Sunday, April 24, 2005

Emergently Jealous

The last two weeks, knee deep in emergency room medicine, managed to redefine what I initially saw as a deficient specialty. I wondered what the need for such a specialty was. After all wouldn’t an emergency room run just as smoothly with a medicine attending on the medicine side and a surgeon on the other? In fact, I hypothesize that it would even run more efficiently. So I did a little digging that inspired this rant.

The origin of emergency medicine began with a need for physicians with multiple skills and who can handle a wide range of medical issues, more specifically, emergencies. Previously, emergency rooms were staffed with various specialists who were “covering” the ER. This would mean that a Motor Vehicle Accident victim would be seen first by a specialist unfamiliar with the intricacies of such a case (i.e. Infectious Disease specialist). Ultimately, this led to a delay in proper treatment.

The idea first surfaced during the Korean and Vietnam wars when physicians who were caring for the wounded there recognized that procedures utilized on the “front” could be used at home to improve quality of care. Previously, care often did not begin until a patient arrived at the hospital. This delay in appropriate management worsened prognosis and led to higher rates of injury and death. In 1966, the landmark report, Accidental Death and Disability: The Neglected Disease of Modern Society, described the deficiencies in emergency care and brought to the forefront the need for a more immediate response. Then, on August 16, 1968, a group of eight physicians who shared a commitment to improve the quality of emergency care met in Lansing, Michigan, to form the American College of Emergency Physicians (ACEP). Ultimately, the American Medical Association’s recognition of emergency medicine in 1979 as the twenty-third medical specialty led to the establishment of 132 fully accredited emergency medicine residency programs. In 1985, Congress enacted the Emergency Medical Treatment and Labor Act which mandated that all patients who come to emergency departments be given a medical screening examination and be stabilized, regardless of ability to pay or insurance coverage. The specialty continued to make headway from there and has evolved into what it is today.

The Mad House is a level one trauma center providing emergency care to a large underserved urban population. A level one center means that most of the truly distressing cases come our way. Over the last two weeks I’ve gotten to see the need for specially trained physicians. For example, one area where Internists would be poor would be at establishing an airway. Our training does not prepare us for this and these guys in the emergency department do it all the time. I can safely say that many of those in our community owe their lives to exactly these skills, provided at the right time.

On the other hand, unfortunately, many in our community have made the Emergency Department their primary care provider. They come to the emergency room to obtain care for non-emergent problems. This is unfortunate because the ER was not intended to provide this care and, often, they will simply stay out in the waiting room for hours on end to obtain a prescription, or seek medical advice about routine medical issues. More worrisome is the fact that many will end up receiving unnecessary tests to rule out emergent disease, as this is the primary goal of the emergency room physician. These tests carry risk, and increased cost. For example, last night a lady waited in the emergency room for treatment of acute diarrhea that she’s had from the morning. She was finally seen at ten at night. She was given Imodium, which stopped the diarrhea. However, someone noticed that her oxygen saturation was low, which led to a Doppler, and then a spiral CT scan. Nothing turned up. Forty hours and four hundred dollars later, she finally went home, free of her bowel difficulties.

I think the biggest gripes internists have with the emergency department is their lack of foresight into the continued management of the patient. This is especially important because if one knows what information will be needed they will appropriate treatment as such. As an internist, I know that the time to make the diagnosis is in the first few hours the patient presents. This is the time that lab values mean the most (for example, urine lytes), that cultures make a big difference, that an Arterial Blood Gas or a fundoscopic exam could save weeks of back peddling. Often, the need of the emergency department to rule out emergent disease, or just the fact that it is so busy in the ER, interferes with obtaining the proper evaluation. Even something as simple as giving fluids unnecessarily can make the search for the etiology new renal failure extremely difficult in the absence of urine tests before fluid was given. This is the shortcoming of the specialty. By confining oneself to acute presentations one loses a true understanding of continued management, and, in certain patients, can even be an overall detriment to the patient.

Overall, I am kind of jealous of these emergency room physicians. I think that we as internists lost a lot when this specialty came into existence. The entire chapter of “presentation” is missing from our clinical experience. “Stabilization”, an art in itself, is too. For me, this is the exciting part of medicine, when the life of the patient is in your hands and the knowledge you’ve labored to learn can really make a difference.

I often put down emergency physicians. Heck, let’s face it; I put down everyone BUT internists. They don’t deserve it. So take if for what it’s worth, my small attempt at a grammatical wink, a devilish smile. Of course, I also know how to poke fun at myself. Just not right now, we’re rounding. After that I have attending rounds, then chief rounds, then chide of service rounds. What can I say, as internists, we’re really well-rounded people.