Emergency medicine in the slow lane

Emergency medicine is a new specialty in Sweden, only recognized in 2006 as a supra specialty. Basically that means you need around nine years of postgraduate training to qualify as a specialist, but still get very little emergency medicine training and exposure. The emergency departments are run by the respective departments, which can add up to eight separate sections under one roof. And I think it’s safe to say that none of the doctors working there follow the EM literature. It’s like evidenced based medicine is reserved for their patients upstairs. To get them to accept that emergency physicians take over their on call work is not a problem, but to make them realize that that will mean a change in practice is much more difficult. They are all willing to teach us their part of emergency medicine, but there are no role models to convey the integrated knowledge. Instead we have looked to international bloggers and podcasters. It has been hard to see how this could be translated to our setting, so I wanted to go somewhere where emergency medicine was an established specialty and my first choice was Australia. Unfortunately that turned out to be too complicated and expensive and I ended up in Botswana instead.

It is fair to say that my experience in Botswana fundamentally changed my perspective on emergency medicine. Talk about culture clash! I knew that Sweden was a developing country when it comes to emergency medicine, but I didn’t expect the gap to be so wide. Of couse it was tough to get used to the heavy burden of disease in this relatively wealthy country, but it was being caught in the interface between advanced, anglosaxian emergency medicine and the more improvised, basic emergency care that made me realize that I didn’t know what I was aiming for in Sweden.

I had tried to describe to the EM specialists in Botswana beforehand, how I lacked training and experience in certain areas. Like Gyn/OB, for instance. We don’t see these patients in Sweden since there is a separate ED for them. As a resident you will do a rotation there, which I hadn’t done yet, but you will be taught by gynecologists who don’t really see the point in your learning something that you won’t be dealing with once you leave their department. Another thing is trauma. I work in the largest ED in Sweden and we don’t see severe trauma cases. Of course the occasional patient wanders in after being stabbed or stomped by a mousse (actually that only happened once, to my knowledge), but it is definitely not part of our daily life. And in fact, hardly a part of our training. Of course we take ATLS and other courses, but in terms of exposure we get two weeks at the trauma center, where they see around 300 severely injured patients per year.

But it is not only the trauma cases that seem to be a lot less frequent here. I have only seen one crashing asthmatic patient. We mostly get old COPD patients with exacerbations. DKA is rare, too, in adult patients. It is hard to find another explanation than that these patients are being adequately treated in primary health care.
We have a high suicide rate in sweden, but I have never seen a serious intoxication on TCA, beta blockers or calcium channel blockers. When I was talking to the second year residents the other day, most of them had never seen a blood transfusion given in the resuscitation room.

I tried to tell this to my EM specialist colleagues in Botswana, but I don’t think they believed me. Admitting everything you don’t know is never pleasant, especially not when people are surprised that you don’t know the basic things. Like placing a chest tube. I have never seen a chest tube placed in the ED. The same goes for central lines, but maybe we just missed that train, since CVP is going out of fashion and IO is gaining ground for the really acute cases. But if one was to be placed, someone from anesthesiology would come and do it, in no time. Just like they come and intubate the patient if necessary, which is rarely done in the ED. Cardiac arrests are often intubated in the field by a nurse anesthetist. (I won’t go into whether that is optimal practice or not.) If the critically ill patient needs to be intubated, they will mostly be taken to the ICU and have the procedure performed there. An emergency medicine program director even questioned that intubation skills were necessary for emergency physicians!

My hospital only has around twenty ICU beds and it is hard to get a patient admitted there. The STEMIs go there of course, but they bypass the ED and go straight to cath lab, so we only see the not so obvious ones.

What it all comes down to is that as much as we need to increase our resuscitation skills for the really sick patients, these cases are not common enough for us to train a large number of emergency physicians. Our work is more of preventive emergency medicine and driving in the slow lane. And even though I would love to bring upstairs care downstairs, I have to ask myself if the outcomes won’t be better if we keep bringing downstair patients upstairs.