Agraphia Medical Tragicomedy


The Grind

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.

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  1. I hear you on the radiation danger.

  2. I hear you on the “not enough time” with each patient. On overnight calls I have the ER admission pager, the code pager and the house pager. I will be checking on someone, see a code is happening and tell my patient, “Sorry, someone’s trying to die. I have to go. Get some rest”…before running away to the code. I also try to hustle down the ER so that we can get people moving and get bays open to meet the “goal” door to bed time for some bullcrap quality thing.

    I like your blog a lot, by the way :)

  3. My mom just had an ER visit that resulted in a hospital admission for an overnight stay and a bunch of tests (most of which may not have been necessary) so it’s easy to get frustrated by the system when viewing it from the outside.

    But apart from the fact that the ER can get busy, It seems like a lot of the protocols are designed to generate income as much as they’re designed to “move the meat” (your phrase, not mine).

    I’m motivated by the profit motive and I don’t expect healthcare to be any different.

    Still, there just has to be a better way…

  4. Ron –

    As far as I’m aware, my billing & coding is strictly enforced by the presenting complaint. ER visits usually count as an “emergent” level 3, 4, or 5 visit and are reimbursed as such. We also bill for additional procedures that are needed (central lines, chest tubes, etc) but those are not done unless needed by the patient presentation. Then again, I’m not out practicing in the private world, so my knowledge of exactly how billing occurs is a bit fuzzy.

    I will say, I think the ER is probably the place LEAST focused on income generation, as we’re pretty much trying to identify diseases in a population of people that (mostly) feel that they have an emergent condition, and many of our patients don’t have a way to pay us.

    A lot of the overtesting that is done is actually to cast a wide net for disease (e.g. not missing a fatal heart attack if the patient only has a probability of 6%).

  5. This post basically nails on the head why I am second guessing my original plan of going into EM. I loved being an emergency nurse but I know it’ll be a very different ballgame for me as a physician. Having to become formulaic, rushed, curt and losing direct patient contact are the things I dread.

    Yet I love the emergency department like an emotionally unavailable rockstar.

    Thanks for writing about the good and the bad of EM.

    I know that every specialty has its downsides.

  6. I don’t mean to be too negative; this field is ebb and flow. Just last night I had an incredible shift and was in a fantastic mood afterward.

    Depends on the day. I’m sure every specialty has it.

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