I guess I ought to weigh in since I'm one of the few EPs on here. I'm having a hard time deciding whether to be nice or not. First, for the interested students/residents etc, a bit of information about military EM in general. I work in two military facilities, the first a "useless care clinic" at a base where I am the only active duty emergency physician. We are staffed with 1 military FP, 1 military PA with an EM fellowship, 1 experienced emergency civilian PA, 3 or 4 civilian contractor FPs, and 1 civilian contractor EP, and myself. The level of acuity we see is somewhat greater than most civilian urgent cares, but less than most military EDs. (You'll notice most EPs don't use the word ER, a holdover from the 60s and 70s when the ER was literally a room in the basement of the hospital where the medicine and surgery residents watched patients die, I mean attempted to practice emergency medicine without attending support.) We are overwhelmed with patients turned away by the clinics but do a fair number of abdominal pain, vaginal bleed, minor ortho, minor ophthalmologic, primary care, chest pain etc work-ups. My AF consultants are generally quite responsive to my needs, mostly because they know I don't call them unless I really need them. The last peds consult I called on was a 3 month old with a subdural that I had just put an IO line in because none of our staff could get access. But I frequently bounce things off of ENT, Ophtho, and ortho and arrange close follow-up. I rarely call any of those specialties down/in to see a patient. Cardiology, GI, neuro, neurosurg are at "the big house" down the road and I do mostly phone consultations with them. If a patient needs to be admitted there, the patients are transferred to the care of the medicine team at the big house. The second facility I work in is the ED of "the big house" a military emergency medicine residency program. It is staffed with medical students, interns, EM residents, and board-certified EPs. Its level of acuity is intermediate between my useless care clinic and a civilian community ED. It is not a trauma center and in 8 shifts I have not yet had a patient that needed intubation, but after the trivial stuff is drug off to the fast track, I seem to be admitting about 10% of the patients, mostly to IM and gen surgery, rarely to the ICU. The consultants are mostly residents and of course, as with any academic center, take FOREVER to come and see the patients. CT scan, US, x-ray, and lab are available 24-7 at both facilities and the big-house has an MR, if you can talk the resident radiologist into letting you use it.
Now the mean part:
EPs work in a fish bowl, everyone gets to see our mistakes. But I am quite confident that the sum of my missed diagnoses are less than the amount of work I have saved the other physicians in the hospital every week. In the last week I have seen patients that were turned away by psych, peds, medicine clinic, and family practice clinic. I have seen patients turned away by ophtho, ENT, and ortho. I see post-surgical complications (and post-surgical patients who think they have complications) on nights, weekends, and holidays and keep those doctors at home with their families. Yes, sometimes I wake them up to chat for a minute, but I rarely call them in unless a patient needs to go back to the OR. I even write holding orders most of the time late at night. I see patients referred to the ED by surgical sub-specialists for chest pain that was so obviously not cardiac nor emergent it wasn't even funny. I have taken care of apneic hypotensive patients given retro-orbital blocks by ophthalmologists in an outpatient surgical center without an anesthesiologist within shouting distance. I have seen the children of our staff pediatricians. I have seen the spouse of the chief of staff of the hospital. The wife of a four-star admiral comes to me for emergency care. Surely someone thinks our care is decent, because emergency care is the one thing that NO military member has to go to a military facility for. Tricare pays for all emergencies to be taken care of in a civilian ED. Don't trust us? Go somewhere else. Better yet, get the patient I admitted to you out of the ED within 3 hours of the time of consultation so I can actually take care of the 30 people in the waiting room. (8 hours for ortho to finally make a decision and provide care to a patient the other night)
For every stroke I've consulted ENT on (OK, I admit, that was a huge miss) I bet I've seen 10 bleeding post-tonsillectomy patients. For every time I didn't get enough x-rays for the ortho consultant I've saved them 10 consults for ankle pain, knee pain, back pain etc. For every time I consult medicine for a chest pain patient I've sent 5 chest painers home. For every abdomen I call surgery to evaluate because the radiologist thinks the appy has a bit of fat stranding on one slice, I've sent 8 belly painers home.
I mean, I'm just a family practice doc who can intubate, but those who would prefer that emergency medicine didn't exist can go back to the world where you were lucky to be seen by a medicine/surgery resident in a dark corner of a hospital. The reason EDs are crowded is because either the care elsewhere is unavailable or the care in the ED is good. Either way, its a gold star for emergency medicine.
Military emergency medicine deals with the same problems that military medicine deals with everywhere. The only difference is our training teaches us specifically how to take care of people in a broken medical system. We learned on the homeless, the drunks, and the stupid who couldn't line up follow-up care if their life depended on it (and it often did) so it is relatively easy to transition to a system where obtaining good medical care for a patient can often be difficult. I frequently do my own follow-up care because it is so hard to get a patient into primary care. I worry more about the care that my patients get from under-trained or under-employed consultants after they go upstairs than the care they receive in the ED. I mean, if the general surgeon's case load that month consisted of one appy and 12 colonoscopies....how well will he be able to care for this lady with SLE, CAD, and an ischemic colon?
My commanders at both facilities are physicians all the way up to the 0-6/0-7 level. We get stupid e-mails and extra administrative tasks that civilians don't deal with, but they're fairly minimal and we have the greatest population in the world. Higher acuity patients, higher pay, and fewer deployments would ALMOST make me consider a career.
If you're interested in military EM, I recommend you attempt to get civilian residency training and prepare yourself for the possibility of a GMO tour and/or a military residency. But in my case, I have been pleasantly surprised many times so far. Expect the worst and you frequently will be too. I'm still bitter about the flu-goo though. I just got my voice back today.
