I appreciate the need for physicians and others to sleep.  I’ve spent a great deal of my career awake in the wee hours.  In some very real ways, emergency medicine as a specialty exists as a shield between patients and their sleeping (or otherwise engaged) physicians.  But I fear we’re all wearing a little thin.  Because the emergency room has become an all hours clinic, and increasing numbers of other physicians simply won’t be bothered at night.  Sometimes they take themselves off of the call rotation.  Other times, they simply make it obvious that the ER needs to deal with it.  My friend Doug is fond of saying ’emergency medicine is the residency that never ends.’  That is, some other doctor is always telling us what to do for them.

Also, in an era of increased medicalization, a populace under-educated on health and the human body simply panics at the slightest event.  I’m sympathetic.  There are lots of unknowns in life, and if I weren’t educated I’d panic sometimes too.  (Heck, I still over-diagnose myself all the time and I’m wrong 98% of the time.)  My wife has said that she doesn’t know how moms do it when they aren’t married to physicians!  Nevertheless, better education in high school is certainly in order.  This ‘overmedicalization and undereducation’ leaves us addressing life-issues more than medical emergencies.  But hospitals are fine with that, since administrations seem to view every customer as a bill about to be paid.  Which in fact is often untrue, but I digress.

Back to the point.  I’ve worked in Tiny Rural Hospital in several states.  I’m an advocate for the Tiny Rural Hospitals of the world.  But after hours it’s a strange time.  Patient’s physicians try their best not to see the patient 1) on admission, since the ER doctor already did and was compelled under by-laws to write orders and 2) during the night because, well, it’s night.  In many locales, the ER doc is tasked with seeing, working-up and stabilizing the patient, then calling the admitting doctor to tell the story, getting approval for admission, then writing the admitting orders.  The admitting physician will pick it up from there. But not always. Often, the nurses still call the ER doctor for clarification.  Wouldn’t want to wake up the admitting doctor after all. ‘He get’s grumpy when we call,’ I’m often told.  Obviously, this is different in facilities with active hospitalist programs, those work-horses of the modern hospital.  God bless ’em.

In addition, most folks don’t realize that many services taken for granted in the past aren’t available at even large institutions at night.  But even less so in small ones.  Obtaining an after-hours ultrasound in a small hospital can be a nightmare.  The techs simply won’t come in.  Sometimes they will for select cases, ruling out tubal pregnancies or ovarian/testicular torsion (twisting) which can be surgical emergencies.  But in a few locales, it’s simply ‘transfer the patient.’  I worked in a charming little hospital where the ultrasound tech was a very nice, very competent man who simply never learned to do any OB/Gyn studies.  ‘I just never was trained to do it.’  And he remains so.  Thus, women in need of formal obstetric or gynecologic ultrasounds at night had to be transferred.

Frequently, simple radiology interpretation services are not performed after 5 or 6 pm unless specifically requested.  CT and MR images are read remotely, of course.  But plain x-rays?  Not so much.  Of course, and it’s a pet peeve of mine, they still bill an emergency reading fee in the morning. By then I’ve already acted on what I saw.  It’s just how things are.

The American populace doesn’t realize that many hospitals don’t have much specialty access.  General surgeons are usually available, but not always.  Orthopedic surgeons are sometimes available, but frequently are not.  (Just transfer him!)  ENT surgeons are a rarity.  Gastroenterologists and cardiologists are luxuries.  Ophthalmologists, neurologists and psychiatrists?  A miracle.  In fact, I worked in a very busy hospital that had no pediatricians on call most nights.  (Pediatricians!)

The American hospital as we know it is in peril.  Some of these folks made themselves unavailable for good reasons.  They were overworked, underpaid and reacted to changes in billing and by-laws by voting with their feet.  Others, I don’t get.  Sometimes I think it’s simply sloth, or a lack of genuine concern for the community.  Other times I understand that it’s sheer exhaustion.

The sum total, though, is that specialist or not, ancillary services or not, the ER is open and the physicians and nurses who work there have to deal with the same complex situations, but without much back up.  Even when back-up exists, doctors don’t come in like they did in years past.  If there’s no procedure to be done, the specialist says ‘call the hospitalist to admit them.’  Or says, ‘I don’t admit.’  I remember telling a cardiologist, ‘I’m concerned about this patient.  You want to swing by and see him?’  ‘No, not really,’ was the reply.  End of discussion.

The hospital after hours is increasingly a barren, lonely place, offering less and less care for more and more money.

I don’t know the answer.  But I know that my colleagues and I, emergency physicians and hospitalists and hard-working nurses, will still be stuck holding the check at the end of the night.

And in the morning, will always be held accountable when things didn’t end well in the lonely watches of the still dangerous night.

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