What exactly does an emergency physician do?

I am an emergency medicine physician.

I save lives.

As an ER physician, my job is frequently misunderstood. A common question that patients ask is, “What specialty are you hoping to go into?” The misconception is that emergency rooms are staffed by cardiologists, internists, etc., who are trying to make extra income. That’s likely not the case anymore. Some also believe that we can take the place of their family doctor. Or that we exist to do whatever they demand because we are the ER. Even non-ER physicians have some misunderstanding of our qualifications, our duty, and our specialty.

Acute-care scenarios are why we exist — or why we train. That’s our expertise. Clearly, it would be disingenuous to proclaim we are masters of every organ in the body. Rather, emergency medicine (EM) physicians are masters of resuscitating the dying, the dead — stabilizing the sick. Take, for instance, my 50-year-old patient who suddenly dropped dead at home. He had suffered a heart attack severe enough to stop his heart. His first stop was through the ER, where I could get his heart beating again. I placed a tube in his airway to keep him breathing, led our team in chest compressions, electrically shocked his heart, and chose medications to keep his blood circulating. All of this must occur first before the cardiologist can unclog his arteries. He has to be alive before the cardiologist can make that difference.

Perhaps more recognizable for what we do are traumas. Recently, a 30-year-old driver hit a light pole and smashed his face on the dashboard. He was rushed to the ER and was losing vision in his right eye. We discovered that blood was quickly building behind his eye, and the pressure was making him go blind. I had to cut the ligament that supports the eye to release that pressure on the visual nerves or else he would go blind forever. All of this had to be done before the ophthalmologist could bring him to the OR.

All of these instances do seem straightforward, except when they are not.

I remember one of my first patients as an attending. He was sent from an urgent care clinic for antibiotics and fluids for strep throat and dehydration. As a new graduate, I thought this would be simple case. Then, I saw him. Something was off; something was wrong. His oxygen level was low-normal. His voice was deep and muffled. His energy level was flat.

He had much more than a simple strep throat; he had a pus pocket in the back of his throat that was impeding his airway. He was getting worse quickly; he couldn’t even swallow his own saliva. If he can’t get oxygen to his lungs, he will die. If I can’t get a breathing tube from his mouth to his lungs, I may have to cut his neck to do it. I phoned for help from other specialists, but time was running out. Thankfully, we did it.

ER doctors take care of patients — now. Our job is to rapidly diagnose, treat and decide what the next steps are. Our training dictates that we search for the bad and the really bad. Where others think it’s a strep throat, we think it’s a pus pocket that can block the airway. Where others think it’s stomach acid reflux, we think it’s a heart attack. On that same token, we can think in reverse and eliminate critical diagnoses.

Many times, we don’t know, and that’s OK. ER doctors aren’t afraid to say “I don’t know.” But we do have the courage to mobilize a team to help. We will make phone calls to consultants, social workers, case managers; we will do procedures that others can’t or aren’t willing to do.

But sometimes, these fast decisions are not so distinct. To save a life, sometimes we do nothing. An all too common scenario is the 70-year-old man with lung cancer that has spread to almost all his organs, whose family has called 911 because he is having trouble breathing. He can no longer walk, no longer breathe without an oxygen tank and no longer eat without a surgical tube.

He is spiking another fever and coughing up green phlegm. This is his fifth bout with lung infections this year. His quality of life is nil, and this time he says he’s not going to recover. Our options are to run the gambit — IVs, antibiotics, breathing machines, admission to the hospital for likely weeks. However, I ask what kind of medical care he would want at the end of his life. Would he want to stay in the hospital with these invasive interventions knowing he may not get better? Or at home knowing he may die, but with the ultimate goal of comfort? Ideally, these conversations should happen elsewhere, but unsurprisingly they don’t. So we do it. After a lengthy discussion with his family and him, he decided to go home, possibly to die surrounded by familiar faces and a comfortable home.

No patient is turned away. Not only are we mandated by law, we are mandated by conscience. Whether it’s the poor, rich, insured or uninsured, all patients will receive medical care. Sometimes, it may not seem like much; sometimes it’s a Band-Aid or a “Please follow up with your primary care doctor” — but, in fact, it’s much more. You have been evaluated by an EM-trained physician whose job is to evaluate you, treat you and determine if you need to stay in the hospital. Unlike other doctors, our job goes beyond a 9-to-5 office day. We are here every day, all day. Every night, all night. All year.

Hopefully, you will never need to come to the emergency room for any reason. But if you do, be reassured you are in well-trained, expert hands. We evaluate for emergencies. From simple to complex, we are trained for anything, anyone, at any time. That is what we do.

Edward Lew is an emergency physician. 

Image credit: Shutterstock.com

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