The more I learn about emergency medicine, the more I realize what I don't know. And that's OK. It's an honest assessment of my limitations. It drives me to keep learning. I go to meetings, I read, I listen to podcasts on my drive to work, and I'm constantly amazed and impressed by the people out there writing, speaking, and teaching about the science and practice of our amazing specialty.
Our brilliant colleagues are constantly publishing new guidelines for sepsis, STEMI, trauma, and everything else. It's actually a great time to be a physician. We save more lives and ease more suffering than at any time in the history of medicine. Despite our amazing system, brilliant educators, and thorough researchers, some fundamental problems persist. No matter how many great saves we pull off, how many disasters we manage, or how many complex diagnoses we pull out of thin air, incredible frustrations persist. These are the lesser monsters of our lives, not huge but still very troublesome, buzzing and biting things.
You know what comes to mind first? I struggle to have patients put into gowns. There are nurses who are great at it, nurses who forget it, and patients who simply refuse. “Nope, not putting that on.” Some patients put the gown on over their clothes.
I try to explain to patients why they don't need CT scans, and I'm still faced with, “I'd rather be safe than sorry.” I cajole and educate them about antibiotics, only to be met with, “Sure, it's a virus. My doctor always gives me Zithromax for this, and I always get better.”
Research aside, my patients with back pain tell me that ibuprofen is like candy, and they might as well leave if they're “going to lie here and suffer like a dog,” meaning without Dilaudid. No number of scientific papers will convince them that narcotics are not beneficial, or that they can go home without an x-ray.
Despite my constant protestations that I'm not, in fact, a dentist, patients tell me that they couldn't possibly arrange to go to a dentist for the tooth decay that has obviously been taking place for, oh, their entire adult lives.
The Little Beasts
Regardless of fever, confusion, and infected urine, the hospitalist tells me, “The patient's workup isn't complete” without the CBC, liver function tests, ammonia, and head CT. I may beg and plead, I may be overwhelmed, but if they're admitted and “something else is wrong,” whatever will the admitting doctor do?
And no matter how fast we move in the ED, CT scan reports sometimes still take two hours, even with multiple phone calls. Likewise there's that soul-crushing news three hours into the workup when I call the lab for results, and the tech says, “Oh, he was getting an x-ray, and we never drew the blood. Didn't the nurses do it?”
As we plow through the mass of humanity that fills our waiting rooms, exam rooms, and hallways, trying our best to sift out those who are very nearly dead from those in dire need of a work excuse stat, we still end up arguing with administrators about wait times. Overdose epidemic be damned, some of our colleagues are still berated for denying pain medication in the interest of patient satisfaction. Others are told, as they struggle to manage the critically ill, that the really important thing to remember is they can't have a drink at their desk. Nurses, already pressed to the limit, have panic attacks when the Joint Commission cruises through in the middle of a busy shift and asks about the policy for handling Ebola patients.
In addition to all of our life-saving work, we still spend too much time explaining to psychiatrists (who apparently forgot most of medical school) that the patient is medically cleared despite that devastatingly low sodium of 134, that chest x-ray reading that says “signs of COPD,” or the ECG that says “age indeterminate MI.”
Emergency medicine is full of scientific wonders and gifted men and women dedicated to fighting the good fight against suffering and death. The funny thing is many of our greatest challenges have little to do with the quality of our diagnostic or therapeutic activities. They lie in the day-to-day battle of communication, saying no, reassuring, educating, and just getting things done that should be remarkably simple.
Yes, we're good and we're smart. But some days, it's the little beasts that worry us and wear us down and the times we slay them that matter most of all.
“Sure, I diagnosed that PE. But he was actually in a gown! Miracles do happen!”.
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