Why Choose to be an Emergency Physician?
Early in my career as a physician in the early 1970’s, I would moonlight working in emergency rooms at city hospitals in the deserts of West Texas. During that time emergency room medicine was still not considered a specialty. During the week I did primary care in my office practice in a small oil town called McCamey, Texas and on some nights on weekends I would work in ER of city hospitals of Odessa and Midland for a company called Emergency Medical Associates.
Working in the ER is hectic, and unpredictable too, as you usually can’t anticipate what kind patients you’ll see in a day. For all personnel, it’s important for to be adequately prepared for patients who enter the department with a variety of issues.
Emergency Room Healthcare Safety Net
The ER is open 24/7 to care for all patients the come in for any type of medical problem. By law in the US everyone who presents emergency department for medical care receives an appropriate medical screening examination, stabilizing treatment, and may be admitted or transferred to a higher level of care facility or discharged, regardless of their ability to pay.
If you go to ER to seeking medical care and are refused to be given an evaluation and treatment, that violates the EMTALA (Emergency Medical Treatment and Active Labor Act). The physician, and the facility are subject to civil penalties of $25,000 to $50,000 per violation, lawsuits for damages, and/or exclusion from Medicare.
Before gave I up fulltime ER work I was a partner owner of an all board certified 23 physician group and our billing consistently showed only a third of patients had insurance. Many of those uninsured would have had trouble finding medical care else where.
Evolution of Emergency Medicine Specialty
I have practiced emergency medicine for the last 37 years. The specialty has evolved from employing physicians who did not have any formal residency in emergency medicine, the only requirement was just a license to practice medicine. Then physicians were eventually required to have Advance Cardiac Life Support, Pediatric Life Support and Advance Trauma Life Support certifications and have to periodically re-certify. Eventually Hospitals required Emergency Board Certification for physicians to work in their ER.
For me emergency medicine has been a challenging career, also exciting and satisfying. Challenging for having to keep up the dynamic changes in the emergency care and the need to have a broad knowledge base in deferent areas of medicine. To me, being an ER doctor is the exciting and I enjoy fast-paced environment the work offers. Doctors’ shifts are often busy, and we see many types of patients every day. This keeps our work interesting, diverse and exposes us to new situations every day.
Another I like with emergency medicine is being able to get medical tests results immediately, to aid you in the care of patients. Being able to interact with various specialties when you need their help, keeps you updated with current trends. Early in my career there were no diagnostic ultrasound, CT scan, MRI scan, angiograms and other diagnostics procedures now available 24/7 in the ER. We then had to rely more on the history and physical findings. Now the in digital age we have aid of the virtual medical libraries and artificial intelligence assisting the physician in electronic medical records guiding us with prompts.
Even nurses working in ER these days have to specialize in emergency nursing. Nurses, physicians, and other paramedical personnel in the ER are trained to identify medical emergencies that need to be promptly to attended to, to help save the patient’s life. Having these people as a part of your team makes it easier to care for your patients. Early on, I have learned to respect and recognize them as an important part in patient care.
Through the years, protocols are developed modified consistent with evidence based medicine in the care of patients . These help us intervene early, to save lives in patients with life-threatening health issues. When I started ER practice, when a patient presented with a heart attack there was not much we could do except give pain medications. Now we have medications to treat life-threatening complications or even reverse the attack.
Then came the use of clot busters to reopen obstructed blood vessels that cause the heart attacks. These days, heart attack patients immediately are taken by an interventional cardiologist to the Cath Lab for angioplasty and stent placement. The term “angioplasty” means using a balloon to stretch open a narrowed or blocked artery. However, most modern angioplasty procedures also involve inserting a short wire mesh tube, called a stent, into the artery during the procedure. The stent is left in place permanently to allow blood to flow more freely. This saves heart muscles, and many times they are able to be sent home the next day and resume normal activities.
Clot busters (thrombolytics) and angioplasty with stent placement are used too for acute strokes due blood vessel obstruction. This needs to be given within four and a half hours of the onset of the patient’s stroke symptoms. In some circumstances, the patient’s doctor may decide that it could still be of benefit within six hours. However, the more time that passes, the less effective thrombolytics will be. So it’s important to get to the hospital as quickly as possible when your symptoms start.
I remember a patient that came in for headache, weakness of one side of the body and slurred speech. A CT scan of her head was done immediately, and showed a bleeding stroke (cerebral hemorrhage) which was creating pressure to the brain. When she came back from CT scan, I noted that she was less responsive. I immediately called the neurosurgeon on call, who, fortunately, was at the hospital. He was young, a new member of the hospital staff, and was just out of training.
He came and accessed the patient and her CT scan. He said he needed to do a Burr Hole procedure. Burr holes are small holes that a neurosurgeon makes in the skull, These are used to help relieve pressure on the brain when fluid, such as blood, builds up and compresses brain tissue. He asked me if I could sedate the patient, to which I said yes. He then requested that a burr hole tray from OR. He then shaved the patient’s head and clean the scalp with antiseptics. I then gave the patient intravenous Propofol enough to sedate the patient.
The neurosurgeon used a drill to burr a hole in the patient’s skull where the bleeding area was located. He then placed a small catheter into the hole and attached in rubber bulb suction to help drain the blood compressing of the brain tissue. Propofol is short acting sedative and general anesthetic. After a few minutes, when the surgeon finished the procedure, the patient was fully awake, free from the headache. Her one sided body weakness got better and she was talking normally. The change was so profound, like day and night. The patient was then admitted to ICU for further care.
Why do many ER physician get burn out
It is also exciting and satisfying witnessing dramatic reversal in symptoms in strokes due blood clots and heart attacks that responds to clot buster treatment. On the other hand, however, in the ED you will make lifesaving decisions that may not always result in a good outcome; you will bear witness to terrible trauma and illnesses in both children and adults. You will also have an upfront view into many tragic aspects of society that the majority of the population only hears about on the news, including gun violence, child abuse, drug overdoses, elder neglect, suicide attempts, intimate partner violence and sexual assault, as well as the short and long-term consequences of poverty, homelessness, mental disorders and substance use disorders. I have been assaulted by intoxicated and mentally impaired patients. This may explain why there is 3 times more burnout among EM physicians compared to other doctors.
While EM is an overall fulfilling choice of specialty, it comes with its own set of emotional, mental, and physical challenges. These stresses come from the pressure to quickly evaluate, treat, counsel, and disposition patients while also being held accountable for meeting quality metrics and improving patient satisfaction in a chaotic environment that can be made even worse when dealing with long wait times, patients suffering in pain, alarms ringing, and constant distractions. Emergency physicians must also deal with the physical effects of shift work, as their waking hours may frequently not follow a normal circadian rhythm.
The Bottom Line
- EM is a dynamic, exhilarating, ever-changing specialty that is best fit for those with strong interpersonal skills, a calm demeanor, and a desire to work as part of a team for brief, poignant encounters.
- Successful EM physicians are kind, hard-working and flexible, with a penchant for controlling chaos and tolerance of the emotional toll our role entails.
- The EM lifestyle allows for flexibility and portability, without being responsible for a panel of patients during off-time. Emergency physicians work hard when they are on duty and can play and plan when they are off.
- It is our privilege to act as a safety net and care for all who present to the ED.
If you ask me if I could start all over again, would I choose emergency medicine specialty? The short answer is YES.
“People have access to health care in America. After all, you just go to an emergency room.”
