For Emergency Department personnel, a contagious disease scare is nothing new. But I’ve seen more concern, frustration, and fear among ED staff about Ebola than any other disease outbreak during my career. This one is clearly striking a nerve.
I know all of us in the ED have thought about it. What happens when a patient from some West African country stumbles through the Emergency Department doors, sweating, vomiting, and bleeding? They are going to die. Do we still risk our own lives by performing interventions?
And what happens when that person collapses and becomes unresponsive before even getting to an exam room? Do we jump in and begin CPR, or leave the person lying in cardiac arrest while we slowly and methodically use the buddy system to gown up according to CDC protocol?
We’ve all wondered.
We’ve wondered if it makes sense to provide care to someone who is lethally and contagiously sick. As one colleague stated, “Why would we send in good meat for bad meat?” Yet we’ve also wondered about the ramifications of withholding care – loss of work, relentless media coverage, and litigation, to name a few.
It doesn’t take long to realize that there is no good answer. This, I believe, is why ED personnel are afraid and frustrated.
In a previous post (http://myerlife.com/?p=751), I discussed the reality that Emergency Department staff regularly expose themselves to all sorts of terrible illnesses, risking their own health and well being in an effort to care for others. It’s a profoundly complicated situation, fraught with ethical and practical considerations, and raw human emotion.
I’m certainly not the only ED physician to have written about this type of thing. Especially now, due to the outbreak of Ebola, there has been an increased number of similarly themed posts.
As always, the public response to such posts intrigues me. Some people sympathize that ED staff must regularly risk their own safety and health on the job. But many others declare, almost angrily, that any doctor who so much as expresses concern about contracting severe illness from a patient is unethical – even worthy of criminal prosecution. Surprisingly, the commonly cited justification for this sentiment is the salary that doctors receive. Apparently, we doctors are living such an easy, high-roller lifestyle (I missed this memo), that we have to accept and expose ourselves to whatever comes at us no matter how horrible.
Per this logic, as super-rich doctors we have no right to express fear or concern. We are cowardly and abandoning our Hippocratic Oath if we hesitate when a patient with a lethal, contagious disease arrives on our doorstep. We should be scorned for taking into consideration our own lives and the lives of our staff. We deserve to be prosecuted if we act to avoid contracting an illness that would cause us to internally hemorrhage to death.
In the opinions of many, our paychecks make us something other than spouses, parents, children, friends, siblings, significant others, and human beings. We are just doctors who must unflinchingly go to the bedside of every patient. Even if it puts us at extreme risk. Even if we are inadequately protected and lacking appropriate resources. Even if we are aware that interventions will be futile. Because of our salary, we must fall on our stethoscopes.
It is true that in becoming a physician, one accepts a certain degree of risk. I’d even suggest that Emergency Medicine is a high-risk specialty. Needle sticks, typical disease exposures, violent patients, threats of litigation, and the long-term health consequences of stress and shift work are just a few of the unfortunate, regular realities of the job.
I entered the medical field knowingly accepting debt and such risks. I did it for the practical reasons that it was an interesting and challenging career, and a way to obtain job security and make end meet. I also became a doctor because it satisfied the less tangible parts of me – the desire to serve complete strangers by assisting them in times of critical need.
But being a physician is not a suicide mission. At least, in my opinion, it shouldn’t be.
With Ebola, unlike diseases we are used to, not much is known. We know it is contagious, but beyond that we have only contradictory “evidence” and arguments over semantics. We know that it is currently uncontained and spreading exponentially in certain parts of the world. We know that it kills a very high percentage of those infected – far higher than the flu, for comparison – and does so in a horrific manner. And we know that people from badly affected countries are traveling to other areas of the world every day.
So why, given Ebola’s degree of lethality and mystery, do so many people still fiercely condemn doctors for expressing concern or hesitation? Is it possible that this is actually about something other than doctors’ paychecks? Are these people afraid, too? Are they looking for reassurance that, were they to fall ill, doctors would care for them?
Ironically, these demands create the potential for the obvious Catch-22. If we require those on the front lines to care for everyone, no matter how ill or contagious, and without regard for the benefit-risk ratio of interventions, medical providers will more likely become ill themselves. It is then possible that the people who demanded that doctors treat everyone will be left without anyone to care for them. We got a hint of this when two nurses fell ill after caring for an Ebola-stricken patient in Texas.
As real-time lessons are being learned with Ebola treatment in the US, certain things have been improved. Leaders recognize now that not every hospital should be expected to admit and care for Ebola patients. “Rush to your local Urgent Care or Emergency Department” is being acknowledged as reckless advice. Centralized call centers are being discussed. Designated transport teams and treatment centers have been established to assure that patients will receive care by those who are the most trained and experienced.
Yet being in the Emergency Department has not changed. Anyone can walk through those doors.
So we will continue to wonder.
Me: Hello, Sir. What brings you to the Emergency Department at three in the morning?
Him: I want an MRI.
Me: I see. Is there any particular reason that you want an MRI?
Him: Yes! I need an MRI!
Me: Okay. On any specific part of the body?
(Long silence. I wait. He waits.)
Me: Um, alright. I should explain that we do not do MRIs from the Emergency Department—or any test or intervention, for that matter—unless there is a medical indication. So I am still trying to sort out why you are requesting an MRI.
Him: Because something is wrong!
Me: I understand. Can you elaborate a bit? Tell me what symptoms are you having.
Him: I’m having everything! And no one has been able to tell me what is going on! (Angrily whips out a stack of papers) Look at these!
Me (Flipping through the mammoth stack of papers, which turns out to be his past medical records): Sir, it appears that you have had six MRIs in the past eighteen months. You’ve had your head, cervical spine, chest, abdomen and pelvis, your head again, and your lumbar spine all imaged.
Him: I know!
Me: And all of the MRI reports indicate that your tests were normal.
Him: I know!
Me: Sir, do you have a primary care doctor?
Him: Yes! I have an appointment to see her in the morning!
Me: Do you mean, later this morning? As in, perhaps, five hours from now?
Me (nodding understandingly): Sir, I have no doubt that something, indeed, is wrong. But what I would recommend is that you follow up with your primary care this morning, as scheduled. I think that will be the best course of action.
Him: I know!
Me: Very well. I am glad we are in agreement with this. Thank you for coming to the Emergency Department. Have a wonderful rest of your day, and I hope things get sorted out soon.
Him: (Grabs his stack of medical records with a smile, gets up, and walks out)
In a time when we’re forced to focus on how happy and satisfied our patients are almost more than anything else, this is an interesting commentary. Not necessarily a defined cause-and-effect, but a correlation that supports what many healthcare providers instinctively suspect – and it is certainly cause for pause:
“What’s all that yelling about?” I asked as I came out of Exam Room Nine.
A nurse glanced over her shoulder toward Room Four, then looked at me again and shook her head. “The patient in there is a bit upset.”
“Upset?” I repeated. “What’s she upset about?”
The nurse smiled slightly. “I’ll let you find out.”
I hesitated for about one microsecond, then my curiosity got the better of me. Grabbing my stethoscope, I headed across the Emergency Department for Room Four. I announced my presence, slid the curtain aside, and entered the room.
Sitting on the bed was a middle aged, slightly disheveled appearing woman. She seemed agitated and restless as she shifted about. Her pupils were dilated. Her teeth had not had the best of care. And she smelled heavily of cigarettes.
“Hello, ma’am,” I began with a professional smile. “What brings you into the Emergency Department today?”
“My chronic back pain is killing me, and your *&^#@#&* nurse tells me that you’re not gonna give me what I need for my pain!” she screamed in response.
“Ah,” I replied understandingly. “How long have you had back pain?”
I nodded my head. “And is there anything about your pain today?”
She nearly leaped off the bed at me. “No, you &*@#*@! I just need my pain meds!”
I retreated a few steps, just in case. “So, you’re out of your regular pain medication, I take it?”
“Yes! I ran out early, and my @*#*&*$ doctor won’t give me an extra refill!”
“Understood,” I stated. “I do want to make it clear that the nurse was right: we in the Emergency Department do not give out refills of narcotics for chronic pain.”
The woman looked like she wanted to strangle me. “But I need my oxymoron!”
I paused. “Your what?”
“My oxymoron! I want my oxymoron! I need oxymorons!” she began to shout.
I glanced over at the computer, where the nursing triage note was still posted: 48-year-old female specifically demanding “oxymoron” for her chronic low back pain.
I turned again to the patient. “Well, ma’am, I know that this situation seems pretty ugly. But this is the only choice I have. I don’t mean to be passive aggressive. However, policy—which is, in a way cruel to be kind—states that I cannot provide oxymorons to patients.”
The patient got up and stormed out. To this day, I don’t think she appreciated my creativity.
“I’m not really sure what to do for my patients in Room Three.”
I looked up at the PA. “Patients? You have more than one in the room?”
The PA nodded. “Yeah. A mother and father, and their two children. They’re…well, no one could argue that they’re not proactive.”
“Uh oh. What, exactly, might that mean?” I inquired, already cracking a smile.
“Well,” the PA began, starting to smile himself, “the family was watching TV together after dinner, when they saw on the news that there was a recall of milk in a town on the other side of the country.”
I leaned back in my chair. “Oh boy…”
The PA chuckled. “So, the family I’m seeing became very concerned that they might get sick, too. You see, they had a new carton of milk in their fridge. They had not drunk any of the milk yet, but they feared that it still might make them sick. So, the parents loaded the kids in the car and they all came to the ED to get checked out.”
“I see,” I said seriously. “They are worried that they will get sick from an unopened carton of milk, because they saw a story of people getting sick after drinking contaminated milk fifteen hundred miles away.”
“Yes. And, they brought the carton of unopened milk so that we can do tests on it, as well,” the PA added.
“Excellent,” I told him, shaking my head. “I will get out my STAT milk testing kit immediately.”
“Or, maybe I could just discharge them from the ED right now,” the PA replied.
“Hmm. Good thought. Maybe that is a better solution,” I told him. “And good work in there. Another life…actually, several lives…saved.”