It was my first year out of residency and I was working a night shift when a patient involved in a domestic dispute arrived by ambulance. She was stabbed multiple times with at least one injury to her trachea, and two others in the neck. She was awake but had air leaking out of her tracheal wound each time she exhaled or coughed. When I called a consultant to take her to the operating room for surgical exploration, the recommendation was that she be admitted to the ICU (by someone else) and optionally explored at a later time, if necessary. The tracheal wound was the equivalent of a “traumatic tracheostomy” and there was “nothing emergent” that needed to be done. After I spent the better part of 5 minutes explaining that this was a zone 2 injury of the neck and surgical exploration was warranted, the consultant relented and took her to the OR noting “fine, but I’m going to need another person to help with the vascular examination”.
A few things have changed in the management of penetrating neck injuries since that time, but the scenario has not. Emergency medicine is unique among the specialties and this encounter highlights one of the reasons. EM physicians frequently call on our consultants at all hours of the night, on weekends, and on holidays. Consultants may be tired or sleep deprived, and the tendency to dismiss findings and cut corners in that scenario is alluring. Vigilance on behalf of the EM physician is required to combat this issue as we evaluate the advice given.
- Dynamic EKG changes, now better, in a patient with continued chest pain. Cardiology recommendation was to admit to a primary team for stress testing…
- A compartment syndrome who the orthopedist asked be discharged home or admitted to medicine for “pain management for a sprain” because the injury mechanism was not consistent with compartment syndrome…
- An ischemic leg whom the vascular surgeon refuses to see emergently because “I know this patient and their leg is not ischemic, it’s a chronic vascular insufficiency”…
- A testicular torsion whom the urologist does not want to see because “this isn’t going to be a torsion…and even if it is, it’s too late to do anything about it now anyway…”
- A tib/fib fracture that orthopedics insisted be discharged home with a splint when the next morning another orthopedist calls to state “why did you send him home? this is clearly a surgical fracture and all we have done is delay his repair?” …
An informal poll of 200 EM physicians revealed that over 75% had been given recommendations by a consultant that would harm a patient. This supports the notion that calling on consultants at all hours of the day, and asking them to intervene urgently may result in significant influence of outside (non-medical) factors. It also underscores the importance of familiarity with the expected course of treatment before calling for the consultation. If the advice given is inconsistent with what is expected, it is necessary to ask for clarification. In addition, if the answer given is not sufficient, a cordial and polite assertion should be made that the consultant physically examine the patient. My own experience has shown that once the consultant has done so, a better decision is mademostof the time. We need to know more than just the initial stabilization and treatment in order to best advocate for our patients.
So what do we watch for?
First: It is important to recognize the unique nature of what we do in the emergency department and to acknowledge that, though we may not be experts in the specific field in question, we need to have sufficient understanding of the typical treatment. This allows us to evaluate the recommendations of our consultants and ensure the safety of our patients. Bad advice is not malicious, and is usually the product of multiple outside factors (burnout, sleep deprivation, or multiple simultaneous competitors for a consultant’s attention)
Second: We need to be aware of the effect these interactions have on us, the EM physicians. They stay with us and can inadvertently effect our next patient encounter. We become resentful of patients for presenting with certain illnesses and may dismiss the obvious diagnosis or necessary treatment because of the inconvenience it may cause us. Few will admit it, but the constant fight to admit patients and have consultants do the “right” thing takes a tole. We are humans as well, and this battle can effect our own decision making. We may avoid the consultation at all costs, even to the patient’s detriment. This can often be combatted by some time off and a discussion with the specialist, department chair, or chief medical officer.
As a specialty, emergency medicine has many attractive features. But the specialty is not without its unique pitfalls. Being aware of them helps us to provide the best care for our patients while acknowledging that we are all human and prone to error.