EM Mindset: Andrew Sloas – Emergentologist
- May 11th, 2015
- Manpreet Singh
Author: Andrew Sloas, DO, RDMS, FACEP, FAAEM (Assistant Professor of Adult and Pediatric Emergency Medicine, The University of Kentucky; Editor-in-Chief: The PEM ED Podcast (www.pemed.org) – @PEMEDpodcast) // Editors: Alex Koyfman, MD (@EMHighAK) and Manpreet Singh, MD (@MPrizzleER)
What makes the practice of emergency medicine special? Why are we so different from the myriad of other providers that it is imperative we have our own subspecialty? It’s not like we have an –OLOGIST at the end of our name; those seven all-important letters designating to all they encounter that this doctor has a depth of knowledge about their specialty that exceeds all others. How would the -ologist define our specialty? I suppose it would start with what we do best; we are the masters of the differential diagnosis. To be a successful emergentologist, one must possess a depth of knowledge about physiology, critical care, and procedures that exceeds all other subspecialties. We must have it all or patients die!
We are a life and death subspecialty. While most may argue that cardiology is the best doctor for the heart and anesthesia is the best doctor to manage the difficult airway, I would dissent. An emergentologist does not have the luxury of meeting their patients in a clinic where they can casually sip coffee as the patient provides a thorough and detailed history. In fact, with the sickest of patients in the emergency room it is often the exact opposite. As an emergentologist, you will be asked to make life and death decisions with less than 10% of the total information 99% of the time. If you fancy yourself a rebel and that gives you absolutely no pause then consider this: you will be asked to get it right every time or it could cost the patient their life. That is a tremendous amount of pressure once realized and usually not in the forethought of those considering a career in emergency medicine.
While many subspecialties lend themselves to a culture of relaxation, a career in emergency medicine cannot be a lifestyle choice. If the anesthesiologist does not like the look of an airway, much like a pilot who decides they don’t like the weather conditions, that flight/case is canceled. That case is then rescheduled with a plan, a back-up plan, and a redundancy plan to successfully intubate that patient. In the emergency department you do not get that option. You don’t get to look at the patient with hepatitis C, and an active GI bleed and say, “I’m not feeling it today, sir. Perhaps you’d like to reschedule on a day that someone who’s infinitely better at difficult airways is here.” You, as an emergentologist, get to meet the bloodiest most vomit-laden airways in the world whenever they choose to meet you. Now here is what is truly unfair; when we struggle with the difficult airway someone may ask, “do you want me to call anesthesia.” Why? Because they are viewed as the airway experts and you are the novice. They are the masters and you are guy or gal who’s good enough to do the basic ones, but because they have an -ologist behind their name they must be technically better than you could ever be. Is that true? We just established that they have the ability to plan their cases on the golf course the day before or, at worst, over coffee in the hospital atrium that morning. Either way, the plan is in place long before they have to cross the threshold of commitment to paralyze and take the airway; a luxury you don’t have. As an emergentologist you are also a vomitologist. Vomit happens in real time, not over coffee before you meet the patient. For that reason, it is my propensity to believe that the emergentologist is the absolute best practitioner to manage the most difficult airways.
But what truly makes the practice of emergency medicine different is our innate ability to recognize sick from not-sick. If you go into this specialty under the guise that you will someday be a master diagnostician then you will be sorely disappointed and that disappointment will likely spiral into despair as you burn out in a matter of years. That is not our lot. Our responsibility is to be excellent differential diagnosticians not definitive diagnosticians because ours is a specialty of recognizing the sick. Like a goalie, we prevent those in extremis from slipping by while simultaneously redirecting all others to continue their “medical” fight another day. Not every disease needs to be diagnosed in the emergency department. It is your job to figure out which ones do and which ones are safe to go home. It has been said that a good emergentologist can make the diagnosis of sick–not–sick in three seconds from the bedside and in thirty seconds form the doorway. This skill must be developed for you to be successful in this business; this must be your overall mindset. You must be able to differentiate quickly, rule out the worst-first in disease processes, and use a series of complex hierarchical algorithms to determine how sensitive you will be when your tests return. Pre- and post-test probability rule the day and utilizing gestalt combined with concomitant data points such as labs and rads is the only way to develop the confidence to decisively send patients home to do well… and not lose any sleep. Easy right?
If you are interested in reading the rest of this and other EM Mindset pieces, please see “An Emergency Medicine Mindset,” a collection evaluating the thought process of emergency physicians. This book is available as ebook and print on Amazon.