Goals in the ED

When I walk into a patient's room in the emergency department (ED) I have 3 questions in my mind. 1) What diseases / pathology can kill this patient given their presentation? 2) What can I do for this patient while here in the ED? 3) Where is this patient going, following my treatment? 

It is important to make sure that I do not miss something that could kill the patient if missed. Fortunately I have lots of back up at this point in my training to make sure I do not miss something. In order to rule out things that may kill the patient I may need to do a thorough history and physical exam. I may also need to order certain imaging and lab studies. Eventually when I have ruled out things that could kill the patient and in the process narrowed down their diagnosis I can start a treatment plan. Finally I figure out where the patient needs to go. I could discharge the patient home, admit for observation, admit to the ICU, send the patient to the OR for surgery or several other options. Then I need to make this happen which may include getting a specialist involved or talking to the patients family. 

This is a very basic outline of some of the ED physician responsibilities. It can be easy to assume the patient is fine and just discharge the patient without worrying about some of the other things but this is a rookie mistake and will eventually get the ED doctor in trouble. 

These are just a few of the thoughts that go through my head as I meet a new patient and their family. 

Inside Emergency Medicine

I am really getting the whole idea of what it means to be an emergency medicine physician. Every specialty in medicine / surgery has their own niche in the medical world. As you finish medical school and pick the specialty you want to pursue you have to have a paradigm shift. Medical school is all about general broad level learning. You have to learn a good amount about a lot of areas of medicine. During residency you focus the learning to know a lot about your area of expertise. I am starting see what will be necessary to learn / master in order to be an excellent emergency physician. 

The unique thing about emergency medicine (EM) is that it requires a broad knowledge on a ton of subjects within medicine and surgery. You basically never know what is going to come through the door. It can be a trauma to any given area of the body, fracture, delivery of a baby, heart attack, stroke, seizure, pediatric diseases, gun shot wounds, suicide attempts, etc. You have to be prepared to see every area of medicine. You mostly focus on the acute treatment of these pathologies. You are not there to treat the chronic pathology although you are forced to treat some chronic condition for those who use the ED as primary care. It can be overwhelming because you have to know a lot about a lot.

You will end up admitting about 30 - 40% of the patients you treat into the hospital which means the remaining 60 - 70% you treat and send home and you are the patients only contact with a physician for the given problem. You are the frontline of medicine and often your diagnosis and starting the treatment will guide the rest of the care for those patients you treat. This means you have to get it right because the doctors who will go on to treat the chronic side of the pathology will rely on your diagnosis. If you get it wrong then the remaining care is often wrong as well. You have the potential to get everyone on the wrong path or steer them onto the correct path to wellness.

There is a lot of liability and lawsuits in EM. You have to juggle many complex patients at the same time. While you are delivering a preterm infant you have a patient in respiratory collapse in the next room and blunt trauma from a car accident in the trauma bay and you have to manage all of the cases, particularly if you are the only doctor working the ED that shift. Another frustrating aspect of EM is that it is always easy for others to see your mistakes in hindsight. The critics always forget that you are working under extreme time pressures and with many other patients and generally without a diagnosis. You have to simultaneously diagnose and treat all at the same time. 

EM can be fairly demanding and thankless to a certain degree. You either love it or hate it. So far I seem to love it.