improving the human condition or battling natural selection?

I am an emergency medicine physician. A lot of people don’t understand what that means. When I tell someone that I am a doctor they invariably ask “what kind?” to which I reply “emergency medicine”.

“what?”
“I work in an ER”
“oh. I see. So what kind of doctor are you going to be?”

Guess what people. Emergency Medicine is a specialty. We don’t have offices or schedule appointments; we just show up for our shifts in the ER and take care of whatever happens to roll in through our doors. Or, as is often the case with stab, gunshot, and overdose victims, whatever is dumped off on our loading dock. Every shift is different. Sometimes I find it exciting with cases that challenge my intellect and ability to multitask while managing several critical patients at the same time. At other times it is almost overwhelmingly monotonous as I examine the 12th 4 year-old kid with a fever and runny nose that I have seen that shift while trying to stay alert at 3am so I don’t miss the 1 kid out 100 who is actually sick.

Saving lives happens daily. Sometimes it is dramatic and may involve a patient in respiratory distress ready to arrest or a patient with severe hemorrhage from an arterial bleed that is shooting blood across my emergency room. Other times it occurs quietly when I resuscitate a patient with evolving sepsis or initiate treatment for a patient with a pulmonary embolism.

That capacity to “do good” is always present. Relieving pain from symptomatic gallstones or getting a patient with appendicitis to the OR for surgical intervention is always satisfying. The amusement factor in the ER is also quite high with patients getting themselves into predicaments like sticking a pool ball in their mouth and then being unable to get it out or, more often, putting something in their body from the opposite end and then finding out they cannot retrieve it. But, in spite of the satisfaction of treating disease and helping people out of their sticky situations, I often wonder how much good am I really doing? Every shift that I work is also riddled with patients who suffer from disease of their own making. They have substance abuse problems, social problems, and emotional instability with little insight and, often, almost no desire to help themselves. They rely heavily on emergency services as their primary source of medical care. All they seek is stabilization or a quick fix so that they can continue to lead lifestyles that invariably put them right back in the ER.

Every shift that I work involves taking care of chronically, often severely, debilitated patients who have suffered from head injuries, strokes, or just old-age and dementia. Often I see these patients on a weekly basis to treat whatever infection or problem they are currently suffering from. The families demand that I “do everything you can, I don’t care what it is” to save the unfortunate patient who often does not even realize what is going on and has no quality of life whatsoever. Such is the unrealistic expectations of the American public.

Every shift that I work has many opportunities to “do good”, but likewise, in a busy ER where the action rarely abates, there are often even more opportunities for mistakes. Miss one lab, one X-ray, or one physical finding and you could completely miss the diagnosis or administer improper treatment. In today’s litigious society being right 99.9% of the time is not good enough. With that success rate you may still mistreat one patient out of a thousand. I treat an average of 400 patients a month which means that even if I function at 99.99% then every three months I could be at risk for a career-threatening or even career-ending lawsuit. When you consider the inherently chaotic nature of a busy ER where I can be pulled away from the 12 patients I am managing simultaneously to go run a code-blue in the ICU for an hour you can understand the pressure involved in this line of work.

In addition to all this pressure, in spite of the satisfaction of having appreciative patients who have received excellent care, as an ER doctor I am forced to deal with the “repeat offenders” the drunks, druggies , and chronically ill patients that no one can “fix”. I do the best I can. I treat, stabilize, discharge, or admit for further management, but invariably they return in a week or two with the same problem. When I see these patients I have to ask myself “am I really ‘doing good’? Am I improving the human condition by treating these same patients over and over or am I struggling against the forces of nature and battling Darwinism and theory of natural selection?”

I don’t anticipate ever having the answer to that question. I’ll continue working at the job I love; I’ll continue enjoying the rewards and satisfaction while fighting the challenges and angst. And I’ll document my progress in this blog. This venue is my chance to share my small world with whoever wants to experience it. It may be a small world but multiply it by 10’s of thousands of EM doctors throughout America and the implications of what I see on a daily basis are quite sobering.