In the emergency room, I find myself torn between wanting an adrenaline rushing, gory, severe patients and wanting people healthy. The cardiac arrests or heart attacks, stroke patients qualified for thrombolytics, medical mysteries, and overdoses: these are what makes emergency medicine worth pursuing. However, what kind of a person am I to secretly hope some unfortunate human being has to enter a hospital under those conditions? I feel… heartless. Yet at the same time, the people that aren’t significantly injured, such as the viral respiratory infections, chronic pain patients, sniffles, bumps, bruises, and coughs annoy me. Don’t waste the doctor’s time on such frivolous matters when there are people that are literally dying down the hall. The perfect example of this: We go from a heart attack victim’s room, into a mystery decreased level of consciousness patient’s room, into a room where a guy has a cough. This is where I feel as though I lack empathy and compassion.
I do know that the patients are in pain. As a doctor, the mission is to find a cause for the pain and make it stop. The problem is this: there is a disconnect between the patient’s expectations and what the emergency medicine doctor is able to provide. The emergency department is a place where people go when they have something that could be considered a medical emergency. It seems like it should be a simple concept, yes? MMERrrrrr, wrong. The emergency department appears to have become a place to go when you don’t feel like making time to schedule an appointment later in the week with someone who would be able to better assess your symptoms and define a definite answer. Although severely painful, dental pain is not deadly. Ear infections are not life threatening. As Bill Nye the Science Guy would say: Did you know??? That over 80% of ear infections resolve on their own without antibiotics? Now you know!
Emergency medicine is to rule out life threatening causes, not to find the exact source of your symptomatology. For example, there are hundreds of causes for chest pain. You walk into an ER and they are concerned for five: myocardial infarction, pulmonary embolism, coronary artery disease, acute coronary syndrome, and pneumonia severe enough to cause sepsis. Not concerned for one of those? Well, here is some pain meds and a discharge instruction sheet on unspecified chest pain with instruction to follow up with a primary care doctor.
What about cancer? Cancer is life threatening. This is true. Additionally, cancer will not likely kill you within the next one or two days, especially if it is a primary diagnosis. That breast lump that has been present for two months and growing? The doctor will just take a simple chest xray, tell you it is a mass, and refer you to a primary care doctor or oncologist for a biopsy procedure. The first step could more than easily be performed in a primary care setting, for a lower cost, and wield one less hoop to jump through in the course of evaluation.
Okay, okay. I understand that most hospitals will not accept a person for an appointment if they do not have health insurance and are unable to provide at least a down payment on their fees at the time of scheduling. I also understand that you will be paying a impressively greater amount on the exact same tests if you go to the emergency department.
Now that I have vented and clarified that issue, I have more to say. Many ER physicians become desensitized to the severity of situations. “Oh, you have a patient that had a stroke resulting in right hemiparesis today? Yeah, well, I had one with 98% arterial blockage in three of his coronary arteries, found after he was emergently sent for coronary angiogram.” A critical page is called and the doctors pull out their rock, paper, scissors hands to “fight” for what is being rushed in on ambulance. As the adrenaline begins pumping, it seems the majority lose all other human emotions. You do realize that when someone becomes scared, love is what gets them through? Doctors, even in urgent situations, need to remember this. When they observe a patient is severely ill, rudely asking family if they have any end of care life plans, with expectation of an immediate answer, is not appropriate. Again, I know this is valuable information that is needed in that moment, but there are better ways to approach this situation.
Other situations that tear at my heart are the teenage mothers-to-be that come in all doe eyed in the headlights. They don’t know how to care for themselves, moreless for another very dependent being. Oftentimes, the mother does not have the support of the father, the grandmother/father to be, and lost most of her close friends because she is busy being responsible for the situation. Where is the love for these patients? Some doctors walk out of the room and make jokes about making sure to add “poor judgment” as a part of the physical examination. Give them a break. For the love of all that is good, leave them alone. They have it rough enough the way it is. Raising a healthy baby is not easy when it appears they are merely a product of their social class.
Then again, where is the line drawn? Am I supposed to feel sorry for the patient who has been non complaint with his dialysis treatments, not taking his recommended medications, and continuing to use substances that he has been reminded on numerous occasions is detrimental to his health? Am I supposed to feel empathy for the patient who has smoked two packs per day, dang near lived at McDonalds, rarely checked his blood sugars, and never exercised when he is told he is having a heart attack? What about the man with known treatable cancer, likely curable with chemotherapy and radiation, who refuses all treatments stating his God will cure him? I am not even going to begin on the drug addict, pain seeking, “accidentally” compulsive liars. Yes, a doctor is supposed to feel compassion and pain towards these self inflicted train wrecks.
All of this leaves me in limbo. How many jokes are appropriate to get me through those rough days? How many ill-timed, stifled giggles need to be tallied before I shift from having a sense of humor to becoming rude? Are any of those tallies erased when my heart goes out to a patient? I have seen several doctors struggle with the fine line between the wanted honesty and presumed mockery exacerbated by frustration.
At least limbo has adrenaline, joy, humor, health, death, and a concoction of other elements that make me get into my very plain navy blue scrubs every morning. And it has coffee in all of its sweetly bitter, life giving deliciousness.