I work in a busy, medium sized emergency department. Because we’re busy, and because of the ridiculous burden imposed by EMTALA, lots of consultants don’t really want to come to the emergency department.

Can’t say I blame them, really. It’s often a thankless job, thanks in no small part to our legislators who made sure everyone has access to health-care, but conveniently forgot to pay the people who are doing the hard work and actually seeing the sick, dying, wounded, drunk, angry and annoying.

If I were in another specialty, I’d honestly consider going off the call schedule, opening a surgery center or any of the other options docs do to avoid hospital affiliation and EMTALA-mandated work.

However, we’re still stuck with the problem until we all unite together and insist on it being changed.  For now, people still come to the hospital and need care, need studies, need specialists.  For now, I have to sort through it all.

Which brings me to the point of this post.   A few nights ago I cared for a small child with abdominal pain and fever that began about 12 hours prior to arrival.  He had no vomiting or diarrhea, no cold symptoms, no urinary symptoms.  His knees were drawn up, and he was lying on his right side.  He was quite tender to exam, and showed guarding.  One year ago, he had an appendectomy.  One less thing to worry about.
His CT abdomen and pelvis, with contrast, was essentially negative.  His CBC, urine and electrolytes were normal.  I called the on-call surgeon and described the child and studies.  He told me that it sounded viral.  I admit, I hadn’t re-examined the child at that point.  I asked, and probably with the wrong tone, ‘So are you telling me that nothing bad can be wrong with this child?’  My surgeon friend became annoyed with me (not with the patient), and came to the department to do an evaluation.
What followed was a back-hall argument that turned out to be a little too loud.  I felt badly and apologized, and so did he.  But I tried to point out that in the emergency department, we are often faced with a conundrum:

Sick patient, worrisome exam, negative studies.

So, what do we do?  Now, I’m throwing this out to everyone, ER doc, FP, Internist, Hospitalist, Surgeon and all.  I’m not being sarcastic; I want to know.  Have we reached a place in medicine where the science of labs and imagining is sufficient to rule out dangerous etiologies without exam?  Have we reached a place where history and physical exam are simply vestiges of the old days of medicine?

I’m not a researcher, but many of you are.  Please give me your thoughts on this.  I don’t want to argue with anyone, and I don’t want to miss a diagnosis.  I also don’t want to cause already over-burdened specialists to have to come to the hospital when they needn’t.  But sometimes, frankly, I want another pair of eyes, another set of hands, another brain admittedly sharper than my own, to help make a decision.

And I’m just not sure the scanner qualifies.

What do you think?  If I’m all wet, if I need to quit my belly-aching and stop worrying, I need to know.

Let me have it!  And please forward this to other docs in other specialties as well.  Because it applies to cardiology, ENT, pediatrics, anyone who relies on any kind of lab-work or imaging.

Have a great day!


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