February 6, 2019

Fellow’s Corner

Dr. Evan Chong

Third year family medicine fellow in care of the elderly, Toronto, Canada

“Geriatric emergency medicine is really hard” – that was one of the last things I said to Dr. Melady at the end of our last shift together.  I’ll admit -- not my most eloquent moment, but I would say that the statement sums up my experience in the emergency department at Mount Sinai Hospital quite succinctly.   As a geriatric medicine trainee, my two-month rotation in the ED, where I focused on acute care of older people, taught me a lot about the challenges of this particular point on their continuum of care. 

First and foremost, my experiences in the ED were challenging from a medical standpoint. No case I saw was ever particularly straightforward, and even in my very last week there were plenty of challenging patients.

There were the patients with challenging acute presentations, superimposed on often complex comorbidities, such as the 87-year-old patient presenting with DKA who I attempted to manage initially with fluids -- only to push him into fluid overload. Then there were the patients presenting with relatively mild and non-specific symptoms, who looked well but ended up having serious underlying pathology, such as the 90-year-old with “just a touch” of intermittent improving abdominal pain and completely normal labs who was diagnosed with acute diverticulitis on imaging. Then there were the patients who sent you on a treasure hunt, like the 82-year-old with Alzheimer’s Disease presenting with delirium and no other localizing symptoms. Finally, there were the patients who didn’t really have any acute medical needs, who for various social reasons either couldn’t or wouldn’t go home, such as our 80-year-old patient with shortness of breath and COPD who was on appropriate therapy for an exacerbation and was ambulatory and maintaining her saturations throughout her stay in the ED.

In order to be properly managed, all these patients required my time and attention, in addition to my knowledge of geriatric emergency medicine principles. And I have great respect for all emergency physicians who do this type of work every day while still managing the rest of the department.

But overall, my experiences in the ED were also challenging in a personal way, and this rotation forced me to think and work in a way that was different than what I am used to doing in the ambulatory setting.

For one, I had to bring back the acute medicine mindset; the mindset that looks at a patient and immediately thinks up of the broad differential and lists the top three potentially dangerous diagnoses that could have led to this presentation. That part of my brain has not exactly gotten worked that often in the outpatient geriatric setting. On top of that, I had to practice bringing out the “bad cop” to my usual “well-mannered, pleasant and charming good cop”. Whether it was to advocate for my patient with other specialties, or whether it was to say no to sometimes unreasonable patient requests, I learned sometimes you needed to be a bit bolder. For me it’s clearly a work in progress, and I don’t expect a monumental shift in the core of my personality to occur any time soon, but it was certainly a valuable lesson for me to learn as I start my career.

So yes, I stand by my statement that “geriatric emergency medicine is really hard”. And yes, as I’ve discussed with Dr. Melady, it’s unlikely this will be a significant part of my career moving forward. But at the end of the day, doing this rotation allowed me to step out of my comfort zone and see geriatric medicine from a different perspective, and for that I am grateful.