Tuesday, June 27, 2006

coulda been cool

The thing people tend not to get about Emergency Medicine is this: it's not about diagnosing what's wrong. I mean, yeah, 99.9% of the time, our people can tell what's up, they can find the problem behind the problem, and they have a plan that will in fact fix it. But when it comes down to it, that's actually what primary care is about. The ER is not supposed to be a source of primary care, and it will never be an optimal one. We're... well, it's a big issue, but suffice to say, we're not about that. Emergency is instead about finding out what is not causing someone's symptoms.

Headache? Hmm. Could be a simple tension headache. Or maybe a sinus headache. Or maybe, a DEADLY BRAIN TUMOR. Go to your friendly local clinic, and they'll be sensible about what it probably is. They'll test you for the most likely causes, and if it turns out it's not one of those , they'll start busting out the more expensive tests, looking for the weirder things. This approach catches more things sooner, and wastes as little resources as possible. Almost all the time.

Meanwhile, in the ED, our list of potential causes -- our differential diagnosis -- starts with the scary shit, and works downward from there. It treats time as the king-daddy most important resource, which is absolutely true, in the most emergent cases. Chest pain, shortness of breath, dizziness: not uncommon things, and probably not serious. Except when they're really serious.

This, by the way, is why so many things seem to take so long in the emergency department: if it can wait, it will, because there's probably something else going on that really shouldn't wait.

So for that headache, we knock the deadly tumor off the list first. We can check off stroke or other hemmorhage soon after, if not with the same test. And soon, we know what the headache is not. We may or may not yet know what it is, and that's the point. Honestly, at a certain point it ceases to be important, within the realm of emergency care. It becomes the kind of headache that the emergency room is simply not well-equipped to handle.

Anyway, long story short, when a resident said to me recently, "I have no idea what's causing her symptoms," that was not a bad thing. In fact, since he could say exactly why it wasn't malaria, or encephalitis, or any of a number of other things on the list, it was probably good news.

My shift ended before I got to hear the end of the story, so I can't pass it along. I just know it's not malaria. Which of course is good, because nobody needs malaria (and too many people have it). It would have been a neat thing to be able to say, though.

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