In the Arena: Take a Deep Breath

ACEP News
December 2009

baehrenBy David F. Baehren

Possibly I was just paying attention more than usual, or it was just the odd collision of random events that flashed a bright light on our existence as emergency physicians. During a busy evening shift, I encountered two events that made me look both inward and outward to gain a better understanding of what we do and how we are viewed by others.

I received a phone call from a prominent person (more in his own mind) at my institution to tell me he and his partner would be arriving soon for treatment of his colleague's back pain. I told him we would leave the light on for him, and I proceeded to care for the sick and those who think they might be sick.

When I finished suturing the victim of a kitchen mishap, I learned that royalty had arrived 10 minutes prior, and they awaited me.

I made a quick note in the EMR, answered two phone calls, and discharged the boy with the laceration. To his highness, it seemed that I was doing nothing at all, when in fact I was providing important discharge instructions, speaking with the radiologist about a carotid aneurysm, and accepting a patient with a crushed hand in transfer from an outlying hospital. I actually packed quite a bit into those 5 minutes.

However, to this person--who should know better--I was sitting on my butt.

You can imagine the tirade that followed, with the threats to make trouble for me, and the storming off to radiology to handle the problem himself. At moments like that I recall the scene in "Top Gun" when Maverick has created trouble and his co-pilot, Goose, suggests to him that they could consider going to trucking school.

At the time, I was angry--and I even told this doctor that I thought he was being a ... well, you know. Believe it or not, that did not help. Who knew?

While it was satisfying at the time, I later remembered the sage advice of Dr. Sam Kiehl: Don't let someone's actions dictate your reaction. That piece of wisdom has served me well over the years--except, of course, when I forget it.

Not long after that wonderful experience, a breathless nurse asked me to check on the quite elderly man in Room 9 who had a sudden turn for the worse. He had arrived intubated earlier in the evening and was awaiting ICU admission. The man had taken a large overdose of sedatives and pain meds and had been stable on the ventilator. The physiologic stress was too much for him, and he developed v-tach.

When I had spoken to his family earlier, I learned that the man did not wish to be resuscitated. So there I was with my hand on his chest, one eye on the monitor and one on his wife. A classic v-tach wave form clipped along. The family was remarkably calm. Normally, I like to have more than 20 seconds to decide whether to resuscitate a suicidal man who has stated in writing that he does not desire what I have to offer.

There was no time for an ethics consult, or even to run through the ethical ABCs. On one hand, I thought that he had been treated for his overdose and this was a separate, but tangential, issue. On the other, I felt that there was a direct relationship to his suicide attempt. On one hand, there was patient autonomy, and on the other the caveat about wanting to commit suicide.

Intellectually and ethically, I could have gone either way. I asked the family what they wanted to do.

After a brief discussion, they asked that I let him die.

The patient died soon after, and the coroner came to see him because he was already there investigating a cardiac arrest from a few hours before. I read the man's obituary in the newspaper days later.

I thought about both of these events, and I came to the conclusion that, even though emergency medicine has been a specialty since Carter was president, people (and doctors) still have no clue about what we do.

How strange it was to have to deal with someone spitting mad over waiting an extra 5 minutes to be seen for muscle pain, and soon after that having to make a life or death decision in the time that passes to take a deep breath.

Emergency medicine has been, on many levels, an enormous medical success. What specialty would not want the explosion of patient volume that has occurred in the past 20 years? Except for the part about nobody having to pay, emergency medicine is a winner on all counts.

The public knows very well that even if they have to wait, we deliver fantastic care.

Something hasn't been conveyed well enough, however, when many people (and doctors) still don't understand that a wait for many of the patients we see is a microsecond. It means nothing.

They also fail to understand that for a few patients, 5 minutes is an eternity. It means everything, and everyone else must wait while we attend to these patients.

We still practice in a world where specialists descend from above and bark orders like we are their indentured servants. Who do they think they are, the federal government? An emergency physician would never walk into the operating room or the office of another physician and think that they could tell another physician what to do.

It could be that, after 30 years, we can conclude that all the education and marketing we can muster will not overcome arrogance and selfishness.

There will always be those, with and without letters after their name, who will never understand what we do--but will still demand that we do it on their terms.

Dr. Baehren lives in Ottawa Hills, Ohio. He practices emergency medicine and is an assistant professor at the University of Toledo (Ohio) Medical Center.

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