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Life in Emergistan: The Overwhelmed EP in a Single-Coverage ED

Leap, Edwin MD

doi: 10.1097/01.EEM.0000499531.42488.5b
Life in Emergistan

Dr. Leapis the president of LeapMedicine, PC, a member of the board of directors for the South Carolina College of Emergency Physicians, and an op-ed columnist for the Greenville News. He is also the author of four books, Life in Emergistan, available, and Working Knights, Cats Don't Hike, and The Practice Test, all available, and of a blog, Follow him on Twitter @edwinleap, and read his past columns at





I was working a 6 p.m. to 2 a.m. locums shift a few months ago and was preparing to leave. There were about 15 patients in rooms and 15 waiting to come back. I asked the lone night physician: “Hey, do you want me to stay a while?'

Her answer, defeated, was this: “No, don't worry. It's always like this.” I packed my bag and headed to the hotel, feeling guilty but exhausted. And wondering why my colleagues are treated so poorly.

I see it time and time again. Overwhelming numbers of patients with increasingly complex medical and social problems vs. inadequate physician coverage at all hours of the day, especially at night. We've all done it. Already fatigued, we have five chest pains yet to see, as well as a trauma on the way into the department. Two more patients have fever but don't speak English, and we're waiting for the translation line to work. And there's a large facial laceration yet to be repaired. And that's just the first nine patients. It's not even three hours into the shift. (And the EMR backup is in process.)

Do we call the cardiologist and internist to take over the chest pain, ask the surgeon to check the trauma, and get plastics to close the face? Hardly. That's just more time arguing on the phone. It's easier to forge ahead as wait times creep from two to four to eight hours. It's the same during the day, with the added gift of acting as backup for all of the primary care offices.

There was a time when we actually might have asked other staff members to help, but those times are mostly gone. As a specialty, we've spent decades saying, “Don't worry. We'll take care of it!” And our fellow physicians have obliged.

But at least, when we're alone and overwhelmed, we don't have to worry about lawsuits, patient satisfaction, quality measures, charting, coding, door-to-needle times, door-to-CT times, door-to-doctor times, door-to- ... oh, yeah, we do have to worry about those things. As well as the sound criticism that will follow in the light of day when all the administrators and other specialists are rested and shocked (shocked, I say!) at how things went when we were alone.

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Win, Win for Old Admin

The thing is, hospitals get a real bargain out of the understaffed emergency department. The physician does a heroic job of seeing every conceivable complaint and doing it with knowledge, skill, professionalism, urgency, and political savvy. If you think of what they bill for that 35-patient, single-coverage shift versus what they pay the exhausted physician, it's a win, win for old admin!

In fact, emergency physicians do the work of several people throughout their shifts, from secretary (filling out forms and entering orders) to social worker, from surgeon to psychologist, pediatrician to hospice worker. And we do it while trying our best to keep up with ever more complex charting rules, treatment pathways, and admission battles.

We also do it when expectations are ridiculous. Why should we in a busy urban department be doing the full stroke assessment when a neurologist could be at the bedside? Why are we arguing about the NSTEMI patient or managing complex rhythms when cardiologists (the alleged experts) are available? Why am I doing the neonatal sepsis workup in all the chaos when a pediatrician could see the child?

I'll tell you why. Partly because we're perpetually trying to prove our worth and fortitude. “I can handle it!” And partly because we simply agreed. Consequently, “call me when the workup is complete” is a common mantra in the ED where we are interns for life.

I wonder, are we training our bright-eyed residents for this in the trauma center or the simulation lab? Because this is how it looks when they leave the medical center for the community. All the exciting, cool stuff but all by your lonesome.

I know that lots of jobs are hard. I get that. But from what I've seen, way too many emergency departments are miserable and dangerous working environments. Does OSHA ever even look at our workplaces? Because when the Joint Commission does, it just increases the workload in the alleged interest of patient safety (and their own job security).

We should all be proud of what we do. But we shouldn't be abused children or Stockholm syndrome hostages to inadequate conditions. We should be treated as valued professionals. And if there aren't enough other doctors to go around, every effort should be made to help and encourage those willing to work in such daunting settings.

Until you've come to work a shift alone with a full waiting room and 10 potentially critical patients right up front, you don't understand what it's like on the ground. And you have no grounds to criticize anyone facing the same tsunami of expectations and exhaustion in the noble effort to save life and limb and to ease suffering.

In the end, the weary look in the eyes of my colleagues breaks my heart. And something has to be done.

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Great Minds...

Read another take on single coverage in Dr. Sandra Scott Simon's column, “Outside the Ivory Tower, Where Resources are Rare,” on p. 20.

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