The patient in room two had the look I've come to associate with years of hard living — nights spent on the street and days spent searching for another high. Her chart held the results — a litany of conditions sprung from dependence and the use of dirty needles. Her chief complaint had always been neck and back pain.
Her second visit was for the same thing, with the Prescription Monitoring Program (our newest tool in the opioid fight) indicating we weren't the only place she had visited with this problem. She had walked away more than once with frustratingly large prescriptions of opioids and muscle relaxers. I braced myself for what I anticipated would be a difficult encounter.
She had little new information to share. Her shoulder and back were firm and tender beneath my fingers and shot lightning bolts of pain toward the back of her head. Every motion caused her agony, but she put on a brave face for the 6-year-old grandchild at her side. The dynamic was different from what I'd expected, and every minute I spent in the room, I learned something new about this woman's struggles. Far from seeking medication for an imagined complaint, I realized she only wanted relief from debilitating pain.
I gave her an injection, and almost immediately, it abated the agony with which she had struggled for weeks. I watched, satisfied, as she turned her neck from side to side, enjoying the movements and motion that just seconds ago had brought immense pain. Tears fell from her tired eyes, and she grabbed me in a hug, grateful that someone had "taken the time" to fix the pain rather than sprinkling more morphine on the ache. "We can finally take our morning walks again," she whispered tearfully to her granddaughter as they made their way to the door, discharge papers and no prescription in hand.
It was just another encounter that I've found to be the most unexpected of escapes from the routine of the emergency department. Despite once despising the minor complaints and rote care of the Fast Track, I discovered a love and enjoyment that I hadn't anticipated in urgent care. Every day has brought new challenges, enhanced and focused by the experience of working without the safety nets to which I've become so accustomed. Like any new attending, I find myself laboring over every x-ray and prescription, taking extra steps with each diagnosis and operating with a conservativeness that starkly contrasts with the aggression and speed in the emergency department.
Urgent care makes it possible. The slower pace gives me the opportunity to walk away from each case with greater confidence while also allowing me to connect with patients in a way I haven't since I've accelerated in the ED and taken on the additional responsibilities expected of a rising resident. The patient encounters in urgent care reinvigorate me for the ED shifts to come, with problem-solving as frequent as it is refreshing.
But it's being an emergency physician that makes me a good urgent care doctor. My sick/not sick radar is what helps me triage what is appropriate for urgent care and what is best sent down to the resources I so regularly use. The tips and tricks I've learned in the department translate well to the minor emergencies in urgent care. Wound repair and splinting are regularly required, of course, but my most satisfying cases have been those where my ED training made the difference: a hemorrhoid excision in a truck driver, a ring removal that didn't destroy the ring of a newly widowed woman or a trigger point injection in an oft-dismissed addict with neck pain.
At the same time, urgent care has made me a better emergency physician. I've learned to trust and rely on my physical findings in a way I haven't needed to before. I've learned how it feels to have the buck stop with me — to hold the responsibility and accountability that have been shouldered by my attendings for so long. I read about the cases I see in urgent care and bring those lessons with me into the ED. I listen each month to the pearls and wisdom of Urgent Care RAP, and am amazed at how often the teachings and knowledge become integral to my work in the ED.
As my final year of residency churns on, it's incredible to take a step back and see where I am and where I've been. My training has given me the tools to make a real difference in urgent care and the emergency department, and I'm so grateful to have the opportunity to play such an important role in peoples' lives. I never anticipated that minor complaints and weekend emergencies could be such an important addition to my clinical practice, but I look forward to including more urgent care experience in my career.