The Costly Complications of Emergency Medical Care

During one Emergency Department (ED) shift, EMTs brought in an older woman to the hospital. She had called emergency medical services (EMS) and explained that she had low blood
sugar, or hypoglycemia. Hypoglycemia can lead to
coma, brain damage, and death as well as other more minor symptoms such as tremors and sweats. But when the EMTs arrived to pick this woman up, her blood sugar levels were normal — there was no emergency at all. In fact, as she admitted once she was in the back of the ambulance, she only called EMS because she had run out of glucose strips, which diabetic patients use to monitor their blood
sugar. A family medicine doctor can easily procure these for a patient, and running out of these strips in no way constitutes a medical emergency. Once this
woman got to the ED, the physicians drew her blood for labs, examined her, and measured her blood sugar again in order to make sure there was no emergency.

In another instance of misused resources, a middle-aged gentleman called an ambulance because, supposedly, he could not walk. However, the patient was able to get himself up from the stretcher and climb onto the ambulance, which his daughter said was normal behavior for him. He received a full workup in the ED with labs and x-rays. Similarly, a mother brought her son into the ED because he needed a full physical before playing sports. The ED physicians spent time speaking to the patient, doing a physical exam and drawing basic labs to look at his blood.

These kinds of situations occur daily — we squander emergency medical resources on non-acute medical conditions. Sadly, emergency physicians and EMTs do not have a choice in the matter, which can be disheartening in a system where resources are precious. And while there are many factors affecting inefficient emergency medical care, we have a law to blame for at least some of the daily inefficiencies — EMTALA (the Emergency Medical Treatment and Labor Act).

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Congress passed EMTALA in 1986 with Ronald Reagan’s signature, ensuring, among other things, that patients requesting emergency medical care receive it regardless of their ability to pay. In a 2001 article published in the Baylor University Medical Center Proceedings journal, Dr. Joseph Zibulewsky puts the law in perspective. In 1986 and 1987, case studies from Cook County Hospital in Chicago described how other hospitals transferred patients to Cook County because the patients could not pay for their care, a practice known as “patient dumping.” The studies concluded, as Dr. Zibulewsky writes, that “this practice was done primarily for financial reasons.” In fact, “the reason given for the transfer by the sending institution was lack of insurance in 87% of the cases.” Moreover, the patients who were transferred were twice as likely to die as those who were not transferred. Nor were these isolated events: “This practice was not limited to Chicago but occurred in most large cities with public hospitals. In Dallas, such transfers increased from 70 per month in 1982 to more than 200 per month in 1983.” As a result of widespread patient dumping, EMTALA was signed into law.

EMTALA consists of three basic tenets all of which must be followed regardless of a patient’s insurance or financial status. First, any person who presents
to the hospital for medical care must receive a medical screening examination (MSE) to ensure that there is no emergency medical problem. As the law reads:

if any individual (whether or not eligible for benefits under this subchapter) comes to the
emergency department and a request is made on the individual’s behalf for examination or treatment for a medical condition, the hospital must provide for
an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available
to the emergency department, to determine whether or not an emergency medical condition…exists.

As the examples at the beginning of this post illustrate, no matter what a patient comes in with, an emergency medical condition must be ruled out, so a medical workup must be performed. Additionally, the ED must “provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility.” In other words, the patient’s condition must be stabilized before discharge. If the hospital is not equipped to care for a particular medical condition, the hospital must transfer the patient to another hospital capable of providing the needed care.

And all this does not just apply to ED physicians. Any specialist consulted by the ED (in fields like neurology or psychiatry) must see the patient within 30 to 60 minutes of being called. EMTs are also beholden to
this law. As Zibulewsky explains, an “appeals ruling in Hawaii has extended this [EMTALA] to virtually any ambulance, even those run by city or county services.”

Thus, once a patient is in an ambulance, he or she “can be considered to have come to the ED.”

Image via Shutterstock

Hospitals and physicians face stiff consequences for failing to abide by EMTALA. The law applies only to those hospitals and physicians who
participate in Medicare, which nearly all of them do. And if the
hospital violates EMTALA, reimbursements can be taken away. On an individual level, physicians can be responsible for up to $50,000 in civil court if they violate the law. Given how many
hospitals and doctors receive reimbursements from Medicare and how much money hospitals receive from Medicare (hundreds of
billions of dollars), it behooves institutions to follow EMTALA as best they can.

Unfortunately, the law is incredibly problematic for many reasons. In the first place, vagueness abounds: what counts as a medical screening examination? Is it just a physical exam? Is it just a history of the patient’s present illness? Must a CT scan be included? This is completely nebulous. Also, what counts as stabilized? If a person is bleeding to death with a broken leg and a physician stops the bleeding and casts the leg, can the patient be discharged without a follow-up appointment with a physician? If the trauma has left someone severely debilitated and is surviving only on a ventilator, is it now the hospital’s responsibility to find an acute care nursing home and continuous care for this patient? Does the hospital keep the patient in the ICU and eat the cost indefinitely?

Furthermore, the law adds population burden and financial cost to a floundering medical system. A 2008 article by Dr. Damon Dietrich and Dr. Michael Crapanzano concluded that while “EMTALA was intended to provide all patients the right of medical care in the ED regardless of ability to pay, a cost: benefit analysis performed by Duke University…suggests it did just the opposite.” Moreover, “EMTALA actually impedes access for an EMC [emergency medical condition] by overwhelming resource capacity.” Many people who come to the ED actually need emergency medical care, not just glucose strips. And putting time and resources into non-emergency care takes away resources and time from emergency care. Also, because care is “free” in the ED, patients have no qualms about coming in whether their problems are or are not acute. In turn, this leads to overcrowding. Some statistics, though not proven to be a direct consequence of EMTALA, demonstrate the severity of the problem. In 2001, “two out of every three hospitals reported diverting ambulances to other hospitals” due to ED overcrowding. Additionally, “ED visits in 2003 rose to 114 million, up from 97 million in 1997.” This overcrowding with uninsured patients costs the hospitals and its patients tremendous amounts of money. As a result, emergency rooms close, further exacerbating the problem of ED overcrowding. Between 1988 and 1998, 1,128 EDs closed, leading to dramatic increases in patient volumes and waiting times at other EDs.

Then, of course, there is the financial burden. An ambulance ride itself can cost over a thousand dollars. Also, the authors of the Duke study estimated that EMTALA has a net cost on hospitals, government agencies, and social welfare that runs in the billions of dollars. We thus have good reason to think that EMTALA places financial strain on our medical system as well.

But it’s not just patient care and hospital emergency rooms that are negatively affected by this law. According to the American College of Emergency Physicians, ED doctors “on average provide $138,300 of EMTALA-related charity care each year, and one-third of emergency physicians provide more than 30 hours of EMTALA-related care each week.” Unfortunately, ED physicians have no say in the matter — the federal government mandates that they donate their time and money. Some physicians are rightfully upset that they are not receiving compensation for the work that they have no choice but to do.

And yet, I support the idea of EMTALA. It would be callous to kick patients in need of emergency care to the curb simply because they can’t pay. As Avik Roy, health care policy expert and Opinion Editor at Forbes, has written in National Affairs, “There are some instances in which we should obviously consider more than economics: Certainly no wealthy nation should allow a destitute woman who has been hit by a car to die in the street. Likewise, in a pressing emergency, catastrophic care should be provided to those who need it, and the costs can be sorted out later.” Absolutely.

However, this law, a classic example of unintended consequences, is not the way to assure that care. It increases the cost, time, and population burden on the ED and also mandates that physicians give up their time and money to treat patients whether or not those patients need emergency medical care. And this is not just a partisan fight: political and healthcare activists of all stripes find this law deleterious and inadequate and have called for its repeal. But repeal of EMTALA seems distant as we try to sort out the effects of the Affordable Care Act. Nevertheless, if we cannot repeal it, we must improve upon it and rectify its effects as best we can to ameliorate patient care in the emergency room.

Image via Shutterstock

Incidentally, the problems arising from this law also illustrate an important point about medicine and politics. Politics is not some drama playing out on a distant stage and leaving most of us unaffected; it affects physicians and patients — so at some point all of us — every day in very practical, tangible ways. Whether EDs or hospitals face overcrowding, closures, or mandated care, all roads lead through the workings of politics, a topic which we can’t ignore if we want to understand medical practice. As John Adams famously wrote in a letter to Abigail Adams, “I must study Politicks and War that my sons may have liberty to study Painting and Poetry Mathematicks and Philosophy.” Adams’s point, though meant for his generation, holds true for all of us. We must familiarize ourselves with politics and ideas — these affect every interest and every profession as all are confined and freed by law. Medicine is no exception.

A Day in the Life, Part 1

My editors here at The New Atlantis suggested I write about what a day is like for me and other members of the medical team. What exactly (aside from
rounding) do we do all day? When do we have to be in? When do we leave? What goes on when we’re not rounding?

We can divide the third year of medical school into three distinct categories of rotations. There are inpatient weeks (hospital work), outpatient weeks
(doctor’s office work), and the Emergency Department, or ED. The roles differ as do the schedules. I have already described a bit about how the ED works here. The hospital is for patients who need urgent medical attention or
medical procedures. If a patient is having a heart attack, for instance, a cardiologist in the hospital will make sure the patient does not suffer
complications from the disease process. Outpatient work, by contrast, involves less urgent medical problems, like adjusting blood pressure medications or prescribing antibiotics for an ear infection. Let me take you through a day on inpatient and outpatient medicine.

Inpatient

On an inpatient service the interns arrive at approximately 6 a.m. or, if on a surgical service, at 5:30 a.m., and print out a patient list from the electronic
health record. This list of patients contains the patient names, chief complaints, possible diagnoses, ages, and other basic information of the patients we
need to see. It contains a summary of tests and test results as well. It may seem a bit silly that physicians need a reminder about which patients they are
taking care of; however, the hospital experiences quick turnover. A patient may be present for only a couple of days before leaving. Then, a new patient
with a new history and a new problem takes his or her place. Additionally, when there are sixteen patients on the list it is difficult to keep up with
every story.

Medical students arrive shortly after the interns (the residents are a bit like our supervisors, letting us know when we can leave and when we ought to
come in). Given how early in the day we usually have to be in, there is little time in the morning to do anything but eat a quick breakfast while
bleary-eyed before driving to the hospital in the dark. If we’re there early enough, we receive checkout from the night intern. The night intern goes
through each patient on the list and discusses the latest news on each patient. Did the patient vomit? Did he or she have trouble breathing? What
interventions, tests, or treatments were done? Additionally, if the night intern admitted new patients overnight, what is the story behind the hospital
admission? These questions are vital to the care of each patient. If the day resident does not know, for example, that a patient was having trouble
breathing or received an imaging study then the resident does not know to look at the results of that study, potentially missing a life-threatening problem
like a collapsed lung or a heart attack. In an ideal world, the transition between resident shifts is so seamless that it is as if the day resident took
care of or admitted patients during the night.

Subsequently, the interns assign medical students to “follow” one, two, or three patients (depending on how far along we are during our third year). Following a patient
means knowing the vital signs daily and keeping up with the results of x-rays, CT scans, and lab tests. It also means we come up with a plan for that
patient’s care and propose it to the attending and residents. In truth, the residents and attendings already know what they are going to do for the patient
and our proposals are merely an exercise for our own edification.

After these assignments, we go through the chart on the electronic health record and read about the patient’s history. We read the night intern’s note on
the patient and we look at the labs (tests) that the intern ordered. These notes give us a sense of what the residents or attendings thought the patient had and
needed. For example, if the patient came into the ED with a fever and a cough, the notes will usually mention a workup and treatment for a possible pneumonia, or lung infection (which includes a chest x-ray, sputum culture, and
empiric antibiotics). More importantly, students and residents look at the vital signs of the
patients we follow. These indicate if the patient needs immediate treatment. Is the blood pressure too low with a fast heart rate and a high body
temperature? This indicates a possible blood infection and we take blood cultures and administer antibiotics.

Despite the fact that the sun has not yet peeked through the hospital windows, we subsequently visit patients in their rooms to do a physical exam. We look
at new rashes that patients have, listen to hearts and lungs with stethoscopes and perform neurological exams. We target our exam at the patient’s
presenting illness. For a patient with pneumonia, we listen closely to the patient’s lungs for abnormal breathing sounds due to the infection. All this, of
course, entails waking the patient up. And since residents, appropriately, will come in after us to make sure that we have done the physical exam correctly
and that the patient is in no distress, we unfortunately wake the patient up at least twice during the early morning hours. This is separate from the
instances where the nurses wake the patient up to draw blood for morning labs. Such is one difficulty of being a patient at a teaching hospital, something
I will discuss in future posts.

Image via Shutterstock

Once we’re finished seeing the patients, we have a little bit of time left before rounds start at 8 a.m. We look up information about the illnesses our patients have. We also write down the information we will need to present the patient to the attending physician on rounds. I’ve written a bit about
patient presentations in this post, but in sum,
our presentations report the relevant medical information and treatment plan in an organized and concise matter.

At 8 a.m., the attending arrives and we round on patients. Aside from the few patient presentation(s) we do for the attending we remain silent and watch and
learn as I’ve described previously. Once we finish rounding
we go over the patient list in the physician work room. We make sure that we all agree on the plans for each patient for the rest of the day. Some patients
need to leave the hospital. Some need more IV fluids or medications. And some need an imaging study or a blood test.

After we’ve confirmed all of this, the residents write “notes” about each patient for the electronic health record. A note is similar in format to a patient
presentation. It contains a brief history of the patient’s chief complaint and illness as well as the blood test results, imaging test results, diagnosis,
past medical history, and past surgical history, as well as the treatment plan for the patient. These notes, though incredibly time-consuming, serve a
valuable purpose. First, legally, the note can help protect a physician from future lawsuits. The note documents a physician’s train of thought and
actions. It justifies the tests and treatments which patients receive in the hospital. Second, it is used for billing purposes by documenting what was done
for the patient. And third, when the patient goes for a follow-up appointment with another physician in clinic, the note acts as a standardized form of
communication to update the clinician on what was done in the hospital.

At lunchtime, medical students usually receive a lecture from a physician in the rotation. In pediatrics, for instance, we may listen to a lecture on
pediatric respiratory complaints from a pediatrician. Meanwhile, the residents remain in the workroom or, if they’ve finished with their notes, they can
grab a quick bite to eat in the cafeteria. Sometimes, though, the residents are swamped. They carry around pagers or phones, and nurses and other physicians
page or call throughout the day with questions about specific patients. A patient may get a headache or feel nauseous and the nurse may page the resident
to ask if it’s okay to give pain medication or antiemetics (medication for nausea or vomiting). Given
that there are a limited number of residents, if multiple patients fall extremely ill and need medications, it can be difficult for the residents to
respond to other more minor complaints. A cardiac arrest on the floor, for example, may prevent the resident from ordering pain medication for a patient
with a headache.

More on a day in the life, in a bit…

PCP Overdose in the Emergency Department

There was a crowd of security guards, physicians, and nurses in an ED room. The patient inside squirmed and writhed on the stretcher while sweating
profusely, soaking his clothing and the hospital bed. Though slender
and slightly cachectic, the patient had fought off the security
entourage multiple times, like a snake slipping from their grasp,
violently twisting and
turning his body.
As he struggled, a nurse tore off the sleeve of the patient’s dark blue jumpsuit in order to get IV
access and administer medications. The 26-year-old man kept his eyes wide open and stared at the ceiling, which made it easy for me to see his
tremendously large and dilated pupils, empty and frightening at once. Seven security guards held him down when the nurse started the IV.

All this went on for about an hour, and as the time passed the monitor above the patient’s bed, which projected his temperature, blood pressure,
and heart rate, changed. The temperature rose: 99…100…101…102…. The heart rate went up to 120 (a heart rate above 100 is considered fast and is called tachycardia). The blood pressure, too, rose
to 160/100 (normal is approximately 120/80). And the patient continued to sweat and writhe. As he exerted himself, his cells produced molecules necessary
for energy, a process which generates heat and increases heart rate and blood pressure.

The patient was experiencing a PCP, or Phencyclidine, overdose. PCP is a drug that was developed in the early twentieth century as an anesthetic. However, the drug also caused
delusions, anxiety, and agitation and was eventually discontinued because of these side effects. In the 1960s, many drug addicts used it illegally in pill
and smoke form. Because PCP acts partially among dopamine receptors in the brain it can cause both
euphoric and, sometimes, psychotic and violent behavior. On medical licensing exams we are expected to recognize the typical PCP symptoms: violent behavior, dilated pupils, profuse sweating and
tachycardia. Additionally, the drug can cause seizures, hyperthermia (very high body temperatures), severe hypertension or high blood pressure – which can
damage the eyes, kidney, and brain as well as other organs – and rhabdomyolysis,
the breakdown of muscle, which can cause further kidney damage. Unfortunately, no medication exists to reverse the drug once it’s been ingested and
treament primarily targets only a patient’s symptoms.

The resident started treating this particular patient with a type of benzodiazepine, a sedative drug
that acts on receptors in the brain to inhibit anxiety and agitation. This class of medications is frequently used for patients who have prolonged
seizures, severe anxiety, or difficulty sleeping. After multiple doses of benzodiazepines over the course of the hour, as well as IV fluids to counteract
possible rhabdomyolysis, the patient continued to fight and his temperature continued to rise. It was almost as if he had not been given any medication at
all.

At this point, the only option was to use drugs to knock the patient out completely, or paralyze him, so that he would stop struggling and his vital signs would
normalize. To ensure the paralytic drugs do not prevent the patient from breathing, a tube is placed down his throat, keeping the airway
open. The resident injected the paralytic into the IV, and once it took effect he
used a glidescope to pry open the patient’s throat in order to visualize
the airway. Then, he stuck a short plastic tube down into the trachea. The hollow tube allows oxygen to pass into the trachea thus acting as the patient’s
mouth and throat. The tube is then connected to a ventilator that pumps air into the lungs and thus keeps the patient oxygenated. A great video
of this procedure with narration is available here.

This last ditch effort worked. Over the next few hours, the patient’s temperature and blood pressure dropped and he avoided the dangerous sequelae of his
toxic ingestion. Although curious to see what would happen to him next, my rotation ended before the patient was admitted to the hospital and I went home
to sleep off the overnight shift.

Opioid Overdose in the Emergency Department

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I had just finished introducing myself to the resident when the EMTs wheeled in a patient on a stretcher. The patient’s face was completely pale and expressionless and his eyes were closed; his hair looked disheveled and unwashed. He wore tattered jeans, a soiled white t-shirt with holes, and white sneakers with untied shoelaces. His age, according to the EMTs, was 34, but he looked as if he were 50, with a sagging face and prominent wrinkles that no 34-year-old should have.

Other than this, we knew nothing about him. An anonymous person had called 911 and reported that this gentleman was “not awake.” This is not uncommon, as many folks who get into gunfights or use drugs do not want to be caught by police, and associate the medical profession with the law. As further contribution to our complete ignorance, the unconscious patient could not tell us what had happened.

Moreover, he was apneic, which means his breathing rate was dangerously slow. Without adequate oxygen intake, his heart and brain
would perish. As I wrote about in my post on running a trauma code, one of the most important aspects of a patient’s care in the ED is the airway — physicians ensure that the system that takes in oxygen works. With diminished breathing, this patient needed oxygen. Thus, the ED resident rushed to set up tools for intubation: sticking a tube down the patient’s throat to provide a space for oxygen entry.

When a patient like this comes into the ED — unconscious with no clear history — the ED physicians give the patient a few basic drugs that can save his life. These therapies target the most common causes of AMS (altered mental status) or total lack of consciousness. One therapy is glucose or sugar administration. Hypoglycemia (low blood sugar) can affect a person’s mental status. The brain primarily uses glucose for its processes; without glucose, it starves, leading to unconsciousness. One of the other therapies is naloxone, also known as narcan. Naloxone is an opioid antagonist, a term that describes its inhibitory actions at opioid receptors in the nervous system. Opioid agonists include drugs like morphine and heroin that cause sedation and respiratory depression. Naloxone acts quickly to reverse these effects in patients who overdose on opioids.

A fellow student and I watched as the attending physician injected a dose of naloxone into the patient’s IV. The patient shot up in bed, trembling, sweating, and breathing rapidly, his eyes wide open. That’s the catch with the agonist and antagonist relationship: because their effects oppose each other, their manifestations also oppose each other. While opioids sedate, naloxone stimulates. The patient screamed at the nurses and physicians and threatened them. He hurled expletives at the healthcare staff and swung his arms at the nurses while demanding to leave the hospital, as spittle flew from his mouth.

The reason, as the attending ED physician explained to the patient, that they kept him in the hospital is that naloxone has a very short life in the body’s system and wears off in about an hour. But some opioids can be long-acting; ergo, this patient could become dangerously sedated again once the naloxone wore off. And he could not, given his mental status, make individual decisions for himself. The patient continued to thrash around until a police officer from another part of the ED came over. Not surprisingly, the patient calmed down.

Watching this elicits mixed emotions. What if this person did become more violent? Would I actually need, physically, to defend myself from this drugged individual — a man who clearly has little sense of what is and is not reckless and harmful? And then there’s sympathy; how unfortunate that such a young person could fall into a life of drugs. Further, what will his fate be? Will he ever give up using drugs? I also could not help but find it humorous that as soon as the police officer came into the room, the patient calmed down. The law and its enforcers have a potent effect, indeed. Lastly, this was an incredible physiologic feat of saving someone’s life using a drug with an antagonistic molecular construction — another wonder of modern medicine to put on the list of scientific achievements.

We may soon witness scenes like this in a more public sphere. The wonder that is naloxone is currently being distributed to police officers in big cities to use on people overdosing on opioids, according to The New York Times. The same thing is happening in New Jersey, too. Government agencies are responding to a rapid increase in the use of opioids: “Gov. Andrew M. Cuomo committed state money to get naloxone into the hands of emergency medical workers across New York, saying the heroin epidemic in the state was worse than that seen in the 1970s, and the problem is growing.” Of course, this is not going to rid us of addiction, but it will certainly save lives. And as the New York City Health Commissioner noted of naloxone, “It’s really quite miraculous. Anyone who’s ever reversed an overdose will never forget it. People wake up.”

Running a Trauma Code in the ED

Hospital image via Shutterstock

The paramedics flying the patient in by helicopter called the Emergency Department charge nurse and described the patient: a 40-year-old male in a construction accident with
deep lacerations (wounds) to the left leg. The moment between the paramedics’ call and arrival was only a few minutes.

During this time, the ED notified the
trauma surgery team that a patient may need surgical care and classified the trauma as level 1 (a level 2 trauma is less urgent). As the ED
notified the trauma surgery team, the ED nurses and an ED resident prepared the trauma bay, which is just a larger patient room in the ED. They kept IV
fluids at the ready; the blood bank prepared to get the patient blood; the resident placed an intubation kit at the stretcher side (if the patient is
unconscious and cannot breathe on his or her own, the resident places a tube down the patient’s throat in order to get oxygen into the lungs); an oxygen
mask was set to deliver oxygen; we medical students placed blankets at the bedside; and everyone put on gowns, masks, and gloves. The whole scene was
chaotic, not least because of the sheer number of people involved: multiple nurses, an ED resident, a general surgery resident and/or an acute care surgery
fellow, a trauma surgery intern, a pharmacist, medical students, and an x-ray technician to take immediate imaging if needed.

As the paramedics rushed the patient in on a stretcher (yes, just like in the movies), they recapped the patient presentation for the healthcare team and
provided slightly more detail about the mechanism of injury. A construction worker accidentally dropped a chainsaw onto his leg. The metal edges
of the saw cut through the patient’s left shin and thigh.

I don’t usually find blood upsetting. During surgery, I had no problem in the operating room watching the surgeons explore bowel or try to stop bleeding
from a severed artery. Objectively, I comprehend that it is gruesome, but it doesn’t induce an intense visceral reaction. However, this particular event was
absolutely disturbing. The metal blades cut the left shin so deeply that only half of the bottom leg was attached to the knee. The tibia and fibula bones
jutted out of the skin over large, severed arteries and veins. Muscle and tissue clung to the leg by a few strands of skin as blood seeped from the wound.
On the upper thigh, the damage was less intense — the saw tore through the quadriceps and the lateral leg muscles. Some of the superficial muscle hung off
the wound, which bled much less severely. This sounds horrible, but the sight of this, akin to some kind of horror movie, was not so affecting until one
pairs it with the fact that this patient was conscious.

His screams were charged with fear and intense pain, while he lay in a completely strange place with no family and no shortage of doctors and nurses and
paramedics aggressively intruding on his personal space. I thought of this passage from Tolstoy’s The Death of Ivan Ilyich: the screaming “was so
terrible that one could not hear it through two closed doors without horror…. ‘Oh! Oh! Oh!’ he cried in various intonations. He had begun by screaming ‘I
won’t!’ and continued screaming on the letter ‘O.’” For this person to experience all this commotion and pain while also realizing the possibility of losing
his leg must have been overwhelming.

But the struggle to provide medical care went on and the trauma assessment began. The upper-level surgery resident stood at the foot of the patient’s bed
directing the healthcare team and the ED resident stood at the head of the stretcher making sure the patient could breathe. The nurses, meanwhile,
confirmed that two IVs (one in each arm vein) were in place and working so that they could deliver blood, fluids, and pain medication as needed. The upper-level trauma surgery resident began with the primary survey, which identifies life-threatening injuries to the patient. For instance, an injury to the patient’s throat
or mouth that prevents the patient from breathing is an immediate concern. The resident scrutinized the vital signs and quickly assessed
for other urgent issues: airway (is the patient’s mouth clear from obstruction?), breathing, circulation (major blood loss), disability/neurological
issues, exposures to toxins/environmental control. We frequently use the mnemonic ABCDE to remember this. The nurses completely stripped the patient of
his clothing during this examination, for the sake of thoroughness.

If the patient is not on the verge of dying, the trauma surgery resident begins a secondary survey and fastidiously examines the patient head to toe for
other, perhaps less urgent, signs of bruising, bleeding, or anatomical abnormalities caused by trauma to bones or tissue. The hospital staff roll the patient
onto his or her side in order to get a clear view of the back and buttocks. The surgical intern usually performs this part of the exam, hollering out any
abnormal findings to a nurse who stands outside the room, documenting the patient’s injuries to a computer. The resident also performs a FAST exam (Focused Assessment with Sonography for Trauma), where he or she uses
ultrasound imaging to search for blood within certain parts of the abdomen, chest, and pelvis. It is a quick and effective way to assess whether a patient
is bleeding internally and needs immediate surgery.

The healthcare team did a secondary survey as the patient continued to groan and scream. Because of the severity of the injuries to different systems, the
trauma surgeons, orthopedic surgeons, and vascular surgeons all came to assess what kind of surgery this patient needed. After a quick huddle with the
attending physicians, the nurses wheeled the patient straight to the OR, never to be seen or heard from by me again. The one aspect of this patient’s
prognosis that I do know is that the surgeons thought they could save this patient’s leg and its function, which is demonstrative of the
miraculousness of modern medicine.

In the early seventeenth century the great English poet, cleric, and lawyer John Donne
reflected upon sickness and health in a book called Devotions upon Emergent Occasions, after battling illness
himself. In it, he wrote that “we study health, and we deliberate upon our meats, and drink, and air, and exercises, and we hew and we polish every stone
that goes to that building; and so our health is a long and a regular work: but in a minute a cannon batters all, overthrows all, demolishes all….” There
is nothing quite like a trauma to reinforce Donne’s observation about how fragile our condition remains; being struck by a car or being in a construction
accident shoves us off the tenuous tightrope of health on which we walk. Here, a healthy patient in the prime of his life was nearly destroyed by poor
fortune.

This is also an example of losing track of a patient’s outcome, which is so common in medical school and residency. I’ll never know his whole story — as
I’ve written, this is something that contributes to cynicism in medicine.

And another thought on this trauma: a Chinese proverb states that “no man is a good doctor who has never been sick himself.” This certainly sounds
right. How can one understand a patient until experiencing his pain? I disagree, though. We know that many who see other people in pain experience pain themselves. But
further, the power of human empathy can be surprisingly vast. True that nurses, students, and doctors may not directly feel the pain of a sharp metal edge
slicing through flesh, but can we not comprehend the horror of this? Can we not, in an admission of never wanting something like this to happen to us,
experience in a small way the terror of such an event? An empathetic emotional response is enough to prime healthcare workers to take great care of a
patient. The potential problem in medicine, then, is not what the Chinese Proverb suggests. The possible outcome is that when we see people like this every
day, the once-astonishing horror becomes treated as a daily experience.

How the ED (Emergency Department) Works

Ambulance image via Shutterstock

The Emergency Department is one of the most active and exciting parts of the hospital because it is the hospital’s sieve. The ED physician determines
whether an injury or complaint is life-threatening or not and then treats or admits the patient to the hospital if necessary. Someone usually comes in by
ambulance or private vehicle with a general complaint — referred to as the chief complaint — such as “stomach pain,” “chest pain,” “leg pain,” or “shortness
of breath.”

But occasionally, the first assessment of this chief complaint begins outside of the emergency room. Paramedics or emergency medical technicians who bring
the patient in by ambulance identify someone clearly in need of medical attention. Outside of the hospital they take the patient’s blood pressure, heart
rate, breathing rate, and temperature (collectively known as vital signs). These measurements indicate the seriousness of the situation. For example, if a
patient looks pale and sweaty, and his blood pressure is 80/40 (extremely low), this indicates the need for emergency treatment. However, if a patient calls
for an ambulance but has normal vital signs and looks healthy, then he can wait a bit longer for medical care, and the ambulance does not rush to the
hospital.

When the patient arrives in the emergency room, he will see a similar setup at many different institutions (I can testify to this because of my days spent
as an emergency medical technician in New York City, where I saw the emergency rooms of many hospitals). The doctors and nurses sit at an open station with
computers in the center of the circular or semi-circular room. The patient beds stand on the outer edges of the circle in small slots separated from each
other by curtains and, in some cases, by an actual wall. Usually, a patient is hooked up to a machine that continually takes vital signs and projects them
onto a screen facing the doctors and nurses.

Once the nurses bring a new patient back to a bed, the resident physician assigned to that bed asks one of the medical students to go see the patient. We
have ten minutes to interview the patient about the chief complaint and do a focused physical exam, which means we only ask about and examine bodily
systems that relate to the chief complaint. If a patient has chest pain, we do not ask about or examine the foot.

Difficulties abound with this assignment. First, some patients come to the ED and want to have all their problems taken care of, which is impossible to do
in a short period of time. Additionally, the ED is only meant to handle emergencies. Someone who has a broken leg, for example, may also want to talk about
a muscle sprain in his shoulder — but a sprain is far less concerning and does not need immediate attention. Second, some patients want to have a long
conversation with a medical student or physician. They may feel lonely at home, or have a difficult social situation, or just want to chat. And while we
must listen to the patient, these conversations may be irrelevant to the chief complaint. Moreover, other patients with life-threatening problems arrive
regularly and need an ED doctor more urgently. Finally, some patients come seeking pain medications because of an addiction, or some may malinger (faking an illness for some type of secondary gain, like getting out of school
or criminal prosecution).

Dealing with these kinds of patients is integral to the art of medicine in the ED. The methods we were taught in first and second year
about how to manage disease and what questions to ask tend to dissolve when dealing with human beings who have different motivations for coming in to the
ED. We need to understand those motivations and, occasionally, quickly work around them in order to address a patient’s life-threatening
illness.

After we see and examine the patient, we tell the resident what we think the diagnosis is and what lab tests or imaging we want to get. The resident then
sees the patient briefly and tells the attending physician his or her plan for the patient. The attending finalizes the plan for the patient and the
resident executes it. All this might be clearer with an example from my own experience.

During one of my shifts, a patient presented to the ED with severe back pain. He could not sit still, and cried out every few seconds. He squirmed on the
stretcher, moving his legs up and down, tearing sheets off the bed and clenching his hands to his chest while grimacing. Watching someone in pain is
extremely difficult and can even cause the observer to feel pain. And
there is no question that I felt incredibly sympathetic for this man — so much so that I didn’t want to disturb him by asking him questions and examining
him.

This is another difficulty in the field of medicine. We need to perform certain exam maneuvers or tests even though they cause the patient pain and
frustration. But it can be so difficult to bring oneself, especially in the student role, to swallow that difficulty and foist the necessary exam onto
the patient. How could I bear to push on and examine this man’s back when I knew this would cause immense discomfort? With difficulty, I continued the
interview and briefly palpated the spot on his back that hurt.

Once I finished the interview, I thought about a differential diagnosis. A differential diagnosis is a list of possible diagnoses for the patient given the
signs and symptoms the patient is presenting with, usually listed from the most likely to least likely. This gentleman with left lower back pain, for
instance, had a differential diagnosis list as follows:

1. Kidney stones

2. Herniated disc

3. Pulled muscle

4. Kidney infection (pyelonephritis)

5. Spinal abscess

6. Appendicitis

This list may not be complete, but it gives a sense of the kind of approach a physician takes to a medical issue. And as the physician questions the patient, the list changes. A doctor might ask if this particular patient had his appendix removed. If the answer is yes, then appendicitis comes off the list. A
practitioner uses interview questions and physical exam maneuvers to narrow the list down to one or two very likely diagnoses.

As for labs or imaging tests, these are only done to rule out or in diagnoses after narrowing down the list of possibilities with an interview and physical
exam. This man most likely had a kidney stone, as his presentation of severe back pain with an inability to sit still is a classic demonstration of this
pathology. Therefore, a urinalysis (examination of the urine) or CT scan (an imaging study to look for the stone) was integral to the diagnosis.

After deciding on this, I presented the patient to the resident. Across the field of medicine, medical students, residents, and attending physicians
present patients to each other in a standard format with an ordered listing of information. This information includes the age of the patient, history of
the chief complaint, relevant past medical history, physical exam findings, and a plan for the patient’s care. This gives all medical professionals a
concise, relevant, and standardized summary of the situation. In this case, for example, I might present the patient to the resident by saying this:

“Mr. B is a 44 year old caucasian male with a relevant past medical history of previous kidney stones, here today with a chief complaint of severe back
pain. The pain began five hours ago while showering with no apparent preceding incident. The pain is only better when the patient brings his knees up to
his stomach but otherwise remains severe. The pain is sharp and unilateral on the left side and does not radiate anywhere. The patient took ibuprofen
earlier, but that has not helped. He reports no blood in the urine, no difficulty urinating and no change in bowel movements. On physical exam, the patient
is extremely tender to palpation on his left flank but the exam is otherwise normal. My differential diagnosis includes kidney stones, pyelonephritis,
herniated disc, pulled muscle, spinal abscess, and appendicitis. I’d like to get a urinalysis and CT scan of the kidneys, ureters, and bladder, and give the
patient morphine for pain.”

That’s not a perfect presentation (and at the time mine was far less comprehensive), but it is the kind of formatted presentation that doctors look for
when they see a patient who has severe back pain.

If the ED attending physician is unsure of what is going on or how to treat the problem, the resident usually calls a consult. If the patient is bipolar,
for example, the ED resident calls a psychiatrist to see the patient in the ED and possibly admit the patient to the psychiatric ward in the hospital. If
the patient presents with a stroke, the resident calls a neurologist, who treats and admits the patient to the stroke service. While emergency medicine
physicians are excellent at figuring out what might be going on and whether it is serious, and while they are meant to know a little bit about everything, they
don’t know as much about specific problems as a specialist in that field. Therefore, it is not the ED physician’s job to treat everything neurological,
psychiatric, or cardiac in nature. It is the ED physician’s job to determine who needs to see which specialist physician, and to treat those urgent problems
that they can treat.