This book was on my Amazon wishlist and I got it for Christmas. I just got around to reading it this summer, and I fully expected to zip through it, devouring story after story that reminded me of my career in Emergency Medicine. I. Was. Wrong. I had to force myself to keep reading. There was so much back story that I really got bogged down in the biographical, geographical, historical, and medical details (that I already knew). This book would be good if you are a non-insider (for want of a better term) to emergency medicine/medical services.
There were lots of cases mentioned, but few were followed through their entire course of treatment in the Emergency Department (ED – the preferred term for what was previously called the ER or Emergency ROOM). Most of the cases mentioned were just a stepping off point for the history of that disorder, or it’s treatment, or the social implications thereof. Don’t get me wrong, all of those things are interesting and important, but they weren’t what I got this book hoping I would find. Honestly, I wanted to work (vicariously) again.
Many of the issues that plagued Bellevue in the 80s (the setting of this book) are still issues faced in EDs today: homelessness, overuse by “frequent flyers”, poor continuity of care, lack of primary care (using the ED as primary care), IV drug use, alcoholism. One issue that was paramount in the 80s was AIDS. HIV is still ever present, but it is no longer the death sentence that it was in the days when emaciated patients presented with Kaposi’s Sarcoma and Pneumocystis pneumonia. Now, thanks to antiretroviral therapy, HIV doesn’t necessarily turn into AIDS, and HIV has become more of a chronic illness that is managed by a lifetime of medication and less of a sentence to certain, premature death. “With appropriate treatment, a 20-year-old with HIV infection can expect to live to reach 71 years of age.”
The book reminded me how much has changed in 35+ years…what Emergency Medicine was like way back when…cassettes in Dictaphones, paper charts, lack of EMTALA (Emergency Medical Treatment and Active Labor Act, passed in 1986) laws to keep patients from being ‘dumped’. MAST (Military Anti Shock Trousers) pants, KEDs (Kendricks Extracation Device), and air splints have all gone the way of the dinosaur.
Goldfrank quotes Hippocrates: “Discussing money before caring for the sick lacks propriety.” Yet he fears that “financial triage” is already eroding medical ethics and leading some to forget that “the health providers’ responsibility is above all the health of the patient.” (p.184)
Emergency Doctor also reminded me how far EMS has come in the 35+ years since this book was written. One scene describes a man who attempted suicide by jumping from a wall on the Brooklyn Bridge, landing on a taxi driving below. His condition is described: “He was still breathing even though his back appeared to be shattered. To try to insert a tube into his throat would risk doing further injury because that would mean moving the neck. Doubtless that would reduce whatever slight chance for survival he had. But it was clear from the gross injuries to his cervical spine that it would be impossible to make an adequate assessment of his airway in the field. About all that could be done was to place an oxygen mask over his mouth and nose and rush him to Bellevue.” (p.188) As a medic, that made me cringe. Although the outcome would likely be the same in this case (death), ignoring a compromised airway because one can’t intubate without c-spine injury is anathema. First, there’s the ABCD’s:Airway, Breathing, Circulation, Disability…in that order of priority. Second, we can intubate without further injury to the c-spine by using certain techniques. Third, medics can now do what was ultimately done at Bellevue for this patient: perform a cricothyrotomy (a “cric” in EMS slang) where the persons’ throat is incised and a tube is inserted through the incision into the trachea. “Scoop and run” might have merit in the urban setting where the trauma center is a mere blocks away (by Google Maps estimation it is 15 minutes from the Brooklyn Bridge to Bellevue) but in most situations, 15 minutes of a compromised airway=probable brain death.
Some things in the book are only foreshadowings of problems we deal with now. Back then, it was DRGs (Diagnostic Related Groups) and HMOs (Health Maintenance Organizations) that threatened to reduce patients to numbers, rather than people who are sick. Now there are many more gatekeepers practicing medicine without a license. Chief among them are insurers (#Anthem, I’m looking at you), who feel they can deem (after the fact) what was or was not an emergency, thereby denying payment. So the person with chest pain waits to go to the ED because “it might not be a heart attack and insurance might not pay” and then dies because it WAS indeed a heart attack.
Overall, I think Emergency Doctor is aimed at the layperson in the 1908s, not a medical professional in 2018. Time to retire, doctor.