12 reasons NOT to go into ER

[december07]

definitely a sticky!
Time Magazine gave it "two thumbs UP!"
Rolling Stone called this thread "an emotional roller coaster!"

This is a nice read before walking into my night shift. Thanks!

---

Members don't see this ad.

 

[vancouvergeorge]

I read this and thought... whoa, this guy must work in my ED. The problem with many of us in NYC anyway, is that we're NOT earning more than 200k.

For NYC, where a decent 2 bdrm in a decent school district goes for $1-2 million, that's pretty broke.

Why are there still doctors in NYC?

 

[la gringa]

best thread ever... thanks for the articles ya'll, Dr Leap put into words so eloquently what i say all the time.

 

[rockydoc]

i concur with the above reviews and call for sticky status

this thread is somehow paradoxically sobering and encouraging to me as a medical student. I hope that gleaning this knowledge from your experience early on in my career will help me be more prepared for what lies ahead (as opposed to hopelessly holding onto to immature and idealistic fantasies about medicine).

thanks

 

[deuist]

Was there ever a time when patients came to the ED with only emergencies? I'm wondering how they would even know. To the lay person, gastroenteritis and appendicitis look very similar.

 

[docB]

This thread has been added to the list of sticky threads.

 

[doctorFred]

Was there ever a time when patients came to the ED with only emergencies? I'm wondering how they would even know. To the lay person, gastroenteritis and appendicitis look very similar.

it never fails to blow my mind the inconsequential things that people come to an emergency room to get evaluated. meanwhile, i'd have to be bleeding to death in the street before i'd even consider going, and that understanding was formed long before i knew anything about EM.

 

[gman33]

It's nice to see some balance with the good vs the bad of the field.

Pretty much every job has things that suck.
Hopefully you can find something where the interesting and fun parts allow you to put up with the bad stuff.

Coming from a previous career, I think I have a different perspective than some of my fellow students. Not sure if that makes the decision easier or harder.

 

[Coastie]

Bravo on a great read! You guys are definitely on the front lines, and deserve a lot more compensation than you currently get.

This coming from an anesthesiology resident...

 

[med2UCC]

There are definitely EPs who want to eliminate night shifts and work more regular hours as they get older. There are EM groups that protect EPs above a certain age from having to work overnights. In my experience, these groups are increasingly rare. In the past, some EPs would "retire" to occupational medicine/employee health practices. Although occupational medicine has been a distinct discipline for quite some time, the ability of EPs to work in this setting owes to the ongoing supply/demand imbalance in occ med.

Most of the older EPs who wanted out of the ED that I have encountered chose to restrict their practice to urgent care/fast track. Some work exclusively for urgent care/doc-in-a-box clinics.

We have one ERP who is over 50 yo (actually, he's pushing 70). He very occasionally works nights when things are really bad on the schedule, typically less than 5 times/year. His other shifts are all 6-13:00 or 9-17:00 and mostly weekdays. The rest of us pick up the nights, weekends etc, on the understanding that we might get similar consideration if we last as long and are still in this area when the time comes. I have no intention of doing this job when I am 70, hence my back-up family practice. It's kind of nice having the best of both worlds (although right now due to scheduling conflicts and generally messiness in the world I am currently working 2 full time positions. August can't end fast enough!). Cheers,
M

 

[Lukephysician]

so med2UCC are you double boarded in Emergency Medicine and Family Medicine?

 

[med2UCC]

so med2UCC are you double boarded in Emergency Medicine and Family Medicine?

No, I'm working in a smaller centre that allows me to work full time emerg with my family practice papers. I'm planning to challenge the EM exam in a few years. I'm in Canada - it's different up here. As a resident last year I spent most of the summer running a small ED up north - a great learning experience and good prep for my current job (back-up was sleeping a minimum 20 minute drive away). I managed MI's , MVA's, OD's and crazy people as a new PGY2 and had a great time and learned loads. There are a few procedures I'd like to get better at as a new attending, but overall I feel pretty well prepared for my job (although my 1st day I had major butterflies).
So, the smaller centre I work in is the only tertiary care centre on an island with a population of 140,000 people. There are 6 periferal sites that transfer in to us. We don't do neurosurgery or cardiothoracics and transfer all our major burns to a centre about 400 km away after stabilisation. Other than that, we manage pretty much everything else in house. For my 1st 6 months I won't be working nights in the main hospital on my own (our overnight shift is solo) but I can work the periferal sites solo day and night (smaller hospitals in satellite communities which aren't suppose to get high acuity patients but invariably do). This is mostly because the night person is the resource person for the periferal sites if someone gets into trouble, and I wouldn't be much of a resource at the moment. It's fun and challenging, and I love it. Cheers,
M

 

[deleted65604]

Then one day someone told me not to apologize for calling someone. I thought about it, and they were right. I shouldn't apologize for calling them. They're getting paid for it. If they don't want to be called, they shouldn't be on the schedule. I do thank them for calling me, but I don't apologize anymore. It makes the days go by so much better.

None of the consultants get paid at my hospital to be on call. The local group of orthopedic surgeons tried to band together and get paid for being on call. The hospital staff voted that if you belong to a group of 4 or more physicians, that you are required to (as a group) provide 24-7 call. Your consultants are lucky to get paid. Mine aren't and I'm a little more apologetic.

 

[deleted65604]

Funny timing. I just had the 4 single worst shifts of my life, with 3 patient complaints about my being rude, and no questions about the patient's behavior, or the amount of stress that I was experiencing.

Anybody know of any jobs in West Colorado or Utah? PM me.

 

[EMS5]

Gonna throw one out there that may have been hit earlier (didn't read all 64 posts)....

As an EM doc, you get to put up with EMS. Since this is the "don't go into EM thread"... I'll give the bad side to EMS as a doc would perhaps see it....

We show up at 0300 with a patient who has absolutely nothing wrong, we are pissed off, and chances are the vital signs we just gave you are the ones the nursing home took at 800 last night.

We will bring you patients with no PMH or any other information, is unresponsive, and intubated, and may even be esophageal esp if there is no CO2 detector. And yes we did try D50 and narcan.

We will ask you questions that make you wonder how the hell we are licensed healthcare providers, and may ask for orders for some of the most mundane things on the radio.

We will bring you a full code that has been tubed and worked to the full extent of protocol...that means no procedures and no fun for you...just call the time

I could go on, but I think that is plenty for inquiring minds. Please don't interpret this to mean that this is the standard of care given by myself or any other EMS providers.

 

[The White Coat Investor]

Funny timing. I just had the 4 single worst shifts of my life, with 3 patient complaints about my being rude, and no questions about the patient's behavior, or the amount of stress that I was experiencing.

Anybody know of any jobs in West Colorado or Utah? PM me.

Do you see the absurdity of mixing those two statements into the same post?

 

[calespine]

For NYC, where a decent 2 bdrm in a decent school district goes for $1-2 million, that's pretty broke.

Why are there still doctors in NYC?

I'm considering NY for residency, but could someone seriously comment on how an EM physician can afford to buy an apartment for a family in Manhattan? Do you just live in the burbs and commute? Or take a massive loan? It's expensive to buy in LA, but NY makes LA look cheap!

 

[EMDrMoe]

Gotta hand it to Dr. J. Spot on. I wish I had fully appreciated some of these things before I committed. Take these to heart.

Agreed. But regardless of specialty you aren't happy if you're not happy. The instant gratification of our society is very apparent by the patients you see. Every day. Good thing it's only 14 of those a month

 

[deleted65604]

...

 

[deleted65604]

..

 

[deleted65604]

...

 

[Substance]

Since when do doctors answer to nurses? I could not care less how much of a supervisor a nurse is, or how long they have been at their job. Seniority only works within professions, not between them.

I've been berated as a resident for refusing to comply with the requests, or "orders", of a nurse supervisor. Though I always try(and try I must!) to stay polite, I never give into their whims if it is not congruent with my evaluation of the situation.

Call it the capitalist or elitist in me, but I don't answer to nurses. Never. If they want to call the shots, they can go to medical school.


Jarabacoa,

it sounds like American hospitals are more about being "consumer oriented" than about patient care. I'd go nuts working in that environment. Have you ever considered working in Canada? The pay is great, the work sounds like it is way better than in the USA, and our economic system is stable.

 

[bamamedic]

Gonna throw one out there that may have been hit earlier (didn't read all 64 posts)....

As an EM doc, you get to put up with EMS. Since this is the "don't go into EM thread"... I'll give the bad side to EMS as a doc would perhaps see it....

We show up at 0300 with a patient who has absolutely nothing wrong, we are pissed off, and chances are the vital signs we just gave you are the ones the nursing home took at 800 last night.

We will bring you patients with no PMH or any other information, is unresponsive, and intubated, and may even be esophageal esp if there is no CO2 detector. And yes we did try D50 and narcan.

We will ask you questions that make you wonder how the hell we are licensed healthcare providers, and may ask for orders for some of the most mundane things on the radio.

We will bring you a full code that has been tubed and worked to the full extent of protocol...that means no procedures and no fun for you...just call the time

I could go on, but I think that is plenty for inquiring minds. Please don't interpret this to mean that this is the standard of care given by myself or any other EMS providers.

Uh...huh?

 

[deleted109597]

J, at this point it's obvious where you work is fairly malignant. Do you have a contract you can't get out of? Because if not, you should take it to your director and either have staffing improved (4/hr of non-fast track patients isn't safe) or you're walking. And walk. There are plenty of less sucky jobs out there.

 

[deleted65604]

I gave my boss my six month notice. I'm contracted until the end of June, but hopefully, they'll let me out of it. After that string of days, I stayed 4 hours after my shift charting and got home around 1030. I laid awake in bed until 6 AM, tossing and turning. Around 3 AM, I said to myself, "Forget it, I'm out."

 

[Stitch]

Since when do doctors answer to nurses? I could not care less how much of a supervisor a nurse is, or how long they have been at their job. Seniority only works within professions, not between them.

I've been berated as a resident for refusing to comply with the requests, or "orders", of a nurse supervisor. Though I always try(and try I must!) to stay polite, I never give into their whims if it is not congruent with my evaluation of the situation.

Call it the capitalist or elitist in me, but I don't answer to nurses. Never. If they want to call the shots, they can go to medical school.

I once told a nurse "If you wanted to fly the airplane, you should have gone to fly the airplane school."

Nonetheless, we have to be careful about this sort of thing as well. JCAHO is starting to require hospitals to have a 'problem physician' procedure. Basically if someone, anyone doesn't like your attitude or the way you interact, the hospital has to have a way of 'dealing' with you. It's meant to address problem/malignant/@$$hole physicians, but it's likely going to be just a grudgematch/retribution system. Something like Press Ganey but for in house staff.

 

[WilcoWorld]

Firstly, I think that a board certified EMP is still in high enough demand that if one doesn't like his or her job that person shouldn't be afraid to walk. Kudos to you J.

Now, on the issue of pushy nurses: I generally give 'em what they want unless it's something detrimental. I recently had a nurse freak out and say "cool your jets" when I wanted to reduce a patella without sedation. So (after taking a deep breath and silencing the inner voice that was screaming "I'm the effing doctor!") I let the nurse give our 80kg patient 4mg of morphine prior to the procedure (any doc reading should know that is far short of the procedural sedation the nurse was advocating for). For the rest of the shift the nurse felt vindicated, my orders were done in a timely fashion, and my pride sustained only a minor bruise which has already healed. There are many cases of similar disagreements (requests) that I give into (grant): IV vs PO meds, 650 of tylenol vs 500, etc.

It seems that by doing this, when I am firm on issues that are important (yes, the patient in 19 needs rectal kayexalate, the patient in 14 needs a nitro drip and no, the patient in 22 can't eat) the nurses usually acquiesce much more readily if they feel that in general I am responsive to their concerns.

In short, I highly value keeping my staff happy. Often times I find that their requests reflect some issue of the patient's care that might not be apparent to the MD-level perspective and I'm glad I listened.

 

[Cerberus]

I'm considering NY for residency, but could someone seriously comment on how an EM physician can afford to buy an apartment for a family in Manhattan? Do you just live in the burbs and commute? Or take a massive loan? It's expensive to buy in LA, but NY makes LA look cheap!

Buy? As a resident or an attending? I'm sure it would be possible to buy something, somewhere in Manhattan on an Attendings salary. Of course, it would still cost an astronomical amount of money. As for residency, unless you last name is the same as a 5 star hotel chain forget about it. A subsidized, 1 bedroom apt in Manhattan at one of the programs I applied to cost 1700$ a month. I live in one of the Borough and still pay a not at all insignificant amount for a 1 br. It's doable renting, definitely not buying.

 

[calespine]

Buy? As a resident or an attending? I'm sure it would be possible to buy something, somewhere in Manhattan on an Attendings salary. Of course, it would still cost an astronomical amount of money. As for residency, unless you last name is the same as a 5 star hotel chain forget about it. A subsidized, 1 bedroom apt in Manhattan at one of the programs I applied to cost 1700$ a month. I live in one of the Borough and still pay a not at all insignificant amount for a 1 br. It's doable renting, definitely not buying.

Thanks for the heads up. I was wondering about buying as an attending. I'm just curious since I'm from a small town in Cali where making 200K+ a year is ridonkulous, but in NY a 2+ bedroom place for a family can easily set you back 1-2 million I hear. Assuming an average ED doc makes 200-300K, I'd probably be paying off my mortgage from the grave.

 

[RADRULES]

ER docs are heroes? WTF? You guys must like drinking your own kool-aid if you believe that.

How hard is it to triage patients, CT scan them head to toe after doing a cursory physical exam and lab work?

Tough complex train wreck pt - admit to medicine ICU stat.
Tough arthritic LP - dump on radiology.
Drunken ***** - dump to hospitalist service.
Most patients - CT the hell out of them with 95% normal scan rate - screw the radiation.
Vague belly pain - call the surgeon after CT, even if negative.

Just move the people through the ER as fast as possible, that is all that matters.

I was buying that you guys have a fairly difficult job until you all started the "heroic" stuff - that is just plain stupid. You are paid to do a job, just like the rest of us.

 

[WilcoWorld]

ehh, I was composing a scathing reply (scathing I tell ya!), but you wouldn't understand anyway.

 

[gro2001]

"Most community practices are full of clueless docs, NPs, PAs etc who won't touch a patient until they have a CT reading."

"Seriously tool - get lost. Your question reeks of ignorance regarding how the modern clinical practice of medicine functions. Do everyone a favor and go into PM&R you loser."

"As for the douche that failed first yr, really, you have ZERO shot at getting into radiology so do yourself a favor and quit medical school now, we already have enough crap clinical doctors out there."

What a mature, refined, post history RADRULES. I wish I could one day be as witty as you, so I could show all those clueless, crap clinical doctors who is boss. Clearly, you are a well balanced individual who is very happy and serene in your personal life. Also, you must have a huge penis.

 

[RADRULES]

Truth hurts, ehh?

I was cool with all the ER doc bemoaning their jobs until they suddenly became "heroes" for doing a job they picked with their own free will.

 

[WilcoWorld]

can't...resist...feeding...the...troll

As I understand heroism, one must be exercising free will in order to qualify. If I choose to throw my body into the path of a bullet and save your mother's life, that's heroic. But if I slip on a banana peel and accidentally fall in front of a bullet headed for the President, that's not heroic, just fortuitous (for the President).

And yes, the truth can hurt, but what you're saying isn't true.

 

[RADRULES]

You guys really live in a fantasy world if you think ER docs are heroes.

Talk about out of touch with reality.

Most med students go into ER to do shift work, get a lot of time off and get paid well. Most ER docs do a decent job considering the circumstances, but only really care about throughput.

But hey, but go with whatever you need to think to get out of bed in the morning, I suppose.

 

[avatarftw]

Now that's not very nice!

ER docs are heroes? WTF? You guys must like drinking your own kool-aid if you believe that.

How hard is it to triage patients, CT scan them head to toe after doing a cursory physical exam and lab work?

Tough complex train wreck pt - admit to medicine ICU stat.
Tough arthritic LP - dump on radiology.
Drunken ***** - dump to hospitalist service.
Most patients - CT the hell out of them with 95% normal scan rate - screw the radiation.
Vague belly pain - call the surgeon after CT, even if negative.

Just move the people through the ER as fast as possible, that is all that matters.

I was buying that you guys have a fairly difficult job until you all started the "heroic" stuff - that is just plain stupid. You are paid to do a job, just like the rest of us.

 

[EMS5]

Just read his past posts...nothing really constructive to say....I think the case here is he prolly got called on a bad read by an EM doc and now has a grudge against the world

 

[Pure Anergy]

I'm going into EM so that I can slay radiology residents. All I have to do is find their secret lair in the bowels of the hospital before I drive stakes into their hearts. Of course, there is a hospital-wide shortage of stakes right now, so maybe I'll have to settle for some 14 gauge needles in my strong, heroic arms.

 

[EMS5]

Waitttt a minutteeee...you mean to say that radiology residents have actually been in the hospital?

 

[Pure Anergy]

Waitttt a minutteeee...you mean to say that radiology residents have actually been in the hospital?

Oh yeah, you see how they have to come in sometimes to stir the pot. But only when they're not smoking it.

 

[EMS5]

bahahaha maybe there's a good reason behind rads never seeing patients

 

[Cerberus]

Heroic = "Please correlate with clinical findings"

 

[Rendar5]

Heroic = "Please correlate with clinical findings"

or when you get an ultrasound read by a resident that says "CT is needed to further evaluate". Then the CT read by the same overnight resident says "u/s is needed to further evaluate"

Granted, I love all my radiologists but 1. Especially the guys who will call to discuss the case when the techs accidentally leave out the clinical history box.

 

[deleted65604]

Now, on the issue of pushy nurses: I generally give 'em what they want unless it's something detrimental.

About 6 months ago, I had a patient who claimed to have vomited and have diarrhea dozens of times that day. I give zofran and a liter of fluid and symptoms improve pretty quickly. With tachycardia initially, and the history, I just order a reflexive second liter to give the patient some time to recuperate.

The nurse gets a little uppity and says, "A second liter? You must give your kids whatever they want too."

I swallow my pride and think, "She's probably right, if he's tolerating PO, and feels better, he can get the heck out of here." I go to give him some water, telling him if he can drink a couple of glasses, he can go.

Patient takes a sip of water, and gets REALLY nauseated. I order a second liter and some phenergan. The nurse then berates me for giving somebody water who is sick. I didn't get irritated. (I swear.) It was so ludicrous that I couldn't help do anything but laugh.

 

[RADRULES]

Especially the guys who will call to discuss the case when the techs accidentally leave out the clinical history box.

Blame it on the tech! How large. Although the history provided is usually "r/o pathology"

 

[docB]

Ok, thanks for the input. Your disagreement with the premise of the cited article is duly noted. Any more would only serve to derail a thread that has a lot of value for EM interested people. So please let us move on.

 

[Rendar5]

Blame it on the tech! How large. Although the history provided is usually "r/o pathology"

Thank you for making stuff up about how my hospital radiology and rad tech system works. I just learned a lot and realize that you know more about what I type in my orders than I do; you are much more brilliant than the radiologists here who also apparently did not know how our system works and incorrectly blamed our techs when they should have been chewing me out for being a stupid ER doctor.

 

[deleted65604]

I was buying that you guys have a fairly difficult job until you all started the "heroic" stuff - that is just plain stupid. You are paid to do a job, just like the rest of us.

The man has a point. The self imposed "White Knights" title is far more than a bit impertinent and narcissistic. The rest of the army is rolling their eyes and giving us the bird. Now we've mooned them and we are all happy.

Why don't we call ourselves the Red-Headed Children of Medicine. Come on, we are everyone's favorite specialty to hate.

Lets perform the following thought experiment:

I'm going to describe our occupation, at least how it can feel about 1% of the time.

We work at night more than others because the demand for our services never goes away. We are forced by our bosses to see clients that are often crazy, demanding, and sometimes, simply dangerous. Our job is generally pleasurable, but on occasion, must be performed with such time constraints and on such nasty people that there is no pleasure derived on our part. The services we provide, and that are sometimes demanded by people are sometimes detrimental to the person involved. Why do we do the job in those times? Because the pay is good, and we'd be in REALLY big trouble if we didn't.

What other "occupation" fits that description?

What?

 

[deleted65604]

Obviously, both comparisons fall down in reality, and being an ER doc is just that, being an ER doc.

It does a disservice to those desiring to go into our field to attempt to glorify or villify our occupation with useless metaphors.

 

[Muscletoe]

Wonderful thread--anyone thinking of going into EM should read this, along with the ample threads about what makes EM great.
As for the sidetrack, I think EM docs are heroes. They have chosen to help those who have fallen through the cracks of our society. I think radiologists are heroes too. They support other specialties and their patients without much thanks. I think that every specialty of our great profession has heroes in it.
As the troll has made clear, this doesn't mean these different fields don't have their jerks.