I’m getting a little more efficient at this ER thing. Today I admitted several patients very rapidly, rather to the admiration of the attending. I even managed to sell one patient to hospitalists who on the face of it ought to have been on a surgical service. But his story was crying out for an in-depth medicine work-up, the kind where you send off a dozen arcane tests including several hormones, and do all kinds of weird imaging tests in order to diagnose a very specific problem. Even in the middle of the night and to my surgical mind it looked like a fascinating problem to explore; and the hospitalists were happy to bite – to the delight of the surgical service and the ER attending.

I’m still not quite on top of the basic ER approach to problem-solving, though. Usually I’ve been taught to order the simplest and cheapest tests first, and then, if those don’t show a good solution, proceed towards more expensive and complicated tests. The ER doesn’t work like that. At the first shot, you order everything you can imagine being relevant, so as not to waste time by going back to repeat yourself later on. Your initial assessment should take only a few minutes, and at that time you should send off every lab, and do basic imaging like xrays and ultrasounds. An hour later, the labs will be back, and you can proceed to either discharge the patient, sell an admission on the basis of a complete set of labs, or do CT imaging. Fortunately, the nurses know this, and I will often find tests that I didn’t order showing up because the nurses knew I would regret it later if they weren’t sent.

It’s pretty painful to watch the surgery teams coming down to admit appendicitis cases, vascular surgery issues, and small bowel obstructions, and be left on the outside. Even though I’m getting the hang of moving things along quickly and selling admissions to reluctant buyers, I’d rather be on the surgery side.