EM Senior

Another July has come, and with it an upgrade in my rank and nominally in my salary. I make a whole $2.75 an hour now!

In the third and fourth years of this program, I’m considered a “senior” resident. Senior residents have some additional responsibilities over those of juniors: we are supposed to keep an eye on the entire emergency department, make sure everyone is pulling their weight, lead resuscitations, and teach novice learners.

After completing two full years of residency, during which I believe ten years of my functional life expectancy has been peeled away, I have learned only a few things:

  • Most spider bites aren’t
  • You must have seven or more episodes of diarrhea in a 24-hour period to meet criteria for insurance reimbursement if you want to be hospitalized for it
  • Procedural competence is a wildly different skill set than medical knowledge
  • I require an average of 4 hours of sleep a night to prevent dementia-grade delirium
  • The number of times per shift we do something because “this is how it is done here” asymptotically approaches infinity, even when “it” flies in the face of current research or standard of care

The above list represent new things learned in residency. I left out old news or obvious stuff. For instance, one of the most eye-opening experiences for most residents is learning that the system in which they work is wildly dysfunctional, works well only if you have money, and is absolutely guaranteed to fail. They also realize that within this terminally diseased system, they are its slaves.

I knew that one already.

Anyway. Working shifts as a senior is interesting and carries a few minor changes: at one of our hospitals, we sit in a different chair. We lead signout. We take presentations from medical students; this is a challenging skill, insofar as it is difficult to pay attention on a busy ER shift to a meandering discussion of someone’s family history of heart disease.

The other major change in becoming a senior is that you know the playbook. Here’s what I mean: admitting someone to the hospital, or getting a consultant to come evaluate your patient, is a game. You are trying to do something to offload your own workload (get another person to take over the care of a patient, obtain expert guidance), which comes at a direct cost to the admitting or consulting resident – they have to do work.

It’s worth noting that after residency, consultants and admitting teams will happily do their job. Consults and admissions are how they get paid. Unfortunately for everyone, residents are paid a fixed salary of 1.23 Chipotle burritos per day, regardless of whether they get thirty consults or zero.

As a second-year resident, most admitting and consulting residents were also second-years. Now, I’m talking to a slew of brand-new R2 consult residents who have no idea what they’re doing, yet are pretending that they do.

I don’t begrudge them this duplicity – I still have no idea what I’m doing fully 80% of the time. The only difference is that at this point, I hide it well.

(I think. The attendings that read this may beg to differ.)

Oh. My point. Playbook.

It is difficult to describe this game, so here’s an example. Let’s say, in a hypothetical ER nowhere on Earth and certainly not within a 3000 mile radius of NARH, there is a patient who has ovarian cancer. She’s frequently in the emergency department with abdominal pain, and came in with what ended up being a bowel obstruction – the mass from her cancer was pressing on her colon with enough force to prevent anything from going through. She was throwing up, in severe pain, and couldn’t drink anything.

Also, I am working in the ER in this hypothetical story. I forgot.

At many hospitals possibly including the one in the story,* there is actually a “gyn-onc” service – gynecologists that specialize in lady parts cancer. Because this woman clearly needed to be admitted, I paged the gyn-onc resident.

*but obviously not NARH. That is hilarious! A functional subspecialty service at NARH! I am so funny sometimes.

After I told her about the case, her first instinct was to request that I instead contact general surgery, because typically bowel obstructions are managed by general surgery.

Here’s the thing: at this point, she and I both know that this patient is ultimately going to get admitted to their service. The patient has a gynecologic cancer that is causing a complication of the cancer itself. Since, in broad strokes, you should admit a specialty patient to the hospital under the care of a specialist for that condition, we all know where this patient goes.

However, the resident refuses to “come see the patient” – hospital code for “ugh fine” – until I have discussed the case with general surgery.

I page the general surgery resident, who is also the trauma surgery resident, and after 5 PM also the orthopedics resident. Let’s call him Jeff. I know Jeff from my trauma rotation as an intern. He’s a good guy, but he’s averaging three hours of sleep a night.

“Hey Jeff, I need to ask you to see this pa-” I am cut off.
“Let me stop you there, am I reading the chart right and this patient has an ovarian cancer?” Jeff sounds grumpy.
“Yep.”
“With a large bowel obstruction… from the ovarian cancer?”
“Yep.”
“Why… why are you calling me?”

For those of you unaware, we ER folks frequently end up as the worst kind of middleman. Not only are we trying to cajole people into doing their jobs, we are also asked to point the finger on behalf of other services. As such, we get punted back and forth with force, like some kind of dystopian, Kafka-esque version of Pong.

I call back the gyn resident.

“The surgery resident says this is a gyn-onc problem,” I start.
“What? It’s a large bowel obstruction. Large bowel obstructions are managed by general surgeons. We won’t DO anything, her cancer is inoperable, so surgery should take her.”

Back and forth we go. (This, by the way, is TURFing in real time.)

The primary problem is that until you can admit the person somewhere, you’re still in charge of this patient – the nurses call you for pain medication, the patient has tons of questions, and their care remains part of your cognitive load. On a busy day, that means an extra burden among the ten to fifteen other active patients you’re trying to evaluate, treat, reassess, and admit/discharge. The patient is stuck in the ER, and you’re stuck with them.

As a second year resident, this would drive me absolutely up the wall with frustration. Once, a situation similar to this one got me so upset that I turned my phone off and went into the staff bathroom, sat on the floor, and just about cried. It’s exactly as pitiful as it sounds.

Somewhere during second year, you figure out how to get consultants to talk to one another directly instead of going through you. You learn how to leverage “triage hospitalists,” who nominally are supposed to help you with this sort of thing, and how to ask your attending for help in a way that doesn’t make you just seem incapable at your job.

You also don’t want to burn bridges – during second year these consult residents, for the most part, are the same year in residency. You know many of them personally and are friends with some. You don’t want to be “that guy.”

…As a senior, I can say this with confidence: now, I don’t give a fuck.

I got into a similar situation on shift a couple of weeks ago, and I made exactly one phone call. After hearing the first service point the finger at the other, I kindly gave the consultant the pager number for his counterpart. I explained that I would give them thirty minutes to figure it out after which I would, sadly, need to get both of their attendings involved. I should note it was three in the morning, and in general one of the perks of finishing residency is that, at an academic center with trainees indentured servants, you are rarely paged at three in the morning. When it happens, you get grumpy.

The problem got solved quickly.

Like I said before, it’s July. The only reason I can get away with this is that no one has any idea what they’re doing right now, so this is probably only going to work for another three or four weeks before the residents figure out how to convince me that I am, once again, in the wrong. Soon, I’ll be back to my “I’m Just A Dumb ER Doctor” script, which to be fair has about a 90% success rate anyway.

It’s a nice Competence Honeymoon while it lasts.

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