Thinking outside the box

Editorials / Commentaries

CJEM 2002;4(5):316

Facing an emergency department staffing crisis, the Quebec government has devised a brilliant solution: legislation that forces doctors to work in emergency rooms on threat of "heavy financial penalties." Normally I'm skeptical of politicians, but this time they've hit a home run with an innovative concept that could change the face of society -- or at least the health care system. Forcing unwilling (and generally unqualified) physicians to provide emergency services is a stroke of genius: It will save politicians the hassle of actually negotiating with doctors. Some call it a dangerous precedent, but I see it as a solution for all sorts of human resource problems.

Why train expensive surgeons when we can force GPs to work in the operating room? And why insist on qualified airline pilots if a zealot with 8 hours in a Cessna can fly a 757? Imagine the cost-saving possibilities when governments tackle private sector problems. Simple legislation will replace lawyers with notary publics and architects with carpenters. Baseball players will never go on strike again; not when they realize there are whole cadres of unemployed synchronized swimmers just waiting to be legislated into the dugout.

Emergency physicians and family physicians are different animals with different knowledge, experience and skills. How many GPs can open a chest and evacuate a knife-induced hemopericardium? But penetrating trauma aside, surely "replacement physicians" can perform the bulk of emergency work. Or can they? Can they use a slit lamp? Stop a posterior nosebleed? Measure compartment pressures in the leg? Do they know that verapamil is a poor choice for SVT with rapid ventricular response? Will they spot the trifascicular block in the syncope patient? Do they realize that the T = 0 troponin assay misses most cases of myocardial infarction and almost all cases of unstable angina? Can they isolate flexor digitorum superficialis function when evaluating a wrist laceration? Will they recognize the Maissoneuve injury -- or treat it as a sprained ankle? Do they know how to place a chest tube? Painlessly? If the patient is in shock, can they vent the chest in 15 seconds? Are they competent to clear trauma C-spine films at 2 in the morning? When was the last time they restrained and sedated a violent, psychotic patient? Do they know enough to intubate the woman with thermal airway burns before it seems like airway management is necessary (and it's too late)? Can they perform a saphenous cutdown, a femoral line, or an internal jugular in a hypotensive patient with no veins? Will they miss the ruptured spleen in the rugby player because they believe early hemoperitoneum causes guarding and rigidity? Can they recognize blood in the basal cisterns? And do they know enough to do a lumbar puncture if there isn't any? Do they remember that methanol poisoning can present without an anion gap -- or an osmolar gap? Do they remember what an osmolar gap is, and how to calculate it? Can they do a rapid sequence intubation? Can they manage a difficult airway at all? Will they know that succinylcholine is not the best choice in a patient with hyperthermia and muscular rigidity?

Maybe the government is right: You don't really need emergency physicians in emergency departments. Unless there are emergencies there.

CAEP President, Dr. François Bélanger, says that this legislation "will possibly subject the public to an increased risk of poor clinical outcomes when faced with an acute medical illness or injury." Dr. Bélanger is a nice fellow, but he is dead wrong in this. This legislation will definitely lead to many poor outcomes and deaths. It is, as he says, "a convenient façade to comfort an unsuspecting public." It will provide them with false hope and expectations when what they need is emergency care.