Crozet Annals of Medicine: Many Hats

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Being an ER doc is not just a job, it’s many jobs. Dr. Amita Sudhir, an ER colleague,  pointed this out to me recently, and we explored it in a series of email exchanges.

AS: I didn’t know how many hats I was going to wear when I started this job. Some of them sit more comfortably than others, but they are all essential parts of being an EM physician. Here are a few:

Chaplain: in a recent documentary about emergency medicine, a physician describes emergency departments (EDs) as the cathedrals of the 21st century, because we are the last-resort refuge of many. It makes sense, then, that the ED doc must take on a pastoral role. No one teaches us how to do this in medical school, but sometimes the only thing there is to offer is comfort. You have to do it without knowing the religious background or beliefs of your patient or them knowing yours. And we have to do it in the blink of an eye because there are dozens of other patients waiting for us, some of whom need what we have to offer medically. This role is most prominent in the death notification. We can explain the medical reasons for why someone’s family member died, but in the end, they often only want to know if they suffered and if they could have done anything to prevent it. Survivor’s guilt is a powerful thing and anything we can say to prevent its onset is helpful.

RCR: This is hard-won knowledge indeed. In addition to ministering to patients and families suddenly going through the worst moments in their lives we also must shepherd our residents, students, and staff through these cataclysms time and again in ways that preserve their compassion and promote resiliency so that they can continue this hard work. In a previous column one of my nursing colleagues shared our “Pause,” a silent moment after a failed resuscitation, honoring the dead and acknowledging the feelings of the caregivers who must move on.

AS: Parent: Every so often, we deal with drunk college students. Most are over 18 so we are not allowed to let their parents know that their child drank “just a couple” of beers and ended up on a stretcher in an ED hallway. When they sober up and are discharged, we find ourselves in loco parentis, lecturing them about the bad things that can happen when they drink too much. And then there are the patients, many old enough to have their own children, who come in for a cold. Drink plenty of fluids and gargle with salt water, we tell them. “That’s what my mom said!” they exclaim with some surprise. Well, it turns out your mom is often right.

RCR: Well, when the parents get the ER bill there may be some explaining to do.

RCR: Bouncer: Once in a while a patient under the influence of alcohol or drugs will attempt to assault our staff. This gets the entire staff’s attention very quickly and in true ER fashion a team response occurs immediately to immobilize the patient safely, with many hands making light the work.

Also, Substance abuse counselor: See above.

AS: Nurse: Sometimes the simple act of getting a blanket or a cup of water for a patient makes all the difference in the world.

RCR: Friend: Some of our patients we know well and they come in from time to time with a quasi-medical complaint but really more just to have some social interaction. In their personal lives they are isolated by illness or personality disorders and have few other opportunities for human contact. They know all the doctors and nurses by name and joke with us as we go about our business caring for the other patients. Eventually we make up a quasi-medical discharge plan and off they go, refreshed, until the next time.

And, as usual in our exchanges, Dr. Sudhir has the last word.

AS: Clinical medicine is often satisfying, but sometimes frustrating. It’s good to remember that we have other roles as well. Hippocrates said the goal of medicine was to “cure sometimes, relieve often, comfort always.” It’s often the other roles that provide the most comfort (except maybe bouncer!), not just to the patient, but the physician too. (And generally, I leave the bouncing to Dr. Reiser and his martial arts skills.)

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