People at San Francisco General Hospital emergency room had T shirts printed up that included the tag line: “as real as it gets”.  That pretty much summed up the big urban County Hospital experience where I was a medical student.   The ER was where lives in crisis ended up—there, or in prison, or sometimes both. People with gunshot wounds, overdoses, car accidents, fights, falls, intoxication and psychotic breaks would show up in the ER, often with a police officer or the EMTs–who knew all got to know the ER staff well.  Compassion, skill, and physical restraint of combative patients were all necessary.  There were almost always underlying psychosocial traumas the ER couldn’t begin to fix.

The intern I was assigned to was arrogant and over-confident.  I was shocked when he walked up to a person with an arm infection from drug use and, without warning, stuck a hemostat into the abscess to drain it, playing the medical cowboy.  It was a negative example I never forgot.

There were also standard medical emergencies such as heart attacks, strokes, pneumonia, asthma, burst appendices, miscarriages, rapes, diabetic ketoacidosis, broken bones and dementia.  Not to mention headache, back pain, work injuries, and high fevers in children.  The list was long, including visits for problems that were not emergent, maybe not even urgent, but maybe the patient didn’t have another place to go due to travel, insurance, language, understanding, time of day, or some other reason that made sitting in the ER waiting room seem like the best option.  Staff and administrators complain bitterly about this “inappropriate” use of the ER.

Working in a busy urban ER can be grueling physically and mentally, but for those who thrive on adrenaline it is a good fit.  Each day is different, and when a life-threatening case comes in, the whole team has to mobilize—nurses, physicians, respiratory therapists, lab, X-ray, pharmacy and clerks working to stabilize, treat, communicate with families and specialists, and move the patient on to teams in the ICU, the surgical suite, or hospital wards (or the morgue) as appropriate.  Emotions can be strong—the satisfaction of saving a life together, or losing one, or just going through an intense period together.  When the shift is over, and you have signed out to the next crew, you can go home with some sense of closure and start again when you return.  You may never know what happened to the people you saw.

I am not an adrenaline junkie.  I don’t bungee jump and don’t even like action movies or gambling.  The high stakes, unpredictability and intensity of working in an emergency room never appealed.  My interest in medicine was always primary care, public health, education, health promotion, community building and relationships over time.  It is not as glamorous or dramatic as acute and tertiary care, but it actually saves more lives to have a strong primary care and public health system.  The longer I worked as a family physician and saw what happened to people sent to specialists and treated in the ER or hospital, the more I appreciated our work.  We kept many people out of the ER.  There is also satisfaction in having someone’s trust, being able to interpret medical reports and recommendations, averting unnecessary interventions and picking up the pieces after the acute care episode is over.  Of course, there was never a clean slate at the end of the day, and I would have the privilege and burden of having people come back over time, trying to manage problems that never went away.

Nonetheless, I did intersect with the ER when I was on call and had to go there to admit a patient.  Always a bit of an interloper, I could still appreciate the pace and ordered chaos of the place, the ready access to labs and Xrays and specialists.  I also worked many after-hours clinics in the office, when people would be seen as drop-ins for a host of problems.  It could be a nice counterpoint to a schedule full of known patients with chronic conditions.  While not as hectic as an ER, I appreciated the variety and I did more procedures such as suturing cuts, splinting injuries, giving injections, assessing pregnancy concerns, or pulling a hearing aid battery out of an ear canal.  With just myself and a medical assistant, lab was limited, but I could assess urine, pregnancy or strep tests on site.  Sometimes people with more serious issues–a possible pneumonia or broken bones–would be sent on to the emergency room.  Occasionally people would come in with a true life-threatening emergency such as a suspected heart attack, and then 911 was our friend.

I never regretted choosing the primary care path and providing continuity of care.  But I have to admit that sometimes it was just incredibly satisfying to solve an acute problem and be done with it, to pull out that splinter and send the person happily on their way.