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» Death by a Million Small Frustrations and a Dozen Night Shifts.

Death by a Million Small Frustrations and a Dozen Night Shifts.

If it is possible to die from a million paper cuts then the Emergency Department is where it’s going to happen. This is literally true considering MRSA and figuratively true considering the mounting obligations piled upon emergency professionals.

Every 2-3 years I feel like I hit a new plateau in Emergency Medicine. During residency I became confident that if I paid enough attention I wouldn’t kill anybody, and I would save most patients it was at all possible to save. After residency the expectations persistently increase like a sadistic, real-life, video game. Not only do I have to save lives, and not kill anybody, but I have to do it faster and faster or the waiting room becomes stacked with more and more patients while tho odds of one of them dying while waiting to see me keeps going up.

I think I finally mastered that one by discovering the ED “flip”. The ED flip is when you no longer perform a complete evaluation on patients before you write orders. You review vitals, read the triage note, eyeball the patient (to make sure the don’t look like death worn over), write orders, say hello, control their pain and then complete the evaluation when everything is back. This turns a fishing expedition requiring 15-30 minutes of my time into a 5-10 minute visit supplemented by a cheat sheet that can often tell me the diagnosis before I see the patient. At that point I no longer need to hunt for the diagnosis, I must simply make sure it fits, and that there are no other big red flags. If I know he has rip roaring pancreatitis before I even walk in the room, I don’t bother worrying if he has vomiting or diarrhea, if he’s dehydrated he gets treated. It doesn’t matter if his pain is burning or pressure like, or if his father had colon cancer. I still ask and note these things, but they no longer have the same level of influence on my assessment or decisions.

Just when i thought I had that one down, then i was told, well you could make more money doing all that if you make sure to document everything you do in a way that insurance and government will pay for. Now I must make sure I use key phrases like interpreted by me, critical care time, HPI and Review of systems not possible due to the severity of the medical condition, etc.

OK 12 years after I decided the ED was my calling I think I’ve got it down. I’m not killing anybody, I’m saving the ones that can be saved, I’m jetting through the department at what feels like a solid pace, and I’m getting paid for what I do because I learned how to speak ‘insurancese’. What’s next some might ask… Now I must continue to all of the above, but also make sure the patients still like me and the department enough to rate us as very good (a five) on every aspect of their care even if they wait 4 hours to see me, even if their blood gets lost between the ED and the lab, even if their ED neighbor is screaming obscenities for all 4 hours and smells really bad. Now I must include PR work on the highest tiers of my priority list, even if I feel like jumping out the window myself at the time. Fortuntely ED’s are always on the first floor!

This is just the latest challenge in the real-life video game-esque world of Emergency Medicine. I may be able to get that high score if I can just keep smiling and be the cheerleader in the department and not let anything slip through the cracks and do it really fast and make my patients feel good without hooking them on narcotics. All the while my ability to care for patients is completely dependent on every system in the hospital operating with a decent level of efficiency.

So, where does that leave me: Despite a circadian rhythm constantly disrupted by poorly predictable eating and sleeping cycles I must not kill anyone, I must save everyone that can be saved, I must do it quickly and efficiently, I must suppress my own frustration and keep smiling when Lab, X-ray, Consultants, Nurses, or anyone else I depend upon falls off-line, and I must console patients enough to earn 5’s for myself and the hospital by acknowledging their frustration, but at the same time not blame my hospital or group or colleagues. No problem, but do I also need to stay off the crack pipe that everyone else must be smoking?

131 Responses to “Death by a Million Small Frustrations and a Dozen Night Shifts.”

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