a little dissapointed

[zinjanthropus]

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Hello:

I am currently on a surgery rotation but I'm interested in doing EM when I "grow up". Anyway, I've been a little disspointed/disillusioned in regards to emergency medicine during my current surgical rotation. This is because of the consults that we get to the ER. Bascially, it seems as though the ER staff/residents/etc are unwilling or unable to work up even the simplest cases - stuff even a med student would try. Not too mention, missing out on the bigger cases that go to the trauma surgeons or someone else. Specific examples:

1. Surgical consult for inguinal hernia - we get down to the ER and find a man with a large inguinal hernia - however, we give him some local anesthetic and reduce it right there. Couldn't the ER have reduced an inguinal hernia without a surgical consult? Why wouldn't the ER wait and consult the surgery team in the case of a NON-reducable hernia?

2. A case of suspected appendicitis with no findings on PE or imaging. This one really annoyed me - a young woman in mild distress presents to the emergency room after dinner one night with diffuse abdominal pain that had incresaed throughout the day. Upon presenting, a transvaginal US was ordered to check for ovarian cysts. A CBC and BMP were also ordered along with a surgical consult. We get down there (10 hours later) and the pt reports that she is feeling a bit better. She has no WBC elevtion, negative PE, no temp, and her transvaginal U/S is negative.
Here's my question(s): (1) If the U/S machine was already out and runnin', why not stick it on the RLQ and look for changes consistent with appendicitis?? (2) If you know that a surigcal conslut for an 'acute abdomen' in a stable pt is going to result in a CT scan anyway, why not have it ordered already? I just think the workup was very incomplete - it seems as though a surgical consult could have been avoided - the pt could have been discharged with her suspected viral gastrenteritis the night she came in by following a few more steps.

3. A 30 yo female, 16 weeks pregnant, presents with RUQ pain and diffuse tenderness - at least that's what we are told on surgical consult for suspected cholecystitis. Upon arriving to the ER, we find that there is no UA ordered and a full workup for pyelonephritis/UTI has not been explored. I'm a lowly medical student, but the pts positive PE findings, including costovertebral tenderness and hx (pregnancy) seem to suggest UTI at least to the extent that a UA could have been ordered first, along with an U/S of the RUQ to check for cholecystitis/etc before calling surgery. UA came back positive and pt was discharged with antibiotics.

I constanty defend the field of EM to students/residents that tell me that I will become nothing more than a "triage nurse". I don't believe this is true, but these examples I have seen during surgery would kinda point that way. Are these just outlier examples from routine practice? Please help me clear up any misperceptions. Thanks.

 

[migraine12]

a UA will never come back positive for E.coli, it will come back with parameters suggestive of UTI such as positive nitrites, leukocyte esterase, WBCs/RBCs. And yes, I am aware that E. coli is the number one cause of UTI, but be very careful about drawing conclusions to lab results when reporting them to others. You need a culture to id the bug and sensitivities.

 

[footcramp]

emergency medicine is all about trying to do as little work as possible until the shift is over so that they can sign off to the next team. this is why patients spend endless hours in the emergency room just sitting around. the same laziness is why people are consulted needlessly. very many people go into emergency medicine for the perceived lifestyle. in others words, they are motivated to join the profession out of laziness and greed. i'm sure there are very good and hard working emergency physicians out there. just like there are occasionally very smart mathematicians working as janitors at harvard.

 

[Y2KPSD]

emergency medicine is all about trying to do as little work as possible until the shift is over so that they can sign off to the next team. this is why patients spend endless hours in the emergency room just sitting around. the same laziness is why people are consulted needlessly. very many people go into emergency medicine for the perceived lifestyle. in others words, they are motivated to join the profession out of laziness and greed. i'm sure there are very good and hard working emergency physicians out there. just like there are occasionally very smart mathematicians working as janitors at harvard.

Suiting up

 

[positiveaob]

Hello:

I am currently on a surgery rotation but I'm interested in doing EM when I "grow up". Anyway, I've been a little disspointed/disillusioned in regards to emergency medicine during my current surgical rotation...

You should keep an open mind as you go through your rotations. Don’t let the ranting and raving of some overstressed surgical residents who have forgotten basic manners influence your career decision. I could point to all kinds of ridiculously stupid things I saw happen both when I rotated through surgery as a student and when I rotated through SICU as a resident. There’s not enough space on this website to list them all. They’re no smarter than we are in the ER. It’s a learning process for us all. The difference is they, and all the other specialties you’re gonna rotate through, have the luxury of seeing the end products of our work and seeing all our mistakes. The only time we see their screw-ups is when they get sent home too early and end up coming back into us as resusc’es. Also, they also only judge us on what we know about their particular specialty. We have a much broader scope to our field than they do. And the “triage nurse” you’re gonna hear a lot of is complete nonsense. It’s not even worth responding to. We all play a part in ensuring people lead longer and better lives. And to think a nurse could do what we do is just plain stupid. Spend some time in the ER and see what we do, then judge for yourself. Also ask yourself the type of people you like working with. As far as your specific examples:
1. Physical exams change. You’ll quickly learn that as a student. I wasn’t there, but if they had made a significant effort to reduce it and were unable, then they would have had to get surgery involved. Time is gut.
2. Again, exams change. I have had times where patients come in with classic appendicitis and tenderness over McBurney’s point. Then by the time surgery got there, the patient was fine. But I would rather have them get pissed at me for that than be pissed for getting called too late when the appendix has perfed. The WBC and temp do not mean a whole lot with a clinical diagnosis of appy, certainly not enough to hold back on a surgical eval. And, most surgeons would tell you, that a CT or US (which is not as simple as just “sticking it on there and looking for changes associated with appendicitis”) is wasting time if you have a strong clinical diagnosis of appendicitis.
3. Pregnant females with RUQ pain is a very tough situation. You certainly cant pass it off as just a UTI even if the urine is positive (and how would it be “positive for e coli?”). It could be pyelo, it could also be appendicitis, cholecystitis, etc. It is a very diffcult exam, and you really want to avoid a CT. U/S is not very sensitive for appy. Again I didn’t see the patient, but it’s certainly understandable to get other services involved in this kind of situation.

Again, spend time shadowing ER residents before you make judgement like this. Don’t just take the surgeons’ take on things.

 

[kungfufishing]

Biggie McBiggietrousers?
Hefty McHeftysweats?
Cornfeddie McOveralls?
Jiggles McMuumuu?

 

[Apollyon]

emergency medicine is all about trying to do as little work as possible until the shift is over so that they can sign off to the next team. this is why patients spend endless hours in the emergency room just sitting around. the same laziness is why people are consulted needlessly. very many people go into emergency medicine for the perceived lifestyle. in others words, they are motivated to join the profession out of laziness and greed. i'm sure there are very good and hard working emergency physicians out there. just like there are occasionally very smart mathematicians working as janitors at harvard.

Quiet, lady, you'll give the game away!

Some women just don't know when to keep their mouths shut. Maybe next time there's an opportunity, you should have your ID changed to "menstrualcramp".

 

[SoCuteMD]

emergency medicine is all about trying to do as little work as possible until the shift is over so that they can sign off to the next team. this is why patients spend endless hours in the emergency room just sitting around. the same laziness is why people are consulted needlessly. very many people go into emergency medicine for the perceived lifestyle. in others words, they are motivated to join the profession out of laziness and greed. i'm sure there are very good and hard working emergency physicians out there. just like there are occasionally very smart mathematicians working as janitors at harvard.

You wanted to do EM didn't you?


But then you called the PD a _____________________?
(Who can fill in the blank?!)

 

[deleted87716]

Suiting up

Here ya' go...

 

[Y2KPSD]

Here ya' go...

That would be the one

 

[EctopicFetus]

I love the trolls.. to the OP every service craps on everyone else. When i did G surg the surgeons werent allowed to write for Sliding scale insulin or treat simple HTN, they required a medicine consult.. What a joke..

Anyways what you see when you get down there isnt necessarily what happened when the MD saw the pt...

 

[NinerNiner999]

For every three surgial consults you see, there are probably another 20 or so abdominal pain patients whom we have already sent home. If we were truly incompetent, we would be calling surgery for everyone with any pain remotely near the abdomen (which we are happy to do if this is what you would like). Don't discount the ED workup - for the most part it is efficient, thorough, and appropriate. Oh, and ultrasounds of the appendix are very difficult to perform and have a very low sensitivity between those who perform it.

 

[DropkickMurphy]

You wanted to do EM didn't you?


But then you called the PD a _____________________?
(Who can fill in the blank?!)

I know! I know! *jumps up and down* It had something to do with the intellect of orthopedic surgeons didn't it?

 

[GeneralVeers]

I'm not sure how ED physicians can be lazy and try to do the "least work before a shift is over".

Me and my colleagues always have a friendly competition over who can see and dispo the most patients per shift. Then, in the private practice situation, most ED physicians want to see more patients, because they receive a productivity bonus for each visit that they can bill.

Not like those "lazy" academic surgeons who are paid a salary regardless if they go to the OR or not.

 

[MasterintuBater]

I guarantee that I burn more calories in my "lazy" 10 hour shift in the ED and make more patient care decisions than the surgery senior on a 30 hour call stretch.

 

[8744]

emergency medicine is all about trying to do as little work as possible until the shift is over so that they can sign off to the next team. this is why patients spend endless hours in the emergency room just sitting around. the same laziness is why people are consulted needlessly. very many people go into emergency medicine for the perceived lifestyle. in others words, they are motivated to join the profession out of laziness and greed. i'm sure there are very good and hard working emergency physicians out there. just like there are occasionally very smart mathematicians working as janitors at harvard.

You mean I could have been a janitor?

Now you tell me.

 

[EMApplicant]

Hello:

I am currently on a surgery rotation but I'm interested in doing EM when I "grow up". Anyway, I've been a little disspointed/disillusioned in regards to emergency medicine during my current surgical rotation. This is because of the consults that we get to the ER. Bascially, it seems as though the ER staff/residents/etc are unwilling or unable to work up even the simplest cases - stuff even a med student would try. Not too mention, missing out on the bigger cases that go to the trauma surgeons or someone else. Specific examples:

1. Surgical consult for inguinal hernia - we get down to the ER and find a man with a large inguinal hernia - however, we give him some local anesthetic and reduce it right there. Couldn't the ER have reduced an inguinal hernia without a surgical consult? Why wouldn't the ER wait and consult the surgery team in the case of a NON-reducable hernia?

2. A case of suspected appendicitis with no findings on PE or imaging. This one really annoyed me - a young woman in mild distress presents to the emergency room after dinner one night with diffuse abdominal pain that had incresaed throughout the day. Upon presenting, a transvaginal US was ordered to check for ovarian cysts. A CBC and BMP were also ordered along with a surgical consult. We get down there (10 hours later) and the pt reports that she is feeling a bit better. She has no WBC elevtion, negative PE, no temp, and her transvaginal U/S is negative.
Here's my question(s): (1) If the U/S machine was already out and runnin', why not stick it on the RLQ and look for changes consistent with appendicitis?? (2) If you know that a surigcal conslut for an 'acute abdomen' in a stable pt is going to result in a CT scan anyway, why not have it ordered already? I just think the workup was very incomplete - it seems as though a surgical consult could have been avoided - the pt could have been discharged with her suspected viral gastrenteritis the night she came in by following a few more steps.

3. A 30 yo female, 16 weeks pregnant, presents with RUQ pain and diffuse tenderness - at least that's what we are told on surgical consult for suspected cholecystitis. Upon arriving to the ER, we find that there is no UA ordered and a full workup for pyelonephritis/UTI has not been explored. I'm a lowly medical student, but the pts positive PE findings, including costovertebral tenderness and hx (pregnancy) seem to suggest UTI at least to the extent that a UA could have been ordered first, along with an U/S of the RUQ to check for cholecystitis/etc before calling surgery. UA came back positive and pt was discharged with antibiotics.

I constanty defend the field of EM to students/residents that tell me that I will become nothing more than a "triage nurse". I don't believe this is true, but these examples I have seen during surgery would kinda point that way. Are these just outlier examples from routine practice? Please help me clear up any misperceptions. Thanks.

Hehehehe, kids say the most amazing things.

 

[basementbeastie]

I guarantee that I burn more calories in my "lazy" 10 hour shift in the ED and make more patient care decisions than the surgery senior on a 30 hour call stretch.

its 0236 hours...just got home from a 12 hour shift...drinking a Guinness....can't even count how many clinical decisions i made today! hundreds??

...love the picture, masterintuBater....~!!

 

[ERMudPhud]

To the OP: Sure there are places like you described but its not always the ED's doing. When I trained we couldn't order an imaging study until the patient was at least seen by the surgical consult intern. Not because we were too stupid or lazy to order the study but because the head of surgery wanted the surgical house staff to learn to evaluate patients with acute potentially surgical complaints and not just take patients to the OR after they've been imaged. Surprisingly probably >75% of the surgical house staff who complained time after time about being consulted on unimaged patients were unaware of this policy. Now I make all the decisions myself. If I think they need the OR without being imaged I call the surgeon and if he's not one of the ones who wants a few extra hours of sleep they usually go to the OR.
As for some of your other points
1. I reduce inguinal hernias but usually with conscious sedation not local anesthetic. Where do you stick the local anyway? In the bowel? Near the bowel and hope you don't hit it?
2. Ultrasound for appendicitis is extremely difficult and operator dependent most of our techs and radiologists can't do it with any degree of accuracy much less the ED docs or surgeons
3. Don't worry you will do plenty in EM. I rarely call the surgeons without a diagnosis and do as much as possible on my own. As an example last night I sent several belly pains home with no imaging, imaged a few more and sent them home, sent one hernia to a surgeon for outpatient followup, sent an appy to the OR, and admitted a trauma patient with an honest to god tension pneumo after placing the chest tube. All without ever laying eyes on the surgeon, although I did speak to him on the phone three times (once for the appy and twice for the trauma). The trauma required two calls because ACS requires us to discuss our trauma plans with the surgeon after the initial assessment and resuscitation and then we usually call back after the workup is complete. I also admitted one patient to him without a firm diagnosis. Middle aged lady with belly pain and a CT showing diffuse bowel edema and ascites Dx: enteritis(probably), Crohn's, ischemia (didn't fit clinical picture), hereditary angioedema (very rare), vs ?. I offered to send that one to medicine but to his credit he is both a physician and a surgeon and agreed to take it himself.

To many of the rest of you: The phrase you were looking for was "Fatty McFattyPants"

 

[poloace]

i was working with chris fox today (ultrasound guru at uc irvine) - we were trying to examine a women with abdominal pain with a slight question of appendicitis. its pretty much pointless using ultrasound for it. the appendix should compress - the noncompressibility and the tenderness elicited by the probe is really the money shot. so, i can understand why the ED consulted the surgery crew.

also, i agree with previous posts... its amazing the stuff the ED docs take care of and send home without ever consulting anyone else in the hospital. i think that hands down these guys are some of the best trained physicians in the hospital. if i'm ever having chest pain randomly in 50 years - i hope that one of the MDs around is an ER physician - - not a radiologist, ophthamologist, urologist or dermatologist.

out,
p

 

[DrQuinn]

1. I reduce inguinal hernias but usually with conscious sedation not local anesthetic. Where do you stick the local anyway? In the bowel? Near the bowel and hope you don't hit it?

tee-hee, you made me snort my morning cereal before my AM shift.

Q

 

[tkim]

i was working with chris fox today (ultrasound guru at uc irvine) - we were trying to examine a women with abdominal pain with a slight question of appendicitis. its pretty much pointless using ultrasound for it. the appendix should compress - the noncompressibility and the tenderness elicited by the probe is really the money shot. so, i can understand why the ED consulted the surgery crew.

Did Fox get the new Sonosite machine yet?