Common Sense, September/October 2012
Original Author: Leana Wen, MD MSc, AAEM/RSA President
As emergency physicians who are trained in acute resuscitation and thrive in high-stress situations, we tend to roll our eyes at the less acute complaints our patients come in with. “Back pain for three months? Headache for a week? Why are they here now?” I admit that I’ve grumbled about the so-called “inappropriate use of the ED,” especially in the wee hours of the morning.
Something happened a few weeks ago that made me appreciate the importance of the ED. Let me tell you about a 29yoF, previously healthy, 4th year emergency medicine resident, who went to her shift at the Brigham and Women’s ED and felt progressively more fatigued over the course of the day. She came home and felt nauseous, but was able to eat the Chinese take-out dinner that her husband brought back. Right after dinner she went to bed but couldn’t sleep because she developed a gnawing, diffuse abdominal pain. Then she began throwing up, and kept throwing up — at least ten times in the next hour.
Being a physician, she came up with a differential diagnosis. This was most likely viral gastroenteritis. It was going around; she had recently seen patients who had it. However, she didn’t have diarrhea, and other than fatigue, no viral symptoms. It could be bad food, but her husband ate the same thing — and she, being Chinese, was sick of Chinese food always being blamed as the culprit. She had no prior surgeries and doubted an obstruction. She had no headache and doubted an intracranial process. She had no urinary symptoms or flank pain and doubted UTI or kidney stone. Any woman could be pregnant, and though the suddenness of her symptoms made that less likely, an ectopic was theoretically possible.
Not wanting to go to the ED in the middle of the night and burden her already over-worked colleagues, she set about to self-diagnose and self-treat. She sent her husband to the local 24-hour CVS to buy a pregnancy test and to pick up the Zofran ODT that she prescribed herself. The test was negative, and the Zofran made her vomiting stop, but as the morning came her abdominal pain was still there. In fact, it was now localized more to the right lower quadrant and it hurt to walk. I’m sure you see where this is going. You’re probably wondering whether you would have bitten the bullet and gone to the ED at that point to rule out appendicitis. Well, this 29yoF was me, and I really didn’t want to check in as a patient or get the radiation from a CT. As it happened, the ED attending that day was an ultrasound specialist and was kind enough to do a bedside ultrasound. My appendix looked fine, and she could see intestinal thickening that was consistent with a diagnosis of enteritis. I got my diagnosis, and over the next few days, I recovered with my appendix intact.
Had someone like me actually checked in as a patient, I could see how there might be grumbling from the providers. “A young woman with viral gastro who’s actually getting better — why is she here?” “If she doesn’t want a CT, why did she come to the ED?” Or, had I gone to the PCP and gotten referred to rule out appy, “Shouldn’t the PCP know better?”
What I learned from this experience is that it’s always easy to say in retrospect that the patient didn’t have to come to the ED. In the moment, when the patient is scared and in pain, it’s not so clear. Even as a away on its own (gastro) or an acute process that required urgent intervention (appy). How can we expect our patients to know whether their chest pain is the same angina as usual or something more worrisome, or how to apply to the Ottawa rules to see if they have a sprained ankle or need an X-ray?
My flirtation with possible appy has certainly made me more sympathetic to our patients who come in with seemingly “non-acute” complaints. It also has me thinking on a larger scale about proposed policies that impose penalties on our patients for using the ED. Don’t get me wrong. There is a need for more PCPs, and our patients will benefit from increased access to primary care. However, patients don’t always know whether they have primary care versus emergency complaints. I turned out to have enteritis, something a PCP can address. But had I been a “normal” patient, I wouldn’t have been able to treat my own symptoms and then walk in to get a bedside ultrasound from an attending ultrasonographer — I would have had to check in to the ED. Would it have been fair to penalize me for that ED visit? It’s important that our policy makers consider that even well-informed patients with good access to primary care need the ED, and that emergency medicine has inherent value in sorting out all patient presentations.
For our part, we EPs need to stop complaining about our patients. Yes, we would rather be resuscitating the multi-trauma victim or the septic patient, but we also need to maintain and create value in our specialty. We need to keep advocating for issues such as having board certified EPs staffing EDs. We need to remind policy makers that EPs are on the frontline of medical care, and our voices ought to be heard. We need to convince hospital administrators that we are the ones with experience in managing flow and improving quality and safety, and we will bring value to the organizations they lead. We need to keep showing our students and residents that the ED is now the home of diagnosis and embrace our role as teachers and innovators. Emergency medicine is a dynamic and exciting specialty, and I am so excited to be part of it. ■
I would love to hear your comments on my columns! Please email me, firstname.lastname@example.org and follow me on Twitter, @DrLeanaWen, and my blog, http://whendoctorsdontlisten.blogspot.com. Along with Dr. Kosowsky, Clinical Director of the Brigham & Women’s ED, I am publishing a book about patient involvement in health care, “When Doctors Don’t Listen: How to Prevent Misdiagnoses and Unnecessary Tests.” Please visit www.whendoctorsdontlisten.com.