When this thread first appeared I was happy to note that even though it was posted in the surgical forum, a place probably second only to IM for having reasons to hate the ED, the response to it was mostly benign neglec t and it looked like it would sink below the horizon fairly quickly. Then kinetic started cross posting links to it and it developed a life of its own. Now there are a lot of angry and grandiose claims being made on both sides of the argument.
First of all to Kinetic: I think you probably were in residency some where similar to where I went to medical school or where I did my medicine training. I thought the ED's there were disasters staffed by a mix of some of the worst and a few of the best docs I had ever met. You are right that there is no excuse for having a chart with no vitals or any other information on it but I think you do a grave disservice to the field of EM by assuming that the whole country is like that.(I recall another post of yours about some informal surveying you did during your recent job hunt that found that the ED was incompetent everwhere you interviewed.) Academic ED's do breed a huge reliance on consults for a variety of reasons. Some of those reasons are because the ED docs might be lazy, scarred, or incompetent but it can go beyond that. If you aren't sure exactly how to manage a specific problem in an academic center you can at least call the consulting service and talk to someone hopefully above the intern level who can give you some advice. This may be done for the patients own good like a patient I once saw with truly the worst case of psoriasis I had ever seen. It seemed to cover nearly his whole body and he was so miserable I nearly wanted to cry. He was indigent, didn't speak english, and his chance of ever actually seeing a dermatologist was virtually nil. I called the Derm resident at around 6:00 p.m. and was lambasted for interupting his dinner. After I chewed him out for being an arrogant and compassionless bastard we managed to come up with a treatment plan for the patient. The lazy thing to do would have been to just send him home with instructions to follow up in derm clinic (if he could ever get in). Other services get consulted because that's what
their attending's want. When I was a resident every belly pain that got a CT also got a surgical consult. The surgery residents hated it and we hated it but we couldn't change it because the surgical attendings felt very strongly that learning to evaluate belly pain without just looking at the CT scan was an important part of their residents education. I don't consult anywhere near as much as an attending in private practice, partly because I can't and mostly because I don't usually need to but when I do consult the consultants know its for a good reason
Kinetic- I've heard this a lot, but it still stinks in my mind - the "cautious admit".
The other thing people who complain about unnecessary admits miss is that there is a certain value in longitudinal observation of a patient. I only have a certain window of time in which to observe a patient and make a diagnosis (more on the make a diagnosis point later). At some point I either have to say to the patient, "I can't find anything seriously wrong with you. Go home and follow up with your PCP. If it gets worse come back to the ED" or I have to admit them. It doesn't happen often but a few times per year I admit an unexplained belly pain to surgery with a negative workup. Its usually older people with intractable pain and negative workups except for maybe a positive white count. The interesting thing is that the surgical residents at the teaching hospital raise hell over these saying, "The CT is negative, I'm not taking him to the OR, what do you want me to do with him?" The attendings at the private hospital say," Fine, if he gets worse I'll exlap him, if he's not better by tomorrow I might still exlap him, if he gets better I'll send him home tomorrow." Some of this difference in attitude is because the private attendings are paid by the patient(not working as indentured servants) and some is due to their increased level of experience. They've seen initially negative CT's turn into abdominal disasters. Syncope in high risk medical patients is similar. I try to send as many syncopes home as I can but its much easier to tell some old guy that his syncope is no big deal after he has had a more complete inpatient workup and 24 hours of monitoring on tele than it is after an hour or two on my ED monitor with an EKG and a few labs. To the medicine residents everything was either vasovagal or micturation syncope(even when it wasn't). To the private attendings it isn't as clear.
kinetic said:
Again, THERE WILL ALWAYS BE THE NEED FOR SOME JUDGEMENT CALLS - I KNOW THAT.
Thats right, and without shouting, that judgement is mine, the ED attending, and not a grumpy intern or R2 with too little sleep, too much work, and too little experience.
Just remember that when you become an attending you may see the same ED you are pissing on now in a different light. We see everyone else's mistakes and mismanagement when they present to the ED and we know who responds in a conscientous and competent manner and who doesn't. We also refer paying patients your way. More importantly when your patient calls you at 11:00 p.m on a friday with a problem you can't address by phone you will tell him,"go to the ER" not "I'll meet you in my office in 15 minutes."
Finally, the types of ED's you've described are more common at big academic usually east coast medical centers where EM has very little respect or power. It's not surprising that the best EM docs don't want to work in that kind of environment.
Now some other issues:
scutking said:
Our ER docs might as well be wearing clown suits and juggling little red balls while circus music plays in the background... ... They don't manage extremely ill patients because anything serious is immediately taken over by surgery and medicine. The funny thing about this is they go home and tell great war stories to their friends and family ("ooh, I managed a big MI today and took care of a GSW chest, it was cool man!"). Meanwhile the cardiologist has the patient in the cath lab and the surgeon has his patient in the OR, both doing the real life-saving work... ...It's comical.
Every specialty has its good docs and bad docs. EM is in the unique position of having many of their patients seen later by people who are more expert in whatever the problem is. On the other hand we get to see their mistakes bounce back to the hospital. Just a sample from my own experiences. The postop bleeds, infections, bile duct leaks etc... from some surgeons. The surgical resident who somehow managed to thread a central line down the subclavian artery, up the carotid, and then left it there for a few hours. The surgical attending I watched using a cautery for an SICU trach who burned through the ET tube(100% FiO2) thus setting the patient and the bed on fire. The medicine residents who D/C'd a syncope patient shortly after admission with a diagnosis of "vasovagal syncope" on her original meds(including several that prolong the QT) who then had to readmit her when she presented in pulseless V-tach. The medicine attending who first asked me,"what's TTP?" then allowed said patient with clearly altered mental status(a component of TTP) to sign out AMA. The medicine attending who apparently had their patient on two different ACE inhibitors at max doses while telling them one was a calcium channel blocker. I can only assume it was because one didn't end in 'Pril. The ortho residents who kept insisting their patient didn't have Nec Fasc and kept trying to send her home until she got septic, crumped, and was taken to the OR and admited by general surg. The ENT residents who sat on a patient with chest pain for more than 12 hours post esophagoscopy until he was completely septic. Cardiothoracic surgery actually found chunks of chicken meat in his mediastinum which had apparently been pushed there by very zealous efforts to remove his esophageal obstruction. The OB residents who misread their u/s from a few day before and insisted a patient had an IUP despite a belly full of blood on my u/s. General surgery took her to the OR too. Their are plenty of clown suits to go around.
As for saving lives. I now work at a community trauma center and surgery response times at night could approach half an hour. So, the first half of the "golden hour" is mine and anything that is going to get done is done by me. Similarly, there are no inhouse docs for the ICU. I do plenty of lines, intubations, and other procedures either in the ED before they go upstairs or on patients that have been in the ICU for days because the hospitalists cover multiple hospitals and might be 1/2 hour away. I've seen questionable management there too. How do you have an intubated ICU patient on multiple pressors with no central access? In any event I may not be the one to finally completely fix what was wrong with the patient but they would still be dead if I hadn't done my part.
continued...
