Years and years in emergency medicine have given me a very enlightening look at the various specialties that make up the house of medicine. I am constantly amazed by the other professionals I meet. It astounds me that pediatricians can manage the tiniest of humans, barely larger than my palm. I am fascinated by the way an orthopedic surgeon can look at a fracture, and reconstruct it in her mind, a kind of spatial organization totally foreign to my cerebral hemispheres.
General surgeons can navigate the complex plumbing of the human body, and leave it running smooth as silk after injury or cancer. Neurologists are at home with the awe-inspiring, labyrinth pathways of the human brain.
Internists and family physicians have the patience of Job himself, and radiologists can detect subtleties in gray shades that would leave an owl shaking his feathery head in wonder. There are so many amazing specialists, from intrepid obstetricians to ophthalmologists who apply optic physics to aging eyes.
Sometimes, I look at the talent all around me, and wonder if I even belong in their world! I could not do what these people do. They impress me; I do not have their talents. I am not like them! And yet, year after year, people say to me, and to you, my readers, “I understand what you're going through. I've done some emergency medicine!”
What exactly does that mean: “I've done some emergency medicine”? Maybe I'm a little sensitive, but it's always said with a kind of swagger that says, “Yep, anybody can do that; wasn't challenging enough, so I decided to become a neurosurgeon!”
“I've done some emergency medicine” usually means that someone moonlighted. Or that he rotated through an emergeny department. Or that while between jobs, he found an emergency department or an urgent care clinic where he could make some money until he actually became a real doctor.
Imagine the laughter if we returned the favor. “Yeah, I've done some heart surgery. You know, back when I was an intern, and needed the extra money!” “Cool, radiation oncology! I did some of that when I was between emergency departments!” “Angioplasty? Sure, I did some in school. It was kind of cool, but it wasn't for me.” We'd be laughed out of the room.
So what makes everyone feel that emergency medicine is the thing anyone can do? I can tell you, after almost 20 years in the field, I have no idea what would possess someone to think our work was a kind of medical default, available to any physician who could fog a mirror with his breath.
What makes us unique? If it is merely the ability to take punishment, day after day, week after week, year after year, that's enough to separate us from the majority of the pack. We can do that. We are the ones who alway take up the excess. When an office is full and a febrile child needs to be seen, that child is ours. When a surgeon is too busy to evaluate the complication, we get the pleasure. When the cardiologist's patient codes during the stress test, likely as not they're sent to the emergency department. And when all of it happens simultaneously, just as four multiple trauma patients roll in, we still have to medically clear the psychiatric commitment, and contend with the fact that other specialists are just too busy to help, despite their prior months of extensive ED experience.
But it's more than that. Just as each variety of specialist has unique capabilities that are their trademarks, so do we. We think quickly, and make remarkably good decisions with a terrifying paucity of data. Our patients are mostly people we “don't know from Adam's house cat,” to use a lovely Southernism. Despite that, we are so good at snap evaluations that we can typically find at least the very bad things people have in time to intervene appropriately. We put the “m” in multitask; each room we enter may hold disease entities as varied as pulmonary embolism and hangnails, but we can't make light of any of it because hangnails may be MRSA infections, and what we thought was pulmonary embolism may be cocaine addiction or drug-seeking.
We are masters and mistresses of negotiation, creativity, and disposition. Our daily skill sets involve cajoling the anxious and insistent to be discharged, the drunk to sit still, and the administrator to listen to our ideas. We must convince annoyed staff physicians to admit the vague abdominal pain patient, and explain to the patient's lawyer-brother that we're really doing a bang-up job. It isn't that we are fiction writers or deceivers; we are simply trying to weave the stories of the day into one great happy ending. And that requires some creative communication.
There's more, and it's only a partial list. We are expected to intubate through vomit, obtain IV access in the violent and delirious, wrestle and restrain the suicidal, splint the fracture, read most of our own x-rays (even as someone else is being paid to do it), and close the vast scalp wound as the meth junkie curses us. Our list of skills is long, but we have to do all of it while doing screening exams, sexual assault exams, and pre-incarceration exams. We have to do it all while everyone else looks over our shoulders with clipboards, asking why we weren't faster, why we weren't more efficient, why we didn't document more, and why we didn't spend more time at the bedside. We're queried about why we gave so many pain pills, and why we didn't give more pain pills, about why we paged when we should have called and called when we should have paged. And all of it while all hell breaks loose around us.
Despite being considered the inbred mountainfolk of medicine, our talents are considerable. And most of them we learned by doing over and over for years and years. We didn't become experts by moonlighting.
I have to say, most people who tell me “I used to do some emergency medicine” really didn't. At least, not the way we do it. Not with the same dedication, long-suffering, and skill. If they had, they would have hugged us, and apologized for not bringing lunch. And more importantly, they would have been ashamed to make the comparison. Not because they're bad. But because we're so good.
Read all of Dr. Leap's past columns in the EM-News.com archive.