The pains of Monday, the gray of growing

In the emergency room, Monday is the worst. There’s no way around it. People hold off coming in during the weekend; they hope their symptoms will get better, figure they can hold off just a little longer. And this sentiment begets the Monday afternoon flood of patients – inevitable, painful, never ending. There are some days when things are simply off – today was one of those. My rhythm was broken – in part by an extra person in my critical care area, in part by the patient volume. And so I limped along, feeling as though I was missing something on every patient. There are days like this, I have come to realize. There are days when I find my rhythm easily, get in the groove of things, and then there are days when this breaks down and frustration builds. Unhappy patients who have been waiting hours to be seen does not help the situation. It breeds a highly tense environment, where I feel that I need to first calm people down, then need to care for them properly, and – lastly – to calm myself down. Easier said than done.

The light at the end of the tunnel is here, though. Tomorrow will be my last shift in the emergency department as a third year resident. Hard to believe, really. Only seven more months to go in the coming year, and I will be an attending physician. My blog post on On winter solstice, or becoming real is ever present in my mind and my heart. This is really it. I am savoring every moment left I have with an attending shepherding me, offering his or her insight. And at the same time, I feel as though I am ready – more than ever – to fly. For my patients, I have a strong, growing desire to execute my own plans rather than those of my supervisor. I am ready to be their doctor.

Hues of Gray, Marsha Heiken

I used to believe that residency was a mountain I needed to climb, and that as soon as I reached the summit, things would become clear. But residency is just a small part of a much larger journey – an uphill climb – continuing to learn, continuing to improve my skills, continuing to question myself. Becoming a doctor is a lifelong process. It requires constant questioning, self-reflection, and yes – even self doubt. To become a good physician is to continue working and learning, day in, day out, year after year.

Because no patient is ever black and white. Each one is gray, with subtleties to their stories that can trick you, trap you, mislead you. The skill and art lies in finessing your skills in interpreting each and every shade of gray, in considering each subtlety, each shadow of doubt that crosses your mind. It lies in continuing, no matter how many years of experience you have, to harbor that fine element of uncertainty, of imperceptible fear, that keeps you on your toes, that keeps you wondering. We doctors will never have all the answers. Thoroughness, experience, compassion, and most of all humility are the best we can offer our patients.

This Too Shall Pass

As I begin to round the bend on my last lap – year four of residency – my view of the world has opened. My tunnel vision is beginning to subside. I take in my surroundings – the rooms of my emergency room, the closets, the counters, these cold, hard tiles. This chair and counter, where I have spent countless days and nights, working, racing, learning. Even these will be gone soon. It is the simple things – the distinct sound of the black phone ringing next to me, begging to be heard as I stubbornly ignore it. Room Number 5 where, for the first time, my attending turned to me and said, “You saved someone’s life today.” I see the ghosts of patients in each bed – how many I have cared for. I wonder if they still remember me.

I realized today that residency is not static. The people who have come on this journey with me – we have traveled through residency together, but we have also traveled through life together. Some have balded, others have given birth. All have cried and laughed and struggled. Some have suffered through their own illnesses during this time, or the loss of loved ones. And our attendings – they too have aged. Four years is not an insignificant amount of time in life.

I had hoped that time would freeze during these last four years – and that somehow I could it win back. I deserved it – after all that I have sacrificed. But time – life – does not work this way. These years have passed…and I have let them pass by simply waiting for the end. Looking back, I realize how much has been lost, swept away, missed. Life has happened during these years of tunnel vision, sleepless nights, and overwhelming hardships.

I feel my feet on the pavement – there is a calm that comes with rounding the bend on lap three. Deep breaths, fresh air – I am finding my stride as a physician. My pace is steady now – the finish line is close enough that I can sense it right there, just beyond my reach. My shifts ebb and flow, all with the knowledge that the river has run its course and I am almost there. The ease with which I now do central lines, arterial lines, intubations, lumbar punctures, calms me. There is a peace that comes with lap three. I will take this time I have left to look around, to remember, and to think about all that has happened on this journey.

The Downsides of the Emergency Room

An article published in Smart Money on January 24, 10 Things the Emergency Room Won’t Tell You, discussed some of the downsides to emergency room care. I will tackle these claims one by one.

1. Patience will get you nowhere.

The emergency room is a busy place, and it is generally true that being clear about your symptoms is important. However, patients are generally triaged by experienced nurses and physicians who are particularly attuned to the dangers mentioned in the article – shoulder pain, for example, should not simply be disregarded because it is not chest pain. The initial workup, including an ekg to analyze the rhythm of the heart, will be performed immediately for patients who are in high-risk groups based on age, gender, and other predictive factors. This ekg will be interpreted by an experienced physician. The moral of the story? Be clear about your symptoms and alert the triage staff if there are any changes in your symptoms.

Patience will get you somewhere – it will get you, even if it takes time,  to the emergency room. Although waiting can be frustrating, if your condition was serious enough to bring you to the ER in the first place, then it is probably serious enough to warrant waiting for a complete examination by a physician. Although some conditions will not cause death or serious consequences in the first few hours, many of these conditions can progress to cause serious problems in the next 24 to 48 hours. Thus, the wait may very well be worth it. It is your health, after all, and it is better to err on the side of caution.

2. There’s a cheaper option down the street.

Urgent care centers, if they are open and are conveniently located, are certainly an alternative worth considering. They are especially good for straightforward medical problems, such as lacerations or sprains. It is true that the ER does not offer extensive information on cheaper options, other locations, or alternatives to ER care – we are there to take every sick patient who walks through our doors and to treat them as best we can. That is our primary focus. And we certainly do not want any patient to feel that we are turning them away just because their condition can be treated elsewhere. Furthermore, many ERs now have urgent care centers as part of the facility, where patients can be seen and treated by physician assistants.

3. Bring a book.

Excellent idea. I could not agree more. Waiting – to be seen, to be treated, to receive test results, or to be admitted to the hospital – are all part of the normal course of things in the hospital. Bring a book, a magazine, music, or anything else that will keep you occupied during this time.

4. Come back in the morning.

Be careful on this one. We have many patients who decide to wait until morning to come to the emergency room – and by this time they may have already been trying to “ride out” a heart attack, aortic aneurysm, or other life-threatening condition for several hours. Although the wait may be shorter in the morning hours, if there is a possibility that you have a life-threatening medical condition, you will be seen quickly at almost any hour of the day – this is the main purpose of the ER. And ultimately, experienced nurses and physicians are better equipped than you to decide how serious your condition might be – patients often underestimate the gravity of their symptoms.

5. We might make you sicker.

This is not any more true of the ER than it is of the hospital. In fact, the case used as an example in the article was of a patient who was admitted to the hospital and underwent surgery – her complications are likely not associated with her ER visit. However, it is true that hospitals are places where infections can spread. As a result, hospitals have been proactive about placing Purell dispensers outside almost every patient room in the hospital. They have also been proactive about instituting hand-washing measures with rewards and punitive measures for physicians, nurses, or other hospital staff based on overall performance. In the ER, we are especially attuned to the potential spread of infections. During the 2010 H1N1 outbreak, many ERs were so cautious that they required patients, visitors, and physicians to wear masks if there were signs or symptoms of flu (fever, chills, cough, and the list goes on).

6. To us, you’re like a lab rat…

I don’t think ER physicians would bother to do such extensive medical workup on a lab rat. And most of these tests are not invasive. The “workup” for chest pain involves blood tests, an ekg, a chest x-ray, and possibly the scheduling of an outpatient stress test if everything checks out – not an unreasonable test, I would argue, for any middle-aged person who has chest pain. Many people have chest pain, but chest pain that is serious enough to bring you to our doorstep – the ER – is taken just as seriously by us as by you. As for unnecessary testing, refer to Defensive Medicine Supersedes Quality Medicine. This is one of the problems at the heart of medicine in this country, and it is a problem that we must fight to overcome.

7. …but don’t expect us to figure out what’s wrong.

This is generally true. In the emergency room, we determine if your condition is life-threatening or if it needs urgent intervention. We decide if you need to stay in the hospital or not. We elicit certain important characteristics about what is wrong, but we cannot necessarily give you a diagnosis in the brief time period that we care for you. In the end, however – and this goes back to the title of my blog – much remains a mystery in the world of medicine and human health. Many conditions will take months or years to diagnose, and other conditions will never be given a formal diagnosis. Many conditions necessitate extensive testing or knowledge of symptoms over long periods of time – information which, for purposes of time and money, the ER is simply not equipped to obtain. But even after all the testing has been done in the outpatient setting, physicians cannot always come up with a diagnosis. This is one of the great frustrations of medicine.

8. Good luck seeing a specialist.

This is completely dependent on where you go. Furthermore, many conditions necessitate being seen by a specialist in the next few days (especially orthopedic injuries, hand injuries, and urologic issues, which are all mentioned in the article), and in these cases you will be referred to the appropriate specialist in a specific time range. Ultimately, these referrals may delay but should not compromise the quality of  your care.

9. Your doctor can get you priority access.

If you have time, alerting your physician that you are going to the ER is a good thing. However, there has been a trend since the 1960s that private physician like to rely on ER physicians more and more, and many private physicians no longer come to the ER themselves. If they are willing to, they serve as an invaluable resource – after all, they know you far better than the emergency physician who will be treating you.

10. You can choose your doctor.

There are two different points made here – one is that you can choose to see your own specialist in the ER. This is generally true if he or she is affiliated with the hospital in some way – otherwise, as in the previous point, it is difficult to get a specialist to see you in the ER if he or she does not have an established relationship with you. In fact, ER physicians often view these people as a valuable resource – even if they do not come in to see you, we make a point of calling them to obtain important medical information.

The second point is about ER certification. The article cites statistics by the Institute of Medicine that 40% of ER physicians are not board certified in emergency medicine. It is almost ironic – and a good thing – that being board-certified in EM is now the gold standard. As recently as the 1990s, it was commonplace that physicians trained in medicine and surgery ran the ER without any emergency medicine training. With the rise of ER residency programs, which began in the 1980s, we are finally catching up with the nation’s demands for board-certified ER physicians. EM residency programs continue to expand, and the requirements for full-time ER positions are becoming increasingly stringent. This is a positive trend, and I hope it continues well into the 21st century.

Emergency medicine is an invaluable part of medical care in this country, and it is important that we fill our emergency rooms with physicians who have the diagnostic skills and the proper training to recognize sick patients, to stabilize sick patients, to save lives, and to devise for all patients who walk through our doors the appropriate disposition plans that will optimize their care. Thus, in spite of some of the flaws of the ER and of the hospital in general, it comes down to risks and benefits. Do not let some of the downsides of the ER turn you away – the consequences of avoiding the health system, however unpleasant it may be, can be devastating.

December Dwindles Away

As December comes to an end, I realize that the whirlwind of intensive care units in the hospital over the last 50 days has taken me away from writing. The table in the surgical ICU is cluttered with Christmas desserts and decorations today. A small Christmas tree, potted in gold, rests in the center – a flicker of golden red cheer among desolate white. Few families come to visit on Christmas. Maybe they, too, want to celebrate – and escape, even if for a day, the reality of this place. Ventilators, monitors, lines, tubes. They will be back tomorrow.

This will be my last holiday in the intensive care unit. And somehow, today, I view this as a privilege. To care for all of these patients throughout the day – many of whom are alone. To be here for them. Today, this is not my job – it is my gift. A small sacrifice. A 30-hour Christmas gift. I did something today which I rarely have time to do while in the intensive care unit – I stopped by my patients’ rooms and spoke with each one of them and their families, answered all of their questions, wished them the best. In my mind, I began to say farewell to them, and to the intensive care unit, as my last moments here approach.

And so it goes…

I have avoided this blog as much as I have avoided the hospital in the last few weeks. In short, it has been wonderful. As I enter the doors of the emergency room again tomorrow morning, I will be facing the world as a resident yet again. This next stretch, two months of intensive care back to back, will mark the finale of my most difficult months of residency. I will finish out most of my 30-hour nights in the hospital and will be more than halfway done with second year by the time  it ends. By this time, the last of the leaves will have fallen from the trees and we will have gotten our first frost and likely our first snow. The holidays will have come and gone in the midst of far too many call nights, and it will be a new year, 2011. This new year marks the end of one long trek and the beginning of a new one – hopefully not as strenuous.

A controversial article appeared in The New York Times and The Wall Street Journal today, CT Scans Can Reduce Lung Cancer Deaths, Study Finds. There have been several recent discussions among health professionals, both in and out of the emergency department, about the risks and benefits of CT scan. Refer to a prior post, To Scan or Not to Scan: The Use of CT, for more information. The study to which it refers, National Lung Screening Trial, is currently being performed by the National Cancer Institute. The preliminary results, which were just released, indicate that there are some potential benefits to CT scan for detecting lung cancer in a high-risk population of current or former heavy smokers. These benefits are not without risks. Until a more comprehensive analysis of study design, participants, and results is released, the information is interesting at best but does not provide sufficient evidence to establish any guidelines for clinical practice.

Researchers found 20 percent less lung cancer deaths among trial participants who were screened with low-dose helical CT as compared to chest x-ray. First, these results only include participants who were at high risk for developing lung cancer. Secondly, the main objective of the study is to assess the number of deaths due to lung cancer – a more important question may be whether or not CT scan reduces overall deaths in this population. Thirdly, other imaging modalities including MRI and PET scan were not included in the study – these may be worth examining before developing screening guidelines.

As with much in medicine, it will take time, further analysis, and additional studies to determine what the best clinical practice should be. And, as with everything in medicine, it is important that we weigh the risks and benefits of any test or intervention. The radiation associated with CT scan poses a significant cancer risk to patients, and recent studies are beginning to estimate that these risks may be greater than we had anticipated.

 

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