The Rewards

So much of emergency medicine is difficult.  It is busy, stressful, frustrating.  The fast pace causes us to close one case and move to the next without any time to reflect.  This morning I'm reminded of all the good things that happen in the ER.  These moments came and went so fast I barely let them register until now.  I need a dose of positive to keep me going.

Last week I had a young, nine year old boy with a eyebrow laceration.  He was a little nervous.  His dad wasn't helping.  The odor of marijuana in the room was a clue that this kid had it rough.  The next clue was when dad left the room to "make a phone call" and didn't come back for thirty minutes.  The kid said, "you can fix it while he's gone.  He makes it worse anyway".  So, I did.  Thankfully all he needed was a wound prep and some dermabond.  I talked him through the procedure as he started to tense up and whimper a little.  We sang a little song, we took deep breaths, we dreamed of big, juicy cheeseburgers.  It was over before he could be afraid.  His dad did finally come back and only said, "you didn't cry did you!"  As the little guy was leaving the department he turned around and ran back to me.  He gave me a huge hug and held my hand. 

It didn't take much, really.  He needed a calm, positive presence and reassurance.  Most families give this to their kids, but some don't.  They probably don't know how because they didn't have it either.  But in these random moments in an ER room, we can give this to a little child.  Will it change his life?  Probably not.  But he had a moment with an adult who was caring, supportive, and steady.  And this little child rewarded me with a hug that meant the world to me. 

It didn't take much, really.  I needed some positive reinforcement and reassurance that what I do can matter.  It can be a hug, a thank you, a kind word.  "That's it, you're done already? I thought that was going to be so much worse!"  Those words make me happy.  We ER people have to move so fast to the next thing that we often miss the positive.  It's there, it just takes a few minutes to remember. 

Thanks and encouragement doesn't come often.  How many codes have you been a part of when nobody says thank you? How many life saving procedures have you completed without a word of encouragement?  You can't 'expect a family in distress to remember.  Their day is way worse than ours.  Remember to give each other that word of thanks and appreciation.  We get it.  We know how hard it is to do this job well.  Be there for each other when nobody else can.


Truth and Love

One of the biggest problems with the customer service model is that it does not allow us to get to the root of the problems we see.  In the customer service model, the customer is always right, and they get what they paid for.  The reality is, in healthcare, the customer isn't always right.  People seek medical attention because the don't know what the problem is or how to manage it. 

Dr. Thomas A. Doyle wrote a summary of an ER shift in his blog for Emergency Physicians Monthly.  "In a single night I had patients come in for the following complaints (all brought by ambulance):  “Smoked marijuana and got dizzy”, “stung by a bee and it hurts”, “got drunk and have a hangover”, “sat out in the sun and got sunburn”, “ate Mexican food and threw up”, “picked my nose and it bled, but now it stopped”, “just had sex and want to know if I’m pregnant.” We have all had these patients.  He continues in his blog to make the point that these people don't need medical attention, they need to hear the truth that these symptoms will resolve without intervention.  They need to hear that their own actions are often causing the disease. 

This requires us to speak difficult truths to people that they will likely not want to hear.  People need to hear that weighing 250 pounds is likely causing their chronic knee and back pain.  Smoking will probably kill you it will just take some time.  If you drink too much, do drugs, engage in dangerous sexual practices, you are going to get hurt.  And it is true that behaving like you are in desperate need of narcotics often means you have a drug addiction problem.  Just because we invented illnesses like fibromyalgia doesn't mean it's real and it isn't an excuse to put everybody with depression on narcotics.  And no, vicodin isn't necessary for every dental pain, sprained ankle, and neck strain.

We have to be able to speak truth.  Truth is hard to hear.  As clinicians we have to speak this truth in love.  Being an asshole to someone who is obese, addicted, or one nugget short of a happy meal doesn't help.  We have to treat people with respect, compassion, and kindness.  Truth without love is more like a vendetta. Truth is not a license to vomit anger and frustration on someone else.  Healthcare providers need to frequently examine their own mental health to ensure we approach patients in the right attitude.

One the other hand, being loving without being truthful enables bad behavior.  Every addict has a co-dependent enabler helping them along.  When the customer service model of healthcare demands clinicians to give the consumer what they want, we are pressured to order CT scans when they aren't needed, obtain blood tests and give narcotics when we know the harm of these interventions will outweigh any benefit.  We have become the enabler.  

When we see medicine as ministry the goal of healthcare changes.  The goal is to help people be healthy and whole physically, spiritually, and mentally.  In order to be whole, we often have to do difficult things.  We have to say difficult things.  We have to confront our inner demons, start exercising, and go to a therapist.  We need the freedom as clinicians to talk about what people need, not what they want.  This may mean we have unhappy customers.  But what we're really after is healthy humans. 

Why didn't I start sooner

Do you know that feeling when someone at a party asks you to tell the "craziest thing you've ever seen in the ER"?  All of the sudden you can't remember anything.  You had a dozen stories from the day before yesterday but now everything just seems mundane and average.  Now that I have finally started to write about my journey in emergency medicine, I can't seem to recall anything interesting.

Well, now that I think about it.  There was the guy who had his penis diced up by his angry girlfriend.  When he came in for suture removal, all he could ask was, "when can I use it again?"  There was the guy found down in his backyard who had a gun in his back pocket.  We didn't realize this until after we started the code. There are the countless facial injuries and gun shot wounds from people who were, 'just minding my own business'.  And what about all the abdominal pains that are really STD checks.  That reminds me of the woman who came in for a staph infection on the inner thigh.  It was only funny when she wanted her visit billed as workman's comp because she worked as a dancer on a stripper pole.

The point is, everything we do in the ER is a story.  It's funny, tragic, frustrating, complicated.  Emergency medicine is complicated.  We love what we do!  Why else would be trudge knee deep through the muck of society's pain every day.  Our coworkers keep us going.  They keep us laughing.  Everyone needs a wheelchair derby on night shift every now and again.  Patients test our medical knowledge, our emotional fortitude, and our character.  But sometimes we meet a patient who changes our life.  Sometimes we make a difference in the world.  Sometimes we just survive ten more hours.

This blog is written to give voice to the emergency medicine clinicians who punch the clock every day and just so happen to change the world.  Most of the time we aren't even aware of it. If we were on the mission field, people would write articles about what we do.  But it feels average most days.  Well, it isn't average.  It's extraordinary.  What healthcare providers do in emergency medicine, every day, is nothing short of heroic.  

So, here's to my friends and coworkers who are also my heroes.  I am honored to be counted in your ranks.  I have admired people in the ER since I was nineteen and clueless.  I am still clueless but more aware of how amazing this job is. Thanks to all of you who show up every day.