Saturday, November 6, 2010

Butchers Move the Meat; Doctors Care for Patients

It was my day off and I was hoping to relax. But my wife's grandfather, Herb, an elderly man with chronic illness, developed severe dyspnea and was rushed to the emergency department (ED). He insisted that EMS drive to the ED where I am an attending physician. I appreciated the vote of confidence. So much for my day off, though.

As I jumped into my car to meet Herb at the ED, my mother called. “Your grandmother [who lives 2 hours away] doesn't feel so good.” What terrible timing! She is tough and vibrant, a retired physician herself, 84 years young. Grinding my teeth, I asked my mother for details. “Her eye really hurts and she had a terrible headache all night. She can't see well. She thinks it's neuralgia.” Excellent. Symptoms all night and I was told only now, at 3 pm. “We didn't want to bother you and waited for Tylenol to work.”

I knew frustration was counterproductive. Having a relative go the ED is a nightmare that many physicians have; one we try to avoid whenever possible. But phone medicine would not work here. “She could have acute glaucoma. Please take her to the nearest ER and call me after she gets evaluated,” I told my mother.

Meanwhile, Herb had a complicated life-threatening illness and I stayed at his bedside. After a comprehensive ED workup over several hours, he was nicely stabilized and admitted. My mom called me around 6 pm. “We're at the ER,” she said. “Grandma's eye is hurting a lot. The resident promised to give her something and left 30 minutes ago.”

I called the resident. “Oh, yeah, I ordered the morphine. I think. Maybe the nurses didn't do it yet. Sorry, we are very busy.” Yes, I understand busy. But busy is a poor excuse here. It means you don't care enough that grandma suffers, I thought to myself. I requested clinical findings.
“While the pupil is not reacting, her vision is good, her eye is red, and the cornea is clear. I checked the eye pressure and it is 15; normal. We ordered a head CT and, if that is OK, will probably send her home,” the resident said.

I asked about the fundus exam or an ESR. “ESR? Why? That means blood work and we are so bus...I can't see the fundus in older people,” the resident said. I demanded the ESR to rule out temporal arteritis and a stat ophthalmology consultation to perform a dilated eye exam. The resident promised to comply. To me, the case was confusing. I hung up, angry at the limited and superficial evaluation motivated by desire to expedite disposition. At least now we were on the right track.

An hour passed and I felt nauseated by inconsistencies in the case. I called grandma directly and requested that she read words from the nearest TV. Her right eye vision was very poor, probably 20/200 or worse. “It's been that way from the beginning, but the resident said that's OK,” my mother chimed in on the phone. Now, I was livid. The resident's data were garbage. Garbage in, garbage out. At this academic ED, it is difficult to convince an ophthalmology consultant to come in at this hour, so the resident made that unnecessary by doing a careless eye exam and finding “normal vision.”

I called the ER attending. He was a nice guy with decades of experience. He reported that the CT was done and read as normal. Because the vision was also normal and the pressures were fine, as per the resident, this must be simple conjunctivitis and an ophthalmology consultation is unnecessary. Doing my best to maintain professional decorum, I responded that vision was not fine and a painful red eye with rapid loss of vision is an ophthalmologic emergency. He caught on to my emotional state and promised to “take care of it.” An hour passed and he called back, apologetic. “The clinical picture was so consistent with glaucoma, I did the tonopen myself. The pressure is 40 in the affected eye. We initiated IV and topical therapy. When pressures improve we'll send her home. The ophthalmologist on call will evaluate for iridotomy tomorrow.” Holding back, I thanked him and hung up.

Trying to calm down, I checked my Blackberry to find an e-mail from a coworker. “Check out this blog, it's funny.” I could use funny then. I was welcomed by a large title: Movin' Meat. It was followed by daily musings of an emergency physician like me, commenting on the crazy work we do and the broad range of human drama and stupidity we witness. He wrote with skill, from experience, and with plenty of jokes.

Today it was not funny. By exposing our residents to concepts like “movin' meat,” we teach them that this is OK. We tell them to see patients “faster” because “thorough” is for the admitting doctors and in the ED, efficiency matters most. We push residents to find the most rapid path to disposition, at times at cost to integrity.

We must see the error. Our work is not just about pattern recognition and efficiency anymore. Our understanding of diagnosis and therapy must be sophisticated, no matter how busy the department. When followed, our high standards of care lead to prompt reversal of most acute threats to life and function. Emergency medicine today is about comprehensive efficiency where disposition follows a thoughtful and efficient workup, as thorough as necessary, and based on a complete differential diagnosis.

If you're movin' meat, you may be a butcher. Real emergency physicians thoughtfully care for patients.

Boris Veysman, MD
[Ann Emerg Med. 2010;56:578-581.]


gloria said...

That is an excellent article. I absolutely cringe every time I hear that phrase and no resident in my program and no attending was allowed to use it (I am sure that behind my back might have been a different story.)
The resident is culpable as he/she can't (by own admission) do a fundoscopic exam (and is OK with that) and based on reality can't do a tonopen exam correctly. The resident also doesn't know the importance of "acute" decrease in vision.
Finally, the resident is willing to send home a very ill patient just because he/she doesn't know what is wrong, has not tried to figure out what is wrong, and has not gotten help to solve the problem.
Finally, and perhaps most frightening, the presentation of the situation is totally inaccurate making me wonder about all of this residents other presentations.

The attending is culpable as he did not have the resident present the case and then go see the patient. He missed an excellent teaching opportunity, cheating the resident of a learning opportunity and this perhaps explains the poor performance of the resident. Sounds like no teaching, no learning, and no interest.

I don't know which has come first: over crowding which seems to be overwhelming our brains or intellectual laziness which is harming our patients.

Evidently the "phrase be the best you can be" and if you are not the "best" work to become the best has left our lexicon. I completely shudder when I hear stories like this. The adage "Never treat your family" might have been wisdom in the past but today it means your family may be harmed or actually die if you are not there to protect them.

Thanks for sending this out. It would be interesting to have a discussion of it. I am going to do just that with the residents at SG
Gloria Kuhn

Dr Larry Schwartz said...

Outstanding!!! Another one of my pet peeves is when discussing patients that can be either discharged or sent to TCU, the nurse or the resident may ask the attending, "are there any patients we can get rid of?" Totally inappropriate. If I was a patient and I heard that, and I could get out of the stretcher I would walk out. I'm currently at the AAMC meeting and have spent most of today on professionalism discussions. Things like "moving the meat" negate the time we spend teaching the students to behave in a professional manner.

Dr Larry Schwartz