Territorial medicine

I work in Emergency Medicine. This means I see a complete undifferentiated range of illnesses and injuries and have to deal with anything and everything that gets thrown my way. Half of my patients I refer to “specialties” for further management or follow-up.

Sometimes, referring a patient is a battle. Some doctors on the other end of the phone see Emergency Departments as causing them “extra” work, so resent us for that. The reaction is to try and find an excuse not to see the patient or accept the case.

Each “specialty” takes responsibility for a part of the body or related group of diseases. For instance, General Surgeons deal with abdominal problems where an operation may be required. Orthopaedic surgeons deal with broken bones and limb problems. Ear Nose and Throat deal with, you guessed it, problems with the ears, nose and throat. Cardiology treats heart problems.

Common excuses for not accepting a patient are:

  • Diagnosis too complex: “We don’t normally see patients with Condition X here in this hospital, so we won’t know what to do”
  • Somebody else’s problem: “That condition should be treated by Specialty Y, not by us”
  • Won’t require our favourite treatment to give so we’re not interested: “We’re not going to operate, so there’s no point in us accepting”
  • Bounce to GP: “They don’t need this sorting out now, get them to see their GP, so the GP can refer them to us”
  • Magic telephone patient examination: “I don’t think the patient has diagnosis Z. Instead I think it’s Diagnosis A and they should be sent home” (without having actually seen or examined the patient)
  • All initial treatment steps not complete: “You’ve not tried the fifth line medication (despite the first four not working). Try it, give it 4 hours to work, then ring us back.”
  • Everything else hasn’t been ruled out first: “Get a Gynae opinion first then we’ll think about seeing the patient”

The strategy seems to be for specialty doctors to try to minimise the scope of their area of medicine to avoid taking referrals.

However, if I as an Emergency Medicine doctor make a diagnosis and decision about a patient get all the evidence together, start what I think is the best treatment, then make an solid (hard to refuse) referral, the opposite happens… Specialty doctors criticise me for doing the treatment wrong:

Typical complaints are:

  • You’re not skilled / That’s our specialty’s job:
    • “You can’t use propofol, that’s an Anaesthetist-only drug”
    • “You shouldn’t close wounds on the torso, that’s Plastics’ job”
    • “You shouldn’t reduce that fracture, that’s an Orthopaedics job”
    • “You can’t look at that gallbladder with the ultrasound, that’s for Radiologists only”
    • “You’re not allowed to interpret that CT scan, wait for the Radiology report”
    • “You mustn’t use amiodarone, that’s for Cardiology only”
    • “You shouldn’t reverse warfarin, only General Medicine can do that”
    • “Only Respiratory Medicine should put in a chest drain”
    • “You can’t use Metaraminol to support that septic shock patient, that’s an ITU-only drug”
  • You failed to ask all the specialty-specific minutiae questions: “Why haven’t you taken a full travel history of the last 6 years?”
  • You haven’t run all the specialty-specific tests they might want: “Where is the selenium / copper blood test result?”

You know, a minute ago you were trying to claim that this wasn’t in your area of expertise (to avoid taking the referral), and now you’re an expert again picking holes in what I did. Make up your bloody mind: are you the expert or not?

Do me a favour… either be the know-all expert in your area, in which case willingly accept my patients when I ask for your help, or, if you’d rather not help, then shut the fuck up and leave me alone to do the best I can.

If Emergency Medicine didn’t exist:

  • General Medicine would have to see every single chest pain.
  • General Surgery would spend all night seeing the abdominal pain patients.
  • Every sprain would require Orthopaedics to attend.
  • Every nosebleed would need an ENT surgeon.
  • All delirious patients would need a Neurologist.
  • Urology would have to see and catheterise every patient in urinary retention.
  • Every mild pneumonia would need a Respiratory doctor.
  • Gastroenterology would have to see every diarrhoea and vomiting.

If Emergency Medicine is that much of a trouble in the lives of the specialty doctors, then they are very welcome to staff the hospital’s front door themselves.  It’s not much fun having to go non-stop all night long under high pressure, while your specialty colleagues sleep in the mess.

I was recently criticised by a specialty doctor for suturing up a 2cm deep clean wound which I had explored to exclude any debris or bleeding vessels before closing. So, going forwards, guess who I am going to be referring every single laceration to…

TL;DR: We’re batting for the same side. Be helpful, or be quiet.



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