Description of a Working Day as a Senior Emergency Medicine Resident; Burning Candle at Both Ends!

To the Editor:

This text is a real-time description of an emergency medicine resident’s shift in an overcrowded emergency department (ED), Tehran, Iran. It is 3:35 pm of a warm afternoon; the emergency department is filled up with ill patients. Carrying in hand the file of a patient who had three episodes of convulsive seizure, you have to writing an order for another patient with suspected pulmonary embolism. Simultaneously, you are confronting with a pregnant woman complaining from loss of her baby’s movements and an addicted case with hangover feeling and low blood pressure. In addition, you have to provide a bed for the patient who is complaining from typical angina pectoris from the last night. When you decide to give the orders of the first patient to the nursing service, an intern informs you that another patient with ST segment elevation myocardial infarction has been presented. Meanwhile, the mother of the addicted patient requests you to attend to her boy. As you visit him, you find out his condition worsen than you thought; he is burning with fever accompanying with prominent respiratory distress and tachycardia. While you are completely being exhausted and stressed due to the work pressures, you have to control your anger to do not tearing the disastrous history sheet taken by the intern. As you ask the intern to rewrite the history, another patient presents with decompensated cardiac heart failure. When you leave the last patient, notice that no one has yet applied venipuncture to the addicted case because of fear from his positive history of acquired immune deficiency syndrome (AIDS). At this time, you are called for joining to grand round of ward’s patients by corresponding emergency medicine attending physician. You eventually feel the world are collapsing on your head. After about 12 hours uninterrupted presence in the ED, hand over the shift with lots of patients with unknown diagnoses and partial treatments. You may just satisfy because of the addict’s mother deeply praying for you! What is your judgment? In such aforementioned situation, is medical errors, delay in service presentation, and patients’ dissatisfaction avoidable?

Today, overcrowding in EDs has turned out to be one of the most important problems in health systems around the world. The short and accessible solution in this regard could not be reached easily. In fact, several basic reasons play a role in such a problem and eliminating each of them would require a long-term planning. This issue not only has a negative effect on the quality of services, but also produces both psychological and physical effects on the ED staff. In addition, it also causes increased dissatisfaction among referees as well as excessive exhaustion among staffs (1, 2). An increase in the number of unnecessary referees in non-emergency cases is one of the major factors for overcrowding. Another recognized factor responsible for overcrowding in emergencies is the lack of timely disposition. Requesting the unnecessary paraclinical procedures and unrelated consultations are other defendants. Lack of difference in the calculation of costs between emergent and non-emergent cases are considered as some of influencing factors that increase the expectation level of referees and overcrowding in state emergency centers (3, 4).