the front of UNC Hospital emergency department
Many hospital managers worry that too many patients use their emergency departments for routine care, at greater cost to the their institutions and the health care system. NCHN file photo.

Emergency medicine resident Katherine Fredlund juggles multiple roles, even as she hones her abilities as a doctor.

By Patrick Mustain

Dr. Katherine Fredlund stands back 20 feet from the bed, looking into the dark, curtained-off room in the UNC Emergency Department. In the bed, a woman heavily under the influence of alcohol lies in restraints, one leather cuff chained to each wrist.

the front of UNC Hospital emergency department
UNC Hospital hosts one of the five emergency medicine residency programs in North Carolina. Photo by Patrick Mustain.

“She’s not fighting the restraints, so that’s good,” said Fredlund, a second-year emergency medicine resident. Earlier, four police officers helped secure the woman after she started yelling, trying to remove her gown and stumbling into other patients’ rooms.

Now Fredlund is standing out of the patient’s sight to avoid setting her off again.

“It looks barbaric, but sometimes it’s necessary,” she said of the restraints, which would remain secured until the woman sobered up. Fredlund’s responsibility is to ensure not only the safety of her patient but also that of her staff and other patients in the emergency department.

Fredlund doesn’t take her eyes off the woman. Her expression conveys a mix of concern and concentration as she visually assesses the patient’s condition. Fredlund adopts that expression frequently. As new patients in gurneys are wheeled past her desk, or as she passes a patient’s room, a quick glance can provide her with a lot of information.

Fredlund’s ability to think quickly on her feet likely helped her during the application process for her position at UNC. Every year, fourth-year medical students go through applications and interviews, sometimes at dozens of residency programs.

In a process called “The Match,” students indicate their preferences for residencies and the residency programs indicate their preferences for incoming students. A not-for-profit corporation called the National Resident Matching Program (NRMP) ultimately decides the fates of these students every year on “Match Day.”

Applicants who perform well in the interview and application process are more likely to be ranked higher by the residency programs, and therefore more likely to be placed in a program they requested. In 2012, according to an NRMP report, of those medical students who went through the process, 81.6 percent matched to one of their top three choices.

According to a report from the American Medical Association, in 2009, 4,750 emergency medicine residents staffed 149 residency programs across the country. North Carolina is home to five accredited emergency-medicine residency programs, which tend to be competitive.

A balancing act

These residents, like Fredlund, play not only the role of caregiver, but also that of investigator and educator.
“There’s a lot we can tell just with our eyes,” she said. Within seconds, Fredlund said, she can see if a patient is breathing normally, distressed, bleeding, in pain or slipping into more critical condition.

As she goes over her patient list, she moves constantly – bouncing a knee, shifting position in her chair or quickly clicking through her patients’ electronic medical records, adding symptoms and recommendations. Then she is up, speed walking to the next room, juggling a clipboard, her stethoscope and a cordless phone.

Fredlund’s energy serves her well in the emergency department. She said she’s never bored. Patients come to the emergency department for a variety of ills. Tonight the problems include a urinary tract infection, a 45-mile-per-hour head-on collision, too much drinking, a hallucinogenic psychotic break involving imaginary parasites crawling into the skin, an asthma attack, a flare-up of pain from stage-four lung cancer, dizziness, pain in the knee, suicidal thoughts and a garden shears accident.

“As emergency doctors, we worry about things that are going to kill people tonight or tomorrow,” Fredlund said. “If someone comes to the emergency department, there’s something that person needs, right now, and I need to find out what that thing is.”

She describes the balancing act that emergency physicians have to perform. With each patient, doctors have to decide: What treatments are needed? Does the patient need admission to the hospital? Can the patient go home? Often a patient simply needs referral to primary care.

“Sometimes what we end up doing here is just a lot of education,” said Fredlund.

As if to drive her point home, she drops in on a patient with a urinary tract infection. To be cautious, Fredlund had ordered lab tests but found that the problem could be handled with standard antibiotics and painkillers. Fredlund tells the patient she is going to be OK, explains the tests results, and sends the patient home with a referral to a primary-care clinic.

Judith Tintinalli, chair emeritus of the UNC Department of Emergency Medicine, pointed out in an email that ED visits often result from common chronic issues. Sometimes patients don’t know about community health resources. Although some patients visit the ED for less acute care, these patients don’t tax the department resources, Tintinalli said.

In those cases, the ED fills an important educational role. Until an emergency arises, or a chronic condition worsens to a point that patients seek care, they might not have any reason to learn about the health care resources in their area. An ED visit can be an opportunity to get patients directed to the care options most effective for them.

Fredlund said she is happy to send people to the appropriate place for care; it’s a part of her job. “I give them the contact info for all of the primary-care clinics. Why not optimize it?” Providing a range of options allows patients to find a clinic that will fit their budget and schedule, she said.

At one point, Fredlund’s attending physician asks her about the status of her patients.

She smiles at him. “Everybody’s breathing. Blood goes round and round, air goes in and out; it’s that simple,” she said.

Maybe so. But the process by which Fredlund decides what level of care or education each patient needs is far from simple. Though she self-deprecatingly calls emergency doctors “jacks of all trades, and masters of none,” she also describes emergency medicine as its own art – a combination of deduction, treatment and education.

Later Fredlund has a chance to put that art to the test. Two bearish guards escort a frail, elderly inmate from a nearby prison into the ED. The man is wearing handcuffs and his ankles are shackled. Fredlund asks him what’s going on.

“To make a long story short,” the man said, I’m dying and they don’t know why and they don’t know what’s killing me.”

“I’m in pain,” he said. He tells Fredlund that he has stage-four lung cancer. He had a double bypass, and that’s how they had found the cancer in the first place. The cancer in his chest was causing him pain, but he had recently developed a great deal of pain in his wrist.

Fredlund feels his wrist and notes that it’s swollen and hot to the touch. She tells the man she’s going to get an ultrasound to see if she can find pockets of fluid that she can extract from the swollen area to run some lab tests on.

“They’re gonna take good care of you, Mr. W—,” said one of the guards, with real concern in his voice and affection in his eyes. “They’ll do everything they can.”

“They’re the best,” said the other, repeating softly, “simply the best.”

Author Patrick Mustain is a second year masters student in the Medical and Science Journalism Program at UNC-Chapel Hill’s School of Journalism.

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Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...

One reply on “ED Docs: Caregivers, Investigators, Educators”

  1. Thanks for the look inside the Emergency Department. Very well written and informative.

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