Actually had a good shift last night. Been a while

[wareagle726]

As the title says I actually had a good shift. Felt like I was doing good for my patients and felt like a good ED doc(I know I am, it just rarely feels that way). In the spirit of posting some uplifting things, I was wondering what makes your shifts better. Last night was all about things working. Ankle dislocation...tell the charge set up for reduction. I walk in 10 mins later patient on EtCO2, my AMAZING ed pharmacist has all drugs ready, ortho cart in room, in and out in 10 mins. One trauma with extensive facial injury ENT took without difficulty. Another trauma who was histrionic had a PTX so chest tube and admit. Afib RVR after ablation? Etomidate and 200j back in sinus and he goes home happily. This is the big one...droperidol and capsaicin to the "I don't smoke weed" but positive on UDS guy who was doing the "I'm going to make the vomit sound as loud as possible but nothing actually comes up" says he feels great and wants to go home.

IDK I felt like the stars lined up and my role as an ED physician was actually what it's supposed to be. Still, admin "made up" 10 new beds in hallways that I didn't know existed but whatever. Par for the course. It's just nice when things work and people are appreciative.

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[Pigg-O-Stat]

A great day at the office means a bunch of sick patients I can actually help, no OB or Peds disasters, the mid-levels deal with the rinky-dink BS, I get to eat my meals, and get out on time. Happens fairly regularly. I still love the job, despite all the noise.

 

[thegenius]

As the title says I actually had a good shift. Felt like I was doing good for my patients and felt like a good ED doc(I know I am, it just rarely feels that way). In the spirit of posting some uplifting things, I was wondering what makes your shifts better. Last night was all about things working. Ankle dislocation...tell the charge set up for reduction. I walk in 10 mins later patient on EtCO2, my AMAZING ed pharmacist has all drugs ready, ortho cart in room, in and out in 10 mins. One trauma with extensive facial injury ENT took without difficulty. Another trauma who was histrionic had a PTX so chest tube and admit. Afib RVR after ablation? Etomidate and 200j back in sinus and he goes home happily. This is the big one...droperidol and capsaicin to the "I don't smoke weed" but positive on UDS guy who was doing the "I'm going to make the vomit sound as loud as possible but nothing actually comes up" says he feels great and wants to go home.

IDK I felt like the stars lined up and my role as an ED physician was actually what it's supposed to be. Still, admin "made up" 10 new beds in hallways that I didn't know existed but whatever. Par for the course. It's just nice when things work and people are appreciative.

We chit all the time here and it's frustrating to read the same message on every thread. I don't visit here as much as a result. I still like being an ER doc, fits my personality pretty well and I still get a few patients / shift who genuinely say "thank you doc we appreciate your time" and I know I did well, and it makes me feel good. I can think of worse ways making 500K/year.

 

[wareagle726]

We chit all the time here and it's frustrating to read the same message on every thread. I don't visit here as much as a result. I still like being an ER doc, fits my personality pretty well and I still get a few patients / shift who genuinely say "thank you doc we appreciate your time" and I know I did well, and it makes me feel good. I can think of worse ways making 500K/year.

Amen to that. I can also think of a lot of worse ways to make $100k/year

 

[The Knife & Gun Club]

One trauma with extensive facial injury ENT took without difficulty.

It's just nice when things work and people are appreciative.

This is the one that always gets me up or down. If the consultants want to do their jobs everything is always so pleasant. The emotional drain of having to try to compel someone to come do their job when they don’t want to and spend hours with blocking tactics is what always kills my shift.

At my trauma center - Bad facial injury? ENT says they’re not on call. Schedule says they are. Call page operator. Confirm they’re on call. Call ent back, yes you are on call. No, not on call, you’re sure? Ok I’ll call the medical director for your group to see who is. Ok. Oh you’re seeing someone across town so it’ll be “probably 4-5 hours until you can see the patient?”

 

[HemorrhagicShock]

At my trauma center - Bad facial injury? ENT says they’re not on call. Schedule says they are. Call page operator. Confirm they’re on call. Call ent back, yes you are on call. No, not on call, you’re sure? Ok I’ll call the medical director for your group to see who is. Ok. Oh you’re seeing someone across town so it’ll be “probably 4-5 hours until you can see the patient?”

The best part about this is that the ENT likely makes so much money for the hospital that they can get away with this behavior indefinitely.

Meanwhile, if the ED doc so much as forgets to put in some useless sepsis-related line in their documentation resulting in the inability to bill the DRG that ED doc better start the credentialing process at another hospital just in case.

 

[bravotwozero]

The best part about this is that the ENT likely makes so much money for the hospital that they can get away with this behavior indefinitely.

Meanwhile, if the ED doc so much as forgets to put in some useless sepsis-related line in their documentation resulting in the inability to bill the DRG that ED doc better start the credentialing process at another hospital just in case.

Or even better, GI makes so much that they can work at most community hospitals and not even have to take call.

 

[The Knife & Gun Club]

Or even better, GI makes so much that they can work at most community hospitals and not even have to take call.

Tbh though there’s really very few true emergent endoscopies for GIB. Like the vast vast majority need an urgent endoscopy but can wait until the AM.

I can’t imagine most hospitals have very many cases per year where someone truly has an upper GIB that is both stable enough for scope and unstable enough to warrant a middle of the night scope rather than a 1st case at 7a or an add on at 7p.

Maybe I just haven’t come across many but I’ve only seen it done a handful of times at our 120,000/year teriary hospital and never at out at out 60,000/community hospital. N=2 so I’m limited.

 

[bravotwozero]

Tbh though there’s really very few true emergent endoscopies for GIB. Like the vast vast majority need an urgent endoscopy but can wait until the AM.

I can’t imagine most hospitals have very many cases per year where someone truly has an upper GIB that is both stable enough for scope and unstable enough to warrant a middle of the night scope rather than a 1st case at 7a or an add on at 7p.

Maybe I just haven’t come across many but I’ve only seen it done a handful of times at our 120,000/year teriary hospital and never at out at out 60,000/community hospital. N=2 so I’m limited.

It doesn’t matter. Try admitting anything gi related to the Hospitalist without GI coverage after hours, even if it can wait till AM. Not going to happen at most community shops.

Occult positive colitis with a normal hemoglobin? Transfer

Stable vitals and hemoglobin with a lower go bleed? Transfer

ERCP that can wait till tomorrow? Transfer.

Why do hospital admins put up with this, when they can easily say to them
If you want to use our endoscopy suites then you have to take call, is beyond me.

 

[thegenius]

It doesn’t matter. Try admitting anything gi related to the Hospitalist without GI coverage after hours, even if it can wait till AM. Not going to happen at most community shops.

Occult positive colitis with a normal hemoglobin? Transfer

Stable vitals and hemoglobin with a lower go bleed? Transfer

ERCP that can wait till tomorrow? Transfer.

Why do hospital admins put up with this, when they can easily say to them
If you want to use our endoscopy suites then you have to take call, is beyond me.

why do the hospital admins put up with hospitalist shenanigans like the ones you list above?
All this stuff is $$$ that the hospital doesn't get, and they should either force the hospitalists to do it or get new ones who wil only be hired if they accept all of these hemodynamically stable patients.

 

[The Knife & Gun Club]

It doesn’t matter. Try admitting anything gi related to the Hospitalist without GI coverage after hours, even if it can wait till AM. Not going to happen at most community shops.

Occult positive colitis with a normal hemoglobin? Transfer

Stable vitals and hemoglobin with a lower go bleed? Transfer

ERCP that can wait till tomorrow? Transfer.

Why do hospital admins put up with this, when they can easily say to them
If you want to use our endoscopy suites then you have to take call, is beyond me.

Yea I guess there’s a lot of variability in this practice. Doesn’t seem at all unreasonable to say to the Hospitalist “you have an ICU that’s on call, if they become unstable from their GI bleed you send them to the unit” since that both alleviates the hospitalists anxiety and even basic ICUs should be more than capable of managing a semi stable GI bleeder.

 

[HemorrhagicShock]

Why do hospital admins put up with this, when they can easily say to them
If you want to use our endoscopy suites then you have to take call, is beyond me.

The GI guys will immediately threaten to take their highly reimbursing elective scopes elsewhere if the hospital even hints at making this a condition of suite time. Most of the time (even in most rural areas) these procedure-based subspecialists tend to have a few options when it comes to where they do elective stuff (ASC vs compliant hospital vs other)

The hospital doesn't want to lose that revenue stream, and word spreads fast if a hospital suddenly becomes hostile to certain $pecialists

 

[wareagle726]

The hospital doesn't want to lose that revenue stream, and word spreads fast if a hospital suddenly becomes hostile to certain $pecialists

Wouldn't it be great if we were considered "specialists."

 

[Mount Asclepius]

Wouldn't it be great if we were considered "specialists."

We’re not specialists unfortunately as much as we would like to think we are. That’s why we have no decent off-ramps and are dependent upon hospital ED employment. We are generalists of acute care medicine, as much as I would strongly prefer to think of myself as a resuscitationist of the critically ill. Our ocean a mile wide and an inch deep somehow still leaves us treading water trying to find our way.

 

[wareagle726]

We’re not specialists unfortunately as much as we would like to think we are. That’s why we have no decent off-ramps and are dependent upon hospital ED employment. We are generalists of acute care medicine, as much as I would strongly prefer to think of myself as a resuscitationist of the critically ill. Our ocean a mile wide and an inch deep somehow still leaves us treading water trying to find our way.

By the other specialists' standards we are not specialists. Ask any specialists to do our job. Literally any. My dad is very much a specialist and is one of the smartest and best physicians I know. He would sink in what we do. If nobody else can do your job I think that makes you a specialist. At minimum an expert. I'm not arguing with you at all. I know you have the same feeling. I'm just venting.

 

[Mount Asclepius]

By the other specialists' standards we are not specialists. Ask any specialists to do our job. Literally any. My dad is very much a specialist and is one of the smartest and best physicians I know. He would sink in what we do. If nobody else can do your job I think that makes you a specialist. At minimum an expert. I'm not arguing with you at all. I know you have the same feeling. I'm just venting.

I hear you. I couldn’t ever do a FM job because I don’t have the training/expertise, but would anyone call a FM physician a specialist because of that reason instead of a generalist? I suppose you could make the argument that they are the experts of health maintenance/prevention and chronic disease management. Just like we are the experts of acute care medicine. Semantics probably.

No one makes me feel very special though as most of my skill goes unrecognized. Not waking up a consultant in the middle of the night managing something myself. The ‘specialists’ don’t know how much I let them sleep. Running a code superbly despite the likely outcome of death and a devastated family who understandably won’t be thankful since you didn’t keep their loved one alive. Who are also experiencing too much grief to remember your name or appreciate the toll it takes on you as well. Despite way more years of schooling, the administers won’t appreciate you wallowing down in the muck with the drugged out destitute of society in the middle of the night. The viral hoard who won’t believe that there isn’t a medication, any medication, that will make them get better faster. None of them will think you are a specialist, because they don’t know when you pick out that one case of Kawasaki’s disease in the haystack. So since I’m not special to most, hard to feel like a specialist. Just another quasi-burned out EP waiting to be replaced by another EP with dreams of being a specialist.

 

[wareagle726]

I hear you. I couldn’t ever do a FM job because I don’t have the training/expertise, but would anyone call a FM physician a specialist because of that reason instead of a generalist? I suppose you could make the argument that they are the experts of health maintenance/prevention and chronic disease management. Just like we are the experts of acute care medicine. Semantics probably.

No one makes me feel very special though as most of my skill goes unrecognized. Not waking up a consultant in the middle of the night managing something myself. The ‘specialists’ don’t know how much I let them sleep. Running a code superbly despite the likely outcome of death and a devastated family who understandably won’t be thankful since you didn’t keep their loved one alive. Who are also experiencing too much grief to remember your name or appreciate the toll it takes on you as well. Despite way more years of schooling, the administers won’t appreciate you wallowing down in the muck with the drugged out destitute of society in the middle of the night. The viral hoard who won’t believe that there isn’t a medication, any medication, that will make them get better faster. None of them will think you are a specialist, because they don’t know when you pick out that one case of Kawasaki’s disease in the haystack. So since I’m not special to most, hard to feel like a specialist. Just another quasi-burned out EP waiting to be replaced by another EP with dreams of being a specialist.

That was very well stated. Just totally got me amped to go to work tonight lol.

 

[alpinism]

We’re not specialists unfortunately as much as we would like to think we are. That’s why we have no decent off-ramps and are dependent upon hospital ED employment. We are generalists of acute care medicine, as much as I would strongly prefer to think of myself as a resuscitationist of the critically ill. Our ocean a mile wide and an inch deep somehow still leaves us treading water trying to find our way.

I'm one of the very few "resuscitationist" physicians that primarily sees critical patients.

The big problem with EM here in the US is that as it stands now there are very few hospitals with the volume to support having resuscitationists.

Where I work at our 100K visit trauma center there's a dedicated 10 bed resus unit that averages roughly 1 PPH but its common to have shifts with much less and see around 6 over 12 hrs. I'd say from experience that you'd need at least 6 over 12 hrs to be able to justify having a dedicated team. Most high acuity tertiary hospitals don't even get anywhere close to that level of volume during a normal shift and to be honest there's probably something like maybe 100 EDs of 1,000+ EDs in the entire nation that could support a dedicated group of resuscitationists.

 

[The Knife & Gun Club]

I'm one of the very few "resuscitationist" physicians that primarily sees critical patients.

The big problem with EM here in the US is that as it stands now there are very few hospitals with the volume to support having resuscitationists.

Where I work at our 100K visit trauma center there's a dedicated 10 bed resus unit that averages roughly 1 PPH but its common to have shifts with much less and see around 6 over 12 hrs. I'd say from experience that you'd need at least 6 over 12 hrs to be able to justify having a dedicated team. Most high acuity tertiary hospitals don't even get anywhere close to that level of volume during a normal shift and to be honest there's probably something like maybe 100 EDs of 1,000+ EDs in the entire nation that could support a dedicated group of resuscitationists.

What do you all define as a resus? Intubated? Major trauma? Unstable vitals on arrival like hypoxia or hypotension?

We’ve talked about setting up a similar thing here but the triaging gets difficult though is certainly doable

 

[Rekt]

I'm one of the very few "resuscitationist" physicians that primarily sees critical patients.

The big problem with EM here in the US is that as it stands now there are very few hospitals with the volume to support having resuscitationists.

Where I work at our 100K visit trauma center there's a dedicated 10 bed resus unit that averages roughly 1 PPH but its common to have shifts with much less and see around 6 over 12 hrs. I'd say from experience that you'd need at least 6 over 12 hrs to be able to justify having a dedicated team. Most high acuity tertiary hospitals don't even get anywhere close to that level of volume during a normal shift and to be honest there's probably something like maybe 100 EDs of 1,000+ EDs in the entire nation that could support a dedicated group of resuscitationists.

Weird. I would feel slighted being the doc on the outside of the “resus” area unless you guys rotate roles. Why are they fine with that? The worst part of EM is all the riff raff nonsense patients. Sign me up for sick ones only.

 

[alpinism]

What do you all define as a resus? Intubated? Major trauma? Unstable vitals on arrival like hypoxia or hypotension?

We’ve talked about setting up a similar thing here but the triaging gets difficult though is certainly doable

We see all the EMS level one notifications so whatever needs immediate care.

Basically anything that will potentially require future ICU admission.

Elmhurst has a very similar triage model.

Resuscitation team orientation

 

[alpinism]

Weird. I would feel slighted being the doc on the outside of the “resus” area unless you guys rotate roles. Why are they fine with that? The worst part of EM is all the riff raff nonsense patients. Sign me up for sick ones only.

We're all in academics so its easier to have a resuscitation team.

Generally speaking a lot of docs prefer to do the regular shifts cause its much less work and its easy to just sit at your computer doing nothing while on the resuscitation shifts its different and I have to immediately physically see every patient and closely supervise all of the residents.

 

[CoolDoc1729]

Weird. I would feel slighted being the doc on the outside of the “resus” area unless you guys rotate roles. Why are they fine with that? The worst part of EM is all the riff raff nonsense patients. Sign me up for sick ones only.

I definitely have colleagues who would prefer the non resuscitation shifts. I could see this working at a busy place. Split off the nonsense to pod 2-4 and resus to pod 1 or whatever. Then someone suturing a lac doesn’t get pulled to a priority 1 either. Cool concept.

 

[wareagle726]

I'm one of the very few "resuscitationist" physicians that primarily sees critical patients.

The big problem with EM here in the US is that as it stands now there are very few hospitals with the volume to support having resuscitationists.

Where I work at our 100K visit trauma center there's a dedicated 10 bed resus unit that averages roughly 1 PPH but its common to have shifts with much less and see around 6 over 12 hrs. I'd say from experience that you'd need at least 6 over 12 hrs to be able to justify having a dedicated team. Most high acuity tertiary hospitals don't even get anywhere close to that level of volume during a normal shift and to be honest there's probably something like maybe 100 EDs of 1,000+ EDs in the entire nation that could support a dedicated group of resuscitationists.

Wow that seems crazy to me. I work in a double coverage place. We routinely intubate multiple people every night and I would say have a minimum of 6 ICU admits between med and trauma. Not academic either. It's a grind but it's fun. usually see around 22-25 in 11 hour shift. We have great support staff which is what makes it possible.

 

[Rekt]

Wow that seems crazy to me. I work in a double coverage place. We routinely intubate multiple people every night and I would say have a minimum of 6 ICU admits between med and trauma. Not academic either. It's a grind but it's fun. usually see around 22-25 in 11 hour shift. We have great support staff which is what makes it possible.

I don’t really believe this tbh. Unless you’re very inappropriately tubing.

 

[BoardingDoc]

I don’t really believe this tbh. Unless you’re very inappropriately tubing.

Agree that this feels like an exaggeration. Intubating several people out of 22-25 seen (even if you mean several out of both docs' pool of 44-50) means you're intubating what, 3 patients at least if you say several? That means your chance of getting intubated if presenting to this ER is at least 6%.

Either this is an extremely unique patient sunset going to this ER, or someone is very liberally applying the 3 F U rule.

 

[RustedFox]

Agree that this feels like an exaggeration. Intubating several people out of 22-25 seen (even if you mean several out of both docs' pool of 44-50) means you're intubating what, 3 patients at least if you say several? That means your chance of getting intubated if presenting to this ER is at least 6%.

Either this is an extremely unique patient sunset going to this ER, or someone is very liberally applying the 3 F U rule.

3 F U rule?

 

[BoardingDoc]

3 F U rule?

You say F*** You to me 3 times and you get intubated.

 

[hoot504]

You say F*** You to me 3 times and you get intubated.

I’d probably be intubating at least 6% of my patients if I followed this rule.

 

[BoardingDoc]

I’d probably be intubating at least 6% of my patients if I followed this rule.

Yeah, something I heard about in residency but have obviously never seen in practice. Not because it's unethical, but because it would create a massive disposition problem.

 

[southerndoc]

Yeah, something I heard about in residency but have obviously never seen in practice. Not because it's unethical, but because it would create a massive disposition problem.

Nah. You complete your workup, turn off sedation, and await for them to extubate themselves.

I've discharged a few people after extubating them (drunks with negative CTs).

 

[hoot504]

Nah. You complete your workup, turn off sedation, and await for them to extubate themselves.

I've discharged a few people after extubating them (drunks with negative CTs).

More power to you, truly, but I can count on one hand the number of people I’ve extubated and discharged. I quite simply don’t have time for shenanigans like that.

 

[bravotwozero]

More power to you, truly, but I can count on one hand the number of people I’ve extubated and discharged. I quite simply don’t have time for shenanigans like that.

He probably just tells his resident to take care of it while he heads home from his shift