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Dr. Brian Goldman. (Fernando Morales/The Globe and Mail)
Dr. Brian Goldman. (Fernando Morales/The Globe and Mail)

Brian Goldman

When the emergency ward becomes habit, something needs to change Add to ...

Brian Goldman is an emergency physician in Toronto. His new book – The Secret Language of Doctors – Cracking the Code of Hospital Slang – is published by Harper Collins Canada.

On one recent night shift, I taught a resident how to put back the dislocated ankle of 25-year-old dude who fell off a motorcycle. An hour later, when a 47-year-old woman came to the ER with an abnormal heart rhythm called atrial fibrillation, I showed the resident how to cardiovert or shock the heart back into a normal rhythm.

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Both times, I caught a smile and a look on the resident’s face that says, “This is why I love emergency medicine.”

Unfortunately, patients like these – and the moments of professional pleasure and glory that they bring – are like oases in a desert of frustration and boredom.

To the people who work in ERs these days, the majority of patients don’t bring much of that kind of professional satisfaction at all.

Recently, I’ve been exploring hospital slang – the secret language doctors, nurses and other health professionals use to talk about patients, situations and even colleagues they can’t stand.

One of the post popular bits of slang is the term frequent flyer. Note the irony in the term. In the airline industry, a frequent flyer is a highly desired customer because he or she symbolizes repeat business and more profit. In health care, the frequent flyer is the polar opposite; a patient who drains the system of time and resources without any obvious benefit or end.

Betty is a 33-year-old woman who visits the ER five or six times a month complaining of vomiting. She has been admitted to hospital a dozen times as a small army of doctors tried to figure out the cause – to no avail. She’s had 10 CT scans of her abdomen – enough to boost her lifetime risk of cancer. None have shown anything wrong. Betty also has high blood pressure and type-2 diabetes; she’s on a fistful of medications she rarely takes.

Clarence is an 87-year old man with end-stage Alzheimer’s dementia. He has lived in a nursing home for the past five years. Clarence receives his nourishment by a feeding tube inserted into his stomach through a hole in his abdomen; the feeding tube was put there because his doctors thought nourishing him that way instead of by mouth would prevent him from aspirating food into his lungs. Once a month or so, Clarence is sent to the ER with symptoms of aspiration pneumonia and gets admitted to hospital. Clarence can’t talk, can’t walk, can’t dress and is bedridden. The only thing Clarence can do is pull out his feeding tube, which usually necessitates an emergency consultation with an interventional radiologist to put in a new tube.

Sophie is a 22-year old woman with borderline personality disorder (BPD), defined as “a serious mental illness marked by unstable moods, behavior, and relationships.” Sophie copes with emotional upset by swallowing kitchen utensils and other sharp objects. At times, she visits the ER 15 or even 20 times a month to have the utensils fished out of her stomach with a gastroscope.

Sophie, Clarence and Betty are composites based on hundreds of frequent flyers I’ve seen over the years. And their numbers are growing. According to the Public Health Agency of Canada, three out of every five Canadians has at lease one chronic disease, such as arthritis, chronic pain, cancer, dementia, diabetes, mental health, not to mention chronic problems stemming from serious injuries.

An aging population is a big driver of this trend. Rising rates of morbid obesity is another.

The slang I have uncovered that is used by some health professionals to talk about these patients is cruel. Morbidly obese patients are sometimes called whales or seals. An ER colleague in Western Canada says he’s heard frail elderly patients with dementia referred to by the initials FTD, which is short for failure to die.

There are several reasons why these patients flock to the ER in droves. Most do not have access to comprehensive primary care. Some don’t have a family doctor. Others have one but don’t get counseling in how to manage chronic conditions like diabetes and how to avoid the complications that bring them back to hospital again and again.

ER physicians and others who work in hospital ought to be thrilled for the business. Truth is, they aren’t. First, they face health problems they aren’t trained to diagnose and fix. I can treat a life-threatening episode of high blood pressure. But I’m not an expert in starting a patient on lifetime blood pressure regime. That’s the job of a family doc, an internist or a nurse practitioner.

I’m also not an expert in patients with borderline personality disorder. Most surprising of all, despite fair warning of an impending tsunami of aging boomers, most ER physicians receive little if any education and training in managing frail seniors.

And many ERs lack the proper equipment and training needed to lift, transfer and care for bariatric (obese) patients.

You can’t fix health problems you aren’t trained to recognize and deal with. When you lack proper equipment, an easy job becomes impossible. To us, the problems of the frequent flyers are unfixable – at least in the sense that a dislocated ankle can be popped back into place.

Health care is trying out new solutions. Specialized psychiatric and geriatric ERs hold out the hope that they’ll be equipped appropriately and staffed by well-trained and motivated professionals. Getting more and better primary care to Canadians who need it could divert many frequent flyers away from the ER.

Most important, we need to attract young health professionals who love taking care of frequent flyers.

Slang that demeans patients is both unprofessional and unethical. But I believe slang isn’t the problem so much as a symptom of these larger issues. Solving them will do much to make it disappear.

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