How in the heck would three nurses and I ever orchestrate ECMO in the middle of the night in my community ED? I pondered this over tuna tartare while listening to ivory tower docs discuss cutting-edge modalities like they were part of treatment algorithms everywhere. The conversation turned to REBOA, and I wondered how many academicians had ever manned a single-coverage ED.
Ivory tower medicine and my world, where there is only one doc and three nurses to handle whatever comes through the door, are vastly different. Practicing in the trenches of a small community ED means I'll never see REBOA or experimental treatments offered at only a handful of hospitals. I'll read about cutting-edge modalities, but I'll never provide them first. I've never used TXA. Our pharmacy doesn't even have it. And ketamine, now widely used for multiple indications, is still strictly thought of as procedural sedation in my ED. Instead, I wait impatiently to try new practices.
We not only lack ivory tower treatments but also ivory tower resources in community medicine. We have fewer consultants, and the number actually awake and in house in the middle of the night is smaller still. If my patient has a weird disease I've never heard of, I figure out how to handle it on my own. There is no expert down the hall like at a teaching hospital. And residents? I haven't seen a resident since my residency graduation. I do all procedures myself, and if it's busy, I go through multiple pairs of sterile gloves as I keep breaking sterility for interruptions.
Often, there is a difference between what we should do according to administrators and academicians and what we realistically can do with the resources we have in a smaller community ED. Looking retrospectively at one case does not account for how else our finite resources were being utilized. Why was his length of stay so long? The lifesaving code for a cardiac arrest we were running meant labs weren't being done on anyone else because our whole staff was in the resus room. The lengths of stay for everyone else in the ED were increased by the duration of the code. The frustrating part is that none of their charts will reflect what else was going on in the ED.
I've invited administrators who want to know why our wait times are so long to hang out during a night shift to see how things work in the middle of the night. With no residents or other attendings to share the workload, the pace can be frenetic. My shift starts at 10 p.m., and it is not uncommon for me to have 15 or more charts from a shift with the pre-midnight date. You do the math. Often, there's no time to empty my bladder. Because of night shift coffee requirements, I go anyway and receive calls on my cell phone from my charge nurse while on the toilet.
And there is certainly no waltzing out at 7 a.m. on the dot for community docs. It's difficult to leave if you have complicated patients to sign out to the single-coverage 7 a.m. doc who is getting slammed with new patients. Despite the emphasis on moving the meat in emergency medicine, sometimes complicated cases take time to sort through to give good care.
Walk in their Shoes
Working outside the ivory tower does have its perks. The autonomy in a solo-coverage ED is tremendous. Everything filters through the EP — doing procedures, handling logistical hurdles, and seeing all the patients primarily. I may get every 3 a.m. “I think I lost a tampon up there,” but I also get every cool case and every critical patient with no one to steal the procedures.
I can still teach in the community, too. I was tickled when the charge nurse recently asked for fentanyl for post-intubation sedation. “I remember what you said about the tube being painful and needing to control pain to decrease agitation.” That made my night.
I've also achieved resourcefulness working on my own that I wouldn't have if I worked at a teaching hospital. I've learned more being on my own than I ever did from any textbook, even if something is out of my comfort zone. If you put something in front of me, I will figure it out. I'm good at making calls to whomever I need whatever the hour when I'm not quite sure what to do. Asking for help, an integral part of EM, comes easily after a few years in the community.
But the biggest perk of community practice is learning how to hustle. I'm fast out of necessity. If I'm not, there's no getting the chaos under control. After a decade in the trenches of single coverage, I'm a capable and confident EP because I have to be.
When I was training in the ivory tower and taking transfer calls from community docs, my attending told me to accept, without pushback, without questions. “Just take them,” he said. “You'll see what it's like, how much they have on their plate, and how much they have to juggle when you get out there.”
It's true. Don't engage in fishbowl emergency medicine. Respect your community docs, and don't judge what they do until you've been in their shoes.
Read another take on single coverage in Dr. Edwin Leap's column, “The Overwhelmed EP in a Single-Coverage ED,” on p. 19.