Another problem with the ER is that, for me at least, when I have flashes of intelligence and diagnose things correctly, it’s usually bad for the patient. I’m learning to think like a surgeon. I don’t really go in for musculoskeletal issues, or psychiatric issues, or bread-and-butter family practice things like allergic rhinitis and irritable bowel syndrome. When I see a patient, I tend to say either, “this patient seems sick; I can tell that there’s no need for surgery, so I’m not sure what else could be wrong,” or, “this patient isn’t sick; either they have gastroenteritis or a viral sore throat.” Those seem to be about the only benign diagnoses that I can remember from medical school. Surgical causes of abdominal pathology I can tell you in detail, but somehow my attendings in the ER aren’t too thrilled with that kind of differential. “Come on, Alice; just because it’s not surgical doesn’t mean it can’t exist.”
So when it’s not surgical and I do get the diagnosis right, it’s something bad: lung cancer; brain cancer; hemorrhagic strokes; subarrachnoid hemorrhage.
I also give my attendings histories like, “the patient is fairly demented and can’t recall what medications they’re on or what medical problems they have, but by looking at them, they’ve apparently had at least one CABG (coronary artery bypass graft), a fem-pop (femoral-popliteal bypass), an open cholecystectomy, and some kind of midline incision, either colon cancer, or AAA (abdominal aortic aneurysm) repair; or maybe small bowel obstruction.” To which the answer is, “that’s a very nice surgical history; but the complaint is altered mental status with underlying dementia, and I don’t think their history of vascular disease is very relevant. Go get a urine sample and a chest x-ray.” (ok, yes, there could be a stroke from vascular disease; but you get the point)
I also tend to confuse consultants. Neurology comes down to see a possible stroke patient, and gets very concerned at seeing a surgeon outside the door. I have to cover up my coat’s embroidered identification, and explain that I’m masquerading as ER for the month. The hospitalists, similarly, are wary of admitting an elderly lady with reported viral gastroenteritis and severe dehydration, when they find a surgeon in the vicinity. Did it suddenly turn into a small bowel obstruction? In which case they’ll stay out of the way. . .
At least I’ve gotten over my med school stunt of trying to diagnose every single abdominal pain as appendicitis.