12 REASONS NOT TO GO INTO EMERGENCY MEDICINE:
BY JARABACOA
In a recent thread, a poster asked us to talk him into Emergency Medicine. I think we do a good job of telling people why to go into the field, but a poor job letting them know the realities that make our job tough. So, in an effort to keep it real, here are 12 reasons NOT to go into ER:
12. The ER has now become a sort of convenience-mart for the community, a problem solving center, especially in the department of psychiatry. While the psychiatrists sleep in their beds, you have to deal with psychiatric problems of patients who are on psychiatric holds, or who desire voluntary admission to the hospital. The patient really needs counseling, compassion, a quiet/safe place to re-group, etc., none of which are provided by the Emergency Department. However, psychiatry functions in an 8-5 manner, only wanting to deal with staffing issues when it is convenient for their unit, not the ER.
11. The unfunded EMTALA mandate. I had a 3 month old patient with head injury after her mom fell down a few stairs. The child had a tiny head bleed, and was acting appropriately, feeding, alert, vitals normal. I wanted to transfer to a PICU by ground, which is about 2 hours away. The accepting facility wanted to meet our crew half-way. It was about 20 degrees out with a 40 mile an hour wind, and intermittent snow-flurries. We thought that it would be wise to meet in the ambulance bay of an ER about an hour from us. Our nursing supervisor thought that would be an EMTALA violation if the patient presented on the middle hospital's premises. My nursing supervisor talked to our hospital attorney, who thought it would be a bad idea. I spoke to the ER doc at the middle-ground, who spoke to their hospital attorney, who thought it was OK, as long as another physician had already stabilized the patient. The middle-ground hospital has an adult neuro-surgeon, whereas, we don't have any at all. So, in my mind, it would not violate EMTALA if in the worst-case scenario, the patient deteriorated and needed to by stabilized in the middle-ground ER. But because our hospital attorney thought it was a bad idea, the patient got transferred from ambulance to ambulance in the middle of a McDonald's parking lot with a below zero Fahrenheit wind-chill, carrying the infant across an icy parking lot, instead of in a heated, dry, ambulance bay. The very fact that we talked to our hospital attorney, and they talked to theirs to figure out what to do, speaks volumes about our current medicolegal climate.
I got a call a few months back from a local paramedic, who I trust, who said a woman fell from a significant distance, lost consciousness, then seized. She was given some ativan on scene and she came around, was talking, and only complaining of headache. She was protecting her airway and her vitals were stable, with no abdominal trauma or chest trauma that was obvious on physical or history. He said he was calling the helicopter to meet them at our hospital for emergent transfer to a trauma center with a neurosurgery availability as he thought she was at high risk of head bleed. I said, "Sounds great, get her out of here." A few weeks later, I was informed this was an EMTALA violation and I should have admitted her to our ER, generated paper-work, and then sent her out, to fulfill our EMTALA obligation. If I had told them to avoid our premises, say in a field somewhere, that wouldn't have been an EMTALA violation as they didn't come near our property. The fact that a helicopter pad is the best place to land for a helicopter doesn't factor into the equation.
The fear of breaking federal law gets in the way of doing what is right for the patient.
10. The politics of an ER are complex and painful. We have many bosses. First, you have your ER director. You are also beholden to the CEO and medical staff of the hospital. If they don't like you, they can block you from having hospital privileges at the hospital, even though your director likes you. You also have medical records, and your billing office constantly hounding you to sign this and sign that, and don't order things using that abbreviation, etc. Hospital politics suck everywhere and you can really get thrown under the bus in a hurry.
9. ER nurses can occasionally be difficult to work with. The young ones don't know a lot about setting up chest tubes, central lines for pressure monitoring, etc. and don't catch your mistakes like the more seasoned nurses. The older nurses are often jaded and as they age, they get increasingly @#!*% off that you get paid way more than them, even though they think they could do your job. This is especially bad because you generally have little input over who gets hired, fired, disciplined, talked to, etc. The drama and back-biting amongst nurses is the stuff soap-operas are made of, making a pretty consistently caustic, disfunctional work environment that tends to grind up and spit out a lot of nurses.
8. ER techs can come in two flavors: A. The pre-nurse, pre-med, uber-eager tech who will work their tail off for you in hopes that the experience will further them in life. B. The lackadaisical tech who doesn't quite know what to do with their life, who thinks they may want to be involved in medicine, but doesn't want to work too hard, or doesn't quite have the self-confidence to take the next step. The A's are fun after they have been working for several months, but they turn-over so fast that you get sick of trying to get things done your way. B's get increasingly lazy, and less helpful as time goes on, and unfortunately, stay on longer than A's.
7. You are at the mercy of the randomness of chaos. Our ER announces the arrival of every patient with Patient in triage plus or minus stat. As I heard 8 people check in one hour yesterday, I would be talking with a patient, and would wince every time I heard the overhead page (Im single coverage in a ten bed ER). By the eighth, I was cussing more and more vehemently. You dont get this with an office. You know you have a maximum number of patients that you can be deluged with.
6. Patient satisfaction is currently god in hospitals. ERs consistently have the worst patient satisfaction of any part of the hospital. With emergent patients, I tend to focus on medical care and not on stroking their ego. With non-emergent patients, it is hard for me to keep up the act that I actually care. Anywhere you go, you are going to be constantly barraged by dark-suit business people, and clip-board carrying nurses giving you tips on how to get high scores. No one ever asks the question, are we sure this is the best thing for patient care?
5. EMTALA has castrated our ability to put limits on patient behavior. Because we are legally obligated to see all comers and rule out emergencies, we have to put up with their poor behavior until we can do that. Private offices/physicians can just tell jerks to take a hike. They can screen up front with firm secretaries/nurses that dont put up with guff, and will tell people Pay the co-pay or get the heck out of this office. Behave yourself, or we will call the police.
It is hard to not become jaded by the drunks, personality disorder etc. Sometimes, patients suck your compassion in a manner very akin to dementors straight out of Harry Potter. I dont know about you guys, but a bad patient interaction can really turn me ornery for hours, or even days (a couple of times, a few weeks for me). You go into medical school with intentions of becoming a compassionate human being and after a really rough shift, youd rather drop-kick the next patient that checks in for a BS complaint or behaves inappropriately. We are in a similar boat to police officers. We see the absolute worst of society- the rapes, the assault, the addiction, the stupidity, the slothfulness, the manipulative behavior, etc. Its an environment that could turn Obama Republican. Who are the policy makers and think-tank people in this country? The high-brow professors and executive types who spend all day in meetings, lectures and events associating with intelligent, high functioning individuals. The only interaction with humanity they have is from the windows of their cars as they drive through that part of town. They remark as they drive through, Jeeves! Look at these poor people. They look absolutely miserable. We must do something for them!
4. Abuse by other doctors. We get dumped on a lot by other specialties, but they never like getting dumped on by us. Yesterday, I got a call from an internal med doc, who said, Im sending a patient in from radiology. She had a DVT for the past several weeks, but in the past day, her leg has become much more swollen. US today shows that the clot has propagated to the entire leg. My husband and I (her husband is one of our hospitalists) think she needs to have catheter-directed thrombolysis arranged. Will you do it, because I am home and dont have the numbers? Come to find out, the clot has been that big for the past 8 weeks, looking at the reports, and the vascular surgeon said the clot is too far out for thrombolysis to be effective. The same person who thought I should be dumped on consistently tries to block admissions on weak chest pain admits, and TIAs all the time, even though our groups and the CEO have met repeatedly over the matter and decided that when we decide to admit, there will be no push back.
It is really hard to work in the ER, and not make mistakes from time to time, either in being too aggressive in treatment, or not aggressive enough. As much as we complain about lawyers, NO ONE is more critical of one another than physicians. The frequency that you see people get thrown under the bus by colleagues is astounding.
3. Lots of drug seekers. The lengths that people will go to in lying to get narcotics are astounding, and frustrating. The main way that you get information as a doctor is by performing a history and physical. With a history and physical in hand, you proceed with more advanced testing and treatments as clinically warranted. What do you do when people are making up symptoms, past medical problems, lying about social histories? What if they are too stupid/ demented to understand questions? Tell me I'm not the only one to have ever asked the question "Did the pain start suddenly or gradually?" and got the response..."I don't understand your question." You want to say, then you are too stupid to be wasting my time with. What do you do when people are faking severe abdominal pain? One of my personal pet peeves is facial droops and arm weakness that amazingly, have normal MRIs. The classic pseudoseizure patient is also gut-wrenchingly irritating.
2. It is all about money. Many, if not most ERs in the country have become money generating boons to the hospital. The hospital administration, and the ER directors who generally work a lot less, if at all, want all the business through the ER that they can get. Where is the down-side from their perspective? The result is that most hospitals actually encourage BS complaints to come to their ERs. They WANT non-emergent patients. In fact, their bottom line depends on catering to people with non-emergent complaints, who use the ER out of convenience. Where I currently work, I have been told in no uncertain terms, that I will never, ever tell anyone that they are not welcome in the ER for any complaint day or night. That is a hard pill to swallow as I'm walking down the hall after the rare night-time nap, thinking, and "this darn well better be an emergency". It never is. But hey, I get paid good, so I just shut my mouth, put on a smile and welcome them back for any concerns whatsoever. "We're always open, you know that. We'd love to see you again if you have any concerns" I tell most of my patients.
This is manifested by the common marketing ploy of The Thirty Minute Promise. ERs advertise that you will be guaranteed to be seen within 30 minutes of checking in by a physician. ERs around my area have even started posting their wait times online in an effort to attract non-emergent patients from other, more busy, ERs.
The exception to this are the ERs that have no room to grow physically, and are consistently unable to meet the persistent onslaught of patients. Most of these hospitals also have limited in-patient beds with frequent ER boarding, resulting in massive ER wait times, poor morale, terrible patient satisfaction scores, and high risk of litigation. So, while they don't try to force their physicians to bend over backwards and kowtow to non-emergent patients, they are not generally pleasant places to work.
1. Whiny, entitled patients-
Yesterday, I saw 27 patients in an 11 hour period. You would think that there was a local boot-camp for medicaid or something. There were a couple of interesting patients, but for the most part, it was an endless parade of nonsense. When your negative imaging rate is approaching 95%, you know your patients are a bunch of whiny hypochondriacs.
66 hours of EM a week 
