Tuesday, December 04, 2007

Dousing The Fire - Sort Of

Regular readers are no doubt aware of my intermittent burnouts ( I count at least 3 major ones since 2003 -- SARS being the start of it all ).

I still get minor attacks on and off, but have learnt to accept that it comes with the job.

Each individual episode, however, has its own unique trigger. The SARS period took its toll on me physically ( I couldn't get sick when I desperately needed medical leave to rest! ) and of course emotionally ( helping to write Ong Hock Soo's obituary for the SMA News remains one of the most difficult things I've ever had to do ). Subsequent burnouts occurred for various reasons, be it insane patient loads, intolerable ER overcrowding ( not a problem anymore, thanks to a friend's marvelous initiative and some administrative pushing ), or most recently, a traumatic event which revealed someone's terrifying ability to camouflage pure evil with a sweet, innocent smile.

Don't worry, I've been able to recover successfully so far. But each bout inevitably eats away at one's soul, sapping energy and blotting out what little optimism one has left in a fast-emptying arsenal of defences.

Wow, that was a mouthful. :/

So lately, I've been asking myself: Why did I choose emergency medicine? Why do any of us emergency physicians do it, when it pays less than most specialties, is no less demanding in terms of hours and workloads, isn't exempt from angry complaints and adverse events, and rarely gets the recognition it deserves -- from fellow colleagues who treat the ER like a dumpster, and patients who never give us credit for saving their lives, choosing instead to bestow their appreciation and gifts on those upstairs who take over from us once the case has been resuscitated and stabilized?

We battle forces from all directions -- intubated patients who get rejected by every specialist we call, ward nurses who give us hell when we want to send cases up, patients who make unfounded accusations, administrators who scrutinize the numbers and don't bother to solve the underlying problems.

Contrary to what some people would like to believe, no, emergency physicians aren't losers who chose this specialty after unsuccessfully applying for other traineeships. Many of us have been encouraged to train in surgery, paediatrics or medicine during our MO postings, but had either already set our hearts on the ER, or subsequently picked the emergency medicine route, after considering our options.

Having spent many years in the ER, I've seen emergency physicians trump other specialists in making the right diagnosis ( without the need for scans or numerous blood tests ). They override decisions that are deemed incorrect, saving lives, improving outcomes and reducing costs ( lawsuits included ). They take their roles as patient advocates seriously, have some of the thickest skins in existence ( try talking to certain disciplines when you need a HD / ICU bed ), and have no opportunity to sit down or answer nature's call during most shifts.

You know I love what I do. But honestly speaking, it's a bloody thankless job, and there're times when I want to tear my hair out, slap people, or say, "To hell with you, I'm sending my patient up whether you say yes or not."

But of course, the real world is nothing quite like that.

A few hours earlier, my registrar described a complaint from the ward concerning a case where the diagnosis relied primarily on the history given by the patient. The team upstairs was unhappy about the admission, and some harsh words were used.
The registrar's side of the story made good sense to me, and it was clear that an underlying condition needed to be excluded. I don't know if the patient was entirely truthful or lucid while he was in the ER ( additional consideration should be given to the fact that an interpreter was needed ), but apparently he said something different once he got to the ward, hence the impression that the emergency physician made a huge mistake.

I know the author of the complaint -- a senior consultant who isn't famous for whacking others just for the fun of it, unlike some nutcases strolling along the hospital corridors. Still, the harshness of the correspondence had a significant negative effect on my registrar's psyche, and his tone was a mixture of sadness and frustration.

What we all need to realize is that nobody's perfect. But IMHO, the ER deserves special consideration because we pretty much function like the control tower at our Changi International Airport, juggling hundreds of patients a day, making snap decisions and hoping no-one dies in the process.

We don't have the luxury of ordering 20 different tests to evaluate a single complaint. On the contrary, we almost always decide whether to admit or discharge within the first 3-5 minutes of consultation. There're efficient management algorithms in place to expedite disposition and treatment. We don't believe in doing urgent CT abdomens for no good reason.

I suppose the main difficulty in getting other specialties to understand our limitations stems from the fact that most doctors don't have experience working in the ER. Back in 2001, when I did my first ER posting, I worked alongside trainees from surgery and medicine, as ER rotations were still considered a compulsory component of their training at the time.

Since then, this has been abolished in favour of more specialty-specific training -- surgeons do only surgical postings, and vice versa. Those who desire a more well-rounded CV may opt to work with us for 6 months, but of course, it's no surprise that most prefer to stick to what they know and like rather than set plugs, do manual evacs and treat our regular drunks and PSY cases.

Many of the trainees I worked with are now consultants in their own fields. I speak to them from time to time when I need to override their juniors' strange decisions, and am always glad to hear that they haven't forgotten what it's like for us down in the trenches, often taking us at our word and accepting the admissions without any argument.

Contrary to what many people would like to assume, I derive no pleasure from overriding other disciplines. I don't do it out of sadistic glee, or as part of some power play. In fact, none of us is happy to do it, because it means there's been some disagreement between medical colleagues, and the patient is caught in the middle. If our decision turns out to be correct, the patient benefits ( although s/he is totally oblivious to the preceding shoving match ). If we're proven wrong, then it's a lesson worth learning ( +/- a complaint letter from the ward ).

I'm sure some specialists have their own store of ER boo-boo's. But like I said earlier, NOBODY'S PERFECT. If you can't get past the childish assumption that emergency physicians exist only to make your life miserable, then government hospital practice may not be the right place for you ( private ERs, on the other hand, operate on a completely different set of rules ).

The other gripe I have is how the younger generation of ward doctors treat their more senior colleagues from the ER these days. When I was a house / medical officer, I spoke to my seniors with respect and never dared to answer back.
In recent years, however, I've had registrars and MOs irritate me with their sarcastic remarks and stubbornness. Some of them even yell at me over the phone like rabid animals, cutting me off in mid-sentence and telling me what to do before I can even finish my story. Does any of this help the patient?!

Occasionally, I pull rank on the bugger by announcing my status firmly, or threatening to speak to his/her senior-on-call ( or get the ER consultant on shift to do a bit of arm-twisting on my behalf ). This works in most cases, but one particular female registrar was a real piece of work. She had the gall to reprimand me ( her senior by rank ) and attack my fellow colleagues for being "incompetent", then bullied another discipline's reg-on-call to take over a case in the middle of the night, despite what we thought was an obvious diagnosis.

I followed up on this case who, after a long list of invasive and costly procedures, turned out to have the condition we diagnosed the night she presented at the ER. Suffice to say, my entire department was informed of the incident, and the registrar's chief was alerted to her antics.

Such incidents are becoming more common nowadays, necessitating the the need to track cases on the computer after they've been admitted, to determine whether my assessment was correct. Problematic encounters with other disciplines are flagged out, and nasty comments received are diligently documented under the confidential remarks section, WORD FOR WORD.

So back to the original question about why I chose to work in the ER.

It takes a special type of person to endure such an environment. We may not be experts in new-fangled surgical techniques or know the 50 tests to order for some rare disease. What we're good at is resuscitation in its many forms, rapid assessment and decision-making using the minimum number of investigations, and sifting through some patients' lists of 10 different complaints in order to determine which symptom needs the most urgent evaluation, and hence which admission discipline is most appropriate.

Emergency physicians aren't in it for the money. We're not doing this for the easy lifestyle ( I work most weekends and public holidays -- though by choice, haha :)) or the recognition ( still sorely lacking, despite everything I've said in the above paragraphs ). Getting any present or thank-you card from a patient is like striking the lottery, and the petty nitpicking never ends, so being appreciated isn't on our list of priorities either.

I left for America feeling pretty dejected ( after all, it was only a few weeks after that encounter with The Evil One ). But interacting with thousands of fellow colleagues at the American College of Emergency Physicians Scientific Assembly in Seattle changed all that.

Many of the lectures I attended discussed the same problems I experience here in Singapore. The professors, attendings and residents I chatted with voiced frustrations which echoed my own. But their passion for emergency medicine never abated in spite of all these trials and tribulations. They just kept on fighting.

Then I realized that we actually have some advantage over our American counterparts, since Singaporeans haven't quite developed a thirst for medical litigation just yet ( whew! ). This makes it easier to avoid the practice of defensive medicine, which poses a significant problem considering the ER's limited resources and the healthcare funding policies in our country ( Americans rely wholly on personal insurance coverage ).

I left the conference completely rejuvenated and tremendously inspired. Truth be told, some of those effects have worn off since my return to the warzone, but the underlying lesson will never be forgotten.

Why did I choose emergency medicine? Because I just wouldn't be happy doing anything else. :)

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