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Crisis Central: A Day in the Life of The man in the exam room has come to Saint Barnabas Medical Center's Emergency Department to be treated for burn injuries after spilling a hot cup of coffee on his lap. He is in considerable pain and the attending physician in emergency medicine, James McEnrue, M.D., Associate Director of the Emergency Department at Saint Barnabas, addresses both the injury and the need for pain relief for such an acute condition. Of all the injuries he has seen, Dr. McEnrue finds burns to be among the most painful and the most horrifying. A father of three, the physician still clearly recalls a nine-year-old child he once treated over 15 years ago who had been severly burned in a tragic accident. "The boy's football had lodged on a high tension wire, so he took a metal pipe and tried to knock it down," relates Dr. McEnrue. "He definitely had the worst burns I have ever seen. To insert a urinary catheter, we had to brush away the ashes because there was not much left of his skin. The boy's family didn't speak English so their older son became the interpreter, with the help of staff members. I watched the brother grow up in the course of a long day as he handled that terrible situation. I was really moved by the experience of that family." Despite his injuries, the child eventually recovered. Like all of the men, women and children who come to the Emergency Department at Saint Barnabas, the boy received the kind of specialized, immediate medical treatment that is the cornerstone of emergency medicine. The Emergency Department is directed by Jay Kaplan, M.D., Chairman of the Department of Emergency Medicine for the Saint Barnabas Health Care System, and staffed by a rotating team of 15 full time board-certified physicians, including pediatric emergency medicine specialists, emergency and critical care nurses and other staff members who provide intense, round-the-clock care. To keep pace with the volume over the last two decades -- more than 50,000 patients are treated annually -- the Department has recently received its third renovation. Unlike the pediatrician who watches patients grow to adulthood or the obstetrician who cares for women throughout pregnancy, an emergency medicine physician has a relationship with patients that is more fleeting. Although he sometimes misses the "continuity of care" with patients, Dr. McEnrue finds other benefits from his role. "I like the immediacy of being able to give someone relief and in this particular emergency department we have been concentrating on the goal that pain be addressed as quickly as possible," says the 20-year emergency department veteran. "I also like the diagnostic challenge and the incredible variety of patients and conditions that we encounter. Just when you think you have seen everything, you have to think again." For the most serious conditions, an emergency department serves as a hub for stabilization and frontline treatment of patients followed by their transfer to more specialized areas of the hospital. At Saint Barnabas, many patients come to the emergency department on their way to other centers of excellence, including The Burn Center, The Renal Transplant Center, The Maternity Center and The HEART HOSPITAL of New Jersey at Saint Barnabas. In less serious cases, patients receive all the immediate medical care they need from the emergency medical staff. From sprains and breaks, pregnancy complications, fevers and vomiting, back pain and abdominal discomfort, respiratory distress and chest pain, to asthma attacks, severe rashes, dog bites and bleeding, the emergency physicians encounter all types of patients and conditions. On this particular day, one that started at 6:30 a.m. for Dr. McEnrue, the department's steady activity level has started to rise by 8 a.m. and reaches a brisk pace by 10 a.m. Most emergency departments see an increase in patients in the morning and experience another peak beginning at 6 p.m. with individuals who wait until after work or until they can make childcare arrangements. Not surprisingly, weekends and holidays are also busy because many medical practices do not have office hours, and patients turn to the Emergency Department. And then there is the weather. "Several years ago, we named one day Black Thursday because the weather was terrible," recalls Dr. McEnrue. "Freezing rain had left a thin layer of ice over everything, and that gave rise to one accident after another. There was such a great number of falls and motor vehicle mishaps that we had to call in additional staff." As he stands at the primary nurse's station, Dr. McEnrue is the focal point in a whirl of activity. A phone call has come in from a consulting physician; the Emergency Department's physician's assistant has a CAT scan back from the Radiology Department that needs Dr. McEnrue's attention; his own pocket radio phone is ringing as is the phone at the main desk; there are patients still to be seen and others to be discharged. With a master's composure, he handles everything cleanly, quickly and calmly. If Dr. McEnrue is feeling any stress, it is not evident today. He says his secret to inner calm is staying abreast of the most reliable information sources at his disposal and remembering the image that the entire department is projecting. "In a sense, we are always on stage," he says. "Our department gives maximum access to patients' families, so there are always concerned people in the area watching us work. For example, if I am looking at x-rays on a view box within sight of relatives, every family member in that room will automatically think I am looking at test results for their loved one. Body language and overheard comments can be misinterpreted, so it is important to remember the implication of your words and actions." After treating the burn patient, Dr. McEnrue enters the room of a man with spinal injuries. The patient has a history of chronic pain but is especially concerned about having problems on an upcoming overseas vacation. "Some of your nurses have their eye on my plane ticket," he jokes. "Me too," Dr. McEnrue adds, "but I'm sure you will be able to use it." After taking a medical history and performing an exam, Dr. McEnrue concludes that the man continues to have an ongoing back problem and "Sometimes the thing that is the most stressful to a patient is not the pain of an injury, but that he or she has missed work and might be fired," says the physician. " I have learned that it is just as important for me to be aware of social issues as it is to treat the medical condition." Sometimes the biggest concerns remain unexpressed due to the person's embarrassment or other reluctance. This is particularly true with domestic violence or substance abuse cases. Back at the front, Dr. McEnrue examines an x-ray of the arm of a baby who had a fall. He notices some abnormality in the left shoulder, but experience tells him that growing children often have a great deal of variation in their bones. He orders an x-ray of the right shoulder, which has not been injured, to use as a comparison. On to the next patient. A young boy, still in diapers, has been brought in with possible pneumonia. As Dr. McEnrue listens to the lungs, the child tugs urgently on the stethoscope. With a quick hand, the physician finds a toy to occupy the child. "He wants to be a doctor," says Dr. McEnrue with a smile. "They say that grabbing the stethoscope is a sign." During the examination, the physician points to several large bumps on the child's arm and asks the departmental resident-in-training how she knows that they are not chickenpox. The answer: chickenpox begin on the back and chest, spreading later to the limbs. Further history reveals that these bumps are mosquito bites and the physician says they should be treated topically. After more investigation, Dr. McEnrue determines that the boy has a ecurring asthmatic condition that requires the use of steroids, but he does not have pneumonia. The child is treated and released. During the lunch hour, Dr. McEnrue snacks on mints and continues to see patients. When he and his colleagues do find time for lunch, it is eaten in a staff room on site. "I eat standing," he says with a laugh, and tells an anecdote about a physician from another hospital who worked briefly in Saint Barnabas' In between seeing patients, Dr. McEnrue handles administrative issues that include everything from a broken air conditioner to new construction in the unit. He has a detailed discussion with two nurses about a new catheter to order for pediatric patients. Suggestions from any staff member about improving care are taken very seriously. The Emergency Department administration is especially concerned with issues relating to patient satisfaction. Patient surveys are given close attention and the administration continues to implement initiatives to reduce patient waiting times and maximize patient care. For the past four years, the Emergency Department has ranked in the 90th percentile or greater in patient satisfaction nationwide as compared to hospitals in the same peer group, according to surveys conducted by Press, Ganey, the health care industry's largest national patient satisfaction survey company. In the hours that follow, Dr. McEnrue will treat numerous patients, including a young girl with a recurring fever of 104 degrees, a camp counselor whose nose had a close encounter with the foot of one of her campers, a baby with a finger that requires stitches, several elderly patients who experienced falls, two individuals from a car accident, and several people with conditions ranging from kidney stones to cardiac distress. He will meet with a variety of specialists from all over the hospital and call several primary care physicians about their patients. As his shift nears the end, Dr. McEnrue recalls a time when he was on the opposite side of the desk, a parent waiting for his child to be seen by the doctor. Four years ago, his then ten-month-old son had a terrible asthma attack. Dr. McEnrue had just completed a 12-hour shift, and had to return to the Emergency Department to have his son treated. "I remember that one of my more junior colleagues asked for my opinion, and I said that I just wanted him to take care of my son," says Dr. McEnrue. "I was so physically exhausted and close to the situation that I lacked objectivity. It was tremendously consoling and a great relief to know that the staff would care for him. I try to remember that day when I am with parents. I always ask myself, "What would I want done for my child?" At 3 p.m. -- the end of his shift -- Dr. McEnrue pauses to reflect on life as an emergency physician. "I haven't had a regular schedule in over 20 years," he says. "Now and then the round-the-clock lifestyle can be a bit difficult, but we all pitch in and relieve each other. We have a great team and it is amazing how everyone really pulls together. I enjoy my work and the amazing variety of patients that each day brings. It is an inspiration and a privilege to observe the courage of individuals in times of distress." [ top ] |
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