Thursday, March 22, 2007

More from the ER

I've discovered that some traditional rumors are false. Surgeons are supposed to be very difficult to consult and intimidating to talk to. But I've found that if you know the basics of your patient, and have a legitimate question, they are fine. The tough ones to consult are neurologists, or cardiologists. Surgeons basically want to hear "belly pain, blood in rectum, pulse." Cardiologists want all sorts of labs, and an exquisitely detailed accounting of the nature of chest pain before they deign to descend to the ER. At least in my experience. And this is from someone who wants to do cardiology. And neurologists? Oh, boy.

About ten days ago I consulted neurology for the first time in this hospital. The patient in question was experiencing severe pain in her hands, in a median nerve distribution. The pain had come on quickly, with no inciting event, and my attending and I were at a loss to explain it. She was a bit hyperreflexic on one side, at least in the large tendons, though I didn't check the Babinski reflex. (more on that later) She had no surgeries, no neck pain, no trauma. X-rays showed no fracture. Lab values all normal, except for an elevated ESR. The pain was, in the patient's words, as bad as labor pain. As she was crying and rocking back and forth while cradling her arms, I believed her.

At this point, I wanted to call rheumatology. There was some distal clubbing, and I was ready to start a scleroderma workup, but my attending wanted a neurology consult first. So I called the neurologist, and gave him my presentation.

I got reamed. The neurologist was not, to put it mildly, having a good day. The first words out of his mouth were "tell me a story and get in line." And at every point in my presentation, he either swore under his breath, or rattled off lists of obscure eponymous neurological tests that I should have performed. When I stated that the patient was bit hyperreflexic, but that I hadn't checked her Babinski, he reached boiling point. He spat something about "this case being completely inappropriate for an ER consult," and then got very silent. I finished my presentation quickly and asked if he had any questions, and received the reply "nothing pertinent!" When he got into the ER (seven hours later), he didn't speak a word, even to the attending, saw the patient, wrote admission orders, and disappeared. I still have no idea what he thought the patient had, and I thought this was one point at which I probably ought not let curiosity guide my actions.

This is my chiefest frustration with emergency room medicine. The concern is, in the words of one of my attendings, "to make sure the patient doesn't have the five worst case scenarios possible with his symptoms." Often, it isn't even that many. Once we rule out the two or three quickly diagnosable possibilities, we move the patient either back to the street or upstairs, where the real problem solving begins.

Obviously, I'm not destined for the ER. Good thing I matched to internal medicine, eh?


Judy said...

The neurologist who consults in our NICU is a fascinating person. We seldom have him come emergently, though, so perhaps he's in a better mood as a result. My major gripe with him is that he doesn't dictate his notes and it takes at least 3 of us to decipher them.

Can't have everything, I suppose.

medstudentitis said...

I have to say, internal drives me crazy and I love the fast pace and elimination medicine of the ER. Good thing I'm not going into internal!