Tuesday, January 24, 2012

The job of the emergency resident...

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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