The Chaos

I struggled today. As an intern that's not uncommon for me (or anyone I imagine), but today was different. There was nothing special about the day, a random wednesday on the outside but absolute chaos on the inside. Every patient room was full (some with whole families being seen), the waiting area was standing room only and there were even patients being seen in the hallways.

I remember getting oriented and listening to my program director tell the intern class that we really aren't expected to see more than one patient an hour. That's all well and good until a day like today comes along and your looking around seeing everyone from the ANAs to the attendings trying to maintain some sense of sanity in the department. I don't know if it is the competitive spirit in me or if I feel the same urge to maintain a steady flow in the department the upper levels have, but inevitably I realize I am carrying way to many patients for not only my educational benefit but, more importantly, the well-being of the patient. In this I case I've noticed I start treating the patient's chief complaint rather than being a competent emergency physician. For example, I will enter a new patient's room already overloaded with patients and say, "Hi there, I'm one of the ED residents. What's the problem today?"

"My stomach hurts, doc!"

Abdominal complaints are classic in the ED, and I especially like them because I feel a good ED physician that takes a solid history and performs a thorough physical exam will, more times than not, be able to to discern the cause of the pain: whether it is a hot appendix, a lower lobe pneumonia, a biliary process or any of the other seemingly million causes of abdominal pain The problem with days like today is that when the person is further explaining what has been going on, I'm half paying attention and half thinking about the other labs and x-rays that I have to review, and by the time I leave the room I realize the only thing I truly remember is that my new patient has belly pains. Now I could go back in and repeat the questions, but then the patient will think I'm an idiot and lose all confidence (if he had any) in me in the first place. The other option is to go back to my computer an order all the labs possible that would like determine the cause of this guys abdominal pain: CBC, basic, hepatic, lipase, amylase, urinalysis, acute abdominal series, CT, EKG, cardiac enzymes, lactic acid, the list goes on...

The good thing about this technique is if all the labs come back negative I can feel pretty good telling the patient there is nothing emergent going on and he can be sent home to follow up with his regular doctor. After all, I am an emergency physician right?

There are so many things wrong with that scenario it is difficult to know where the critiquing should begin. FIrst and foremost this is terrible patient care, and secondly I gain nothing of educational value from practicing medicine that way. I don't mean to sound self-seeking, but that is the purpose of resident, right? I guess I'll maintain hope that improved efficiency comes with time....