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The Most Fun I’ve Ever Had in the Emergency Department

AAEM PRESIDENT’S MESSAGE

Jonathan S. Jones, MD FAAEM

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nstead of discussing Academy business, challenges to our specialty, or new initiatives, I want to ask a question paired with my answer.

When and where was the most fun you’ve ever had in the ED? Fun may not be the most accurate word to use, but it fits the sentence. Replace “fun” with any word you would rather use such as rewarding, satisfying, enthralling, sincere, humbling, exciting, or whichever word you need most.

I recently asked this question of myself, not because I was bored, but because I was stressed out, burned out, tired, and perhaps a bit depressed. I (mostly) love emergency medicine and the Academy, but that does not mean everything is roses. The field of emergency medicine is continuing to face challenges and while addressing these is satisfying, it is a long process. The hardest working physicians in the world are still being taken advantage of by corporate entities.

And other professional societies and organizations are actively fighting to keep it this way. The Academy’s latest setback—we are now searching for a new lobbying firm since our current firm dropped us at the request of one of their other clients—The Emergency Department Practice Management Association (EDPMA). Ha! So much for pleasantries and working together. But more on that later.

Yes, I am frustrated and stressed out. And while I haven’t run my theory past a psychiatrist yet, it seems that when frustrated and stressed out, sometimes instead of doubling down on the problem, it’s best to focus on the positives and change the topic. So, I asked the question to myself, “What is the most fun I’ve ever had in the emergency department?”

I must have an answer to this, or maybe many answers. After all, I’ve been telling students

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What is the most fun I’ve ever had in the emergency department?’ I must have an answer to this…I’ve been telling students and residents for years that emergency medicine is fun. Was I lying this whole time?

and residents for years that emergency medicine is fun. Was I lying this whole time?

No, no I was not. Nearly immediately I knew I had not been lying because when I started to think about the most fun I’d had in the ED, it was difficult to narrow down to just one time.

There were too many great experiences.

Sure, I momentarily thought of some of those incredible chief complaints, those “accidents” which result in some foreign body, and the bizarre logic which at times has brought patients to the ED. No, these are all superficial.

I next thought of rewarding instead of fun experiences. Those patients who truly came in with minutes or hours to live and who days or weeks later were successfully discharged home. The hemiplegic and aphasic patient who hours later was talking normally. The CHF or COPD patient breathing 40 times a minute who was successfully not intubated.

The patient leaving the ED happy after a fairly benign visit but with a new understanding of their disease because no one else had ever explained it properly. Those babies I have delivered and handed to their new mother to hug for the first time ever.

I even thought of a patient that I treated on a recent holiday. After a good meal, he clutched his chest and collapsed. CPR was started and still in progress when he arrived at the ED. We obtained ROSC but with further investigation it was obvious that he had suffered a fatal injury. While his heart was still beating and his blood pressure was maintained, I knew that I could not save his life. I engaged with multiple specialists who agreed. But this did not end my care for him. In caring for him, I needed to care for his family. We had extensive discussions. It was hard for me and I can only imagine how it was for them. This was a horrible and completely unexpected occurrence. However, I think that I was able to help him and his family. There were questions and answers, hugging and crying, grief and resolution. As they left, we shook hands. When he passed, I know he felt no pain, dyspnea, or suffering of any kind. I think that I provided some comfort. I hope I did. This was certainly not fun, nor good, nor rewarding. I’m not truly sure what word I would use to describe how I felt. I do know that this encounter came to mind when I was trying to think of the good things about emergency medicine. Bad things happen in this world and death is ultimately

AAEM PRESIDENT’S MESSAGE

unavoidable, but that doesn’t mean we can’t help, at least a little.

We each have had so many experiences in the ED. Some negative for sure, but many more positive, at least in some way. So many thoughts were coming into my head about things I liked about EM, I was struggling with a way to wrap them all together. And I instantly knew the answer to that…the Mississippi Delta.

A little over a year ago, I started doing some Locum Tenens work in the Mississippi Delta.

In case you’re not familiar with this part of the country, I’ll provide a bit of background. First, the Mississippi Delta is not actually a river delta. Yeah, when I first moved to Mississippi, I figured the Delta was in the south, you know, where the river deposits sediment in the Gulf of Mexico. No, not at all, that is the Mississippi River Delta and is actually in Louisiana. The Mississippi Delta is the northwestern part of Mississippi and includes small parts of Arkansas and Louisiana. Its soil is incredibly fertile and its people are incredibly poor. In fact, it is often ranked as the poorest part of the country. And while there are lists of areas of this country with the poorest people, I’ve had a harder time finding lists of areas with the nicest people. But what I have discovered is that the Mississippi Delta would rank very high on that list as well.

I remember one particular shift from not that very long ago. I nearly always work night shifts at this location and started my 12-hour shift at 7pm. Walking in, I already smiled a bit to myself as I received a warm welcome from the nursing staff. We all know that any professional is only as good as their team, and I had a good team this night. And they were happy to see me. I’m not sure how good I am, but they couldn’t stop talking about how happy they were that I was on shift tonight. It may have something to do with the fact that it is rare to have a true board-certified emergency physician on shift. Regardless of the reason, it sure is nice to walk into a shift with smiling faces.

were a few sign-outs, mainly waiting on labs or CT results. The hospital was once fairly large, and physically still is, but now only has a grand total of twelve inpatient med/surg beds, plus a fairly busy OB service. We typically have no specialty services but have a friendly hospitalist and OB/GYN. There is also one incredibly nice general surgeon, but only if it happens to be Wednesday. It was Monday.

Patients here are different than at the large urban centers where I’ve typically worked.

Yes, it’s a generalization, but they just seem more straight-forward. Not their medical cases, but their histories. They work hard and when something doesn’t feel right, they simply tell you. There are almost no ulterior motives. I see more people wanting to get a doctor’s note stating it is OK for them to return to work than I do asking for work excuses. They don’t come in with a diagnosis and treatment plan in mind, they simply explain their symptoms and ask my opinion. They are nearly universally thankful for whatever advice and treatment I can provide.

This was a typical Monday night shift, busy but not unmanageable. In a 12 hour shift at this hospital, I’ve seen anywhere from 14 to 40 patients. I’ve admitted anywhere from zero to five, but I often end up transferring more patients than I admit given the lack of local services.

As most of us know, the most frustrating part is nearly always arranging the transfer. Luckily, there is an excellent pediatric hospital about an hour away which has never refused any of my patients. Similarly, transferring acute strokes, trauma, or STEMIs is handled very well and is quite easy. Everything else…not so much.

This evening I had a patient with a Type A aortic dissection. Amazingly the patient was fairly stable and controlling his blood pressure and pain was the easy part. Finding a place to transfer him was the hard part. We called dozens of larger hospitals and were repeatedly told their thoracic surgeon was out or they didn’t have beds. Previously, in situations like this, I would end up contacting the state’s only >>

I walked outside as I try to do this time of the morning to watch a Mississippi Delta sunrise. It was quiet, a little bit cool, and beautiful.

I thought about people and the good they can do.

This hospital ED has ten rooms and usually at the start of night shift they are full or nearly full, just as they were on this evening. There

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AAEM PRESIDENT’S MESSAGE

academic medical center for assistance. However, Mississippi’s only academic center has been so bogged down with bureaucratic processes that they basically don’t accept any transfers. The system in place even precludes me from merely speaking with a specialist.

While I was treating other patients, one nurse kept trying. She finally told me that she found an accepting physician and hospital. I was thrilled… until she told me that it was in St. Louis, Missouri. Needless to say, that was not really great news. I called back one of the large community hospitals which had initially refused the patient due to capacity issues. I ended up speaking to the thoracic surgeon and explained the situation.

He agreed that transfer to Missouri was not appropriate. He also agreed that bureaucracy should not cost a patient his life—exceptions must be able to be made. He accepted the patient and even thanked me for calling back and not transferring this patient to St. Louis. All of this at about 3am.

The other interaction which made an impression on me was an elderly woman with a small bowel obstruction secondary to an incarcerated hernia. She was accompanied by her even more elderly husband and despite her condition, they were both incredibly happy and thankful for anything we could do. I was able to get her accepted at a hospital a little over an hour away, not too bad really. But I thought more about her as a person and her husband. Neither of them drove and they had no other local family. I knew we technically didn’t have surgery at this time, but I called the local surgeon despite this.

His reply was fairly close to, “No, no, don’t send her to Oxford. Keep her here and I’ll take care of her. I know I’m not on call but I don’t care. Call me 24/7/365, sometimes I can’t help, but if I can help a patient here, then I will, that’s why I’m here.”

By now it was a little before 6:00am and the ED was empty. I walked outside as I try to do this time of the morning to watch a Mississippi Delta sunrise. It was quiet, a little bit cool, and beautiful. I thought about people and the good they can do. I thought about the hard-working patients I treated over the night. I thought about the two doctors who technically had no obligation to work or to help a patient but who also had absolutely no hesitation in doing the right thing.

Doing a little Locums work can be refreshing. For all its challenges, rural America is amazing. Systems and bureaucracy can be frustrating, but people are good. While Robert Johnson may have had to sell his soul about half a mile down the road in this Mississippi Delta town for success, all I had to do was show up, smile, and try. Rural EM is rewarding, refreshing, fun, and even has better sunrises. It can renew your excitement in practicing medicine. The Academy even has a Rural Medicine Interest Group and Locums Tenens Section to help you along the way.

Consider giving it a try. (Scan the codes below for more information.)

As we begin a new year, I urge you to think about the great things you have done and the many patients you have helped. And maybe even consider a change of scenery, I know one place where you would be welcome and rewarded.

Rural Medicine Interest Group aaem.org/get-involved/interest-groups

Locum Tenens Section aaem.org/get-involved/ections/lt

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