Viewpoint

We emergency physicians, who trained in acute resuscitation and thrive in high-stress situations, tend to roll our eyes at our patients' less-acute complaints. Back pain for three months? Headache for a week? Why are they here now? I admit that I've grumbled about the so-called inappropriate use of the ED, especially in the wee hours of the morning. Several months ago, though, something happened that made me really appreciate the importance of what we do. A 29-year-old woman, a fourth-year emergency medicine resident who was previously healthy, came back from her shift at a busy Boston ED feeling a bit under the weather. She was a little nauseated, but was able to eat the Chinese takeout dinner that her husband brought home. Right after dinner, she went to bed, but couldn't sleep because she developed a gnawing abdominal pain. Then, she began throwing up, and she threw up at least 10 times over the next two hours. Being an EP, she came up with her own differential diagnosis. It was most likely viral gastroenteritis; the only atypical feature was that she wasn't having diarrhea. It could have been bad food, but her husband ate the same thing (and she, being Chinese, was sick of Chinese food always being blamed as the culprit). She had no headache, and doubted an intracranial process. She had no urinary symptoms or flank pain, and doubted UTI or kidney stone. Any woman could be pregnant, so of course that was on the differential. Not wanting to go to the ED in the middle of the night and burden her already overworked colleagues, she set about to self-diagnose and self-treat. She sent her husband to the local 24-hour pharmacy to buy a pregnancy test and to pick up the Zofran ODT that she prescribed herself. The test was negative, and the Zofran made her vomiting stop, but her abdominal pain was still there when morning came. In fact, it was now localized more to the right lower quadrant, and it hurt her to walk. I'm sure you see where this is going, and you are thinking that you would have taken yourself to the ED at this point to rule out appendicitis. Well, this 29-year-old woman was me, and I really didn't want to check in as a patient or get the radiation from a CT. As it happened, the ED attending that day was an ultrasound specialist, and was kind enough to do a bedside ultrasound. My appendix looked fine, but she could see intestinal thickening that was consistent with enteritis. I got my diagnosis, and I recovered with my appendix intact over the next few days. Had someone like me actually checked in as a patient, I could see how there might be grumbling from the providers. “A young woman with gastro who's getting better. Why is she here?” Or, “If she doesn't want a CT, why did she come to the ED?” Or, had I gone to my primary care provider and been referred for rule-out appy, “Shouldn't the PCP know better?” What I learned from this experience is that it's always easy to say in retrospect that the patient didn't have to come to the ED. The answer is hardly straightforward in the moment when the patient is scared and in pain. Even as an emergency physician myself, I couldn't tell if what I had was something benign and self-resolving or a life-threatening process that required urgent intervention. How can we expect our patients to know whether their chest pain is the same angina as usual or a heart attack? How can we expect them to apply the Ottawa rules to see if they have a sprained ankle or need an x-ray? My flirtation with the ED has made me more sympathetic to our patients who come in with seemingly nonemergent complaints. It also has me thinking on a larger scale about proposed policies that impose penalties on our patients for using the ED. Don't get me wrong; we need more primary care doctors, and our patients will benefit from increased access to primary care. Patients don't always know whether their complaint is primary care or an emergency. I turned out to have enteritis, something a primary care doctor can address. But had I been a “normal” patient, I wouldn't have been able to treat my own symptoms and get a favor from an attending ultrasonographer. Surely, I would have had to check into the ED to be seen. Would it have been fair to penalize me for that emergency visit when it turned out that I had a less-than-emergent illness? Policymakers should be aware that even well-informed patients with good access to primary care need the ED. Legislation should aim to increase availability of primary care but not penalize the use of emergency services. We EPs need to stop complaining about our patients. Yes, we would prefer to be resuscitating the multitrauma patient or caring for the sick septic person, but we also need to maintain and create value in our specialty. We need to keep advocating for issues such as having board certified EPs staff our EDs. We need to keep teaching our students and residents that the ED is the new home of diagnosis, and embrace our role as teachers and innovators. We should embrace our duty at the frontlines of medical care, sorting out all patient presentations and working to diagnose and treat all of our patients. Click and Connect! Access the links in EMN by reading this issue on our website or in our iPad app, both available onwww.EM-News.com.

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