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Life in Emergistan

The 26-Year Intern

Leap, Edwin MD

doi: 10.1097/01.EEM.0000604568.12724.29
Life in Emergistan

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Dear other specialists,

I admit that I can be a bit much sometimes. I work in the emergency department, and therefore, I tend to think everything is, well, an emergency. Still, I sometimes overtest and overtreat. I have believed myself an expert on lots of topics when in fact I am better described as an expert in the first two hours of lots of topics. Oh, and I can be sarcastic. I hold it in most of the time, but it's a bad habit.

Sometimes you can be a bit much too, particularly on those days when you are convinced that you and I are engaged in a little role-playing fantasy. You know the one! It's the fantasy where you're the medical school attending and I'm the intern. Forever. This little game happens from time to time, so please forgive me while I vent a little.

First of all, the administration isn't the dean's office, and they aren't likely to flunk me as long as I'm doing good work and generating bills. When you get annoyed at me, when we have a disagreement that devolves into unpleasantries, try to resist the urge to say, “Fine, I'm taking this to administration.” I can't recall a time in my 26-year career when I called the CEO or another administrator to say, “Dr. X said mean things to me, and it made me sad!” If you're mad, tell me. Let's talk it out. We'll both feel better in the end.

If you think what I'm doing is incorrect, educate me! Or allow me to refute. Once your patient is admitted, I'll never see the things you do wrong unless they come back to the ED as a complication. Even then, I'm not likely to rebuke you. I might simply give you a heads-up that something happened. That's how professionals deal with one another. They don't storm into each other's workplace, raising their voices and gesticulating in some mock display of dominance. They have a dialogue. That's what we should do.

Second, despite all belief to the contrary, it really isn't my job to complete the workup before the patient is admitted. I'll do my best to find out everything I can that is relevant. But the lipid panel before the pancreatitis admission? The second sodium level? Calling the GI consult? Those can wait. If you know a patient needs to be admitted and I know he needs to be admitted, let's just get it done. If it's a matter of a transfer, I'm happy to do a bit more so that the patient gets access to the correct resources. More often than not, the answer is obvious, the patient can go upstairs, and I can move on to the next obscure history and physical.

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Misty Half-Truths

Third, I have been told that my history relayed by phone wasn't organized in the way you like. Or when you saw the patient, you thought things weren't exactly as I reported. This is a fair criticism, but I can't limit how many people come in or when they do. Nor do I have any control over their complaints. I can't simply send them elsewhere. This makes the emergency department a place of constant distraction in which I may be managing four, five, or six patients with chest pain, two with respiratory distress, one with a fracture, two with suicidal ideation, one who really wants to hurt me, and a sincere but misguided request for narcotics and a work excuse.

I have been told by you, “I don't know anything about this patient.” Ditto. My patients are not usually known to me, so each one is a mystery who requires that I dig to find all the relevant facts. These are not always readily available, and some of my patients are not forthcoming; some are demented, some are evasive, and some are abused. Others are simply and completely disconnected from the realities of their medical history. It is entirely possible that they will say as I discharge them with a UTI and fever, “Is it OK for me to have my chemo tomorrow?” (After saying, “I don't have any medical problems.”)

I'm pulling in lots of information from different directions, and it can seem as if none of it fits together. I agree. It doesn't. I labor in a veil of misty half-truths, untruths, and impending disasters. I sometimes have to share that with you. I apologize when I can't organize it better. I honestly try. It isn't always easy. I'm not calling you to make a presentation on medicine rounds but to move patients in and out safely. Or to ask your guidance as a colleague!

You could also come to the bedside to see the patient in person before he is admitted. I know you have your own demanding practice, but this would avoid a lot of uncertainty. And I would make a point to have donuts.

We need to be a team in patient care, in medical politics, and in our community. I know I'm not perfect, and I promise to try to do better. But please, treat me like a colleague. Being an intern for 26 years is long enough.

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Dr. Leappractices emergency medicine in rural South Carolina, is 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 atwww.nursingcenter.com, and Working Knights, Cats Don't Hike, and The Practice Test, all available atwww.booklocker.com, and of a blog, http://edwinleap.com/. Follow him on Twitter @edwinleap, and read his past columns athttp://bit.ly/EMN-Emergistan.

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