Emergency medicine is chaotic in nearly every way. Our shifts are beset by the seemingly senseless ebb and flow of illness and injury, where one minute can be serene and the next saturated with screams. We cobble together work schedules meant to balance work and life, but almost always end up with a circadian calamity that robs years from our lives. (Chronobiol Int. 2004;21:1055.)
We search for order and sensibility, for fellowship with other emergency physicians, for broader parallels that help us make sense of our unpredictable universe.
Mine has not been a long career, but it has been a full one so far. I've benefited so much from tremendous mentorship and broad clinical exposure, but I have encountered the same senselessness that defines emergency medicine as all others. Eager for some parallel to a more reasonable reality, I drew lessons from all the sources that I could—teachers, patients, and even pop culture. Forrest Gump, in particular, taught me a lot about emergency medicine.
“Life is like a box of chocolates.” This is perhaps the most venerable line from Tom Hanks' 1994 film. “You never know what you're gonna get,” he says. (https://bit.ly/38TsiFo.) It's a simple metaphor, a recognition that life is full of surprises and that a candy-coated shell can hold coconut horror within.
Just a few years into practice, I found a fast adjustment for Forrest's phrase: Geriatric patients' bellies are like a box of chocolates. Every EP is well acquainted with the ticking time bomb of the elderly belly. More than half of patients over 65 with abdominal pain will be hospitalized, and many will have serious and life-threatening intra-abdominal emergencies. (Curr Gerontol Geriatr Res. 2018;2018:9109326; https://bit.ly/32nHJER.) It's rare that an elderly patient with abdominal pain in the ED should escape without a CT scan or a surgical consultation. (While they're on the scanner, put the box of chocolates beside them to root out the coconut spoilers.)
“Do the best with what God gave you.” Forrest's mom dies. “She had got the cancer, and died on a Tuesday,” he says. (https://bit.ly/2Ztdeex.)
Before she passed, though, she told Forrest that she believed you do your best with what God gave you and figure things out for yourself. So do we.
We don't have much to go on with syncope, and we do a pretty terrible job evaluating and disposing those with it. I've written before about incorporating NT-proBNP into the syncope workup in select cases; it provides a clinically reassuring and medicolegally justifiable way to reexamine syncope over-admission. (EMN. 2018;40:20; https://bit.ly/2C9TlAs.) I think there's still benefit in our population, but recent literature pushes back on this. (Ann Intern Med. 2020;172:648; https://bit.ly/3089s9H.)
“Stupid is as stupid does.” (https://bit.ly/2AWSgeE.) Abdominal radiography is stupid, especially for kids. Despite its near-eradication in adult emergency medicine (aside from niche applications), abdominal x-rays remain a staple in evaluating children presenting to the ED with abdominal pain. It is, frankly, a bizarre practice—the use of ionizing radiation equal to 35 chest x-rays—to confirm a benign diagnosis, despite overwhelming evidence of the test's complete inability to do so. (Medicine [Baltimore]. 2017;96:e5907; http://bit.ly/2Im4ECy.)
“My mama always told me that miracles happen every day. Some people don't think so, but they do.” (https://bit.ly/2Zr7NwD.) I have extrapolated that about probiotics. Probiotics are extremely effective in decreasing antibiotic-associated diarrhea and Clostridioides difficile colitis when the institutionalized elderly are excluded. (Nutr Clin Pract. 2016;31:502.) The authors of a well-organized meta-analysis in children found a number needed to treat of only 10 to prevent antibiotic-associated diarrhea. (Cochrane Database Syst Rev. 2015 Dec 22;:CD004827; https://bit.ly/3ev2fp8.) Reinforcing the importance of proper patient selection, the benefit persists in adults when probiotic use alongside outpatient antibiotics is principally examined. A review of nearly 100 randomized trials found an NNT of 25 to prevent C. diff colitis and just 13 to prevent antibiotic-associated diarrhea. (JAMA. 2012;307:1959; http://bit.ly/2N4W6E3.)
“Sometimes, I guess there just aren't enough rocks.” (https://bit.ly/32u2C1d.) One of the constant themes in the movie is Forrest's relationship with Jenny, his oldest friend and enduring love. She was physically and sexually abused by her father. Years later, Forrest and Jenny are walking along a path and happen upon Jenny's childhood home. She sees this emblem of her tortured childhood and throws rocks at it.
As an intern, I was taught the coins metaphor by a sage attending. You start every shift with a number of figurative coins. Every tough patient encounter, argument with a consultant, and fight over antibiotics costs you a few coins. Every amazing case or once-in-a-lifetime save puts a few in your pocket. Things might cost more at the end of a shift than at the beginning; a string of night shifts might get your ledger dangerously low. The goal should always be to end your shift with a few coins for you and your family.
I've been guilty of spending my coins too early and too often, of fighting every battle as if it were a hill worth dying on. Maybe it's been worth it sometimes. Maybe I just never found enough coins to put in my pocket. Maybe there just aren't enough rocks.
“Run, Forrest, run!” (https://bit.ly/38UjTBE.) Forrest Gump wore leg braces in childhood because his back was “crooked like a question mark.” His disability defined his early years until he threw them off while fleeing bullies. “You wouldn't believe it if I told you,” he says, “but I can run like the wind blows.” I think you should run, too. Away from ABGs.
We don't need ABGs in the ED except for an extremely narrow cohort of patients. For the overwhelming majority of cases, venous blood gases will give you reliable markers of pH, carbon dioxide, bicarbonate, lactate, and electrolytes. They're cheaper, easier, and safer for patients. (Emerg Med J. 2001;18:340; https://bit.ly/2Wj9fQ2.)
“There's an awful lot you can tell about a person by their shoes.” (https://bit.ly/308jEyZ.) Forrest tells his benchmate that he has worn a lot of shoes. It's how he segues into the scene where he receives his leg braces as a young boy. The shoes metaphor finds its way throughout the movie, with Elvis's suede shoes at his mom's bed and breakfast and shoe-shining in the Army, among others.
You can tell a lot about a person by his shoes but not by his orthostatics. Orthostatic vital signs have been litigated a thousand times in emergency medicine. Internists seem to cling to this perennially disproven marker of volume status and syncope etiology as if there were an epidemic of Shy-Drager syndrome invading our EDs. Orthostatic vital signs for orthostatic syncope have a diagnostic performance equivalent to a coin flip and no place in the modern evaluation of syncope.
“Mama always said dying was a part of life.” (https://bit.ly/309NfIb.) Mrs. Gump tells Forrest that we're all destined to die. He recites this again at Jenny's graveside years later.
We see so much death in the emergency department. At times, I'm jealous of my wife (an OB/GYN), for whom an encounter with death is a rare and notable event, instead of what too often in the ED becomes ... routine. We see death in all its forms. The long-rigored patient brought in as a 7 a.m. code. Expected passings and unexpected tragedies. Quiet transitions to the next adventure and loud, screaming, chaotic moments of loss.
It has taken its toll on me these past few years. Too many young deaths, too many bad deaths. Too many tears, too few tender moments. “Mama always said dying was a part of life. I sure wish it wasn't.”
“And ‘cause I was a gazillionaire and I liked doing it so much, I cut that grass for free.” (https://bit.ly/2DIaGAZ.) I love emergency medicine. Seated at the nexus of patient care and public health and privileged to stand next to our friends, families, and neighbors during their most vulnerable moments—and fortunate often to possess the tools and knowledge to allay their pain or solve their crisis—I cherish the opportunity I've been given to serve. I hesitate to put these words on paper lest the contract management groups get wind of another opportunity, but I'd cut this grass for free.
There are lessons to be found all over, and sometimes the simplest things can help us make sense of the world of emergency medicine.
That's all I have to say about that.
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Dr. Pescatoreis the chief physician for the Delaware Division of Public Health and an emergency physician in New Jersey and the host with Ali Raja, MD, of the podcast EMN Live, which focuses on hot topics in emergency medicine:http://bit.ly/EMNLive. Follow him on Twitter@Rick_Pescatore, and read his past columns athttp://bit.ly/EMN-Pescatore.