IONS

IONS should be the sign over the door of the ER. IONS stands for “Interrupters Of Natural Selection,” which is what we do. The same patients—both medical and trauma—100 years ago would not have survived without us. Those who work in emergency settings recognize this as part of the dark humor that we share. Those who don’t likely see it as somewhat insensitive and disrespectful.

However, the other truth is that through my many years of doing this, I see that all patients are simultaneously treated as if we (the providers) are fighting the Grim Reaper. Regardless of who comes in the door, we are doing battle against death on their behalf. We don’t accept that whatever they did—if it was worthy of a Darwin Award—will end them if we have anything to say about it. I have not seen patients treated with bias against their race, color, creed, sex, socioeconomic status, or any other thing that we get accused of.

I’ve heard it said that the critical care area of an ER is the most anti-biased place in the hospital. Having worked there, I can attest that it’s true. Despite being accused of any number of biases, none of that matters—particularly when patients are the sickest. There is no distinction. When you hit the door of the ER, you are a human being, death is the enemy, and He has to get past us.

Like my colleagues—everyone from the registration person who checks patients in and collects insurance information, to the techs who draw blood and perform EKGs, nurses who start IVs, give medications, and do the thankless tasks of cleaning up and comforting patients—we all get accused of biases without any basis, and it happens regularly. I wouldn’t say I see it every shift, but it’s frequent.

Racial slurs are common, thrown in all directions at all types of diverse providers. Accusations of doing or not doing something based on ability to pay are common.

I saw a 40-year-old man who died of a rare condition despite our best attempts at resuscitation. He was initially talking with EMS and had a cardiac arrest in the ambulance garage. Besides myself and three other doctors at the bedside, there were probably 10 nurses and techs also at the bedside doing everything possible, including heroic efforts that were borderline futile. When I was updating the family about his dire circumstances and likely poor outcome, a family member said to me in the midst of the crying and yelling, “We’ll pay anything!”

I can assure you that a patient’s ability to pay has never crossed my mind in a critical situation. The only time I discuss finances with patients is when they bring it up, and that’s usually in the setting of doing some test that is reasonable but not absolutely necessary for that ER visit—and they are concerned about their bill.

The same week, I saw a patient for a benign headache and mild hypertension. I did a head CT (which was conservative, i.e., perhaps more than necessary), treated her headache, and we discussed her BP. It didn’t need treatment that night. She had not officially been diagnosed with HTN, so I recommended primary care follow-up to confirm the actual diagnosis of HTN and discuss the pros and cons of long term anti-HTN meds. I thought all was well until the nurse went to discharge the patient and the accusations started. She demanded a dose of medication for her BP and a prescription for medication—even though she was going to see her primary care the next day. Her accusations were that I didn’t do enough because of her race and her ability to pay.

Arguing against accusations has the same effect as a heated debate on X: no one backs down, and no one changes their mind. But it’s the providers who take that home with them. It doesn’t feel good to leave a shift having been accused of something you know deep inside does not represent who you are. It’s a helpless feeling.

Since I started writing this post, I received the most severe ass-chewing I’ve probably ever had—for being an “arrogant asshole” and “terrible f***ing doctor” who should “quit your job.” Nothing I tried to say helped. My nurses even heard the patient yelling from their desk outside the room.

So, we bottle that up and take it home. And we end up with some dark humor.