Saturday, June 30, 2007

IM VERSUS ER PART II

In my last post I responded to 911doc's post about the decline of primary care by posting a vignette I experienced which crystallized one hallmark of ER medicine nowadays: DISPO!

Clearly the ER mentality is that the workup and stabilization are NICE, but the mindset has become that of an over-educated administrator: ADMIT EM OR STREET EM! Once the decision is made, the job is done, more or less. ER residents are inundated with this advice from the moment they start residency.

I want to address specifically the complaint about these lazy internists/hospitalists upstairs and their desire for "completeness".

What does "completeness" mean? Does it mean we want EVERYTHING done? Does it mean we expect a diagnosis if admitted?

No, of course not. What it means is basically not STICKING YOUR COLLEAGUES WITH SCUT!!

I will illustrate with one of my favorite personal examples.

When I was a third year resident, a famous incident occured between the ER and our department. It was a particularly busy winter evening, and during the night, there were so mnay patients in the emergency room, you could hardly walk without stepping over someone. There was a tremendous pressure to get people upstairs (naturally) and of course there were NO ICU beds.

One younger, sick patient had symptoms typical of meningitis. However, the ER was so desparate to get people out, they had assigned a bed on the regular medical floor, DESPITE that no LP had been done.

The famous part of this story, is that the third year IM resident, who was the liason between the ER and the IM department, LEAPED ON THE GURNEY and refused to let them move the patient. The ER was aghast, and they would NOT do the LP or anything else for the patient. So this IM guy gowns up (even though he's busy as hell), does the LP, and guess what... PUS comes out of her spine. So of course she has to go to the ICU, and he REFUSES to let them send the patient anywhere else.

Can you imagine?

So that's a good example of where "completeness" might mean one thing to the ER doctor, and something else to an internist/generalist.

The point is NOT to criticize ER docs. Its to point out that the system isn't perfect. So STOP lamenting how primary care docs are responsible for all your ills. It's not so.

Part III in my next post, where I'll address the idea about what kind of patient gets referred to the ER from the office.

38 comments:

Anonymous said...

Anecdotal, for sure. Your residency must not have much in the way of a QI department. Using residents as the de facto standard of how EM is practiced is shallow at best. There are plenty of situations where IM residents f'd up royally. Or how they were pathetically inferior in procedural skills. Hell, I chiefed my senior resident on how to do LP's on my IM service! We're not here to discuss how screwing up is part of the learning process in medicine. Surely that would make IM the most learned practice.

Mike said...

Misses the point of the post. Its about "completeness". Read 911doc's column, and then my rebuttal.

Save the insults for some other site.

Rob said...

What does DISPO mean?

Mike said...

DISPO = DISPOSITION. It means either the patient gets admitted or discharge. No other treatment of patient is required after that. (In the bizarro ER world)

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