I can't see myself enjoying anything but EM. Is the job market *that* sketchy?

[RustedFox]

QFT.

Examples, with the med school ones being actual real things that happened and real thoughts I had, vs my reaction if the same patient were to come in now:
Med school me, on EM rotation: WHOA, this person got into a motorcycle accident and the paramedics are literally bringing him in a gurney, and his entire (detached) leg in a bag!

Post-residency, attending me: Oh god, this will be an interesting conversation with my spouse who is in medicine for tonight, but if I (but honestly, mostly the surgeons) don't do him right, we'll be getting hit with a lawsuit.

Med school me, on EM rotation: This elderly guy who was dehydrated just got a bag of fluids and he feels so much better and gave me a hug!

Post-residency, attending me: GTFO of my ER so I can clear out the 25 other people in the waiting room so my door to doc metrics don't fall and the admins don't breath down my neck

Med school me, on EM rotation: Oh neat, this 10" lac on this guy's leg that I get to close up! (Did this one with another med student)

Post-residency, attending me: Can I just staple this? This is going to waste me 45 minutes when I should be seeing another 2-3 more patients. Where's the half-competent medical student who can do it for me and not increase my liability?

I wrote the same empathetic personal statements to get into med school/residency and took the same humanistic touchy-feely classes in med school as OP and everyone else on this thread. I actually like my job too because I feel I'm relatively well-compensated, it's lower stress and there's low malpractice risk. But it doesn't stop me from getting QI/peer review requests in my inbox for s*** I missed, my bonuses being partially tied to how many patients left without being seen, and having 10 people find me to give me EKGs, give me the phone to a consultant, tell me about the crashing patient 3 doors down and say the chemistry panel on Bed 7 hemolyzed...all at once. As a medical student, you see none of those (except maybe the last example, but even so, you're not in the position of cognitive overload trying to triage all of these).

How about THIS one; any death within 24 hours of admission is an automatic peer review.

Now this is Florida, where the average age of a patient is 75-85.

Thanks admins, for this absolutely stupid rule.

---

Members don't see this ad.

 

[dadaddadaBATMAN]

How about THIS one; any death within 24 hours of admission is an automatic peer review.

Now this is Florida, where the average age of a patient is 75-85.

Thanks admins, for this absolutely stupid rule.

97 yo with gi bleed on anticoagulation in context of cad, chf, copd, dm2, esrd, admitted after rosc dies 4 hrs after admit.

Admin: insert surprise pikachu face: “what went wrong? Let’s do a root cause glarblagagagaga”

 

[RustedFox]

97 yo with gi bleed on anticoagulation in context of cad, chf, copd, dm2, esrd, admitted after rosc dies 4 hrs after admit.

Admin: insert surprise pikachu face: “what went wrong? Let’s do a root cause glarblagagagaga”

Yep.
My last peer reviewed case:
88 F. Acute on chronic renal failure. Mostly bed-bound. Demented. Comes in with AMS.

HR = 45.
K = 8.8

I did all the things.
She died anyways. Family is relieved, as "it was her time".

But admins want to know why we didn't pursue dialysis.

 

[dadaddadaBATMAN]

Yep.
My last peer reviewed case:
88 F. Acute on chronic renal failure. Mostly bed-bound. Demented. Comes in with AMS.

HR = 45.
K = 8.8

I did all the things.
She died anyways. Family is relieved, as "it was her time".

But admins want to know why we didn't pursue dialysis.

Probably because battery is illegal.


But this is why we let them steal the big bucks.

I’m sure her hemodynamics would have done great with hd, it would totally have fixed the underlying pathology, and the alternative crrt would of course have worked so quickly she would have asked you for a werthers on the way out the Ed with her referral for renal xplant in one hand and a bottle of Percocet with a press ganey in the other while her family slow clapped. Freeze frame with grandma tossing her dentures towards the ceiling and roll credits

 

[JAFERD_MD]

How about THIS one; any death within 24 hours of admission is an automatic peer review.

Now this is Florida, where the average age of a patient is 75-85.

Thanks admins, for this absolutely stupid rule.

Yup, I got one of these ridiculous ones about 2 months ago.

70yo guy brought in by wife who told us he had been unresponsive for 30 minutes. The hospital staff ran out and did CPR in the parking lot while bringing him in.

Death within 24hr triggered a peer review with wording that made it sound like it was our fault he didn't live (explain why he died, if there was anything else that could have been done, was his death preventable if staff were more competent/if there was any missing equipment/if intubation was performed correctly...)

This guy had been dead for at least 30 min before his body even touched any hospital equipment, much less any hospital staff member, and I'm being asked to waste my time explaining that we did everything right and we didn't screw up.

Talk about moral injury.

 

[RustedFox]

Yup, I got one of these ridiculous ones about 2 months ago.

70yo guy brought in by wife who told us he had been unresponsive for 30 minutes. The hospital staff ran out and did CPR in the parking lot while bringing him in.

Death within 24hr triggered a peer review with wording that made it sound like it was our fault he didn't live (explain why he died, if there was anything else that could have been done, was his death preventable if staff were more competent/if there was any missing equipment/if intubation was performed correctly...)

This guy had been dead for at least 30 min before his body even touched any hospital equipment, much less any hospital staff member, and I'm being asked to waste my time explaining that we did everything right and we didn't screw up.

Talk about moral injury.

Yep. Pretty much how my shop works, too.
"Explain how you failed, even though people die no matter what."

 

[cyanide12345678]

Yup, I got one of these ridiculous ones about 2 months ago.

70yo guy brought in by wife who told us he had been unresponsive for 30 minutes. The hospital staff ran out and did CPR in the parking lot while bringing him in.

Death within 24hr triggered a peer review with wording that made it sound like it was our fault he didn't live (explain why he died, if there was anything else that could have been done, was his death preventable if staff were more competent/if there was any missing equipment/if intubation was performed correctly...)

This guy had been dead for at least 30 min before his body even touched any hospital equipment, much less any hospital staff member, and I'm being asked to waste my time explaining that we did everything right and we didn't screw up.

Talk about moral injury.

No compressions for 30 minutes? That’s a time of death on arrival or maybe 1 or two rounds at max. Ridiculous how that made it to peer review.

I guess i don’t work in such terrible environments, i don’t think I’ve ever had a peer review for a death. Actually I’ve only had a peer review once in 3 years - something silly, admitted a lumbar fracture for pain control, couldn’t get a hold of the specialist who does kyphos after multiple attempts, hospitalist admitted and she kept trying to get a hold of the specialist on his personal cell phone until she finally got in touch with the specialist. Got an automatic peer review because the person was transferred within 12 hours of an admission to the hospital for a kypho the next day. The hospitalist who admitted was on the peer review committee and actually told me to not even bother attending the zoom call and that she will take care of it.

Can’t imagine being questioned every time there’s a death. Most people in cardiac arrest don’t make it and die.

 

[CoolDoc1729]

No compressions for 30 minutes? That’s a time on death on arrival or maybe 1 or two rounds at max. Ridiculous how that made it to peer review.

I guess i don’t work in such terrible environments, i don’t think I’ve ever had a peer review for a death. Actually I’ve only had a peer review once in 3 years - something silly, admitted a lumbar fracture for pain control, couldn’t get a hold of the specialist who does kyphos after multiple attempts, hospitalist admitted and she kept trying to get a hold of the specialist on his personal cell phone until she finally got in touch with the specialist. Got an automatic peer review because the person was transferred within 12 hours of an admission to the hospital for a kypho the next day. The hospitalist who admitted was on the peer review committee and actually told me to not even bother attending the zoom call and that she will take care of it.

Can’t imagine being questioned every time there’s a death. Most people in cardiac arrest don’t make it and die.

My nurses look at me like I’m nuts when I ask them to change “DID (died in department) to DOA. But this is why.

 

[TysonCook]

Yep. Pretty much how my shop works, too.
"Explain how you failed, even though people die no matter what."

...I'm thinking at this point in our careers it's perfectly acceptable to go above the peer review group and complain about the process. It's one thing when you're a new attending, new group, etc, but a whole different story 15 years in, and you realize that nobody is watching the watchmen and they need accountability as well. At a certain point of your (our) career these become mountains worth dying on. I maintain that the delete button was made for emails like that. My group and system are amazing, and I can't imagine getting a peer review for something like that.

 

[dadaddadaBATMAN]

...I'm thinking at this point in our careers it's perfectly acceptable to go above the peer review group and complain about the process. It's one thing when you're a new attending, new group, etc, but a whole different story 15 years in, and you realize that nobody is watching the watchmen and they need accountability as well. At a certain point of your (our) career these become mountains worth dying on. I maintain that the delete button was made for emails like that. My group and system are amazing, and I can't imagine getting a peer review for something like that.

Yeah. I think it’s worth reviewing by someone if somebody dies immediately but when you see a k of ~9 in a geriatric pt it’s probably time to let your eyes glaze over and move on.

It’s definitely not appropriate to email the treatment docs every time. Huge time suck with zero benefit. I would flinch every time I picked up a critical chart.

 

[RustedFox]

Yeah. I think it’s worth reviewing by someone if somebody dies immediately but when you see a k of ~9 in a geriatric pt it’s probably time to let your eyes glaze over and move on.

It’s definitely not appropriate to email the treatment docs every time. Huge time suck with zero benefit. I would flinch every time I picked up a critical chart.

I kept my response brief.
"Hyperkalemia treated as appropriate; repeat value was 5.9. additional measures instituted for follow-up in ICU. At the conclusion of my care, no additional items were identified."

 

[dadaddadaBATMAN]

I kept my response brief.
"Hyperkalemia treated as appropriate; repeat value was 5.9. additional measures instituted for follow-up in ICU. At the conclusion of my care, no additional items were identified."

That’s actually even funnier. Did they want them to dialyze to 5.5 from 5.9? If only.

 

[RustedFox]

That’s actually even funnier. Did they want them to dialyze to 5.5 from 5.9? If only.

I guess at some point, her K+ spiked up to 8-something again after I had her admitted and went home and nephrology wrote that they weren't consulted in time.

 

[dadaddadaBATMAN]

I guess at some point, her K+ spiked up to 8-something again after I had her admitted and went home and nephrology wrote that they weren't consulted in time.

I’ll stop baiting you to post details of it, but that type of finger pointing always drives me nuts. It helps no one, particularly not the demented patient. It also seems that the icu should probably be capable of placing that consult themselves. I’m sad you’re going through that though, sounds like it sucks

 

[Brigade4Radiant]

I don’t even understand why admin is asking some of these questions. Do they practice medicine? They removed us from owning hospitals because we were to good at it but there is no conflict of interest here?

Also I would either do radiology or Direct primary care in a nice city so I don’t have to deal with insurance

 

[dchristismi]

I guess at some point, her K+ spiked up to 8-something again after I had her admitted and went home and nephrology wrote that they weren't consulted in time.

Clearly there isn't a door-to-palliative-care-consult metric in play.
Because that is the only thing that would have saved you on that one, bud.

<clutch pearls> gasp death panels???
Oh, wait, that's so pre-covid...

 

[RustedFox]

Clearly there isn't a door-to-palliative-care-consult metric in play.
Because that is the only thing that would have saved you on that one, bud.

<clutch pearls> gasp death panels???
Oh, wait, that's so pre-covid...

Right? RIGHT?!

I even wrote in my email to the review committee; "the potential causes of this change are multiple, but the most common is the inevitable pathways of end-of-life physiology ".

The committee ended up saying nothing more about it to me (ER BuddyDoc is on the peer review committee), but he also told me that the real fight is between nephro and critical care, because critical care at this facility is often totally unavailable for whatever reason and the hospital has "Effing Had It" with them.

At night, there is only a NP/PA to handle ICU stuff, and we're all getting tired of being asked "offhand" how to ICU by these pretenders. I straight up said to one: "No. Stop. Go wake up Dr.Diva. No; I don't care."

 

[sylvanthus]

Just read an email that we as a hospital are not referring enough cases to peer review. Isnt that a good thing? Naww they want more fodder.

 

[EctopicFetus]

Just read an email that we as a hospital are not referring enough cases to peer review. Isnt that a good thing? Naww they want more fodder.

Keeps the docs on their toes and allows admin to better control the docs.