At the Still Point of the Turning World
Residency is over, NOW what? (While I'm waiting for the answer, I'll get some spinning done....)

Wednesday, May 14, 2003

THIS MINOR NUISANCE CALLED WORK


A few days ago, Deb asked what working in the ER is really like. My view is biased by the fact that I don't spend the majority of my time down there (phew!), and so I tend to associate the ER with really sick people who need to be admitted to the hospital. This makes it hard for me to spend much time down there on this rotation, because I'm constantly reminded of every bad call night I've ever lived through. Sigh.

First, it's important to understand that our hospital is not a trauma center, so we don't see as many seriously-injured people as they do on the television show. Every so often, someone will arrive who is so gravely wounded that they cannot be moved by air transport to a trauma center. We have an overhead public announcement system, so the arrival of these patients is heralded by "BEEEEEEEEEP! Cardiopulmonary, radiology and laboratory to the ER stat!". Hearing this tends to make all the residents feel edgy. If you go down to the ER when they're working on one of these patients, the scene resembles the television show, except quieter. The trauma bed is located near the nurse's station and a straight-shot from the ambulance bay. We do not steer seriously-wonded patients down several winding hallways to arrive at the trauma bed, as they seem to do all the time on TV. There's something seriously wrong with the layout of that hospital, if you ask me. Our trauma bed is located right across from the nurse's station, so the staff don't have to yell orders out the door like they do on TV. The interventions we make for a gravely injured patient are similar to those on TV, except that we do not perform as many emergency thoracotomies (i.e. "cracking chests") as they do. On TV, it seems that they have to crack open a chest on a daily basis, when the fact is that this heroic measure, to provide internal cardiac massage, is rarely used. The bleeding from the procedure is considerable, and even if a patient were to survive, the recovery would be horrendous.

Like the TV show, our ER is the safety net for a large population. The majority of visits are for sick kids, fractures, jail checks (did you know that if you get arrested, your first stop is the hospital to make sure you're not contagious or have gaping open wounds?), and a huge category of visits that can only be described as owing to human fallability. People who've had too much to drink, run out of their essential medications, or feel overwhelmed by the stress of life and come into the ER complaining of chest pain, palpitations, inability to breathe, or pain. Taking care of these patients in the ER is not exciting or amusing, as it seems to be on the show, but routine. You examine the child, tell the parents she has a viral infection and should get better on her own. You write the prescription for the blood pressure medication and, if you're me, give the patient some hints about how to get on the county program so that these medications will be paid for. You order a few lab tests and wait hours for the results, while the patient sleeps off the alcohol or gets antsy because the wait is too long. On the TV show, the doctors and nurses often get personally involved with the social problems of their patients, going to a patient's home to make sure they're all right, or having passionate conversations with the Powers That Be on their behalf. In real life, this almost never happens. The only people who call social workers down to the ER are the residents, who are trying to deflect admissions by finding homeless people a place to stay.

Is this a sad commentary on the state of medicine? Not really. The emergency room was never intended to be the place where people find lasting solutions to their problems, was it? That's why it's not called the Salvation Room.

Finally, the biggest difference between real life and the TV show is the medical management of the patient. I once watched an episode of ER in which a man came in with respiratory failure, got intubated, had lines placed, received chest compressions, and then was taken care of by the ER doctors until he got extubated and was talking to them. Only when he was making normal conversation was he transferred to the ICU. I remember thinking, "I want to work in that hospital, 'cause they do all the work!" In real life, once the patient is stabilized, the ER docs starting calling residents to get the patient out of the emergency room. They do not assume management of the patient's medical problems for days on end, as they seem to do on the show. This is why call nights are so busy for residents. If the ER actually managed the patients, we'd sleep all night.

That's about all I have to say about ER life. If I have any major epiphanies about the subject, I'll let you know.

A Postcript: BAM Update

Yesterday, I attended a meeting that lasted all day. It was a quarterly state-of-the-residency meeting, and painful does not begin to describe the experience. I did not work on a sock (pity, because I probably could have finished one in that time), but got 15 rows of Alka done, almost a whole pattern repeat on almost 450 stitches. Not bad.

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