Twenty Years of Change and the “View from the Box”

Once, a really long time ago, before blogs if you can conceive of such a time, I embarked on a part-time writing career. My subject matter was the parade of frailty, the courage and the just plain bizarre that were to be found daily – hourly – in the ER. My first collection of essays and stories was to be “The View from the Box.”

I never got to publish that book, although I did publish a few articles here and there. 

With the arrival of the all-the-time, in-your-face Internet, I gave up the idea of chronicling the ongoing drama-rama since there was no way (I thought at the time) that anyone could sustain that kind of pace with any pretense of interesting writing.

Who knew? The whole blog thing took off, and I blew an opportunity. Don’t get me wrong: I think there’s way too much dull, dreary, bludgeon-you-with-my-opinion-till-you-bleed-from-your-ears stuff, and I still think the ER pageant is a worthy topic of reporting. And I still like the title “The View from the Box.”

But what you can see from here has changed a lot.

It looks like traffic is worse and there’s a storm coming. (Bad analogy alert? Was there maybe another reason I stopped writing?) There are plenty of big differences from twenty years ago to now. Just a few examples:


Patients now ask about whether they really need radiation. Sometimes this means they don’t want the CT scan, and want an MRI instead but they question how we use a basic tool.

Kids? What kids?

Over the time of my practice, a plethora of vaccines have melted away huge swathes of disease, including the worst Pedi-nightmares: H. flu, rotavirus, chicken pox and pneumococcus (both the 7- and 13-valent vaccines). “Occult bacteremia”, once the scourge of the general EM doc facing a healthy but febrile baby, is now under 1% and a number of studies show there are 3 or 4 falsely positive blood cultures for every true positive out there.

Mental Health Rising.

Why are we seeing so many psych patients? Well, with an extremely limited number of inpatient mental health facilities, and prisons and jails the only other place for the chronically mental ill to go, the ER is just one of very few places to go. Read Pete Early’s “Crazy” if you want to understand this issue better.


‘Home’ is still home (um, that is, if you have one…)but ‘admit’ is not the same admit. Believe it or not, kids, when I started out, a patient’s doc still admitted their patients, and Emergency Medicine drew a hard line against writing holding orders. There were hospitalists in a limited way, but I doubt many docs saw then that they were going to be the Next Thing. Keep that idea in mind because we are just on the threshold of the ‘Observe’ era, and twenty years from now (God grant me the faculties and desire to still be able to practice then…) are you going to marvel at the fact that you actually admitted to an inpatient hospitalist service?

Embrace change, since it’s already embracing you. Happy Holidays!