with you because when you're off shift, you're off shift.

3) We're adrenaline junkies. Most of went through third year of medical school bored to tears with endless rounding in the general inpatient wards, and similarly exquisitely impatient standing in the O.R. acting as a human retractor of fat while the attending surgeon tried to find what he or she was looking for. Things get interesting, however, when someone is crashing in front of you and you have to figure out something very quickly.

4) We like patients, but not that much. Of the people I see, I like the vast majority of them, really I do. They tend to be nice, understanding, and in need of something quick (stitches, a cast, removal of that bowling trophy from their rectum). However, I don't want to be lifelong friends with them. I even like the challenge of having to establish trust quickly. However, there are a few patients that make me wish I DID run a clinic and could see them repeatedly.

Point number 4, however, creates an ominous, obvious flipside: you can't refuse anybody (by law). EVERY ER doc can regale you with stories of incredibly difficult patients that you wish would either a) leave AMA or b) arrive DOA. The drunks, the belligerent, the MEAN, the "I'm gonna sue you" patients, the demanding ones, the self-entitled ones, the emotionally disturbed patients. However, they provide fodder for good party stories -- that's why we're a hit at Holiday gatherings.

5) We like a little bit of everything. Every ER doc I know went through third year of medical school on each rotation saying, "I could probably do this field." While the thought of doing a vaginal exam horrifies internal medicine docs, I don't mind them so much. While a surgeon would hate to acutely manage malignant hypertension, I don't mind that either. But I like managing the emergent aspects of all those differing fields of medicine.

6) We enjoy solving diagnostic dilemmas. There are very few areas in medicine these days in which the treating physician does not know the patient's diagnosis. The ER is one place left where undifferentiated patients arrive and you have no idea what is causing their symptomatology. The patient fainted? Could be anything: cardiac arrhythmia, stroke, low blood sugar, etc. We get to figure it out, then pass that person along to the next most appropriate service with a working diagnosis (which may or may not ultimately be correct).

Thus, we can do a little bit of everything, but few things to complete depth. The most famous descriptive axiom is that we're a "jack of all trades, master of none." The blue-collar MDs, if you will. There aren't very many things we can do that someone else in another specialty can't do better. The anesthesiologist may be able to intubate better (sometimes) than we can, but they cannot cast a broken leg; the cardiologist can read an EKG better than we can, but they cannot intubate or treat acute salicylate poisoning.

I don't mind that at all, except it sets us up for what is usually a big problem during residency: the rest of the hospital hates you. I was unprepared for this fact (yes, fact) when I started residency. It makes sense, however -- you only give other residents more work to do. NO ONE likes to get a page from the ER. We are frequently second-guessed and blamed for "incomplete" work-ups. This is mostly a byproduct of particular residents' personalities -- assholes are assholes no matter what field they're in. However, all residents are overworked, and I do understand that sinking, angering feeling when your pager goes off and it's coming from the ER. But in terms of general patient care, it works. You're really sick (and by that I mean REALLY sick), you go to the ER. The ER doc works you up, triages appropriately, makes initial interventions, then passes them along. We stabilize. Patients need it and like it. Other residents don't appreciate it until THEY'RE done with their own residencies and then make a buck off of the work we give them.

The biggest fights occur between residents when the ER thinks a patient should be admitted to the hospital and the resident from x service thinks they can be discharged. Admitting someone is a large amount of work for a resident, and they certainly don't get paid extra for it. At this hospital, however, the ER has unlimited admitting privileges, so the resident from whatever service can say what they want, but if the attending wishes that person to be admitted, it's done. More often than not, the ER was correct, but you rarely hear the admitting resident who was previously spewing venom do a mea culpa to the ER. There was, however, an intra-hospital study done about "inappropriately" admitted patients. And guess what? Over 90% of the time, those patients that other serviced wished to discharge decompensated rapidly in the hospital -- they died, required emergent surgery, etc. Most of the time, however, even though the workload is increased, both the ER and the admitting team agree when a patient needs to be admitted. I have the privilege of being part of a reputationally-strong ER program -- some programs are mediocre (true of any field). The attendings here are VERY smart, and it's considered an "intellectual" ER program, so generally there's a high level of agreement.

Having said that, however, we as a department also quite physically isolated from the rest of the hospital -- what goes on above the first floor is largely a mystery, though you'll find most ER doctors follow-up on their interesting patients that have been admitted.

However, as an emergency medicine resident, we are required to rotate through different services that are considered germane to the study of emergency medicine: trauma surgery, ob/gyn, critical care units, orthopedics, etc. We don't spend all 4 years totally isolated in our ER bubble downstairs. So we get to know other residents on other services, we make friends, it helps politically. Orthopedics and ER tend to get along the most well together, and that's probably because we're the most fun and know how to relax. Work is work, play is play, work hard, play hard, do each other every now and again (it happens all the time).

But when I rotate on other services, I hear criticism all the time of the ER, and nearly 100% of the time it's unwarranted. "Well, the ER did THIS," "They totally mismanaged this person," "Can you believe they *didn't* do this?" We work with limited information. We do the best we can. The other residents are largely just expressing displaced anger at having more work to do.

Because the ER is downstairs and largely isolated, however, I have seen many, MANY residents simply LIE to their attending to save their own ass and because they know it's almost impossible to get caught. The party line is, "It was the ER that did that, I'm not sure why."

True example:

Trauma situation -- car accident victim comes in, both lungs require chest tubes to drain bilateral hemothoraces. The ER resident put one in on the right side, the surgery resident put one in on the left side; I was there, I was a witness. The patient is stabilized and brought upstairs.

The trauma surgery attending sees the patient an hour later in the critical care unit upstairs, and he pulls up the x-rays. The right-sided chest tube is in perfect position and drained the blood in that side of the thoracic cavity and the lung is re-expanding nicely. The left-sided chest tube is kinked, not in far enough, essentially useless and needs to be re-done. Without even being queried, the surgery resident said, "The ER resident put in that screwed-up tube. I put in the other one."

A complete and total lie, and he knew it. But he knows no one is going to take the time to verify the truth or non-truth of that statement.

And so it goes, on every unit, at some point, some resident will cover their own tracks and say, "That was done in the ER," knowing it's a lie.

Sure, we make mistakes like everyone else. But by and large, all residents from all services try to get along and work together. It's the right thing to do. And it most certainly helps that all residents in surgery, medicine, orthopedics, urology, and ob/gyn are required to rotate through the ER too so that they can see reciprocally see what life is like on OUR side of the fence. They usually leave the rotation with a very good understanding of what we go through, but they also typically lose that perspective about 30 days after finishing the rotation. I suppose, however, the same is true of us after we leave THEIR rotations.

And so the cycle continues.