A rather painful ER shift. I had to call some surgical consultants, and they were less than thrilled, to put it mildly. My colleagues acted as though the fact that I am a surgeon ought to prevent me from calling other surgeons into the ER. On the other hand, when I tried to make a surgical assessment of a patient and act on it (giving pain meds to someone whose pain I thought was clear enough to warrant an immediate surgical consultation, but who then became pretty comfortable by the time they got to the ER), they weren’t happy with that either. So I’m just a little bitter with the guys who I thought were my friends for getting so uptight on me. I tried to play it as some ribbing back and forth, but they wanted to take it farther than that. This is the first time that I’ve really felt I’m not able to play the men’s game by their rules. I guess I just need to stop thinking about this in personal terms.
As for the clinical question, I’d welcome opinions on the subject of giving pain medications in the ER before the surgeon evaluates the patient. It serves me right, actually, because a few months back I gave another ER resident a hard time (jokingly, I thought) for doing the same thing, and he fiercely quoted me some literature articles (such as this one) decrying such an inhumane practice. I think perhaps one might avoid inflicting too much suffering on patients by distinguishing between community practice, where it might be an hour or two before a surgeon gets in to the ER, and academic practice, where the surgery residents make it a point of pride to evaluate any consult within ten or fifteen minutes.
Either way, I was insulted that the surgical team wouldn’t trust my evaluation of the patient. My physical exam skills haven’t been changed by the fact that I’m working in the ER this month. I’ve been laughed at enough times for taking abdominal pain seriously when it isn’t that I think by now I have a good idea of what constitutes “severe abdominal pain” for a surgeon. When surgeons say severe pain, or a rigid abdomen, they mean they want to go to the OR now. If that’s not your management plan, then the patient’s belly isn’t that bad. That’s why we don’t appreciate it when medicine consults us for “acute abdomens” in patients who are sitting up, talking, and drinking. The ER attendings, on the other hand, are frustrated at me for discounting abdominal pain of the gastroenteritis/pregnancy/peptic ulcer variety. So I know the difference between serious pain and non-surgical pain. (A surgeon at my medical school described it best. She said, “If the patient makes any movement quickly and easily when I ask them to, it’s not an acute abdomen. With real peritonitis, the patient won’t move unless they absolutely can’t help it.”)