Time in an Urban ER

Time flies when you're working night shifts, slogging through residency applications, and getting ready for boards, part deux. It looks from the record page of this blog that it's actually been three months since I've posted anything here.

An interesting three months...ditched my med school apartment (and insane landlord) in favor of a year "on the road" and all the adventure (and bad hospital and truckstop food) that entails. It's been fun, being unleashed on the world with no rent to pay and no kitchen to clean, but then again, it's gonna be nice to have my own place again next year, wherever that turns out to be.

The summer began with a month of shifts in an inner city emergency room. You may have heard in passing that there is a lot of bad heroin going around the East Coast. Not to imply by that description that there is "good" heroin, but this stuff is really bad, in that it is killing relatively young, healthy people. From what I've been able to gather, this particular brand of smack is laced with fentanyl, and/or coke, and/or speed, depending on your luck. (In case you haven't heard of fentanyl, it's a super-potent pain killing drug, usually reserved for surgical cases and cancer patients.) The problem with the fentanyl is that it seriously depresses a user's drive to breathe. That alone is killing people. Add to that the coke/speed, and you jack up the oxygen demand on the heart enough to crash almost anyone's ticker. Bad scene.

Another problem with this situation is that the standard line of questioning for a young patient presenting with chest pain is "Have you been snorting/shooting coke?" Nine times out of ten, if the person was actually doing the bad heroin described above, they have no idea there is more to it than meets the eye. Even in the rare case that the patient willingly 'fesses up at that point regarding the heroin, the ER staff is not neccessarily going to make the leap that it's causing the chest pain. (Not knowing this information doesn't drastically change an approach to chest pain of unknown cause, but it doesn't help.)

My other major memory of the ER is the tendency for good staff members to become pretty damned embittered. Because no one who presents to an emergency department can be turned away, far too many people use it for sore throats, pregnancy tests, and other BS reasons. One month was enough to make me a lot more skeptical than when I walked in, so I can imagine what a couple years or more does to people. It's a shame, because what ends up happening is that really sick people who walk in with vague complaints end up getting treated as malingerers and drug seekers. You can't blame the doctors and the nurses, but it's not a good situation for the patients.

Although this explanation is one sided, many staff members felt that hospital administrators use ERs as a cash cow, in that there is guaranteed cash flow from government reimbursements for the kind of uninsured, non-refusable ER patients I mentioned above. The ER docs I talked to thought the administrators were using these funds to prop up unprofitable programs in their hospitals and other pork barrel type stuff. You can imagine the kind of tension this created in the hospital. So, although I enjoyed some aspects of my time in the ER, I walked away grateful that it was not my life's dream to practice this kind of medicine.