The Language of Emergency Medicine By Neal E. Flomenbaum, MD, Editor-in-Chief

Medicine has never suffered from a lack of colorful terms to describe abnormal appearances, sounds, colors, smells, and motion. Rusty sputum, seagull murmurs, Coca-Cola urine (acute glomerulonephritis), mousy odor (diphtheria), and cogwheel rigidity (parkinsonism) are but a few described in a 1976 book entitled "The Language of Medicine," by John H. Dirckx. A particularly interesting group of metaphors is the variety of foods and drinks used to describe pathological lesions: strawberry hemangioma or tongue (scarlatina), bread-and-butter pericarditis, apple-jelly lesions (lupus vulgaris), oat cell carcinoma, and nutmeg liver, washed down by port wine stains and coffee ground emesis—all ending up as currant jelly stools (intussusception). Yet another collection of medical metaphors refers to the animal kingdom: spider angioma, butterfly rash, harelip, bull neck, buffalo hump, and stag horn calculi.

This terminology came into use over the past few centuries and for the most part reflected the state of medical diagnosis at the time: observation, gross anatomy, light microscopy, and plain-film radiography. Modern diagnostic modalities such as computed tomography and magnetic resonance imaging render most of these terms obsolete or useless, while concern for political correctness makes their continued use or the coinage of new metaphors inadvisable.

As a still-young specialty, emergency medicine largely missed out on inventing and using such colorful language—but not entirely. The words we invoke to describe who we are and what we do sometimes conflict with other words applied to our specialty. On the one hand, there are emergency physicians, safety net, urgent care and fast-track centers, triage, scoop and run, the golden hour, and FAST (focused abdominal sonography for trauma) exams. But there are also ambulance diversions, overcrowding, walkouts, and patient boarding.

Some expressions provide a useful means of understanding what a new concept actually means. Thus, "performance indicators" are referred to as "pay for performance." Let's hope it doesn't come to mean "less pay for less performance" instead.

There are, of course, terms that are mean-spirited—or worse—and never justified because they demean patients. A popular current term is "frequent flyer," used to describe the recidivist patient well known to the emergency department staff. This label almost always implies that the patient is at fault, as opposed to acknowledging our own shortcomings or system failures. It might actually be beneficial to the patient if only it were understood in the same sense as "the boy who cried wolf," as a warning against complacency and the dangers of categorizing patients too quickly. Ironically, this term originated from a positive concept. Who wouldn't want to be a real "frequent flyer" and receive complimentary services, upgrades, and first-class accommodations? How many emergency department frequent flyers are treated that way?

Then there is the term that always struck fear in my heart—the emergency physician as "gatekeeper." I never quite understood how I could be expected to objectively and aggressively care for the patient in front of me, while simultaneously trying to reserve that last in-patient bed for the potentially even more serious needs of a patient who has yet to arrive. For me, "gatekeeper" evokes the disconcerting image of a doorman at a trendy club who decides which patrons get in and which ones have to wait on line.

Given our penchant for using colorful language and appropriated slogans in medicine, I would like to propose borrowing one from the current administration in Washington and applying it to all the non-"pay for performance" patients in the waiting room and all those whom the gatekeeper keeps waiting for an in-patient bed: "No patient left behind."

Emerg Med 38(12):9, 2006