ER: Meet & Street? I don’t think so

I am an Emergency Physician, residency trained to save lives quickly, economically and compassionately. Recently, I read a mildly derrogatory post about the “meet-em and street’em” attitude of Emergency Physicians, and it spurs me to comment about the realities of Emergency Medicine.

Yes, there are cases which require only a brief history and physicial examination, allowing a focused evaluation and treatment, appropriate for the complaint. The majority of my practice is not that patient, it’s the 92 year old I had today who fell and broke a hip, who is also hypotensive and has an altered mental status. He needs a quick and comprehensive workup, taking into account all his infirmities and illnesses. While at the same time caring for the 70ish lady who came in for her ankle fracture but is hypotensive from her adrenal crisis (no kidding). How about my ED partners’ case, the hemophiliac with HIV, now with fever, headache, and thrush. Yeah, there’s a meet and street.

So, we all need each other in this big medical treatment complex. Yes, ED care is sometimes impersonal, but that’s because it’s brief and intense, not because we aren’t people.


  1. Well said.
    Not to minimize the Urgent Care/Fast Track component of the ER, but it’s the loads of non-emergent patients which make life so difficult for Emergency Physicians, and which are in ER’s with ever-increasing frequency. That’s why I think Fast Track type areas are becoming increasingly important. Of course, in just a month I’ve seen a patient with rhabdomyolysis and progressing renal failure, an MI in progress, several neonates with fever and needing septic workup, a half-dozen cases of pneumonia, as well as several bad fractures.

  2. gruntdoc says:

    I agree completely. It has been explained to me that the Fast Tracks generate the income in ED’s. I understand that but don’t enjoy it.
    Your experience of finding these serious diagnoses buried in an avalanche of colds, vomiting and coughs is exactly why I’m not in favor of turning mid-level providers loose in the Fast Tracks. (Not intended to begin a flame war with midlevels.) I like midlevel providers and feel they have a very valuable place, but there’s something to be said for an actual physician seeing everybody in the ED.

    Thanks for the comment.

  3. I agree completely regarding midlevels. I actually worked with a wonderful, competent FNP in my private practice, but when the hospital here decided to open a Fast Track, they fortunately listened to the medical staff and went with full time physician staffing. A certain amount of hurt feelings were a result, but there is a difference in the care/training of physicians. In fact, one of our board members, a local surgeon, said the only way he’d go for midlevels in the Fast Track was if we could replace the triage nurse out front with a physician. :-)

  4. gruntdoc says:

    Hehe. Actually, a midlevel at triage would make a lot of sense; start ordering tests, etc.

    Thanks, and best of luck.

  5. Well .. as the source of this “mildly derogatory” reference … I’ll stand up to the plate …

    a) I was jokin, guys .. hence the wink ;-) at the end of my post.

    b) Indeed, my message is the same as yours: If we work together, the patients get the best care. I won’t dump little non-emergencies (or non-emergent mega-workups) in your lap .. and you will have the time to effectively juggle the complex and demanding true emergencies that you are trained to manage. Emergent and urgent care – done right – is MUCH more than “meet-em and street-em.”

    c) I was on-call this past weekend and saw ~ 10 patients on Saturday in the office and ~ 5 on Sunday. In my former practice, all 15 of these folks would have been told “go to the ER.” I’m not being critical of the ER physicians when I suggest that the care in my office would be better.

    The care that I can provide for their urgent problems is technically identical to that provided in an urgent care or fast-track clinic, but the continuity that I provide is simply not available in those environments. I have their chart, I know their allergies, I know their family and the family history, and I don’t have to mail or fax a report of the visit to myself.

    Finally, the cost (to the patient or the insurance company or both …) is significantly “better.”

    For the true emergency, not only will I tell the patient to go to the ER, but I’ll call the ER physician to let them know who is coming and why. I’ve found that this is very well received by the ER physicians, and improves our communication in an hour or two when I get a call about the admission .. or just an FYI for the discharged patient.

  6. gruntdoc says:

    thanks! I truly do believe patients are better served for the majority of their problems by their PMD, and I give you and your partners all the credit in the world. I really wish everyone did what you do.

    Also, thanks for not referring your workups to my ER colleagues (wherever you are), and I know they appreciate it, even if they aren’t aware of it. (If it ever comes up, tell them I said they appreciate it).

    And, thanks for the comment!

  7. Kinda funny in light of our discussion yesterday … I got a call at about 4:30 PM from the ER physician about a 10 yr old boy 5 days s/p laparoscopic urologic surgery who was sent directly to the ER by the school nurse who was “certain” that he had a PE as he had some SOB in school.

    The ER doc was sking for my help. She really didn’t want to do a V/Q on him, but he did seem kinda restless and anxious .. and mom was saying that “He’s not usually nervous like this.” 02 sat 100%, HR 85. Afebrile, etc.

    My response … “This kid is Nervous Nellie.” It’s all the ER physician needed to hear. “I’m so glad I called” she said.

    Me too.

    I stopped down to the ER before they went home. Everyone was fine.

    I think we need a Xanax for that school nurse, though.

  8. e mail me your fax number I want to send you an article I think you would like.

  9. Jacob,
    This is exactly the kind of patient I like to call the PMD very early for.
    Usually it’s “I don’t recall anything specific”, but once in a while I get
    ‘oh, again? He’s been worked up for that several times. He’s really there
    for…’ and offers a reasonable solution. That’s gold.
    Thanks for your comments, and thanks for taking care of your patients!

  10. That sounds like a cool job. I have such a great for people who work in the medical field, especially in emergency medicine. They have to see so much stuff that most people can’t even watch at all.