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Second Opinion

Second Opinion

Keep the Faith, Fellow Emergistanis

Leap, Edwin MD

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doi: 10.1097/01.EEM.0000455722.22750.5e

    I love to write about many things: people, pets, children, family, nature. But I always come back to a theme: Emergency physicians and the forces arrayed against us. I'm not trying to be the toxic voice, the endless complainer. But if people like me don't beat the drum, nothing will ever change for the better.

    I was a flight surgeon in the Indiana Air National Guard during Operation Desert Storm, but I was not activated because I was an intern. That year I attended a lecture by a Navy physician assigned to a Marines unit that drove around the desert looking for Iraqi tanks. Unfortunately, they did not have the ability to stop those tanks. They went to a supply depot to obtain the materials to outfit their guns, and were denied.

    This physician cried as he told the story, relaying immense frustration. He wasn't even able to obtain medical supplies. Fortunately, the Iraqi Army didn't last long, and neither did the war.

    The frustration I saw in that passionate physician is not unlike the frustration I see and hear in our nation's emergency departments. The parallels between warfare and emergency departments are striking. Violence is almost expected, some facilities have metal detectors, and some have police officers, but all too many do not have even a semi-retired security guard with an ancient can of pepper spray. The danger is so real it's palpable as mental health patients, drug seekers, drunks, and gang members find their way to the unguarded, unarmed EDs. Exasperated physicians and nurses say administration would prefer to see them injured or dead than invest in security or risk harming a dangerous patient. Too much paperwork, you know.

    There are false expectations for the mission, but I could write an honest mission statement for most EDs: Here at General Hospital, our staff is expected to abide by the highest standards of professionalism, compassion, and medical knowledge. You, the patient, may curse or threaten them as you see fit, and the patient advocate will take your side. Our staff is expected to see everyone as quickly as possible (don't forget our 10-minute-to-doctor guarantee). You may report them if your ankle injury is delayed by someone else's major trauma. It's no excuse. Our staff will have you in and out in two hours or less, no matter how poor the staffing or inefficient the EMRs. You can expect ice, blankets, fluffed pillows, snacks, and satisfaction surveys along the way. Poor staffing on our part is no excuse for delays on yours. We are serious about reprimanding clinical staff for even the slightest infraction to maintain your patient satisfaction.

    Like large military forces, emergency physicians and nurses also experience mission creep. Our job used to be saving life and limb. Now it's those essentials and also immunizations, palliative care, psychiatric and social placement, data entry and data capture on a massive scale, endless regulatory compliance, and every other imaginable activity wisely shunned by the rest of the 9-5 world.

    We also have confusing rules of engagement. “If he's suicidal, don't let him leave, but don't touch him because that's assault. And if you let him leave, you'll be sued, but don't keep him in a locked room because that violates his civil rights.”

    Like the Navy physician and his unit, emergency physicians and nurses struggle with inadequate material and resources. We are usually staffed below necessity, working on the razor's edge between competence and disaster. Nurses and doctors, those unnecessary accoutrements of medicine, are expensive. Don't hire enough of them; what we really need are more vice presidents.) Our access to specialists is getting harder and harder. We're told they can't be bothered, so we must transfer anything complicated to a place where on-call specialists are overwhelmed by their own understaffing. Our ability to refer to family doctors is gone because they have stopped taking the uninsured (and those on Medicaid) for quite practical economic reasons.

    We are expected to do all of this with the most horrific thing to afflict medicine since health insurance: the corporate addiction to EMRs. Touted as a step forward in record keeping, medicolegal protection, and error reduction, EMRs have become an incredible financial boondoggle for those at the top with connections. It has crushed productivity and spirits, and mangled the doctor-patient relationship because competent, caring health care workers are chained body and soul to the keyboard. The keyboard slows them down, earns them the ire of patients, frustrates those tracking throughput, and routinely keeps them an hour or two after work for no compensation to satisfy the corporate, government, and administrative overlords of medicine. Rest assured, if you find an EMR you like, someone will take it away.

    I felt badly for that young Navy lieutenant, and I feel badly for everyone who feels powerless in an overwhelming situation where their opinion doesn't matter. Is it any wonder physicians and nurses are at their breaking points? If there are times you want to cry or scream, I say, “No wonder.” Keep the faith, fellow Emergistanis. I'm proud to fight the fight at your side. Semper a decem.

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