In the mid-1970s I worked as a hospital orderly. I enjoyed getting an up-close view of the hospital culture and learning a little bit about sick people. And though I didn’t realize it at the time, I was watching the early maturation of a relatively new specialty in that hospital: emergency medicine.
One day I happened to be in the emergency room (I know they call it the emergency department now) when a panic stricken dad carried in his toddler who was having an impressive tonsillar hemorrhage as a complication of a tonsillectomy done a few days earlier. The ER staff took one look at this bloody child and told the dad to carry him way across the campus to the office tower where the ENT surgeon had his office practice. I was drafted to escort the dad, still carrying the child in his arms, and left father and child in the ENT’s office thinking everything would be fine.
I’ve thought about this incident periodically since then and come to two conclusions. The first is that I was totally unaware of how seriously ill this child was until talking later with some of the doctors and nurses at the hospital. Of course I’m now a lot better at recognizing which patients are really sick, but I’ve still had situations in which I failed to appreciate the seriousness of the patient’s condition until thinking about it after the fact. My second conclusion is that this child needed emergent intervention by the ER physician, and shouldn’t have been sent across the campus to an outpatient office.
I suspect the ER doctor thought that management of this acute surgical complication was beyond the scope of his training. So he decided that the risk of delaying intervention so the child could get to the ENT’s office was less than keeping him in the ER to get IV access and start volume replacement, and so on.
Though it would sound ridiculous now, you might imagine the ER doctor defending his decision by saying “I’m not trained in the acute management of surgical complications like that.” After all, like most ER doctors of the time, his training probably consisted of a one-year rotating internship or something similar. There were no (or very few) ER residencies at the time.
But if that doctor is still practicing in an ER somewhere, I’m pretty confident he has developed the expertise required to provide the initial management of patients like this one. Like all ER doctors, and the field of emergency medicine as a whole, he needed to adjust the scope of his practice to meet the needs of the institution and healthcare system where he worked. So even if it were reasonable for him to say initial intervention for acute tonsillar hemorrhage was out of the scope of his training and expertise in the 1970s, he can’t say it anymore. Like all ER doctors, he had to seek out ways to gain training and expertise in these kinds of problems in order to respond to the needs of the institution.
I tell this story because I think we as hospitalists—and the field of hospital medicine as a whole—sometimes find ourselves in situations similar to that of the 1970s ER doctor. We are sometimes asked to provide care that might not have been part of the usual scope of practice for someone with our training. I am trained as an internist, but am sometimes asked to admit patients with problems like hip fracture or hypertensive intracerebral hemorrhage when my first impulse is that an orthopedist or a neurosurgeon should admit that patient. Or I might be asked to admit a 17-year-old and wonder if it would be better for a pediatrician to take care of that patient.