The Different Stages of an ER Doc’s Career: Part I

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Three very unique approaches to a pain in the pelvic area.

The following are possible scenarios of how Emergency Medicine physicians’ approaches to different cases can change over the course of their careers. The doctors and patients are amalgams of my own experiences and those of my colleagues.

I am impressed with how well-trained our new EM docs are and know that our specialty and their patients are much better off these days thanks in part to the experiences of their mentors, colleagues and the dedication of their educators.


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Pelvic pain

young doug MacAskill

Dr. Greenhorn:  He’s just passed his first ER boards and is ready to find a zebra when he hears hoof beats. He picks up the case of a young female with lower abdominal pain. He does a thorough chart review, establishes the patient’s preferred pronouns and finishes a detailed history. An abdominal exam makes the patient wince as he palpates the suprapubic area. He makes a note to make sure he checks for a Chandelier sign when he gets her pelvic set up.


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Meanwhile, he whips out his new handheld ultrasound probe, hooks it up to his phone and does a limited FAST exam, while also checking for a gravid uterus. The pelvic rooms are both busy, so he goes back to the doc’s charting room and dictates her history. He notices that one of the other docs has picked up three cases since he was in this patient’s room.

Feeling pressed, he goes ahead and orders multiple labs, deciding he’ll likely need a CT scan too. Better to order it now, he rationalizes; the board is filling up! Noting the triage color coding and wait time numbers, he signs up for the most appropriate patient, as he waits for the pelvic room to open up. Three hours later, he has all the negative results back, when the nurse tells him, for the second time, that the pelvic room is briefly open. The CT was normal.

He realizes he just needs to do that pelvic. Mild, but maybe moderate CMT, with a slight discharge, is the only real finding there. He collects some specimens and writes more orders while the patient tries to remain patient.  Feeling a little guilty for this wait, he takes the time to discuss the findings and treatment options, trying to involve her in the decision-making process. Though her LOS was pushing six hours, the patient still appreciates his empathy before confessing she was mainly worried about an STD. A well scripted discussion on that ensues. They exchange smiles. He hopes she gets a Press Ganey survey.

middle aged doug MacAskill


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Dr. Middleton: After she signs up for two new cases, a young woman with pelvic pain and a frequent flyer with chest pain, this solid, mid-career doctor stops by the young woman’s room for a quick intro. With a confident smile, she encourages the patient to give a urine sample.  She explains that the lab is way behind on ‘those’ and it’s the quickest way to get her home.

Plus, she knows the work up is simplified if the urine HCG is negative. She hands her the urinalysis cup, points to the restroom and says “I’ll be right back.” Knowing that sometimes there is a ‘wolf,’ she is happy to confirm, after reading his EKG, that the frequent flyer was a ‘nothin’ burger; he just added miles to his account.

By now Dr. Middleton knows her other patient is not pregnant, but her subsequent exam reveals some suprapubic pain. She asks the tech to immediately set her up for a ‘Sinai pelvic,’ a technique she learned at the always-busy tertiary hospital where she trained. She’s not waiting for the pelvic room or the rare ob-gyn gurney.

The tech understands, so she dutifully covers a bedpan with a blue pad and gently hoists the patient upon it. After a quick, skillful exam of her cervix, this doc knows her mild wince is definitely not a rare, positive chandelier sign. She knows she can do minimal labs, but does order a wet prep.

Despite those findings, she decides to cover both their rear ends and pulls the trigger on the triple antimicrobial shotgun. She checks with Dr. Greenhorn to see if the regimen has changed recently. He’s sharp, reciting the updated choices, even referring to some new literature.

Dr. Middleton adds a miconazole script to the young woman’s discharge and discharge paperwork. After a four hour stay, she asks the nurse to kindly tell the patient that the diagnosis and treatment are exactly what they had already discussed. But, if she has any questions, she’ll pop back into the room. The doc hopes she doesn’t get a Press Ganey survey.

doug MacAskill current

Dr. Longtooth:  The night doc trudges in and squints at the electronic ‘grease board,’ as he calls it, fumbling for his readers. Perplexed, he wonders what all these new colors in the EMR mean? It doesn’t matter. He signs up for every unassigned case.

Suddenly, we are all caught up, he concludes . . . but then hears, “Hey Dr. L, you just signed Mike up for all those cases,” Mike, one of many APPs, had just respectfully vacated Dr. L’s favorite computer station, knowing he’d be there, as usual, 20 minutes before his shift started. Mike sees the overwhelmed look on the senior doc’s face as he stares back at his screen. Mike switches the logins and fixes the mistake for him.

As Dr. Longtooth heads towards the first patient, he capitulates that the Friday Night Gyne clinic is apparently open. He does a quick history and a very focused physical exam. Suspecting her initial wincing is mendacious in nature, he distracts her and covertly examines her suprapubic area again. No wince is elicited this time.

Depending on his mood, our veteran doc may or may not inform the patient that her symptoms are not an appropriate reason to come to the ER. The tech proudly announces the negative UCG, knowing Dr. L expects it to be done already. Everyone knows that Dr. Longtooth is notorious for not doing his own pelvic exams anymore, so the APP offers to do one. It’s important to stay in the good graces of this well seasoned ER doc.

All the APPs trust his wisdom, efficiency and mastery of the tricks of the trade. They know they will need him for other cases to come. The APP does the pelvic and reports minimal CMT. So he starts pecking out the discharge instructions and a script for an antifungal, one finger at a time, with a surprisingly quick pace.

After the discharge papers are signed, the nurse says the patient needs a work excuse. The doc sighs and feigns an effort to find the blank work excuses, but the RN has already written the electronic work note herself and waves it at him, “Got it.” Turnaround time is < 55 minutes. Time to get these other docs out of here, he thinks, and generously encourages them to hand off their cases with a gruff, “Go home already.”

 

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