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I thought this article summarized up beautifully both all ups and downs of the job. What makes it so great, but also so tough at times. Reading it though, makes me proud to say I do this for a living and drives home some of things that get me up in the morning ready to face another shift.

How to be a Real Emergency Physician: An Open Letter to the Recently Graduated and the Seasoned Veteran

James Roberts, M.D.

You’ve found the bathroom, unknotted your stomach, minimized your palpitations, made your first huge mistake, saw a case you never even heard of before, missed your first intubation in years (in front of the medical students), and ordered a BMW pending spouse approval. And you so loved that 10-year-old Honda Civic.

Now it’s time to consider the magnitude of your plight: a real patient’s life or a child’s future are now squarely in your hands in a real ED. Awesome and frightening. It scared the hell out of me when I started, and it still does.

Allow me to pontificate my personal perspective. I don’t want to sound like your father or be too maudlin, corny, or holier than thou, but bear with me; I’ve been around for a while.

Any philosophy is much easier said than done, and this one is the quintessential example. A lot of what I say here is what I like to strive for personally, but I have often fallen short. I screw up about three times a week; I’m just better at hiding it than you. That also will come with experience.

Even after 42 years in the ED, I still struggle with the ideal and philosophical versus the real world. The real world is rife with serious limitations of resources and time, disappointing to incompetent colleagues, ignorant policy makers, and the unavoidable stresses of treating the sick, injured, frustrated, and downtrodden as well as the noncompliant, drugged, drunk, demanding, and overtly hostile. Keep in mind, however, that the 19-year-old with PVCs and the 43-year-old with obvious musculoskeletal chest pain truly think they are going to die. The prisoner TASERed and beaten with a cop’s nightstick or the 26-year-old single mother of five (with two screaming infants in tow) with lower abdominal pain probably does not want to be in the ED at 3 a.m. any more than you do. And maybe those two dudes actually did jump that drunk guy for no good reason.

Few will ever believe the bizarre and macabre milieu that you know as everyday life in the ED. Most of society could not begin to appreciate or fathom what you have chosen to do, most opt to ignore or disbelieve the unpleasantness and think it’s simply a really cool job. Your significant other and your parents will never understand your day at the office. (When will you get a real office like all those other doctors?) They will never understand that “It’s your turn to watch the kids,” or “Can you walk the dog in the snow because I did it four times already” is really not what you want to hear after a 12-hour shift. My wife forgets that I told her not to get that yappy dog in the first place. They muse, how hard can it really be chatting up loquacious nurses, schmoozing with those all too flirtatious medical students, and ogling those much-too-attractive drug reps? Why are drug reps all so hot, anyway, my wife always asked. The answer to that is … duh! The vomit on your shoes and the dried pus on your scrubs should send a message, but go figure.

Talking to the spray paint cans under the Kmart blue light special will often win you a free trip to the ED. The ED will always be at the end of the social, medical, and unsolvable problem funnel. It comes with the territory. You are expected to handle problems that no one else could ever solve; many would not even try. Welcome to reality; sometimes it sucks. Love-hate does not even begin to describe the ED.

Nothing should annoy or faze you, not even an impossible bipolar crack addict, the child molester with AIDS, hellacious maggot-filled bedsores, a paralyzed teenager, or a sudden infant death. You will be expected to be cool, calm, and collected, a compassionate and caring individual, a sympathetic listener to even the most annoying tales, a quintessential politician, and a role model doctor at the same time. You often perform above your comfort level and way above your level of training. News flash: No training totally equips you for this job.

Many of your patients will have no other advocate or support system. If not for you, they are toast. You are the team leader, and you should always portray a positive attitude and professional demeanor and set the tone for the entire staff. Any negative attitudes toward the hospital, paramedics, administrators, housestaff, or especially the patients are quickly transmitted to and adopted by everyone.

You are often treating the disadvantaged, poor, helpless, hopeless, and hapless in a warzone-like atmosphere. If you want a quiet ED with all the bells and whistles and a respectful, polite, sweet-smelling, cash-paying clientele in Versace, you picked the wrong hospital and probably the wrong profession. Should have been a plastic surgeon in Las Vegas.

The system is imperfect, so very, very imperfect. It always has been and always will be. The ED can be God-awful. You will never ever have enough time, resources, personnel, equipment, or backup to make this job an easy one. Deal with that reality. If you want a thank you or even a lunch break, go sell shoes at Nordstrom’s. What size? Which credit card? Now that’s a cake job. On a good day, you have a cold pizza job.

Always put the patient’s well-being and the family’s expectations first and foremost. Everyone thinks you know a lot more than you actually do, so take advantage of that secret, step up, and be the Godsend they expect and think you are.

Above all, always, always, always be nice. Remember, patients and family rarely remember exactly what you said, but they always remember exactly how you made them feel. There is only one time to make that first impression, a great opportunity to brand you as a hero and angel of mercy or a complete jerk. Be nice to the cleaning lady, security guard, cafeteria worker, and x-ray tech. Learn their names; they know yours.

Talk effusively to your patients, talk to them again, and always, always, always talk to the family. Sit down whenever possible; it says you are truly giving them the personal time and attention you would also want. That 300-pound demented nursing home patient with bedsores and a feeding tube is somebody’s mother, and maybe she was the best third grade teacher your city ever had. Last month we unknowingly treated Joe Frazier’s father, the governor’s cousin, and one of Gladys Knight’s Pips.

Many colleagues and patients need a lesson in manners and compassion. Do not argue with patients over nonissues such as a few Percocet, an x-ray, a blood test, or even admission to the hospital if it’s a close call.

Resist the ubiquitous temptation always to be right.

Don’t publicly criticize another physician or another hospital. You will develop a firm grasp of hindsight, but you are in the fishbowl every day and often talked about by name at surgery’s M&M conference. You may not know them, but the housestaff know you, and they develop a lasting impression after their first encounter. Let that overpaid prima donna surgeon look like an ass to all who witness his barrage against you, a hardworking clinician who has to make the difficult real-time decisions. Take the higher road; emergency physicians respond to a higher calling anyway.

The nurses’ station is a recording booth — with megaphones. Your vociferous opinions about anything quickly become common knowledge with a very long half-life.

Hubris should be eschewed at all times; you’re simply not that good, that smart, or that accomplished to be inflexible or pious with a colleague or a patient. Arrogance gets you into trouble more quickly than incompetence. As Clint Eastwood said, “A man’s got to know his limitations.”

Residents, nurse practitioners, and medical students can be fragile and insecure. You can give them confidence in their ability and career choice or totally shatter their self-esteem with a single thoughtless encounter in the middle of the ED. Housestaff may seem totally in control on the outside, but they are often scared stiff on the inside. It’s a fine art to learn how to critique without criticizing, to instruct without insulting, and to evaluate without emasculating. Teach them how to be a better doctor than you are. Students are expected to surpass their teachers in many talents, and maybe you were not such a good teacher after all if they do not.

There is no shame in calling a consultant for a medical problem or situation that is going poorly or if you are in over your head. Even a pediatrician probably possesses some talents that you do not. If the husband of a woman with her 100th migraine demands a CT scan and neurology consult, tell him they are already ordered, then whisper instructions to the clerk. Then let the family hear loud and clear, “Where the heck is that neurologist I paged?” It’s not your money, she won’t live long enough to statistically get cancer from the test, and just maybe she does have a bleed this time. Again, arrogance is worse than incompetence. If your patient wasn’t happy with your first plan or diagnosis, maybe it is flawed, so reconsider. Calling a consultant is a good way to share the liability.

The family can accept that a loved one will die, but when the time finally comes, it is a harsh reality, even if the patient is in hospice for comfort measures only. The children will always remember their father’s last ED encounter. Make that time as painless as possible for all concerned. Someday you will face that reality yourself, as a patient and a relative. You can’t change much at the end of one’s life, but you can listen, care, and usually do something to console the patient and family. A bed in hospice is waiting for many of us.

Be especially nice to old people; you will be one in a heartbeat. Trust me, I have already had those heartbeats. That old guy from the nursing home can’t remember what caused that 12-inch scar on his abdomen, but he just might remember the jungles of Vietnam.

Be nice to the homeless; these patients don’t need your attitude or comments about their lifestyles superimposed on their illnesses. Get them a meal tray, and don’t discharge them at 3 a.m. That sickle cell patient, alcoholic, or heroin addict would probably like to be drug-free if there were a better life for them. Usually there is not.

Having a baby at age 14 can be a normal lifestyle when your mother had you at 13. The next time you make a snide comment about the pregnant teenager with herpes or the kid who took an overdose after being dumped by his girlfriend, remember that your son or daughter may not be immune to a similar fate.

Most physicians, even family members, shy away from the mentally ill, and it’s very, very difficult to be that patient’s relative or doctor. Usually they can’t find a good friend, let alone a good physician. That’s why they are always in the ED. They actually like you, and sometimes you even seem to care and listen. Nobody wants to be psychotic; just be thankful that your serotonin and dopamine levels are under the bell curve most of the time. If you won’t help this segment of society, who will? Few will even try.

If AIDS, mental illness, teenage pregnancy, or drug or alcohol addiction have not courted you or a member of your family, you are truly blessed.

When things are the darkest, remember what Mel Herbert told you: “What you do really does matter.”

Medicine is a proud and noble profession, but it is actually just another service industry. Get used to hearing, “When are you going to wait on me?”

Everyone feels entitled to the best health care; some feel more entitled than others. No one will ever know how hard you work, and most patients don’t really care. They think you make half a million to start, confusing you with that orthopedic surgeon who graduated the same year you did. I find a patient’s rudeness, belligerence, and most importantly, ubiquitous entitled attitude the most difficult to ignore. Get over it or it will drive you nuts.

Being a doctor can be viewed as a privilege or an entitlement; choose the former. You are well compensated for your time, no one gets paid what they are worth, and although we are not NFL players, we do OK in the grand scheme of things, and are usually spared the repeated concussions.

Please don’t whine or complain. Nobody likes a high-maintenance employee, especially a highly paid professional who should be innovative and self-sufficient.

If you can find a better job, don’t tell me about it, or bargain with it; just take it. But remember that greener grass always requires more fertilizer and more weeding.

I remember some very fun times in the on-call room as an intern, but it’s best to keep your love life (and lover) out of the ED.

The schedule is sacred. Don’t miss a shift for two inches of snow. Learn how to show up on time. No one likes a replacement who is always 10 minutes late. (You know who you are.) That dead battery or behind-a-school-bus excuse only works a few times. We pay you enough to buy a new car, and find a different route to work. Here’s a novel idea: be that doctor who always shows up 10 minutes early. And getting out on time is not one of life’s sacred privileges.

Emergency medicine is a lifestyle, but there is more to life than medicine. You can never make up a missed championship soccer game, anniversary, birthday, or chance to take your son fishing. Remember that you might need a shift off one day, so be ready to help a colleague with a similar request.

In my opinion, we currently have the medical world by the tail. Set schedule, no beepers, no calls for orders, no insurance forms to fill out, and no bills to collect. Heck, we get paid even when the hospital does not collect a cent. You don’t have to fill the nursing schedule or even find a replacement for your vacation time. You clearly work hard for your paycheck, but any general practitioner or pediatrician would take your job and salary in a nanosecond. Next time you think you are underpaid and overworked, consider the GP who works 70 hours a week, calls with lab results at 7:30 in the evening, and makes less than you do. And never discuss your salary with a hospitalist!

Let’s hope Camelot lasts until retirement, but the way things are headed, I doubt it. You will be lucky if you are not making less and working harder five years from now. I suspect these days are the good old days of tomorrow.

If you plan to give expert medical testimony, start a side business, speak for a drug company, watch out for common pitfalls we all make. I have never turned down a chance to earn an honest buck, but it’s a very seductive world out there, and your reputation can sink like a stone.

Malpractice litigation is a slimy business that makes little sense. If you can rid the profession of just one bad doctor or get compensation for someone injured by blatant indifference or incompetence, go for it with gusto. We all need to support a patient wronged by neglect or injured by negligence, but many horrible cases are often bad luck and bad diseases, not bad doctors. It’s easy to second-guess a colleague with a retrospective analysis or the autopsy in hand. But you can build a home in Hawaii on what you make by using your Ivy League education, bloated CV, meaningless titles, and EM board status.

Don’t sell your soul to the plaintiff with absurd opinions and outright lies, doled out so eloquently to a clueless doctor-hating jury with a bizarre, inscrutable, or blatantly concocted definition of standard of care that you yourself would never follow. If you testify for money, and there is so, so much of it to be readily made, all of your colleagues will recognize you for what you have become. Shame on you!

Finally, be careful with alcohol and your ready access to Vicodin and Percocet. Addiction can ruin a lot of lives in a very short time, and it’s so easy to succumb.

Many of those idealistic halcyon thoughts of being a doctor, coupled with the blissful insouciance you had as a medical student, will sadly never, ever materialize. Hopefully this will help you endure a bad shift, embrace your profession, and avoid many of the same mistakes I have made over the past 42 years. Perhaps not. Maybe selling shoes at Nordstroms is not such a bad idea after all.

 

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And despite how busy it was this past month, it didn’t change one bit how I feel about this job. Judging by a few comments advising me to change fields, perhaps that hasn’t been coming across in my posting, but really, this past month has been pretty awesome. Sure there were some obnoxious patients, ones that want to make you pull your hair out (and yes, even fantasize about doing them bodily harm), but there were also plenty of kind, thoughtful patients and family members, ones that inspire you to work hard, put a smile on your face and drive you to do your best for them, both as patients and people. There was actually many times where I felt bordeline high at work, the dopamine and serotonin being released in my brain from some of these experiences was at very high levels indeed. And it wasn’t just from doing sexy adrenaline like procedure stuff either, it was from doing basic things, making a patient with the flu feel better with some fluids and tylenol, explaining to a family what was going on, helping them understand their loved one’s illness, being thanked for doing nothing more than listening.

The hospital I am working at now, is about an hour commute from where our program is centered, but I used to live out by this hospital for 4 years during medical school, so I know many of the surrounding communities, and the people that live in them.  I was caring for this patient and family who actually resided a street over from where I lived. I had never met them before, but there was that natural comradeship of people sharing a geographical location. The cue for inpatient beds was hours long, so they had spent my entire shift in the ED, waiting for one, so I would check in on them every hour or so, just to make sure everyone was alright and what not. At one point we had talked about the neighborhood, and I had mentioned how I loved the hoagies from the place that was at the end of the block. Towards the end of my 12 hours shift, the nurse came over and handed me a hoagie, from my favorite place, saying it was from the family in bed 12. Totally awesome. Made my day.

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It’s been almost a month since my last post, and that’s more a reflection of the busy holiday season, both at work and in personal life, than not having anything to write about. I in fact have a whole list of things to write about, that I jotted down over the past 4 weeks, but now as a little time has passed, the feelings I had at the time, are now faded a bit and the motivation to try to summon them up has somewhat flagged, so we’ll see what ends up getting posted.

So yes, it’s been a very busy holiday season. And it’s not just me saying that. The attendings were all complaining about it, much more so than the resident’s as honestly we don’t know better at this point in our careers. They were constantly remarking how they could never remember it being so busy, so backed up, the weekends and holidays just as bumping as the Monday afternoons. At one point, we were on divert for 4 straight days. Divert means that ambulances, unless it is something super serious and time sensitive, are supposed to take their patients to another hospital. It’s a great idea in theory, except when the entire region is on divert, then it doesn’t really mean anything. And brace yourself for the moment you come off it. Picture a scene in a zombie movie, those bloody corpses piling up against and banging on the glass doors, trying to get in. That’s what the impending flood of ambulances feels like the moment you come off divert.

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“Our Lady of Perpetual Sepsis Nursing home, this is the nursing supervisor how can I help you”

“Hi, this is Dr. ERJedi, I have a man here from your nursing home with what appears to be a 2mm paper cut on his finger. I’m just wondering if I’m missing something or if there was another reason you sent him over”

“We though we should send him over because he’s on a blood thinner and we were worried he was going to keep bleeding”

“What blood thinner is he on?”

“Tylenol”

“…”

The Devil Wears Prada

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It was about 3pm and medics brought in this guy on a stretcher, covered in sweat, all rigid and tremulous, shaking his head back and forth shouting ‘Nope nope nope, not gonna do it”.  I heard the medics telling the nurses “Yeah, his complaint is that someone put the voodoo on him and sold him to the devil”.   Mmmmm hmmm, I see.  The guy wasn’t combative per se, just resistive to treatment, not really wanting to get into the bed from the medic stretcher, in fact just kinda standing next to the bed… sorta bobbing and weaving, moving his feat back and forth, arms pumping up and down, kinda this Gangnam Style meets Techno Viking routine. In fact, as we watching his moves, waiting for security to arrive, one of the nurses started dropping a beat and shit got rather crunk for a hot minute. A B-52 and a 4 point later our hot steppa’ was all snug as a bug in bed. His brother, who had called EMS showed up and told us that when he saw him last night, he was perfectly fine and had just finished a shift at work. The guy had no past medical, never did drugs or drank, and in fact was quite religious. He told his brother he didn’t feel quite right this morning and over the course of an hour gradually went from normal to the rhythm machine that presented to the ED.  Before leaving, the brother placed an open bible underneath the patients head. How sweet.  A few hours later, our patient was awake and calm and pleasant. I sat down and had a little chat with him during a quiet moment, and learned that apparently, after his brother left he “went to the club with a woman I should have known better about”.  Ah, the devil wears stilettos! Who knew!

Looking back, I sincerely feel that if the start I had introduced myself as a doctor AND a priest, whipped off my white coat, fanned at him forcefully shouting “DEMONS BE GONE” we might have saved this guy from most of his troubles. Of course, he then would have fainted and we would have head a trauma on our hands, so maybe it wouldn’t have been such a good idea.

when asked how I’m enjoying my required pediatric rotation

I’m totally like…

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You know there has been a lot of false alarms when your rhythm strips are feeding directly into the garbage….

Had an impressive patient this week. An 82 year man came in with foot pain. On H&P, turns out he had ever running 3 miles a day, ever day of the week except Sunday, because Sunday’s are for church, since he left the army almost nearly 60 years ago… By my quick count, that’s over 55,000 miles, in other worlds, he’s circled the globe on foot twice. Not bad for 82.

When the intern, in the very first week of residency, catches wind of a code blue out on the floor, grabs an intubation kit and runs out of the unit to go tube the patient, without letting a single other person know what’s going on ….(true story!)

I’m totally like….

I’ve been on toxicology for the past month, which basically involves sitting by a phone for 8 hours a day waiting for someone to call the poison center. Got maybe 3 calls a week… super exciting. A nice break though, but it’s back to the ED in two days, so should hopefully soon have some interesting things to write about.  In the mean time, on the way to work today, the woman walking next to me suddenly belted out to no one in particular “HELL YEAH, BAKED MAC n’ CHEESE TOMORROW!” and then just kept on walking. Long live Thanksgiving.

The Beautiful People

People talk about burn out all the time in this field. I know I’m only two years into this, but I’m pretty sure it’s not the job that burns people out, its the asshole patients. Those people that are just unkind, cruel, self centered.  I fully admit, that I have positively loathed some of my patients.

“Hey there, I’m Dr. X, how can I help you?”  “Fuck you, fix my arm”  Ohhhhh kayyyy then.

But these people aren’t anything new. They exist in every ED. They suck your good will out and just pour it down the drain. But fine, whatever, I’ll deal. But everyone once in a  while…. you get that one guy….

There is this guy that comes into our hospitals about every two months. Always an overdose of his calcium channel blocker, usually a half assed suicide attempt, always goes to the ICU, gets tuned up, set up for out patient support, psychiatric follow up, never goes, comes back two months later, rinse and repeat. The thing is though, he is the most racist, sexist human being I have ever met, or even heard of for that matter. Once he comes to, wakes up, he runs his mouth constantly, spewing forth the most vile things you’ve ever heard. When I was in the unit with him one time, he had this kind, sweet nurse, one of the good ones, whom he quickly sent out of the room by calling her a “cunt nigger”.

Everybody hates this man, loathes him, wishes one of these times he would just get it right and come in as a code blue.  How horrible is that, to think that, and then having to perform life saving medicine on him. That’s what burns the docs and nurses out, that’s what eats at the fiber of your soul.  It takes 50 happy, kind, thankful patients to replace one of the scars left by these horrible people.

I wish more than anything, we didn’t have to put up with it. I’ll treat you, quite happily, but only when you act like a human being.  Fine, I’ll come back in 20 minutes and you can try telling me about your arm again. But nope, not allowed to do that, cause door to dispo times matter more.  We have to take it, to the let the patient smear all their vile feces all over our faces, while we stand there and take it. THAT’s where the burnout comes from, not from the long hours, not from the over crowding, lack of resources, or what ever other factor experts say makes us burn out.

It IS a problem though, even in residency. A poster that was presented at ACEP showed  that 50% of EM residents experience mild burnout, 25% of them have SEVERE burnout (Ironically, 50% of participants failed to respond to the follow up survey)

And deep breath. I’m not saying I am in any way burned out. Far from it. I am a little angry about it, but beyond that….well, just keep doctoring on,  and doing my best to not stab these patients in the eye with a angio cath, at least for the time being. There are days when that is a distinct possibility. And I think I’m better than most at keeping my cool. One of my other residents almost came to blows, patient telling the resident “GIRL I WILL FUCK YOU UP IF YOU DON”T GIVE ME A SCRIPT FOR PAIN MEDS” and her in response… getting right in the patients face and going all calm and quiet Clint Eastwood like…. “Go ahead, hit me, I dare you”…..    Yup, let’s just keep packin’ powder into that keg.

I’m not sure what I’m going to do about, other then just vent about it anonymously for the time being. And a good vent always helps. Ahhhh, much better.

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