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After the Match: Hallway Medicine, the Reality of Residents' Future

Cook, Thomas, MD

doi: 10.1097/01.EEM.0000547694.51465.67
After the Match

Dr. Cook is the program director of the emergency medicine residency at Palmetto Health Richland in Columbia, SC. He is also the founder of 3rd Rock Ultrasound (http://emergencyultrasound.com). Friend him at www.facebook.com/3rdRockUltrasound, follow him on Twitter @3rdRockUS, and read his past columns at http://bit.ly/EMN-Match.

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I am excited to announce the publication of a new textbook, Hallway Medicine. I hope this will become required reading for all emergency medicine residents. Some of the topics covered in this exciting new niche of emergency medicine include how to apologize for someone being in the hallway, acquiring a history from the hearing-impaired patient in the hallway, taking a sexual history in the hallway, discussing HIV status in the hallway, and complying with HIPAA in the hallway.

Other topics in the book: controlling bleeding in the hallway, hallway suture techniques, orthopedic splinting at the nurse's station, hallway rectal exam strategies, best practices for hallway pelvic exams, intubating the hallway patient, where to find vent extensions for hallway patients, managing the hallway patient in a Reeves Sleeve, and effective coping strategies for patients who will be in the hallway all night.

Of course, this is sarcasm. Ironically, all patients were hallway patients when I started 30 years ago. The only private rooms we had were for pelvic exams. All the other patients were in a large bay with only curtains for privacy. You could have neonatal fever in one bed and geriatric fulminant diarrhea in the next. Patients got better accommodations as the specialty developed. Beds in a bay turned into beds in rooms with doors, TVs, and quiet. The exception became the norm.

Now the reverse is happening. The ED is becoming physically smaller as rooms fill with patients waiting for inpatient rooms and ICU beds. This does not stop patients from seeking help, and even more space ends up being consumed by the steady stream of EMS and ambulatory patients who cannot wait. Standard protocols developed in the past decade for disease processes like STEMI, stroke, and trauma put everyone on shift under a microscope. We drop everything and move quickly to provide the best care, but this means a lot of important stuff must wait. We all like to provide better and more efficient care, but this makes it feel like we are drinking from a fire hose.

The largest burden is felt by ED nurses. They must routinely create innovative strategies to care for new ED patients while keeping an eye on holds. Overwhelmed on nearly every shift, their heightened anxiety and stress encourage them to consider other employment options, leading to a revolving door of nursing personnel.

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Draining the Swamp

The problem is even more acute in training programs that disproportionately care for complicated patients with low socioeconomic status. Hampered by poor to nonexistent health insurance, these patients often have no resources except the ED, and when they finally show up, they are sicker with fewer options for safe discharge.

The root cause of this problem is complicated and very, very difficult to fix. Hospitals have attempted for years to increase efficiency in the ED by restructuring how the ED manages patients. Move the not-sick through more quickly, and the ED can see and do more. But when you're up to your eyeballs in alligators, it's hard to remember you were sent in to drain the swamp. With holds everywhere, the staff cannot do as much, supplies get consumed, people get tired more quickly, and mission fatigue sets in. So what can we do?

The hardworking, dedicated folks who are trying to find solutions have told me that it can take years just to grasp all the variables and that best practices to improve patient flow in the ED are just beginning to take shape. One colleague from a prestigious university told me the hardest part was getting everyone outside the ED to understand that the cause is not the ED, but how the rest of the hospital absorbs ED admissions and moves them through the system. The solution requires partnerships between factions that often feud.

Getting physicians from different specialties, nurses, and administrators to talk to each other openly and frequently is a start. It is important for non-EM physicians who rarely (if ever) enter the ED to understand the nature of the dilemma. When you are a busy doc seeing patients in your clinic, it's easy to think it's not your problem, but a well-functioning ED is a benefit to everyone, and a struggling one is a tremendous hardship on the organization and local community.

So why bring this up in a column geared toward residents? The simple answer is that this is your future. If you think you will cherry-pick an ED that does not have this problem after graduation, think again. I doubt you will find one that meets your geographic and monetary aspirations. (After all, harder work typically gets paid more.)

But you do have the opportunity to learn about what is being tried in your current institution to fix the problem. It is likely your hospital has a throughput committee and an administrator or physician executive who would enjoy having you tag along. Few physicians understand the demands of administrative work. It is often thankless and impossible to please everyone. Jump in and spend some time with them on an elective or a few free mornings or afternoons. You will gain some insights into one of the biggest challenges facing our specialty and our nation's hospitals.

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