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First Person: In Praise of Today's EPs, Who Work with Poise and Grace

Tornay, Todd MD

doi: 10.1097/01.EEM.0000488838.08326.3d
First Person

Dr. Tornayis an emergency physician and rural EMS supervisor in Oregon and Montana. He is also a writer, author of the forthcoming book Internal Medicine: The Novel, and of the historical novel, Nor'westering, available at on Amazon at Follow him on Twitter @tctornay2.





I've developed the most profound respect for the work of today's emergency physician over the years. As one myself, this might seem a bit self-serving, but I'll explain.

I came out of residency in the mid-1990s with a marginally ambitious career goal: to establish myself in a low-to-mid volume, single-coverage ED in a small community. It would be the kind of job where brief flurries of activity would be interspersed with periodic down times, where the possibility of clearing the board existed, where sleeping during a night shift might be a periodic luxury, and where the excitement of independently managing critical patients would be balanced with lulls, during which the most serious illness for a shift might be a bad case of mono.

I sought a position that was laid back enough to enjoy being more than a shadow figure to my two daughters, who were just toddlers when I started. We ultimately moved to a town of about 25,000 people, with a volume of around 30-40 patients a day, single coverage except for a swing person as a backup.

Fast forward 17 years. Our town became a mecca, one of the leading destinations for urban refugees craving a smaller community, microbrews, and an active, outdoor lifestyle. This transition was fueled into hyperdrive by a local power structure hell-bent on driving the home-building and tourist industries like Indy racers. The town population has more than tripled, and tourism visits skyrocketed. Bucolic boulevards have become major arteries, and what used to be a peaceful downtown stroll feels more like shuffling through a crowd at a major sporting event.

Naturally, our ED reflects this growth. Daily volumes are consistently triple digits now. The hospital is more than ever a referral center, funneling transfers from outlying satellite towns experiencing similar growth spurts.

Coverage, of course, ramped up to deal with the onslaught of patients. We used to have three providers available for 24 hours; now it can be up to eight. But it's not just volume that has expanded. Acuity has intensified with more people around to drive, bike, and crash into each other and with the burgeoning elderly population being drawn to the huge increase in assisted living facilities (another mecca industry).

So we have protocols, codes this or that, designed to streamline responses and maximize patient safety. The physical space, of course, has also been adapted. The old ED is only a shallow core of the new and improved multipod facility.

But still, amazingly, it's not enough. A patient waiting more than an hour for a room used to be a rarity, but wait times now often mushroom into the six-to-eight-hour zone. A quick glance at the electronic grease board can be daunting. Even with 30 beds, the waiting room queue often exceeds those already in a room.

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A Distant Memory

What all this translates to is that my former dream of a job with mellow intervals has long since become a distant memory. Shifts uniformly feel like being the stranger moseying into a bar in an old western movie where the baddie pulls out his six-shooter and cries, “Dance!” A staccato barrage of gunfire hails from first arrival — a complicated covey of patients to be seen, an endless peppering salvo for taking transfer calls, signing off ECGs, ceaseless interruptions, a mushrooming mass of tasks — that make the odds of bathroom or meal breaks less likely than winning the Powerball jackpot. Not to mention the monumental frustrations of dealing with charting and the EMR.

A quick confession here: My wife is an emergency physician, too, and the validity of my bellyaching is undermined by the fact that I don't even work full-time. Even so, the disillusionment engendered by getting stuck in a career so very different from what I'd envisioned has been inescapable. Yes, we could have moved, but anyone who has kids who have attended the same schools and who have grown up in one home can sympathize with how much easier that is said than done. Roots grow quickly.

Finally, the discordance became untenable. With our kids mostly grown, we have had the opportunity to step off the 2+-patient-per-hour treadmill and become travelling docs, doing locums work in smaller facilities. (The pros and cons of that will be the subject of another monologue.)

The significance of all this is that there is nothing unique, I'm sure, about this little sob story. A quick perusal of EP journals attests to the ubiquity of such stressors, with essays like, “How to Manage Decision Overload,” and “Strategies for Preventing Burnout” rampant among the clinical articles. And people have developed an abiding fondness for using the ED during this timeframe. ED visits in the United States increased by 23 percent from 1997 to 2007, almost double what would be expected from population growth, while the number of EDs decreased by five percent. (JAMA 2010;304[6]:664.) Thousands of EDs have been besieged by more and sicker patients, adapting policies to make up for the inadequacies of trying to hire more personnel.

But maybe the hardest and most ethereal downside to all this stress is the loss of civility. Nurses, despite having scheduled lunches, become churlish. Patients get cranky, if not often outright threatening and rude. The sheer number of chores per minute each EP is tasked to juggle now makes the ever-present guillotine blade of the plaintiff's attorney all the more imposing. The stress from having to make the most vital decisions with the least amount of dedicated mind space is, at best, overwhelming. It's a pace seldom, if ever, matched in the workday world.

Yet in the midst of all these depressing trends is one of the most heartening, encouraging phenomena I've been privileged to experience as an EP: the rise of a bright, young generation of professionals who have chosen to take on the challenges of modern emergency medicine. The level of competence and dedication among recent graduates has, thank goodness, seemed to have grown apace with the demands of the job. Regular use of ultrasound and evidence-based clinical scores, and deployment of scientific resources that heighten the efficiency and accuracy for making snap decisions seems to be the norm from the products of emergency residencies of late. The professionalism engendered by the dedicated academicians in the nation's training centers is creating a generation of emissaries who are dragging older docs like myself into a brighter future.

These younger docs also accept the rigors of the profession with poise and aplomb, channeling the buzz of the ED into a thrum of facile grace. They show up early for shifts; they don't explode into tirades at difficult patients and ancillary personnel like used to be the norm among some older docs.

As my wife and I step back to a (hopefully) less harried existence, I want to take the moment to acknowledge all those who work in the pits, especially all the docs in the majority of the nation's EDs, who are grappling with the boom of popularity and need for emergency care. No one who hasn't experienced firsthand the unique tensions and burdens of the job can quite understand the sacrifices of this calling. With words almost utterly forsaken in the deluge of frenetic mayhem in today's emergency department, I'd simply like to say thanks. You're doing a great job!

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