ER

We spend some time in the emergency department here at Sutter Hospital, a different setting than I'm used to. While this is not a trauma center, we do get an interesting splatter of acute cases. The pacing is very different. I look on the triage board, find a case I think I can manage, and do a rapid H&P. I've seen a kid who stuck a finger in a fan, non-responsive alcoholics, renal colic, shortness of breath, shoulder dislocation, and otitis media (did not belong in the ER). It's fun to be the first person (besides the triage nurse) evaluating a patient and under the pressure of time, coming up with an assessment and differential diagnosis. I then go find an ER doc to present the case and make a plan.

The interesting thing about the ER is the low threshold for ordering labs and tests. Almost all women of a certain age get a pregnancy test even if the chief complaint is completely unrelated. Most patients get a smattering of CBC, electrolytes, and drugs of abuse. There are a number of reasons. The ER is in the business of ruling out life-threatening diseases. There is no margin of error for missing meningitis, appendicitis, hemorrhage into the brain. We also don't know the patients. There's no therapeutic relationship to begin with and we don't know how much alcohol they drank or what drugs they're on. Finally, there's always the threat of lawsuit which looms over every ER visit.

It personally bothers me to order so many lab tests because I don't think it's practicing efficient medicine. However, I do understand why it's done and I think it's justified. Unfortunately, that means I'm less inclined to be an ER doc. I love the acuity. But I hate that everyone gets a CT scan just in case. The ER is also prone to misdiagnosis. It's unfortunate, but I've seen patients in followup clinic and upon further investigation find that they didn't have what the emergency department thought. On some level, I understand. They made sure the person was not dying and didn't need to be admitted to the hospital. But once those criteria were satisfied, their attention went to more acute patients.

I did have one interesting ER visit. A 16 year old girl presented with an hour of vertigo, imbalance, headache, and nausea. But she looked toxic to me. Her mother says there was an altered mental status and she was poorly responsive. Although oriented, she did not want to answer questions and was pretty much curled into a ball. It looked serious; I thought she would be hospitalized. This feeling actually prompted me to be extra careful in my history and exam. I was motivated to work extra hard to identify how serious this was and what the cause might be. It may sound bad, but I actually liked that feeling of acuity, that something really was at stake here, and that I needed to act to prevent this toxic-looking girl from deteriorating. The truth was, the episode resolved without any heroic intervention and she was diagnosed with migraine-associated vertigo. But I realized that I am at my best with complicated and serious cases.