Friday, December 19, 2008

The Woes of Emergency Medicine...

First, I find it a huge challenge to write weekly, let alone daily and I apologize - not that anyone has read anything on here. I give people credit who can find the time to write a daily blog. I guess that's why I never could keep a daily diary when I was a kid. The demands of work are great, and when I'm done with a shift, the last thing I desire is to re-hash the last 12 hours.

Years ago, people went into the field of emergency medicine because of a great lifestyle. No call, days off when you wanted them, no pager, you left work and had no other responsibilities. I suspect that for some places, this may still be the case but for me, my work doesn't end at the end of the shift. At the end of my shift, I am still stuck trying to get dispositions on the patients I have seen. The work-up is not complete, consultants have not called me back, I'm waiting for the radiologist to read a CT scan on a patient with belly pain, etc.

Once I stop seeing patients I still need to figure out what to do with the ones I've seen. And even if I know what I'm going to do with them - admit them to the hospital or discharge them home, I still have to complete the paperwork. Since I mainly work in the area of the ED that sees most of the acute injuries and medical complaints, most of these patients are complicated. I'm not talking about a kid with a sore throat, an infant with a fever (although that can be very complicated), or a twisted ankle, I'm talking about patients with headaches, dizziness, shortness of breath (SOB), chest pain, falls, motor vehicle collisions, strokes, loss of consciousness, etc.

In the end, the headache may be nothing but a tension headache or related to stress or anxiety or it may be a brain tumor, a ruptured blood vessel in the brain, or meningitis (infection of the outer lining of the brain). And, the emergency medicine physician's job is to figure that out. Unfortunately, if you are wrong and you send the patient home and the patient dies or suffers ill consequences you more than likely will be faced with a major law suit and end up in court settling a case for a few million dollars (that is of course if your malpractice insurance has greater than one million dollars as it limits). You see, physicians are right if the patient suffers no harm, but once a patient suffers harm, everyone (especially lawyers) puts on the "retro scope" and looks for something that could have been done differently.

Recently, someone asked me what the "standard of care" was in a certain situation. My reply was there may not be a standard of care with every issue since many patients present in so many different ways. There is generally an accepted way to treat patients. You only potentially breech the standard of care if something goes wrong. "Standard of care" is a legal term and can differ in different parts of the country based on resources, hospitals, specialties, etc.

Clearly from time to time I will speak about law suits and other legal issues because in medicine, especially emergency medicine the stakes are high and I practice a high risk speciality. Society expects me to be right 100% of the time and there is no margin of error. That's no different that an airline. The plane has to take off and land safely 100% of the time but in health care, hospitals do not have the same resources and financial incentives as airlines. This is a concept that the public, elected officials, and policy makers don't recognize, or refuse to recognize!

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