First Shadowing Day in the ER

There may be nothing like a busy ER for the rush of constant, purposeful action. Every patient is a new puzzle, a medical and social jigsaw to be solved by the emergency physician. I saw it firsthand on my first shadowing shift with a third year resident at Roosevelt Hospital in Manhattan. Flowing from patient bedside to the flashing queue of tasks on the screen, from teasing out a cogent medical history to presenting that story to one's colleagues, the practice of healing in a crowded urban ED appears a chaotic synchronized dance.

This is not a purposeless or formless chaos. There is a distinct algorithmic cooperation operative in the Emergency Department. Like a school of fish swarming to bait, workers converge around a cardiac patient fibrillating on a bed. Charge paddles are charged and discharged. Patient recovers. The school flutters to the man choking on the fish bone or the other who's fallen from scaffolding.

Other moments are more sedate. They can be solved with a medication. This patient has a relapsing vertigo that left him immobilized on the sidewalk. His heart disease risk factors like high blood pressure and high cholesterol concerned us but his normal EKG and lack of chest pain or shortness of breath rule out a heart attack. That coupled with the way his feeling of the room spinning worsens when tilting his head forward or backward is classic vertigo, a problem of the equilibrium system in the inner ear. The resident orders an anti-dizziness medicine called meclizine and he perks right back up.

Certain patients drive home the need for health care reform in our country. One gentleman came in with some severe congestion due to allergies. The resident I was shadowing asks if he's ever seen his primary doctor about the issue. He has no primary care physician and no insurance. The resident explains he's probably one of the unfortunate working poor who make too much to qualify for Medicaid and too little to purchase private insurance. Another patient comes in with persistent rib pain due to a fall the previous week. They had done a thorough imaging workup (x-rays and a CAT scan) to rule out broken ribs or spleen laceration. The real problem was that he had run out of pain medication and couldn't afford the $20 it would take to refill it. We asked the ED's social worker for help but she said they don't help out with narcotics purchases, a reasonable policy for addictive drugs but little solace to our indigent patient. The country's Emergency Departments are the safety net for those who fall through the cracks of our dysfunctional health care system.

Though the velocity of patient turnover in the ER prevents the doctors from getting to know their patients on a personal basis, the pace and justice aspects of the job can be exhilirating. Like a a NASCAR driver taking the high banked curves at 150 mph, emergency medicine is all concentrated action and reaction with little time to reflect or interrelate. Emergency medicine is a field for those who crave the rush of immediacy. I wonder if it's for me.