10 October 2008

The things you don't learn in school

Emergency Medicine is notable as much for its drama as for the pedestrian and mundane things that come through the door. Every time I meet someone new and tell them what I do for a living, I always get the "Is it as exciting as it is on TV?" question, or some variant.

Truth is, of course not. Headaches, abdominal pain, weak & dizzy, etc account for a substantial majority of our cases. In fact, the critical care stuff is generally less than 10% of what we do. Now sure, if I see 16 patients per shift, then yes, I do perform critical care daily. But it turns out that the simplest cases can be the most challenging.

You see, in residency, there's a lot of focus on critical care. I spent months working in the cardiac ICU, the medical ICU, the pediatric ICU, the surgical ICU, the burn ICU, the OR, anesthesia, and on the floors. I could line, intubate, and resuscitate in my sleep (and did, on a few notable occasions). I could recite the Killip classifications for MI and knew the DeBakey versus the Stanford classifications for aortic dissections. So I was well prepared and very comfortable with caring for severely ill and unstable patients, which is an important qualification for the job. Internal medicine also was highly emphasized: complex physiology, the key things not to miss in chest pain, electrolyte management, etc.

All this prepared me very poorly for some of the more mundane elements of my practice in "the real world." Stuff you might call "family medicine," though I don't know if that's the right phrase. For example, I remember the first time I saw a new mother bring in her week-old infant who was vomiting blood. Holy crap but I was scared. I knew all about GI bleeds -- in adults -- and vomiting blood was really bad. I didn't think kids even got GI bleeds. I was wracking my brain over it, wondering if the baby had some sort of vascular malformation in the stomach, and the nurse just stared at me when I told her to put in an IV and draw blood. "Why would you want to do that?" she asked, "It's just maternal blood."
"Huh?" I stammered, "How do you know that?"
"The mom is breastfeeding. Her nipples are cracked and they bleed when the baby feeds. Happens all the time."
"Oh." I went and examined the mom, and found that the nurse was right.

Or caring for the umbilical stumps of a newborn. (You'd be surprised how often new parents freak out and come in for this concern, that the stump is "infected" or bleeding.) Or the first time I saw scarlet fever. Elevating an ingrown toenail. Hand eczema. These and a thousand other quotidian maladies are the things that the textbooks cover briefly if at all, and that you will probably not see in residency at the high-powered trauma center. So you feel profoundly stupid when you go out to the community as the cocksure new guy from The Big Hospital and are stopped dead in your tracks by the simplest little thing.

If you're lucky, you may have a partner or an experienced nurse to point you in the right direction. Otherwise, you're left to figure it out on your own. The good thing is that knowledge learned that way is precious and you tend to retain it well. I've been doing this for a decade or so now, and I finally have enough experience under my belt that I now very rarely get that feeling of "Oh shit," when I see some minor but completely unfamiliar process. I won't say I've seen it all, because I have not, but I've seen the commoner stuff enough to be familiar with it. And now I get to be a resource for our new partners going through that same learning curve.

I love the variety and challenges this job presents. Still hasn't gotten old.


  1. I'm a Family Medicine Resident and I had no idea about the vomiting blood in newborns. Ironically, I read your post while breastfeeding. You learn somethingnew everyday! PS I'm a big fan - you make 3 am feedings easier!

  2. I also didn't know about the one about the blood from the vagina (maternal hormones)in newborns when I first started.


  3. I think the hardest thing for me - a non-medical person sort of "thrust" into a quasi-medical position - was learning how to figure out who is really sick. Thank god, I seem to have a knack for it. A sixth sense. (Wish I could mention it on my nursing school application.) Working totally front-end, I was the first person that they saw. Literally. Or second if you ignore security.

    I think the worst of it for me was not speaking Spanish. One night, we had a guy come in. He was limping but there wasn't a lot of blood beyond the little bit that had stained his jeans. It was balls to the walls that night, so I sat him down. Guy started chatting with another Hispanic family next to him. I kept an eye on both and, about ten minutes into it, I realized that the guy had been shot.

    Of course, there's no ER-esque scene where the patient is rushed in. He didn't appear to be in a lot of pain. He wasn't bleeding profusely. Hell - I LOOKED at his (clothed) leg and couldn't see any sort of tears or rips to his jeans.

    Gunshot = obvious? not so much!

  4. Second thing was the fucking dead baby. Mom rushes in with an obvious dead baby in her arms. He's blue/purple and mottled. But you still take him in your arms and rush him to the back and they still code him for a good thirty minutes. Most likely a SIDS death (I had a baby brother who died of SIDS when I was four.) But how do you deal with that? Mom wanted to go back, be with baby as they coded him, but she wasn't allowed. NOBODY comes out for a good 45 minutes, leaving me with this lady who barely speaks English. The early-morning birds are starting to flock in, keeping me tied up.

    Everything just sucks. :/

  5. All those "non-emergency" cases -- the rashes and toenails and umbilical stumps -- are the ones that in an ideal system (ie, one where folks like me make enough money to stay in practice) ought to be booted out without being seen. EMTALA violation? Nope; I've read the legislation and the regs. All you have to do is ascertain that no emergency exists and you are free to tell them to hit the streets. You guys do an awful lot of whining about stuff you don't really have to do.

  6. Hey Dinosour,

    I don't really see SF shining in the post at all. Quite the opposite. The patient likely doesn't have insurance anyway so you wouldn't see them in your clinic anyway. Plus, it was probably 2 am, again, not going to be seen in your office.

    Yes, if no EMC exists then you could be an ass and stop the encounter right there, but you already had to see them so it only takes a few more seconds to print out some discharge instructions and send a bill that won't be paid. Administration doesn't want complaint letters, doesn't want CMS, JCAHO sniffing around, doesn't want bad press

  7. Ok, then.
    If a trained medical professional can mistake a begnin ailment for a major illness, how are WE, the polulace, supposed to know when it is OK to go to the Er or not? We see blood, we rush. I know it's basic, but that's all we know, so don't hold it against us when we show up for no apparent valid reason. ;-)

  8. ad I put my name on the post above and it did not show... Sorry!

  9. Anonymous 12:37 AM,

    In compliance with EMTALA, you screen the patient for an emergency condition, find no emergency condition, and explain to the patient that they need to get that taken care of in the proper place, you are a jerk?

    If you screen for an emergency condition, find no emergency condition, but decide to treat them there, delaying treatment of appropriate emergencies, you are a mensch? This is encouraging abuse of the system.

    If people learn that their non-emergencies will not be treated emergently in the ED, maybe they will not feel it is worthwhile to sit in the waiting room to be seen. Maybe emergency physicians will be better able to focus on the truly sick. Maybe nurses will be better able to address the care of those who need emergency care, rather than diversifying into social services duties.

    We certainly need a better educated public, when it comes to decisions about appropriate ED use. Avoiding education, in order to empower the abusers, is the problem.

  10. When my wife had our son, we had a 1 hour class (provided by hospital) after the birth on how to feed him, change the diaper, swaddle him, how to ID jaundice, etc. I don't remember them mentioning anything about maternal blood. This should be added to the post-birth class.

    And every new parent (especially for their first child) should have a post-birth class. It's only 1 hour.


    Yough talk, but obviously you have no clue to EM practice. What you say could be true and could be done but you would lose your job within a week

  12. Anonymous,

    Are you claiming that where you are, the administrators would never allow this?

    Or are you claiming that nobody anywhere would allow this?

    I am stating that this is how it should be done. Pandering to the most whiny is wrong.

  13. RM,


    Adminstrators everywhere don't want complaints. Don't want hassles. Don't want CMS, JCAHO, plaintiff attorneys, the press sniffing around.

    It's not right, just the what it has evolved to

  14. anon:
    Rogue Medic is just that A MEDIC. Nothing wrong with that, but the fact is the buck (and complaints) don't stop with him.

  15. Anonymous,

    I don't really know if this is just one anonymous post, but I'll combine my answers.

    It is true that I am not a doctor. I did not mean to suggest to anyone that I am.

    "It's not right, just what it has evolved to"

    It seems that you are not so much claiming that it is bad medicine, just impractical with the way administrators handle things.

    I hope that you are wrong or that things change. This seems to me, just a medic, to be less the practice of medicine, than the practice of politics.

    The rogue part of my name should suggest that I am not good with things that are done purely for political reasons. :-)

  16. RM,

    I am the anon you called a jerk and mensch. I am neither, nor am I wrong. You could go to medical school, residency and become an ER doc. You could land a nice job and plant yourself at triage and tell half the patients at a glance to get the f*** out and chart "MSE completed". It would be a curious experiment to see whether you got fired first or killed someone first. So go for it if you want.

    And it is not necessarily bad medicine. I had to see them. Often I am the only one who would see them, so then I treat them the best I can under the circumstances knowing that they probably didn't need to see me. However I would rather be more sensitive (recognizing the potential for disease) than trying to be so specific (intense focus on ruling out and dismissing an important disease process and risk committing the error of missing it). The buck stops with me. I don't need to fill my time with more depositions and complaint letters than I have to.


  17. JD,

    I never suggested that you not examine the patient, but just glance at them, so why do you suggest that I did?

    Or should I read this differently? "You could land a nice job and plant yourself at triage and tell half the patients at a glance to get the f*** out and chart 'MSE completed'."

    I am not suggesting that you should not examine patients. That would be irresponsible and stupid.

    I was not calling you either a mensch or a jerk. I was using two examples of patient care, with a question mark after them to show that I was asking a question each time.

    I do not believe that the physician, who screens the patient, finds nothing, and educates the patient about the use of the ED is a jerk. Contrariwise, I do not think that turning the ED into the local clinic is what makes someone a mensch.

    If you cannot recognize who is safe to be discharged, you will have to admit everyone and have someone else accept responsibility for discharging your patients.

    The difficult decisions are the borderline patients. Still, at some point, you make the decision that this patient does not need emergency treatment and you discharge them or you admit them.

    If you have enough information to make this decision (that the patient does not need emergency treatment) at the initial screening, is it wrong to do that? You certainly do make the decision at the initial screening that you will be admitting some patients.

    I am not referring to the questionable patients. That would be an entirely different topic (one I did not bring up).

    I have no desire to be a doctor.

  18. RM,

    We are very close on a theoretical level. Apparently, you can't grasp the reality so we are done here.



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