The Untouchables

I've never been able to figure out exactly what other specialties have against emergency medicine. As a general rule, emergentologists (I love that phrase) are seen as the cowboys of medicine-- they do the medical equivalent of balancing spinning plates on their fingers. Which also means one false move and they all come crashing down. Emerg docs seem to be viewed with a mixture of envy and derision. Generally speaking a few things make emerg docs different from other specialties. For starters, we have lives outside of medicine. We still make good money (not surgeon money, mind you, but why make buckets of money when you don't have time to enjoy it?). We play as hard as we work. When we leave the hospital, we leave the patients behind and don't get paged when problems arise. We have to know about a lot of things, but we don't know most of them beyond their initial stabilization and management (or as one of my preceptors likes to say, we know the first 10 minutes of every disease). We are always being pulled in multiple directions, often by people who are actively trying to die. We have to handle everything from the small benign stuff (like a sore throat, minor lacerations, sprains) to the worst cases (trauma, VSA, sepsis, anaphylaxis) and everything in between.

So emerg docs also end up being the scapegoat for any number of questionable medical encounters. When you're juggling several critically ill patients at a time, sometimes stuff can slip through the cracks. And sometimes, things don't get worked up as thoroughly as they could be before they're referred on. In the ED, the emphasis is on disposition-- in other words, where is the patient going to end up? If they have an acute abdomen, they're probably headed to surgery regardless of the results of their LFT's-- so it doesn't always make sense to wait for them before calling the surgeon. But then the surgeon turns around and bitches to anyone who will listen about how they got a 'bogus consult' for abdo pain that wasn't even worked up.

I think that the biggest problem in situations like this is that although emerg docs rotate through nearly every major specialty through the course of their training, specialists rarely are obligated to spend any significant amount of time in emergency medicine. So it's rare that a specialist can see things from our point of view. The surgeon might just see that they were referred something as a 'query appendicitis' on the basis of right lower quadrant tenderness, rebound tenderness, guarding, anorexia and an elevated white cell count. In spite of the increased use of ultrasound and CT, the reality is that appendicitis is still largely a clinical diagnosis. Take the same case two hours later, when the surgeon (or, more likely, surgery resident) emerges from the OR long enough to lay eyes on the consult. Suddenly, the patient's tenderness has 'magically' migrated a bit higher, there's no rebound tenderness and they're claiming to be hungry. So suddenly my 'classic appy' now looks a lot more questionable, and the surgeon rolls his eyes at the stupid consult that the ED wasted his time with.

I often feel sheepish, because I know that had I gotten the same story and/or clinical exam that the surgeon did I never would have consulted in the first place. But I have no control these things.

On Facebook (my new addition) there is actually a group devoted to "Stupid Consults from Stupid Doctors". Most of the posts to the group are from residents in academic centres complaining about things that have been sent to them from the ED-- consults which, in their eyes, are inappropriate. My response? It's easy to judge from your end of the filter. Maybe those obs/gyn residents feel like they must get referred everyone with pelvic pain or heavy bleeding, but since they don't see the 98% of patients that I send home it's hard to muster up sympathy. Refer pelvic pain? Only with a positive urine preg test. Heavy bleeding? Only with extenuating circumstances, like the woman I saw last week with the hemoglobin of 68 who was still bleeding heavily in spite of treatment with Ovral. I'm no gyne, but I think that warrants intervention.

The other side of the coin is the spread of defensive medicine. From what I understand from fellow emergency medicine bloggers, the problem isn't nearly as bad here as it is in the U.S., but it's starting to seem that way. Take ortho, for example. At the last two academic centres where I've worked, emerg docs do very few reductions of displaced fractures. As someone who wants to learn these procedures, I find this frustrating. Leaving a patient taking up an emerg bed for hours until ortho can organize themselves to come down and reduce the fracture is silly when we could get it done in just a few minutes. But as it was explained to me, "if something goes wrong with the reduction, the emerg doc would have a really hard time defending their choice to do it themselves when the experts (that would be ortho) are readily available for consult". Gah. A big part of the reason I chose to finish off my training with a year in this 'less-academic' centre is the fact that the attitude here isn't that the A-B-C's of primary assessment stand for airway, breathing and consult. Emergency medicine isn't just 'referology'. We actually do the reductions, the procedures, the conscious sedation, the airway management... it's a refreshing change.

Don't get me wrong-- inappropriate consults happen. And they probably happen more often than they should. Emerg docs aren't perfect. But we do the best we can. And until you've spent a few shifts in our shoes, give us the benefit of the doubt.