"Emergency" medicine or community clinic medicine?

[EC3]

I think they should rename Emergency medicine to Community Medicine to more appropriately represent what we actually do. I've been doing my rotations through the ED and more and more am i disappointed with the stuff i come across. Lacs that could easily be sutured up are handed off to the plastics department. Patients coming in with complaints of belly pain for 10 days and no diagnosis at all is made. Mothers bringing their children in for runny noses and saying that she didn't feel like waiting for a doctor's appointment so that's why she came to the ED. And for so many things now, actual thought is demphasized in favor of just following protocol orders so that the CYA mentality can be maximize.

I think the term "emergency" is a gross misrepresentation of what we do in the ED. It's a shame that it has come so far from actual emergencies and is now more likened to a community clinic. Personally, i really enjoy the actual emergencies (not necessarily trauma) and the really unique cases where you're left scratching your head; but honestly, i think a majority of ED patients would be just as safely treated by a PA or a family physician. It's my understanding that EMTALA has had some role in bringing this about, but is this the way things are going to stay? At some point is "emergency" medicine going to come to the point where most complicated cases are shoveled off to the specialists while we're left to see those cases which would be better addressed by a community FP physician?

i'm looking for some insight here because i really like the atmosphere and the team mentality of the ED but sometimes i get disappointed with how far things have come from actual "emergency" medicine. thx.

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[DropkickMurphy]

Has anyone ever said that maybe you should stop watching EM TV shows? It sounds like you are somewhat jaded because you've discovered that it's not what it's made out to be in the media.

At some point is "emergency" medicine going to come to the point where most complicated cases are shoveled off to the specialists while we're left to see those cases which would be better addressed by a community FP physician?

That's why I plan on doing an EM/IM combined residency followed by a critical care medicine fellowship. I don't see what you're describing happening, but I figure why risk it.

 

[EC3]

Has anyone ever said that maybe you should stop watching EM TV shows? It sounds like you are somewhat jaded because you've discovered that it's not what it's made out to be in the media.

I am aware that most of EM is non-trauma, but i'm finding that even the "emergency" aspect is becoming more minimized. Some of the things that are handed off to specialists really make me crazy. EP physicians are such a competent group of people but i feel like their scope of practice is becoming more FP and less emegency care.

 

[docB]

I know that this has been mentioned once or twice here but the "consult everything" phenomenon does not exist as much outside the big academic hospitals. I don't have plastics, ENT, OMFS, URO, GI, Trauma, Optho, Derm or psych so I don't consult those. My consultants, the ones I do have, shriek like prepubescent girls whenever they get called for anything. So I wind up stabilizing, diagnosing and dispositioning the vast majority of stuff myself.

The "community clinic" and "clinic of last resort" factor is alive and well. It will stay this way for the foreseeable future. I sucks but that's life. I have spent the last 6 years building up a frigid bitterness born of seething rage but others probably have better coping mechanisms. The trick is sorting out the actual sick ones from this deluge of urgent care silliness. It's not really like looking for a needle in a haystack, more like looking for a turd in a pile of mud.

The CYA mentality and defensive medicine is not just the bane of the ED. It is everywhere in medicine. In fact huge numbers of ED visits are initiated by PMDs practicing defensive medicine. Again, that's life (see above comment about bitterness and rage). The only way to change that is to get real tort reform and a victory over the lawyers. Write your congressman. He's a lawyer. I'm sure he'll be a big help.

And one last thing, a belly pain for 10 days with no diagnosis is the rule rather than the exception. Remember, we work up belly pain not to find answers in the philosophical sense but to identify surgical or other treatable conditions. If the work up is negative and they don't need to get cut or get antibiotics then a diagnosis of "Abdominal Pain" and PMD follow up is fine. If your goal is to follow these people out until the get better or their actual illness declares itself then you should look toward primary care.

 

[BKN]

My consultants, the ones I do have, shriek like prepubescent girls whenever they get called for anything.

Course the residents consultants at the big centers often whine like 3 year olds.

 

[EC3]

I know that this has been mentioned once or twice here but the "consult everything" phenomenon does not exist as much outside the big academic hospitals. I don't have plastics, ENT, OMFS, URO, GI, Trauma, Optho, Derm or psych so I don't consult those. My consultants, the ones I do have, shriek like prepubescent girls whenever they get called for anything. So I wind up stabilizing, diagnosing and dispositioning the vast majority of stuff myself.

The "community clinic" and "clinic of last resort" factor is alive and well. It will stay this way for the foreseeable future. I sucks but that's life. I have spent the last 6 years building up a frigid bitterness born of seething rage but others probably have better coping mechanisms. The trick is sorting out the actual sick ones from this deluge of urgent care silliness. It's not really like looking for a needle in a haystack, more like looking for a turd in a pile of mud.

The CYA mentality and defensive medicine is not just the bane of the ED. It is everywhere in medicine. In fact huge numbers of ED visits are initiated by PMDs practicing defensive medicine. Again, that's life (see above comment about bitterness and rage). The only way to change that is to get real tort reform and a victory over the lawyers. Write your congressman. He's a lawyer. I'm sure he'll be a big help.

And one last thing, a belly pain for 10 days with no diagnosis is the rule rather than the exception. Remember, we work up belly pain not to find answers in the philosophical sense but to identify surgical or other treatable conditions. If the work up is negative and they don't need to get cut or get antibiotics then a diagnosis of "Abdominal Pain" and PMD follow up is fine. If your goal is to follow these people out until the get better or their actual illness declares itself then you should look toward primary care.

you make some very good points. it's comforting to know that at outside hospitals the EM folks have a greater amount of autonomy. like i said, i really like the team mentality and the attendings and residents i work with but the community care stuff does get to me. i guess it's time to build a certain frigidness and focus on the other great aspects of EM.

 

[GeneralVeers]

you make some very good points. it's comforting to know that at outside hospitals the EM folks have a greater amount of autonomy. like i said, i really like the team mentality and the attendings and residents i work with but the community care stuff does get to me. i guess it's time to build a certain frigidness and focus on the other great aspects of EM.

As a med student working in a community ED a couple of years ago, we did not have in house plastics or orthopedics. As a result I was suturing up things by myself that probably should have required a plastics repair, and splinting the majority of non-emergent fractures for follow-up the next day with the orthopedist. If autonomy is what you desire, then working in a smaller community hospital is what you want.

 

[docB]

Course the residents consultants at the big centers often whine like 3 year olds.

So true. I had an OB/GYN who was hell bent on dealing with this HUGE labial abscess in the ED and sending the pt home after. Because I had said I thought it needed the OR (and the pt was uninsured) he was going to do whatever it took to make me wrong. He was yelling at the nurses and the patient and throwing stuff, he was really mad that we didn't have something or other he wanted because, oh lets see, we're not the OR. He did very much remind me of my 18 month old when we try to give her peas. I really prefer my 18 month old. I can change her diaper and give her a cookie and she's good as new. This Gyn yahoo jacked my ED for an hour with his shenanigans.

 

[southerndoc]

I can change her diaper and give her a cookie and she's good as new. This Gyn yahoo jacked my ED for an hour with his shenanigans.

Maybe he needed a diaper change and a cookie. Did you try that?

 

[basementbeastie]

Maybe he needed a diaper change and a cookie. Did you try that?

hahahaha...awesome....!!!

 

[docB]

Maybe he needed a diaper change and a cookie. Did you try that?

He almost got a wedgie and a shot to the jaw. That was as close as I was willing to get.