Being the doctor the patient needs

In July Emergency Medicine was recognized as a primary specialty in Sweden. There has been some resistance among my fellow doctors to the recognition of emergency medicine, but I am not sure what their objections really are, since they cover almost every aspect from work environment to patient care. I got tired of listening to them. Or, to be honest, I don’t think I ever really listened to them. Instead I turned to other emergency physicians in Sweden or abroad, who would confirm my conviction that emergency departments should be staffed and run by emergency medicine specialists and even reassure me that this criticism has been part of the process everywhere.

I think this notion exists in every medical specialty, that other specialists just don’t understand their particular field of medicine. It creates a sense of common understanding and builds identity. This identity has been so important to me that I have been introducing myself as a resident in emergency medicine, concealing the fact that I am a specialist in internal medicine. For three years I have spent a large part of my spare time on the establishment of this new specialty in Sweden. We are part of a global movement and ACEP even has an international section. It is presented in the following way on their website:

As the trend towards globalization continues so does the need to support, promote and develop the specialty of emergency medicine. If you enjoy learning about other cultures and traveling to distant places then this is the section for you. By joining this section, you can make a global impact by sharing your knowledge and experiences with others. Together, we can serve as a resource to other countries in their development of emergency medicine and promote international interchange, understanding and cooperation among physicians practicing emergency medicine. With more than 1000 members the Section on International Medicine is one of the college’s largest and most active sections.

The international emergency physicians are going around the world to support, share and serve as a resource for less developed medical systems. That thought hadn’t crossed my mind when I went to Africa. I didn’t go there to teach, I went there to learn. After having lived abroad a couple of times before, I knew these experiences can bring fundamental changes to how you see yourself and others and there are always lessons to be learned. I find this ACEP text provocative and it seems ironical that my stay in Botswana made me reconsider my support for the specialty of emergency medicine in general and international emergency medicine in particular.

When I arrived in Botswana I was surprised to find my name in the specialist column on the roster. I had never seen anyone with AIDS or a seriously injured trauma patient and I had only done one pelvic exam since medical school. But it wasn’t just the unfamiliar case presentations that I didn’t know how to manage. Patients I would feel very comfortable about treating in Sweden made me confused in Botswana. What was the correct workup for a thunderclap headache? The single-detector CT scanner wouldn’t be sensitive enough to pick up a minor bleed, even if it happened to be working. The risks for infection from the lumbar puncture were probably higher than under the more sterile conditions we can offer in Sweden. I also believe the results from the lab were far more unreliable than at home. And if we did diagnose a bleed, the patient would need to be transferred to South Africa for a neurosurgical intervention. I have no idea what the numbers needed to treat would be in this setting. How can I teach the residents and local medical officers what to do? And even if I could estimate the benefit of this workup, it wasn’t really up to me to decide whether or not it should be done. A publicly funded system needs to manage its resources wisely, individual doctors can’t be allowed to order investigations based on neither international guidelines nor personal preferences.

I was going through a few charts for some reason, when I saw that a patient treated by one of the EM specialists had died. The patient had come in with a tachycardia of 160 and had had a CT scan of the head, which didn’t show any pathology as far as I can remember. He died later that night in the ward. Since it was hard to follow up on patients I thought I’d tell the doctor what happened. He told me that patient had only been boarded due to lack of transport back to the referring hospital. I objected. – But the patient had a pulse of 160, he was critically ill. Why did he need a CT scan?
He responded something along the line that the patient had end-stage AIDS and was too sick to be saved. It just made it more confusing to me. Why waste resourses on a dying patient? The only explanation I got was that the patient had been referred for a scan and that is what he got, since it was hard to defy the referring doctor. Scarce resources were wasted, the patient didn’t get optimal treatment and, maybe worst of all, had to die in a hospital far away from his family. Somehow the doctors involved didn’t seem to mind.

My impression from Botswana, and also from talking to doctors from other parts of the developing worlds, is that one of the main obstacles in the development of a better health care, is the autocratic leadership structure. The individual employees are expected to do their job, without being delegated the means and power needed to take responsibility for doing so. Residents and medicine students can even be obliged not to discuss hospital matters with other people. Bringing up complaints to your superiors can cost you your job. Mistakes are swept under the carpet and structural problems are never addressed. Every improvement is a struggle and choosing what battles to fight is the most difficult task. Change doesn’t come easy. Our much-awaited blood gas machine soon ran out of the necessary reagents, or broke down because the air conditioner wasn’t working. No one in the ED had the mandate to fix the problem, so the issue had to be brought further up the hierarchy. Patients in pain didn’t get proper analgesia, because the nurses didn’t find it necessary, even though there was a protocol and the medicines were available. The solutions didn’t work, because the problems were not adequately analyzed.

In an environment where patients died because equipment was assembled the wrong way, where staff, and most probably patients too, were infected with tuberculosis from unisolated patients and where bensodiazepines could run out completely, I was supposed to help train a chosen few to become specialists in emergency medicine. I did my best to prepare lectures about the vasculitides, but could not explain why the residents should even consider Wegener’s granulomatosis in a black patient with a low grade fever, hemoptysis and weight loss. I don’t think anyone thought they should, actually, but knowledge about vasculitides was part of the curriculum and something the residents needed to know for the exam.

I could not accept that a few of the doctors were getting educated about things they would never see, when the daily work was so full of errors and harmful events. Why not just get all doctors and nurses together and discuss how we could work together to improve care, setting up short- and longterm goals? Why not fix the easy things first? The foreign emergency physicians agreed with me that teaching was difficult. One of them even agreed with me that we would save more lives if we started washing our hands and sorted out all the minor problems. But, I was shocked to hear the following comment and it has kept ringing in my head. -We are not here to save lives. We are here to train emergency medicine specialists.

That statement effectively killed the discussion. Unfortunately, it also killed a lot of my interest in emergency medicine. I’ve been struggling to regain it for half a year now, but it is just slipping further away. I had to turn off a podcast where they were laughing about how they never calculated osmolality in their clinical practice, but needed to know it for the board exam. It makes me wonder, why am I doing this and what purpose does it serve? In everything I do, whether it is seeing a patient or deciding to change jobs, I like to define the problem, the short- and longterm goals and the means to achieve those goals. It might sound easy, but often isn’t. Finding out the problem can be tricky, but the hardest part is to avoid confusing the means and the goals. I realize now that I made having the specialty and specialists of emergency medicine a goal, when it is really a means.

I always enjoyed spending time in the emergency department as a medical student, so when emergency medicine started to emerge as a separate field of medicine in Sweden, I was immediately interested. Ever since medical school I have assumed that my interest stemmed from the ED environment; the action and the unpredictability. But through the years of internship and internal medicine residency in a university hospital I came to realize that the ED was the only place where the patient’s care depended fully on me. In the cardiology department a consultant told me that they only did workups for cardiogenic syncope, which of course meant that if there was another cause of the patients loss of consciousness, it wasn’t his problem. I found this attitude common in most departments, the focus was on a particular organ, not on the patient. Many doctors were busy with their research and didn’t spend too much time on their patients at all. A lot of the subspecialized internists were no longer doing shifts in the emergency department and could not provide emergency care for their patients when their conditions deteriorated in the wards.

I am convinced that the primary assessment in the emergency department needs to focus on life- and limb threatening conditions. Doctors making these assessment need to understand the whole spectrum of acute disease. My hospital still has separate sections where internists and cardiology see ”their” patients directly, which means that patients can be turfed around in the emergency department, having a part of their body worked-up thoroughly at every stop. Definitive treatment is delayed and some patients die because of this. The introduction of emergency physicians in our ED has changed the focus and improved emergency care. But the old system had some advantages. Since everyone knew that the ED couldn’t offer advanced care, specialists were fast to come down when they were called. Anesthesia still comes running within a couple of minutes, but if the patients are not unstable, they feel comfortable leaving the patient in our care, even though we don’t have the necessary resources to monitor them properly without increasing the risk for our other patients. Unstable patients are still taken to the ICU, though. We don’t put patients on vasopressors in the ED. But if we start learning how to care for these patients, maybe they’ll be stuck in the emergency department.

We still have the right to admit patients to the medical, surgical and orthopedic wards, after informing the consultant on call. If they object, they have to see the patient themselves and work out another plan. But the yet undiagnosed patients, or the ones with multiple complaints, that I as an internist could admit to medicine, are no longer as easily admitted. And the undifferentiated abdominal pain surgery would earlier gladly accept, now often stays in the ED to wait for a CT scan. The demand for a correct diagnosis before admission has increased. Lately we have started to admit patients to our recently opened observation unit. The ED that was before an extension of the department, is becoming a separate unit. Before the surgeon on call could schedule the patient for a non-acute operation or set up an out-patient appointment. We can’t do that, but have to refer the patient, primarily to primary care so they can refer the patient to a specialist outside the hospital.

But the introduction of Emergency medicine as a specialty has also brought some other changes. When I did my internship in 2003 the drunken young men who had passed out on the street stayed in the ED until they had sobered up. Now they have a CT scan of their brain before they go home, since they never remember the circumstances under which they fell and no clinical decision aid is applicable in the intoxicated patient. Chest pain patients are evaluated for dissection. If radiology allows it. One radiologist refused to scan a patient saying that ”you emergency physicians order too many scans”.

The study Abdominal pain in the ED – a 35 year retrospective (Am J Emerg Med. 2011 Sep;29(7):711-6) found that between 1972 and 1992 the admission rate for abdominal pain decreased from 27% to 18% and diagnostic accuracy increased. The authors of the article published in 1995 assumed that this was attributable to the development of emergency medicine with specialists present in the ED combined with new technology. But when the study was repeated in 2007, admission rates had gone up to 25%. At the same time CT scanning had increased dramatically from 0 in 1972 to 0,8% in 1992 and 25,6% in 2007.

Specialists like to be thorough about their diseases. My father, a master of silly jokes, likes to tell the story about the doctor who told the young man that his mother died. The young man looked troubled and answered: Oh, I hope she didn’t die of anything serious!
The modern doctor seems to reason in similar terms, going to great lengths to make sure that the patient doesn’t suffer or die from one of the diseases on their curriculum, but seeing harm caused by conditions outside of their field of expertise as extenuating circumstances.
During my rotation in nephrology I was surprised to hear how very significant the nephrologists found these 1+ urine dipsticks I had so often ignored in the ED. But surely how serious and urgent a problem proteinuria, hypertension or abdominal pain is must depend on the patient, not on what kind of doctor they see?

In emergency medicine we like to focus on life and limb-threatening conditions. Somehow that has evolved into the perception that every patient presenting to the emergency department has a life-threatening condition until proven otherwise. To prove that a healthy looking patient isn’t about to drop dead within the next 24 hours is costly and the workup definitely has some serious side effects. When I see a nice old lady who has tripped and fallen in her kitchen, I start considering a lot of potential serious causes and consequences of her fall. But when she tells me that all she really wants is someone to help her with her crosswords, which her poor vision doesn’t allow her to solve anymore, I realize that the extensive workups and admissions patients like her get are consuming the resources that could be used for the kind of home care service she is asking for.

When the 90 year-old nursing home patient with Alzeimer’s dementia is brought in, vomiting blood and in shock, I feel confident administering blood transfusions, desmopressin and iv PPIs knowing our protocol and the limited evidence behind it. But I don’t know what to do with the nasogastric tube since the patient doesn’t want it. When I leave the room for a while, the anesthesiologist puts it in and the patient is taken to the operating room. They leave saying I did a good job, but I’m not so sure. Is saving this patient’s life a good deed? Is this what he wanted? The fact that his GI bleed was probably caused by the aspirin he was on, makes it even more difficult. Surely we have to do our best to reverse the harm our medicines have caused?

A Swedish study found that the prevalence of dementia in patients over 85 years of age, had increased 40% in five years. (Increasing prevalence of dementia i very old people. Age Ageing (2011) 40 (2): 243-249.) It is getting very hard to die in our society. Saving money on rehabilitation is so much easier than restricting people’s access to emergency care, but in the end I believe the former is a better way to make people live longer and happier.

When you only have a hammer, everything looks like a nail. When you only have the tools for acute workups, everything looks acute. But most of our patients are not acutely ill. Our society is good at prevention. The traffic related death rate per 100 000 inhabitants is 33,2 in South Africa, 12,3 in the US, 5,7 in Australia and 2,9 in Sweden. (Wikipedia) I assure you that this is not due to our excellent trauma care.

Emergency care has been a neglected field for many years. Other specialists have been promoting there respective specialty. I assumed that if we had emergency medicine specialists, they would look after the interests of the patients in the emergency department. Our curriculum is based on the European one, and I have defended it, claiming that we need to know acute ophtalmology and gynecology to be real emergency physcians, even though the patients in my hospital go straight to the ophtalmologist and we never do pelvic exams. I still think we need to learn airway management to be able to give our patients safe analgesia and sedation, but for the acute intubation we have anesthesiology consultants who show up in a few minutes. Considering that patients are not often intubated in the emergency department, I doubt we could learn to do a better job. It is hard to train emergency medicine residents in this environment and we have been arguing that our ED has to be reorganized to suit our educational needs.

I rarely safe a life or a limb during a shift. My role is mainly to supervise the junior doctors, but it is difficult when I have this growing feeling of meaninglessness. We are chasing DVTs in low-risk patients. At the same time we have patients who get sent home with obvious signs of pulmonary embolism and return in cardiac arrest, chest pain patients where aortic dissection is not even considered by the cardiologist who sees them and lots and lots of patients who are not seen fast enough to keeps risks and complications at the lowest level possible. Critically ill patients are not monitored properly in the emergency department. We are ignoring the obvious risks and problems, looking for atypical presentations but still missing classical ones.

I realize I have accepted a ready made solution without carefully assessing the problem. Instead of discussing with my colleagues from other specialties I have been debating them, losing focus on what matters to our patients. But I know now that my goal is to improve emergency care, not really caring about whether this care is given at the primary care clinic, in the ED or in the wards of the hospital. Nor does it matter to me if this care is provided by an internist, a surgeon, an emergency physcian or any other kind of doctor. I actually prefer a team of different competencies working together, rather than having emergency physcians only. We need to make sure that we keep sharing a common language. To save the limbs and lives of our patients all nurses and doctors have to be better at emergency care. But, it hits me with painful clarity, my goal hasn’t been to save lives and limbs. It has been to establish the new specialty of emergency medicine.