I am an Emergency Physician. This means that I am a doctor who has specialised in the care and management of undifferentiated, emergency medical issues. In other words I work in an Emergency Department and I am expected to handle whatever comes through the doors.
As a rule doctors are becoming more and more specialised. As they gain experience they narrow their field of expertise tighter and tighter, so they are not just surgical doctors who operate on bones, but they become surgeons who just operate on one particular joint, and in some cases one particular operation on one particular joint. They are not just medical doctors who specialise in problems with the heart, but specifically on problems with the electrical conduction system of the heart, and in some cases one specific treatment for one particular abnormality of the electrical conduction system. Generally it is a career where knowing everything about a very specific thing is encouraged and highly respected.
Which may explain why the Emergency Doctor has a bit of a bad reputation. We are the jacks of all trades but crucially the masters of none. We are merely triage nurses who just pass the buck on to another doctor who actually knows what to do about it. We are the sad department who rarely get thank you cards or boxes of chocolates as we are a mere few hours in a patient’s overall journey and therefore not that worthy of thanks. My own father recently passed through the resus room of an Emergency Department as part of a hospital stay which included many other specialist areas. They all got chocolates afterwards, but even the father of an Emergency Physician forgot to say thanks to the ED.
So, if we are so inexpert, what is the benefit of an Emergency Physician? Why have us at all? For a start we take those patients who are at their very sickest, and we commence immediate treatments and investigations which not only keep people alive, but also hopefully start to improve them whilst we work out which of all those specialists that patient needs. The majority of patients do not come in with a banner saying ‘I have a dissecting thoracic aorta which needs immediate surgical intervention from a cardiothoracic surgeon.’ Instead they can come in with chest pain, abdominal pain, confusion, shortness of breath, arm weakness, facial droop, agitation, and in one memorable case was booked in as a panic attack. They tend not to have a banner saying ‘I have a urinary tract infection and need some antibiotics’ but instead they can have tummy pain, back pain, diarrhoea and vomiting, a fall, increased confusion, not walking very well, irritable. We try to pick apart all the pieces of information the patients give us, sometimes their family and friends give us, our investigations give us, and we reach the best conclusion we can as to what is causing the problem. All within less than four hours whilst trying to look after multiple other people at the same time.
We look after people with a cut finger who needed a plaster, and people who turned their ankle and then it hurt a little to walk on, and people who have been in high speed road crashes and have limbs hanging off. We look after people with colds and people with pneumonia and people with respiratory failure and sepsis who need ventilators and tubes everywhere and potentially months in intensive care units. We look after people who have had a shitty day and they’re feeling sad, and people who have taken a few pills because they feel their life is rubbish and they took some last time it all got too much and the time before that and the time before that, and we see the people who are floridly psychotic and need heavy duty medications and a long period of inpatient psychiatric care. We see people who bumped their head and feel a bit sick, and people who have sustained small bruises to their brains which will fully recover and people who will never feed themselves again due to the big bleed inside their skull. We see people who had some indigestion after a big meal, and people who have a narrowing in one of the blood vessels around their heart, and people who are in cardiac arrest and we need to pump their heart for them. We see people who have had too much to drink and need to sleep it off, and people who need careful monitoring of their heart because of some pill their friend gave them, and people who will never go clubbing again because of whatever that pill contained. It may sound obvious from my descriptions but sometimes the very hardest thing is knowing which end of this spectrum of illness the person sat in front of you is actually on, who can go home safely and who urgently needs further inpatient medical management.
We do this every single day of the year, including weekends and bank holidays. We do this in the evenings and at three o clock in the morning and as the sun is rising. It is not a job with ‘sociable hours’ and is definitely not 9-5.
But man I love it. I cannot imagine anything else I would ever want to do. There is nothing in the medical world that is so varied. We are often responsible for the most sick person in the hospital, whilst also the least! There are opportunities to always be learning, always seeing something new for the very first time and gaining a new skill. We can help people through the worst days of their lives and also see the very best qualities that humanity can show. It can be intense, exhausting, terrifying and at times desperately sad. We have the most awesome team and the camaraderie is intense. We are a very varied bunch but it certainly takes a special person to work in this specialty, particularly for a whole career.
Recruitment and retention of staff tends to be a real challenge. A lot of junior doctors will do a spell of four or six months in the ED at some point in their life. They usually feel pretty out of their depth, not use to the speed of work, the multi-tasking, the constant decision making and the badgering from all sides to make a plan for their patient. They are often seeing a range of conditions that they just haven’t experienced in any other part of their training. It is one of my roles to help support them through this. Some of them love it and some of them you can feel the misery and hatred radiating from them at the start of every shift, and the joy when their sentence is over and they can rotate to a new specialty which makes more sense. Of those that love it, they often make more ‘sensible’ career choices when they choose their final specialty. They choose something with shorter shifts, more daytime, weekday hours, less on calls, less pressure when they are at work, more work-life balance as they perceive it. They may always look back on their ED days fondly, but not fondly enough to regret their choices. They may choose to enter Emergency Medicine training but as part of this they must also spend time in anaesthetics, intensive care and acute medicine, and they may realise how nice it is focus on one patient at a time, have a robust support system, have time for teaching and personal development, have slightly more sociable hours. There is a big drop-out rate from the EM training programme.
Once qualified as an ED consultant there is then the issue of making it a sustainable career and avoiding the dreaded ‘burn-out.’ I am definitely thinking ahead to my fifties and potentially sixties and how I can combine the specialty I love with other work which will give me the chance to breath, and keep a manageable career. That’s if I live that long… There is an infamous paper from the British Journal of Cardiology saying the average life expectancy of an ED doctor is the shortest of any specialty at just 57.5 years, compared to GPs with the longest at 77.3 years! There are statistical issues with the research to be fair, but it is still an alarming finding.
So, that is what I do to pay for the roof over our head and the food on our table, and I would highly recommend it as a job to anyone who is interested, but go in with your eyes open. And for any of you who may find yourselves in an Emergency Department unexpectedly some time, we are doing our best under difficult circumstances, and an occasional thank you card goes down a treat!