So we see a lot of young (and not-so-young) doctors leaving A&E for
another job. Is it that bad a job? I don't think so. Somebody (@Attachment Vesco)
mentioned that there are not so much to learn and perhaps it is all too
tempting to use the easy way out (admission, that is...) for the
emergency resident/officer...
There is perhaps some truth in that it is very
difficult to become a good emergency resident. You need to deal with
both medical and social aspect of the patient, and patient do not come
in really sorted by their severity. Triage helps sometimes, but quality
of triage is REALLY operator-dependent (more so than ultrasound, may I
say?).
I have only worked in this emergency department for two
and somehow more than a half year, but in the last month I have
already seen a few patients categorized as category IV becoming rather
critical in my eyes. One of them (an adult) had epiglottitis, and
another had AMI complicating GI bleeding (who complained of mild
epigastric pain, but was noted to have brief episode of seizure-like
activity which lasted only seconds – which turned out to be short runs
of ventricular fibrillation). Both of them of course are identified and
treated in the resuscitation room and was discharged home.
These are not mistakes of the triage nurse – these are stuff that are
not well-covered in triage guidelines – those who complain on the nurse
not listening to the stridor are invited to listen for it in our busy
emergency department (the truth is that even on assessment in the
relatively silent resuscitation room there were no stridor for that
particular patient)
What these cases highlight is that
emergency medicine is a risky, difficult business and is not in any way
easy. It is the clinical sense that developed in these two and a half
year, guided by seniors in my department, that enables me to manage
these two patients appropriately.
And then we (sometimes
appropriately) receives feedback (often not personally, though) that our
admission quality is not good enough. The simple test though, is, “Can I
send the patient home today in few hours' time?”, and, “Out of 100
patient I sent home this way, would one of them eventually had some
problem that surfaces soon after discharge?”.
When we talk
about tests, we talk about the receiver operating characteristic curves.
Whether the patient requires admission is a test. How much sensitivity
do you require an emergency resident to have in terms of e.g.
mortality?, significant morbidity (e.g. undetected sepsis which resulted
in shock in later presentations)? I really do not know the AUC of a
typical emergency resident, but I'd assume that the sensitivity of
mortality (e.g. in 7-days' time) got to be much less than 99% or else we
would be seeing some 3 deaths in recent discharged case in the A&E I
am working in, for example, daily. (Now that's quite gross isn't it). I
guess then it is not unexpected that the specificity would be quite
poor in a high sensitivity requirement.
But then life in the
emergency department is a really happy job for those who are always in a
hurry, those who longed for an answer for every patients. The
availability of various rapid diagnostic tests (particularly imaging via
ultrasound) makes managing patients (in both diagnostic and therapeutic
manner) much easier and quicker.
Of course there are other
problems (e.g. social problems that annoys me very much) but these
really depends on the center one is working in and the interest of the
doctor.
And finally, you get to see different group of
patients, the rich and the poor, the newborn and the centenarian, and of
course people from different ethnic groups. It is only in the emergency
department that one can learn how to take care of all these people (and
your very own family).
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