A Budding Emergencist
Friday, September 08, 2006
  Book Review or Practice Vision?

"Just trying to save a few lives: tales of life and death in the ER" by Pamela Grim, M.D. Warner, 2000.

As I move through my hospital's departments, everybody asks me what I'm going to be when I "grow up," a familiar refrain from medical school, only now I'm a doctor, being paid to repeat my 4th year. Can't complain. Right now I'm in anaesthesia, and this week's subject is scopes. Endoscopies and colonoscopies. Guts. Poop. As a future ER doc, I have superhuman powers--among them is emotional immunity to all bodily fluids. As wet, Golytely inspired farts escape around the colonoscope, which looks surprisingly like a bronchoscope, or the endoscope, the GI docs grimace and apologize to everybody in the room, for the noise, and the smell, which is considerable. Most of us are concentrating on our tasks, and a little smile comes to my face as I think, "you're gonna have to do better than that to gross me out." It's surprising that a GI doc would have such almost Victorian attitudes towards farting, especially since his job consists of inserting tubes in people's butts all day long.

So one unusually talkative GI doc asks me, de rigeur, what I'm going into, after similarly grilling and passing judgement on the medical student's hopes and dreams (anesthesia: approval!). His reaction to my choice, EM, is kind of a pained, confused look. His explanation of his disapproval is, "why would you want to be an intern for the rest of your life?" i.e., presenting patients to specialists.

His second criticism of ER is that, well, gee, you have to know so much! Yes, there are classic emergencies, bread and butter stuff, acute MI, stroke, sepsis...but what do you do if you don't know what to do and there is no specialist to save your butt? His example was a bad fracture of, say, a hand, where you have no plastic/hand surgeon to consult, for example in a rural ER.

I was amused. Mainly becuase, even in my limited 8+ weeks or so of direct ER experience, I'd already managed many open fractures of the hand, and started reciting the management, "well, you've got to explore the wound to assess integrity of the tendons and the joint capsules, and generally start antibiotics--I'm thinking ancef, here--and don't close, cuz they'll need to do washout and further inspection...oh wait." Hmm, no hand/plastics/ortho? What to do if no orthopod is around or willing to carry the ball after you stabilize? Do you turn the ER into some kind of half-assed clinic or make an appointment with any available specialist, knowing full well that, unlike in the ER, wallet biopsies will be performed as triage in those offices?

And so, on to the book review, and the darker world of a lone star ER doc. ER docs have a reputation for being "cowboys". In fact, it's one of the aspects of ER that attracted me initially when I did my first ER rotation as a student on the opposite coast in a huge County hospital. How few consults and non-ER specialists I saw! A closed ER, where anybody there is ER's responsibility! How many residents I saw routinely handling cases where specialists in my top-heavy home hospital would fear to tread!

They used to joke, after presenting cases for M & M, how all patients belong in "C-Booth!" corresponding to my current hospital's resuscitation room. The irony, of course being, that ER docs, especially at that hospital, would routinely and confidently manage complicated and decompensating patients that would make residents from other specialties croak in terror, making yellow stains all over their pristine white coats. Cowboys (and cowgirls!).

Dr. Grim illustrates the flip side of this aspect of ER: [spoilers ahead! Avast!] that, given an impossible situation where help is nowhere to be found, YOU are the doctor. The buck stops with you. If there is nobody to pass the ball off to, you're it. She does so with cases of precipitous deliveries in the ER, including several stillbirths, maternal deaths, and one eye-popping case of anencephaly. Also cases of frustration and death, sometimes of colleagues (police officers are considered comrades and brothers-in-arms of ER ppl). Stories of beating your head against the wall, trying desperately to put your finger in the dam of afflicted humanity swamping our nation's ERs. Walking wounded and the uninsured, punctuated by the occasional actual trauma or resuscitation. She talks of burnout.

The dreaded B-word, second only in potency to the dreaded C-word. I've heard tell that this happens much less often to board-certified and trained ER docs versus the "other" specialties grandfathered into ER work. The crux of the matter is this--since you are a cowboy, you must also undergo significantly more scrutiny, both from within and from without, of your management of cases you may or may not be qualified to handle. But you were there, and you were it. So you did your best. But the criticism doesn't care. Thus are born the seeds of destruction--self-doubt leading to burnout.

Other contributing factors include simply the sheer volume and magnitude of bad news that you are intimately involved with. Death, disability, and disfigurement--ER docs are often the first, and sometimes, only doctors to take responsibility for such cases. According to the books' phenomenology of burnout, you gradually lose contact with emotions and become numb as the emotional overload of suffering and stupidity and frustration, amortized over years, gradually strips you of your humanity. Personal insight is the first emotional capability to go--thus assuring your continued downward spiral if left unaddressed by coworkers, etc., since you are unaware of your ever-more-limited emotional and psychological coping mechanisms dissolving away. Eventually the only emotion left is anger, which quickly becomes your permanent and dominant emotion, subject to irrational outbursts and "small stuff," manifesting finally as burnout when the frayed nerves snap.

She also describes insane schedules that contribute to burnout, like "after the tenth/twelth 12-hour shift," which is a bright spot as this situation no longer exists as far as I know. Side note--I'm told by CHIEF RESIDENT that residents' hours are limited to 60 (versus 80 for floor schlubs) and that they are calculated week-to-week, starting Monday, at least at my institution, with no more than five days of shifts per 7-day period. When I asked him about the difference between these hours and other residents' hours, he said--it's because 60 hours in the ER is like 80 hours on the floor. My other rotating interns' experiences mirror mine in that you don't really get a chance to sit down or take a break for most if not all of those 12 hours.

Her descent is vivid and gripping, although blog-like and autobiographically pedestrian (I was struck with the similarities between some of her chapters and some blog entries I had read) at times. A philosophy professor in my sophomore year at college (Robert Goff, Ph.D. at UCSC), a textbook unto himself, regularly dispensed such pearls as , "Don't psychoanalyze your friends!" which I remember and continue to apply in my life. One of these, echoing Bob Dylan, "Behind everything beautiful there's some kind of pain," was that yes, beauty comes from pain, suffering, and anguish, but there's a difference between true craftsmanship and simply spiiling your guts out onto the page. I'm afraid Dr. Grim devolves into the latter at times, telling her best "war stories," without really integrating them meaningfully into her narrative. Other characters are flat, and the chapters are haphazardly arranged, jumping between time periods, linked only loosely by theme. One gets the sense of exploitatation of these patients' pain in the service of the doctor's effort to save herself, but we are not taken along for the ride. Still, a gripping account of the state of EM and healthcare in general in this country, linked together with a useful insight into the nature of burnout.

-The Emergencist.
Found you through Grand Rounds ... and I'm glad I did!

Blogrolling you! :o)
Thanks Moof!
When were you at LAC-USC? I was there as one of the PA Emergency residents in 82-83, many moons ago, but you are right on.
Cowboys? We're cowboys? Yippeee kayyayyy OOOH!!!! Who gets to play Injuns?

In Emergency Medicine, the biggest aggravation is actually NOT dealing with demanding patients, nor the insane volume of a packed ED, nor the 10th consecutive 12 hrs. shift in a row, nor the high acuity and chaos of a mass casualty, nor beligerent drunks, the drug seekers, the litigious threats...It's none of these. It's none of these because we are well trained to deal with these inherent aspects and intangibles of EM. We are trained to deal and take care of patients no matter what excess baggages they bring into the ED, bilateral Samsonite signs and all.

The biggest aggravation of EM has nothing to do with patient care, but everything to do with the business of EM. You'll understand it more, young Budding Emergencist, once you're out in the real world. If you can, try to learn as much about the business of EM as possible, the contract negotiations (not only individual, but group contracts with the hospital), the ploys hospital administrators use to put a noose around our necks, tying reimbursement rates to patient satisfaction survey scores, the RVU's, the coding and billing, etc...An excellent place to start is the book The Rape of Emergency Medicine. You can get it through AAEM, usually for free if you're a resident.

And the other damn aggravating thing about EM is the damn "Bat Phone". Having to deal with a'hole consultants/colleagues is a royal pain in the derrier. Example:

Me: Hey, I got a 70 y/o li'l old lady here who had a syncopal event...work up is unremarkable.

Medicine on call: So everything's normal and she looks fine. Send her home.

Me: No, dude. I ain't sending a 70 y/o lady with syncope home...

So begins the fight, same damn arguments every night. These consultants will spend more time fighting an admit, teeth and nails, I tell ya, than seeing the patients and admitting them.
Thanks, charity doc!

I appreciate your comments and will get the book. My "big brother" in EM, actually a classmate of mine, was an ER nurse for 10 years before medical school, and a big inspiration for me to go to EM.

He always wanted to get "behind the scenes" of academic medicine into the nitty gritty. Yes, I'm talking about money. He would awe me by explaining how particular patient's management would differ, all medical facts being equal, depending on what ER it was, and the results of the wallet biopsy. My father is an oncologist, as well, so I've got another advisor...I definitely will be trying to learn about the business aspect of medicine, and EM in particular, later on, when I've got a residency! Now I've just got to get a spot...

-The emergencist.
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Hi Dr Grim, you did a great job i look forward to talk or meet with you. I'm from Kosova my email is drluljeta@hotmail.com
Sincerly,L.Istrefi MD
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Emergency medicine, from the beginning of a new doctor's career.

Location: Big City, Metropolis, United States

Walk softly and carry a big vocabulary. Don't be inhuman. Find and greet God in every person you meet. The patient is the one with the disease. Do not get distracted. Charity begins at home. Do good and be happy. Don't just do something, stand still. Wear sunscreen. Don't get anyone pregnant, and don't go to jail, young man. Budget your luxuries first. You don't know what you don't know. People like learning, they just don't like being taught. When in doubt, go out. When life gives you lemons, make lemonade. Honey attracts more flies than vinegar.

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