It’s a problem I’ve written about in the past.  Why is emergency medicine the place where so many good docs flame out and leave clinical practice?  Why is it the specialty the seems to last about 10 years, after which all too many physicians have to find another path?

It came home to me when my partner asked, after a shift, ‘why do I feel so tired?  I only saw about 16 people.  I feel like I was much busier than that!’

I theorized:  because we’re older, because we’re busier, because we aren’t resting as well as we once did.   But those are superficial answers.

It’s harder because America’s emergency departments are the un-edited, un-regulated, all hours, all comers, all illnesses focal points of modern health-care.  So many of those desiring all access reform have never struggled through 30 patients overnight, or argued for hours with drug abusers or consultants. 

Emergency medicine, as a specialty, is frustrating for lots of reasons.  Americans are living longer and surviving difficult diseases.  So, they need more emergency care.  Americans are more ‘medicalized’ than ever, so each and every illness or injury brings them, right or wrong, to an emergency department. 

Other doctors are keeping patients at arms length, as well, and that fills up the old ER.  Had surgery yesterday, have pain, and called your surgeon?  ‘Better go to the ER.’  Have heart disease with 5 stints, impending renal failure and poorly controlled diabetes, and feel worse today?  Called your nephrologist or internest or cardiologist?  ‘Better go to the ER.’  Sick child with a fever?  Called the nurse practitioner?  ‘Better go to the ER.’ 

Out of the Oxycontin you’ve been taking and selling?  Go to the ER. Arrested and need to avoid jail a while?  Have chest pain and go to the ER.  Upset with your teenage baby-daddy or baby-mama?  Go to the ER, please.  Think you might be pregnant?  Go to the ER.

And in the ER, we’re told not to 1) undertreat pain or 2) overtreat pain.  Don’t make anyone sick wait too long, but remember, even the non-sick are ‘customers.’  Hurry them back as well.  No one should have to sit in a waiting room.  And don’t miss anything bad, despite the fact that we evaluate complaints of chest pain all day, every day, from age 15 to 105 years old! 

The job is hard because we’ve become the eternal residents for every specialty, the federally compelled drug dealers for a generation of addicts (thanks JCAHO for the pain-scale mandates), the default psychiatrists, surgeons, ENT’s and pediatricians when those docs don’t feel like coming to the hospital to evaluate nasty ‘ER’ patients. 

The job is hard because amidst all of it is the needle.  The needle in the haystack.  It’s long and sharp.  It’s rusty.  It’s covered in tetanus and anthrax.  It’s lying beneath the enormous haystack of everyone else expectations.  Ultimately, someone always steps on it.

The job is hard because, try as we might, we’re too busy sifting through the hay to find that dang needle and deal with it.

That reality, that uncontrollable, un-modifiable, unrelenting reality is what makes me write this, and wonder how we actually do it every day and make it work.  It’s nothing short of miraculous, I would say.

But that’s just me. 

Edwin

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