When you get ready to examine a patient, there are a few clues you can use beforehand to determine how sick they are. There are some quick ones, such as how many visits they've had in the past 30 days for the same back pain, or whether or not they have any vital sign abnormalities. Sometimes you're in luck and labs or xrays have already been performed.
But all of these methods pale in comparison to Dr. Zac's Rule of Twofers. Now, I don't mean to talk myself up, but this formula is genius. Allow me to demonstrate:
Where the total sickness of your patient is equal to a coefficient (δ) times the total possible sickness of any given patient divided by the number of patients in the room. Please note, there is a separate but directly related theorem when multiple people from one family check into different rooms in the ER.
You may ask yourself, "What exactly is δ, Dr. Zac?" Quite simple. It's the Coefficient of Chief Complaint, goes from 1-10, and it is used to scale the importance of certain chief complaints. Usually it equals 1, but if the chief complaint is, say, "horrific car wreck on the interstate," it allows us to overpower the denominator.
A few examples:
- Mom checks in her four children at the same time, all who have "Fever x 1 Day" listed as a chief complaint. Fever has a δ coefficient of 1. Thus, the maximal sickness per patient is divided by four, leaving us with an essentially social visit. Make your pleasantries, crack a joke or two, look in the kids' ears, no antibiotics necessary.
- Dad, drunk, lights the house on fire. He and his 8 illegitimate children are brought in as well as his mistress. "House Was On Fire," naturally, carries a δ of 10. Thus, 10 divided by 10 patients gives us 1, leaving us with a maximal potential sick value equivalent to that of any other patient in the ER.
- A friend sitting in the room with your patient mentions offhandedly that she coughed once earlier today. Unfortunately, all the sick in the room has already been used up by your patient, leaving the friend with a δ = 0. This is a special case, also known as the "convenience coefficient" and occurs when someone is so far from being sick they couldn't even be bothered to check in at triage.
There you have it, folks. Dr. Zac's Rule Of Twofers. It's bulletproof.
Being an ER doctor isn't all fun and games. Well, it's usually fun, and mostly games, but really we're at the mercy of the city and its drunk and dying denizens. When two trauma 1's roll through the door at the same time, a scattering of chest pains and GI bleeders are still waiting to be seen in the back rooms, and the hallways are filled to the brim with gurneys... well, my heart rate starts to rise.
I enter autopilot, and start doing what I loathe the most - overtesting. It's what emergency physicians refer to as "moving the meat." It's a term I hate, but when there are multiple patients needing to be seen - any of whom could be dying - and the department is bedlam, it starts to make sense.
Chest pain? Check. How long? Describe it for me. Risk factors for cardiac disease. Labs, chest x-ray, pain control, next room. In and out the door in a couple minutes. Scribble on the chart, "typical chest pain story, patient appears well and in no acute distress, check labs. EKG nondiagnostic, will evaluate xray for pathology and admit for observation."
It becomes formulaic at this point. Patients with abdominal pain get "belly labs" and a CT. Headaches get compazine/benadryl/decadron and probably a CT & spinal tap. Traumas get "trauma labs" and a $15,000 full body CT scan to search for any hint of bleeding - it exposes them to approximately half the radiation experienced by survivors of Hiroshima.
My normally friendly bedside manner goes out the window. I'll usually introduce myself, "Hi, I'm Doctor Zac and I apologize for being brief. Unfortunately an SUV just overturned on the highway and they'll be arriving in 5 minutes, so I just wanted to pop in and see how you were doing."
I never yell, but I can be brusque. Before residency, I would have never imagined myself to be the type to say "I'm sorry, I don't have time for you right now," but it happens. At least I always say "I'm sorry" first.
I suppose it's part of being a feast-or-famine specialty. We don't have the luxury of scheduling our patients. It still leaves an unpleasant taste in my mouth when I don't feel like I can care for people the way they need to be cared for. Especially when it means spending thousands of dollars of their money that I know they don't have, and delivering enough radiation to possibly cause cancer down the road.