(Once again, a caveat: I am a resident in a medium-sized Emergency Medicine program in an academic setting. Not as academic as Duke or USC but we have most of the players. I have never worked in private practice in Emergency Medicine so while I welcome the comments of those who have, I am describing my views of residency, not private practice. -PB)

The Spice of Life

The other night I was sitting at our PACS workstation (for viewing imaging studies) discussing a fracture with one of the orthopaedic surgery residents. In front of me were the ultrasound pictures of another patient, a woman who I was working up for a possible ectopic pregnancy. I had three charts on the table; one a lower GI bleed, one a headache (cough…drug seeker…cough), and the other a totally lame alleged intentional overdose of Seroquel. I had just discharged a four-year-old who was perfectly healthy requiring only maternal reassurance and I was keeping an eye on one of our habitual drunks signed out to me by one of my fellow residents, to be discharged when he could walk or obtain a ride home.

In no particular order, my other patients on that shift were a minor laceration to the forehead, a couple of nebulous abdominal pains, a few chest pains only one of which would probably pan out (although all were admitted), a possible meningitis requiring a lumbar puncture, a septic shock requiring the works (intubation, lines), a constipation, and a couple of drunks with whom I am on a first name basis.

That’s how I spent my night and that’s pretty typical. An occasional flat-out, full-throttle emergency, a couple of really sick people who might have become real emergencies if they had waited another few hours, some acute but non-life threatening complaints, and a whole bunch of patients who make you scratch your head and wonder what could possibly induce a reasonable human being to leave the comfort of their bed at 2AM to sit in the hall of our department eating cold turkey sammiches’. I mean, without giving too much away, let me just say that I have had vague abdominal pains at one time or another but I have never even considered calling an ambulance to take me to the Emergency Department.

So you see, while Emergency Medicine is a specialty, most of your time is going to be spent on general medical complaints, not actual emergencies. Still more of your time is going to be spent coordinating care; either referring, consulting, or admitting and a surprising amount of working up and treatment goes on before we get to that point. It is hard to get specialists and consultants to come in or admit so one likes to have a rock-solid case before calling. Not to mention that the Emergency Department has become a miniature hospital-within-the-hospital complete with admitted patients and even critical care. Consequently, the consultants and admitting physicians expect us to do a lot before we actually call, sometimes to the point of doing essentially everything for the work-up of a complicated patient including definitive care. When they start asking me the results of C-ANCA studies maybe it’s time for them to admit the patient.
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A typical shift, like March, starts like a lion but goes out like a lamb. On arriving, I grab the first chart on the rack and start the work-up on my first patient. This is the easy part. There is nothing to starting a patient’s work-up. You either have a pretty good idea what’s wrong or you can temporize by ordering studies, a tactic that will buy you anywhere from twenty minutes to an hour (one of our Emergency Departments, if you can believe it, does not have a “stat” lab and the only fast thing you can get are a few lab values off of the ABG on a critical patient). With the first patient comfortably simmering on the back burner, I pick up the next chart and repeat the process. Eventually I have a bolus of six or seven patients waiting for studies and disposition and then things slow down considerably. At a certain point you start getting close to the resident Event Horizon, that point in the space-time continuum where your efficiency drops to zero; as does your ability to see new patients without falling unacceptably behind on the ones you are following. It is surprisingly difficult to keep track of a large number of patients at various stages of their work-up.

Moving patients is complicated by the structure of residency. Our attendings, who see patients themselves, need to lay eyes on every one of our patients and approve the plan. They are as busy as anyone else so while every patient to be discharged or admitted needs their blessing, coordinating this can be difficult, particularly as our attendings are not only seeing their patients but also supervising a couple of other residents.

So if you look at a graph of my productivity, you’d probably see what looks like a huge effort towards the beginning of the shift tapering off to nothing by the last few hours. In other words, while I’m seeing my required quota of patients, once I get a certain number I lose efficiency rapidly. We typically don’t pick up charts on the last hours of our shift but by that time it’s academic anyways as most of our effort is now spent frantically trying to get rid of the ones we have. Another one of the skills our attendings try to teach us is to keep the patients moving through the pipeline without that kind of bottleneck.

Some bottlenecks, however, are unavoidable. Procedures, things like suturing or doing a lumbar puncture, can eat up a considerable amount of time if you a) are not very good at doing them and b) don’t coordinate with your nurse. Coordination is important. The nurses want to move patients as much as you do and if, for example, they have the patient moved to the OB-Gyn room for a pelvic, you need to plan to be available to do the exam when they are ready. You also need to stay on top of the labs and imaging. The sooner you can make a decision the better.
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The other unavoidable bottlenecks are critical patients and trauma, both of which can suck up large amounts of time. Critical care patients in particular, because they are not likely to be taken off your hands by surgery any time soon, can easily set you back an hour, something that many patients in with minor complaints do not understand. Reason number 1024 not to come to the Emergency Department for a minor complaint. It might seem like a good idea when you breeze through triage on a slow night but invariably there will be delays.

Contrary to the popular belief among critics and sour-grapers of Emergency Medicine, although we see some minor complaints (“I couldn’t urinate for an hour but now I can”) we do not do primary care. Oh sure, patients make attempts to get us to manage their chronic problems but you need to avoid the temptation. You cannot do decent primary care on a patient who you have never seen and will probably never see again and certainly not within the confines of an Emergency Department visit. We do not do drive-by pap smears, in other words.

Imagine how things would slow down if we did.