Rotating on cardiology, I've had the opportunity to see some of the, ahem, differences in how we approach patients. It was accentuated this morning when my staff said, 'your notes are so ER', which I took as a compliment--she said that because my entire written plan in the daily progress note was 'pt to CABG tomorrow'. I hadn't commented that we were replacing the potassium at the low end of normal, keeping the patient on a cardiac diet, monitoring the patient on telemetry, and so on. I just wanted to say what was happening and how they were leaving. Well, what more is really needed?
Although EM grew from medicine or surgery based on which hospital was covering the ED in the sixties and seventies, I would argue that we are now our own full-grown speciality. We're hyper and have the attention span of a caffeinated meerkat compared to the other services, we're the only ones to seriously consider things like toxicology, we think about disposition like no one else, but the real, real difference is one of mindset, and it all goes back to the teaching I got as a 4th year medical student.
My attending said, what do you think is happening, and, at the same time, what are you doing? You're in the ED, buddy, dispo is everything, and you can't sit there and scratch your head forever. 18 in the waiting room, let's go.
We 'diagnose' our patients, although that's a loose term and really an ED diagnosis is more like, are you going to die a) 5 minutes ago b) in the next 5 minutes c) maybe in the next few hours d) in the next 30 days or e) someday, but I don't know when and I bet you'll see another doctor before you do therefore relieving my liability.
If the answer is a or b, then we're at our best, and we DO diagnose to the extent of determining the pathophysiology of the shock present and the subtypes of life-threatening presentations we see, including poly-terrible situations like the 85 year old who either had a heart attack and hit a tree or hit a tree and had a heart attack.
If the answer is c or d, then our 'diagnosis' is not really a diagnosis but rather risk stratification for really bad things that might lead you to be in category a or b. Yes you have chest pain and it might be mantle-cell lymphoma (which if I weren't on a medicine service I wouldn't even know was a disease) but really what I care about is how likely are you to die soon? This is really, really tough and I'm still learning it. It's hard. And it always presents patients that don't fit the mold.
Medicine, god love them, and by that I mean internal medicine, is a vital adjunct to Emergency Medicine. They take all the patients in category c and d that we risk stratify to scary or at least a little bit scary and then they do something called rounding, which involves terribly long and inexorable walking conversations about patients to agonizing detail. They address changes of less than 5% in electrolyte levels over the course of days; they draw crazy tests like trans-thyretin antibodies, ceruloplasmin levels, anti-double stranded DNA antibody tests, dexamethasone supression tests, and so on and on. They get really excited by complicated patients with multi-system disease that affects multiple organ systems and they love the unifying diagnosis that ties all of this together.
This drives me bonkers. I can't concentrate. I pray for lines and codes and then feel bad because that means patients are sick. I go talk to the crazy withdrawing person because it reminds me of the ED.
A discussion the other day epitomized this divide. I wanted to start our sarcoid patient on steroids because we knew she had sarcoid and probably she had cardiac and GI sarcoid and she felt sick, so why not give her steroids and see if she feels better? What am I doing for this patient?
The med resident, who's very good, was all, we don't know for sure that it's cardiac sarcoid.
Well, what are we treating then?
Um, sick person? Hope she feels better?
But that's undisciplined, she meant to say; that's untidy, that's not targeted therapy.
I love them because I admit to them. I'll stick to my version of diagnosis, though. Not sure what the point of this post was, other than to say, we all have a place, and the best way is to figure out how we complement each other.