Dismiss Notice
Hey Texans—join us for a DFW meetup! Click here to learn more.

Ah, the ED ...

Discussion in 'Surgery and Surgical Subspecialties' started by kinetic, Mar 17, 2004.

?

What do you think about the ED?

  1. Stop crapping on them, you ******.

    82 vote(s)
    33.9%
  2. They have some problems, but on the whole they get the job done.

    89 vote(s)
    36.8%
  3. I am amazed at how poorly they do their job.

    51 vote(s)
    21.1%
  4. I'm blinded with rage. (You can't pick this if you are post-call.)

    20 vote(s)
    8.3%
  1. kinetic

    kinetic Membership Revoked
    Removed

    Joined:
    Mar 17, 2004
    Messages:
    14,514
    Likes Received:
    3
    Hey, guys ...question for the residents out there from a fellow resident. You're all anonymous here (I guess), so no harm in telling the truth.

    Before residency, I had the thought that ED docs were just like the rest of us. Since then, in my interactions with them I have developed a clear contempt for them and their disregard for patient workup or care. Every resident and attending I have ever met has the same feeling (although it is fair to say that some are more tactful in that opinon than myself).

    Now, I know that every specialty thinks that they are the bomb and everyone else is just a lazy, ******ed, S.O.B. who is trying to dump work on them. But do you guys think that my opinion is unjustified and rude or do you think there is truth to it? How many of you are frustrated by the ED?
     
  2. Note: SDN Members do not see this ad.

  3. ecpiii

    ecpiii Member
    7+ Year Member

    Joined:
    Jul 18, 2002
    Messages:
    76
    Likes Received:
    1
    I definitely don't think your opinion is rude, after all, it is your opinion, and probably justified, or else you wouldn't take the time to start a thread/type it out if you didn't feel a certain way. I enjoy the interactions of the ED docs, but they can be a bit gruff. I don't think it is a superiority thing. I have two theories.

    1. They are short attention span docs by the very nature of the work/patients/situations they see. Shift work seems to create a mentality of plug away and get through it, often leaving less time for collegial relations outside people they see on a regular basis.

    2. They are somewhat self-indulgent, as noted by the shift work mentality, just hoping to finish so that they can get outside, go mountain biking, get that four day weekend in the mountains going (ever notice how they all wear fleece vests, just to save time in the clothing change?). That said, they work their asses off for the time they are there, at least at our hospital. I can't even imagine how hard they work at a HUGE urban trauma center

    Two cents. Hope your relations improve...
     
  4. jmattwilson

    jmattwilson Slacker Unlimited
    7+ Year Member

    Joined:
    Oct 9, 2003
    Messages:
    178
    Likes Received:
    0
    Our ED is like a 10 ring circus + large side show and I typically dont like going down there. I have to say they are quite agreeable people and usually try to help out as much as possible. They are known to admitt the occasional vicious hangnail or strong case of atheletes foot, but we tend to laugh it off and realize if we were in thier position we might think long and hard about admitting the absurd just in case something worse is brewing.
     
  5. kinetic

    kinetic Membership Revoked
    Removed

    Joined:
    Mar 17, 2004
    Messages:
    14,514
    Likes Received:
    3
    The interesting thing would be to know who is voting how. (I.E., it would be less revealing if all the people telling me I was a ****** were ED people, while all the other people voting were non-ED. Or it would be much more revealing if people in general were telling me to stop crapping on the ED.) Posting replies and explaining the vote might be interesting ...

    This is just something I'm posting for fun, anyway. ;)

    P.S. Don't get me wrong. I know ED people have their own stresses and things that they have to deal with. But I could tell you stories .........:laugh:
     
  6. DrDre'

    DrDre' Senior Member
    7+ Year Member

    Joined:
    May 30, 2003
    Messages:
    883
    Likes Received:
    1
    Status:
    Resident [Any Field]
    We all know the ER is a "glass bowl" and there is nowhere to hide. People find it difficult to understand that the ER is not the place to sit and think for 6 months and come up with a rare but non-life-threatening dx! The job is to prevent the death of the dying, stabilize and prevent the majority of people from being admitted. We all see trivial admits. Would you let a pt go home after interviewing them and watching them for an hour if they just might be having an atypically presenting MI?

    also, remember, the ER staff sees everything the other residents do in their dept. My wife is an ER RN who gets a ong great with most, if not all, residents from other services. You should hear stories about the terrible medicine practiced by the best and brightest who "visit" the ER, however. It is nearly unbelievable the great differences between residents and attendings. NO one's perfect, guys.
     
  7. njbmd

    njbmd Guest
    Moderator Emeritus 5+ Year Member

    Joined:
    May 30, 2001
    Messages:
    9,050
    Likes Received:
    140
    Status:
    Attending Physician
    Hi there,

    The ED here is very good but very busy. Sometimes the residents are a little too eager to do things that place chest tubes in folks who actually don't need them but they are good about assessing patients appropriately and calling surgery only when surgery is needed.

    The biggest problems can occur with major traumas when we are trying to get the patient to the OR in a short period of time. Sometimes we have to "shovel" the "watchers" out of the way so that we can get the job done and get to the real fun (the OR).

    On a whole, I have a lot of respect for our ER folk. They largely do walk-in-clinic medicine and they put up with a lot of grief from folks who have things like headaches that have been bothering them for 2 weeks.

    njbmd:)
     
  8. Mirror Form

    Mirror Form Thyroid Storm
    10+ Year Member

    Joined:
    May 8, 2003
    Messages:
    7,529
    Likes Received:
    22
    Status:
    Attending Physician
    One of the reasons that the EM docs get a bad rap is b/c when there is one bad one, it is really obvious. When you start getting admissions for things like: "well known drug seeking pt came in with back pain, then pumped them so full of narcs they can't go home b/c they're about to go into resp arrest" it makes the whole ED look like crap, when it's really just one bad resident or attending. When there's a bad resident or attending on other services, I don't think it always gets quite as much attention b/c theyre not directly dumping work on others like the ER does by nature.
     
  9. scutking

    scutking Member
    7+ Year Member

    Joined:
    Sep 26, 2002
    Messages:
    50
    Likes Received:
    0
    Our ER docs might as well be wearing clown suits and juggling little red balls while circus music plays in the background. Here's how it is at my institution, a large Level I trauma center with an ER residency: Their workups are incomplete and superficial, we often receive consults for patients that have never actually been seen by them (ie, "there's a burn in Room 33, just call the burn service" or "there's a hand lac in Room 35, just call Plastics"), and they get in the way on trauma hall. All they seem to care about is getting a disposition and covering their butts so that they ultimately have no real responsibility for the patient. They have little to no follow up on their patients, so they have no idea of their complications. They don't manage extremely ill patients because anything serious is immediately taken over by surgery and medicine. The funny thing about this is they go home and tell great war stories to their friends and family ("ooh, I managed a big MI today and took care of a GSW chest, it was cool man!"). Meanwhile the cardiologist has the patient in the cath lab and the surgeon has his patient in the OR, both doing the real life-saving work. Their management of the GSW chest consisted of watching surgery manage the patient and copying our data from the trauma flow sheet onto the ER flowsheet so their staff could sign it and give the impression to billing that they did something. It's comical.

    Again, this is just at my institution. I pray it's not this bad everywhere.
     
  10. kinetic

    kinetic Membership Revoked
    Removed

    Joined:
    Mar 17, 2004
    Messages:
    14,514
    Likes Received:
    3
    ;)

    OK, since someone actually gave me an anecodote, I will have to oblige with the same. One patient I saw had apparently syncopized prior to being brought to the ED. Went down there and found that the chart was (as is the case more often than not) blank of all info. Nobody knew what his admission vitals were, although someone had taken them at some point. I checked the memory of the automated BP cuff and found that on admission his pressure was 220/100. No meds given. No recheck of pressures (his cuff actually had been undone and was on the floor with the machine cycling every 15 min. heh heh). That took a few minutes, by which time I was already being asked "where's he going"?

    It was like there was a party in my mouth and everyone was invited! (From 'The Simpsons')
     
  11. tussy

    tussy Senior Member
    10+ Year Member

    Joined:
    Feb 12, 1999
    Messages:
    714
    Likes Received:
    6
    Status:
    Attending Physician
    OK, i picked the fourth option, but i'm post call after a rather hectic night, so that's my excuse.

    I find there is a great discrepancy in my hospital between the different er docs. Some are excellent - others are wearing the clown suits. I can look at the staff roster in the er and predict just how horrible my night of call will be.

    One thing that i've started doing is sending copies of my dictated OR reports and Discharge summaries to the er doc who first triaged the patient especially if they did either an excellent job, or totally missed the boat. I also flag cases for the ER M&M rounds. Nobody can learn if they don't get feedback.
     
  12. beyond all hope

    beyond all hope Senior Member
    7+ Year Member

    Joined:
    Dec 18, 2003
    Messages:
    624
    Likes Received:
    7
    Tussy, congrats on feedback to the ER docs. This is what we desperately need.

    As for ridiculous admissions: these happen. I apologize. Usually, it's my attending who wants to admit the reducible hernia or the biliary colic. I have no control. Other times, when the surgeon is 'not impressed' by the level of pain but I think it's serious, I have to fight for admissions that seem trivial to the consultant. Sometimes I'm right and they're really sick. Most of the time, I'm just being cautious. Better to admit 10 suspected appys then to perf one, in my book.

    As for ER docs only caring about dispo: well, that's partially true. We are not end-level providers, we treat everything emergent and then send the patient somewhere else. If we don't know a diagnosis but we know who we need to provide dx and tx (surgery, IM, optho, clinic, etc) then we ship off the patient and move on to the next one. We don't have time for subtleties of a long H&P and a good hard think about our next diagnostic move. We have 3 patients decompensating already...:)

    I hate it when the surgeons come down angry because we've called them immediately for a suspected appy/chole/sbo/whatever, and we don't have labs, x-rays or a CT, and they say 'work up the patient!' Of course, if a really sick patient comes in and I didn't call surgery in the first 15 minutes, I get blamed and screamed at.

    In our hospital, where consults regularly take 4 hours, we often have a diagnosis and treatment plan before the consultant arrives. We've already gotten a CT, done US, got lab results, started Abx, gotten (unnecessary) preop x-rays and EKGs. That's not the way it's supposed to be. The consultant is supposed to come down, look at the patient, and take over the workup so I can see my next train-wreck.

    It's not my job to work up the patient. It's yours.
     
  13. kinetic

    kinetic Membership Revoked
    Removed

    Joined:
    Mar 17, 2004
    Messages:
    14,514
    Likes Received:
    3
    OK, let me start by saying that this is a sensitive subject because I understand that ED docs and the people they admit to have different roles and therefore have different viewpoints on the matter. That's a given. And this post is not intended to be a "I'm great and you suck" proof. That being said, I still think that a lot of the way that ED docs defend the status quo of "I don't need a diagnosis" or "I'm just here to triage" is poor form.

    I've heard this a lot, but it still stinks in my mind - the "cautious admit". Yes, we will never have 100% accuracy in the diagnosis of disease and it IS better to err on the side of caution. However, that is not an excuse for lazy decision-making. It is easy and beneath us all (we all went through training and are therefore all intelligent people) to have lax judgement and admit like a sieve. That's not a problem if you're not going to be the one taking care of the people once their admitted (i.e., rounding, discharging, writing notes), which is something that ED docs don't seem to understand. Does everyone with chest/neck/abdominal/back pain have a chance to be exhibiting an "anginal equivalent"? Yes, there is a CHANCE. But that was the point of your training. A guy off the street could say "chest pain, admit to r/o MI" or "abdominal pain, consult Surgery to r/o appy". Hopefully, physicians have more discerning decision-making skills. Again, THERE WILL ALWAYS BE THE NEED FOR SOME JUDGEMENT CALLS - I KNOW THAT.

    That's true and I will whole-heartedly grant you that many EDs are VERY busy. And I will grant you that you have to deal with a WHOLE lot of BS patients. I'm not entirely unsympathetic to your plight. But at my institution they used that excuse to explain why the charts were BLANK (even blank of vitals - you'd have to hunt down the right nurse to get vitals off of a napkin sometimes). That is INEXCUSABLE no matter HOW busy you are. When you call a consultant - as an ED doc, a Surgeon, an Internist, an OB-GYN, etc. - you need to have the proper information as your part of the bargain.

    I hear this ALL the time and it blows my mind. You really don't understand why someone gets steamed when you call and say "we got a person down here with right lower quadrant pain and fever ...I think it's an appy." If you did that on USMLE Step III, do you know what score you'd get? I have heard an ED doc tell someone "call Ortho - the patient has c/o RLE pain and thinks he broke his leg." Wha-? I'm not even in Ortho and I got pissed ...don't you think you'd want to get an X-ray first? On the other hand, yeah, if you have an unstable patient who requires urgent care, why sit on them for six hours before calling (that has also happened)? This is the point: WHERE IS THE JUDGEMENT? I'm not in your shoes, so maybe I'm missing something, but this is just where I'm coming from.

    P.S. It also doesn't help when we get called down and the first question is "so are you admitting them?" I got asked that question by an ED doc while he was holding a cup of coffee and a doughnut and I wanted to kick him in the balls.
     
  14. beyond all hope

    beyond all hope Senior Member
    7+ Year Member

    Joined:
    Dec 18, 2003
    Messages:
    624
    Likes Received:
    7
    I agree that ER docs should at least have a handle on what they think's going on before calling consultants. "RLE pain call Ortho r/o fx" without films is pretty stupid because a broken bone is not a surgical emergency.

    However, appys/choles should and frequently are diagnosed by clinical exam (and bedside US) and are surgical emergencies. The surgeon should just say "get a CT and labs" on the phone without seeing the patient.

    I also have to clarify that emergency medicine is NOT about diagnoses. A perfect ER doc would only be able to do two things 1) identify sick patients, treat the emergencies, and consult/admit appropriately 2) send well patients home with appropriate care and F/U. Note diagnosis is not part of that equation. I treat patients, not illnesses.

    In our less-than-perfect world, I am called to make diagnoses and perform treatments out of my scope of practice because many of my patients will not f/u with anyone else. I treat chronic back pain, hypertension, diabetes, asthma, you name it. That is not my job. I only do it because I have to.

    I also agree that blank charts make for poor consults. I make sure I fill out the consult form before I call. And if I'm sitting down for a coffee and donut it's probably because I haven't been at maximum adrenaline level for the last eight hours and consults are my only time to slow down, or I know that after said coffee and donut I will be at max fear factor until the end of the shift.
    "Sit when you can, sleep when you can..." definately applies in EM. When you saunter down after a relaxed clinic day and I've been insane for 11 hours you'll understand.

    I think we're both dealing with less-than-perfect collegues, who are overworked, underpaid and sometimes burned out. I think we need to extend a little sympathy and understanding. I have worked on the surgery service so I know a little of what they have to go through. I hate BS consults. 'constipation x4 months, eval and F/U'. My surgical collegues, unfortunately, do not do an ER month. That's too bad, because it would really open their eyes.
     
  15. Masonator

    Masonator Senior Member
    10+ Year Member

    Joined:
    Oct 30, 2000
    Messages:
    330
    Likes Received:
    2
     
  16. kinetic

    kinetic Membership Revoked
    Removed

    Joined:
    Mar 17, 2004
    Messages:
    14,514
    Likes Received:
    3
    That's the first thing you thought of?

    Did you at least vote?

    BTW, stalking me into all my posts is flattering. ;)
     
  17. fourthyear

    fourthyear Senior Member
    7+ Year Member

    Joined:
    May 29, 2002
    Messages:
    449
    Likes Received:
    4
    How do you know which consultant to call if you haven't done a workup?
    Many presenting complaints can go to several services and this can't be differentiated without some sort of workup at times. How do you know to call surgery vs. ob/gyn for RLQ pain in a young woman? Or medicine vs surgery in so many different examples of common things that both deal with? If it's a post-op patient, yes, call surgery right away so they can expidite things. If it's someone critically ill, sure, call the most likely admitting specialty and get them involved early. But we all know few patients fit this.

    For you to actually beleive it's the consultants job to order labs and films and come up with a diagnosis is pretty ridiculous. I thought that was one of the fun things about being an EM DOC - figuring out a diagnosis and starting the immediate therapies needed to treat it. If you enjoy being a triage nurse so much, why did you waste so much time and money on med school and residnecy?
     
  18. kinetic

    kinetic Membership Revoked
    Removed

    Joined:
    Mar 17, 2004
    Messages:
    14,514
    Likes Received:
    3
    Yeah, as I wrote in another post, I have heard an ED attending say (regarding a patient with abdominal pain), "call Surgery and if they don't want it call GI and if they don't want it call Medicine".

    The whole "I don't do diagnosis" thing is something that irks me because I've heard it like a mantra. One resident even told me that the ED philosophy is "we make the initial diagnosis and you guys finalize it - but our initial diagnosis does not necessarily have to be correct or even in the right ballpark". So, ANY 'diagnosis' is acceptable? Say, 'diagnosing' someone with foot pain as pneumonia? "Yes, as long as it gets them placed to where their diagnosis can be finalized." That kind of mentality just boggles my mind.

    The other thing that is irritating is that people always talk like the ED is 50 trainwrecks. You hear that word thrown about because it glamorizes the ED - "stay back, mortals, I have to stabilize the trainwrecks". Laypeople get that notion, too, because of the TV show 'ER' - "we have two GSWs, five auto vs. peds, and a volcano just erupted in the middle of the city!!" It may be busy, but it's not like people are routinely exsanguinating in every bed at all hours of the day and night.
     
  19. fourthyear

    fourthyear Senior Member
    7+ Year Member

    Joined:
    May 29, 2002
    Messages:
    449
    Likes Received:
    4
    And please don't forget, EM people, your consultants may be dealing with many other trainwrecks around the hospital too - and they've been doing it for a much longer shift than you've been on. We don't spend too much of our 30 hour shift with our feet propped up watching tv either - we're working our butts off running around the hosptial taking care of patients too.

    Plus, we actually have the added mental stress of taking some responsibility for their own actions and decisions. While you go home and sleep well knowing you consulted someone who will figure things out for you, these surgery and medicine folks go home wondering of they made the right diagnosis and initiated the right treaments for these patients.
     
  20. Masonator

    Masonator Senior Member
    10+ Year Member

    Joined:
    Oct 30, 2000
    Messages:
    330
    Likes Received:
    2
    Sadly, I have nothing better to do then follow you around and stir up hatin'.
    I didn't vote as I'm not yet a resident. As a student I've seen ER docs who were triage nurses extrordinair. I've also seen some badass ER docs. Granted the badasses were at Mass General. I know one ER doc who would consult plastic surgery for any lac on a hand or above the base of the neck, including scalp lacs. I'm sorry but splinting a distal finger fracture should not require a hand surgeon. Most ER docs I've seen are decent. They try to diagnose and work up, they discuss differentials with specialists, and they try to get immediate feedback on whether the admission is warranted. I've noticed that the busier the ER, the more bull**** you have to deal with. I did medicine at a hospital with the second busiest level 1 trauma center on the east coast. We would get bogus admissions that were homeless drunks and drug seekers who would know the magic words they needed to say to get a free admission at our $1000 dollar a night hotel. Unfortunately I think ER docs are so afraid of getting sued that they can't send these guys back to the street. The worst is when ER attendings at this hospital would do end of shift patient admissions. ER docs would consider it bad form to dump patients onto the next shift, so any patients that couldn't be discharged were admitted. It didn't matter if they had a valid medical problem or not. We would also get the drugseeker who is so heavily snowed that they need admission to come out of it. The best is when these patients would then go into EtOH withdrawal the next day. Then they would be on our service for days.

    I always looked at this from the perspective of dealing with difficult patients who had severe psychosocial problems along with a flawed health system, rather then ER docs with crappy skills.

    One thing I do disagree with is the concept that ER docs need to triage and stabilize and not diagnose. I think all physicians need to diagnose. Plastic surgeons should diagnose body dysmorphic disorder, general surgeons should be able to diagnose an MI or heart failure, psychiatrists should be able to diagnose depression secondary to a bleed or hypothyroidism. The whole thing of ER docs only needing to triage and not diagnose and work up seems a little silly. Triage nurses triage. ER PHYSICIANS need to do more. If you are cracking chests, and stabilizing crashing patients then that is a good excuse to not work up a nonacute problem, but cannonizing the fact that ER docs don't need to diagnose, work up or treat is going to far!

    Sorry for the long winded post.
     
  21. endo

    endo Junior Member
    7+ Year Member

    Joined:
    Oct 28, 2003
    Messages:
    23
    Likes Received:
    1
    Where I'm at it seems most often the EM residents actually do the diagnosing and the admitting team does the follow-up treating. Most diagnoses can actually be made in the ED -- in fact, to know where the patient should go you kind of need to find out what's wrong with them, right? I think we have a pretty good idea of how busy other services are -- we rotate on them. But no matter how busy I've been on other services, nothing comes close to the ED. Granted, we don't do the 32hr marathon, just spurts of 12-14hrs, but I'm equally tired from both.
     
  22. Neuron

    Neuron Aequanimitas.
    7+ Year Member

    Joined:
    Jan 1, 2004
    Messages:
    1,005
    Likes Received:
    1
    ED bashing is one of those perenially popular pastimes of residents (and even students) who are not in that specialty. My own experience with the ED has, however, mostly been good. Where I went to medical school, the ED docs were pretty smart, and I don't ever recall ever working with an attending who reeled off half a dozen inappropriate consults while woffling down that 15th doughnut.

    But there is a wide spectrum of EDs and Emerg docs. I'm sure a lot of the bitching here and elsewhere is exagerrated, but all the same I'd bet there is a lot of truth in it for some (most?) EDs. I've met my share of idiots I wouldn't want treating my second cousin's nephew's toenails.

    The thing is, though, my reaction to this is the opposite of many of you. When I'm faced with an ED d*ckhead, my reaction is to gently guide said d*ckhead to the nearest bag of stale chips and assure him that of course I understand that he couldn't find the time to, oh, take the patient's pulse, and maybe even ask her a couple of questions about that nagging thunderclap headache she got a couple of hours ago. After all, he has 20 beds of rhinorrhea and finger lacs to handle. And don't forget those chips he has to finish before his shift is up.

    You guys expect these idiots to diagnose?! Good docs, in whatever specialty, diagnose and treat well. Lousy docs just can't, and it's probably best not to rely on them to try. Everyone gets f*cked if you do. When I receive a page from a known idiot, I basically don't bother to get any info from them, aside from where the patient is, her name, and maybe the CC - all of which are basically knowable to most people with a 4th grade education and above, and so usually within the grasp of most ED docs. Then I get there as soon as I can to see the patient myself.


    I don't know where you're at, but IMHO this is complete bullcrap. It is impossible to generalize about these things (outside of the obvious, like derm being pretty light), but saying that nothing ever comes close to the ED is just patently and completely false.
     
  23. Seaglass

    Seaglass Quantum Member
    10+ Year Member

    Joined:
    Jul 25, 2003
    Messages:
    1,614
    Likes Received:
    6
    Status:
    Attending Physician
    Have you ever actually worked shifts in the ED?

    C
     
  24. kinetic

    kinetic Membership Revoked
    Removed

    Joined:
    Mar 17, 2004
    Messages:
    14,514
    Likes Received:
    3
    From a PRACTICAL standpoint, Neuron, I would say that you have a very mature and realistic way of dealing with the ED. You recognize when there are deficiencies and navigate around them. In many ways, I admire that level of maturity while admitting that I am far from that. Some residents I know also follow this tactic, but it's beyond me.

    But from a THEORETICAL standpoint, you're underlining the problem. Do I expect these idiots to diagnose? Well, yeah - they're doctors. I guess if I stepped back for a moment, maybe my big frustration comes from the fact that these are guys who are identified as doctors by patients, are paid like doctors, and have the privileges of doctors, but who don't have the responsibilities or duties of doctors. The way most ED docs in MY experience practice, they might as well be triage nurses; they generally call people (and sometimes it seems almost random who they call) and tell them the story (and you pray it's the truth) and ask THEM to figure out what's going on. If you allow them to continue with this practice, they basically get rewarded for being buffoons - where's the justice? (And don't tell me life is unfair ...I hate that line.)

    As for the ED being difficult, cg1115, don't confuse 'busy' with difficult. Yeah, you may see a lot of patients, but like I said, don't pretend half of them are exsanguinating and the other half are arresting. And the fact that its shift work AND you're basically dishing any complicated patient to some other doctor completely negates the difficulty level. It's kinda funny that, if you can't get through to the page operator, you can actually ask an ED doc and they'll tell you what number to dial. :laugh: (That's not a joke ...we've actually done that.)
     
  25. DoctorDoom

    DoctorDoom Witch King
    10+ Year Member

    Joined:
    Mar 11, 2003
    Messages:
    963
    Likes Received:
    5
    Status:
    Attending Physician
    Yes, I have. Ever take q2 call in the SICU as the senior resident? Oh riiiight....

    Overall the ED does what they should. They call about pt's after having seen them and come up with a presumptive diagnosis. All studies may not be back but they have been ordered. There is a rationale to the evaluation and some sense of what the likely diagnosis might be. They want to know what the consultant thinks and why we make the decisions we do. It's a generally cooperative effort. It's the occasional attending or resident who feels that it's not their job to have any responsibility for patient evaluation/workup, practices only CYA medicine, or abuses consultants that makes everyone look bad.
     
  26. Seaglass

    Seaglass Quantum Member
    10+ Year Member

    Joined:
    Jul 25, 2003
    Messages:
    1,614
    Likes Received:
    6
    Status:
    Attending Physician
    Actually Dr. Doom, that question was directed to Neuron, who made a criticism of endo--who actually has rotated on the services he commented on.

    I'm glad that you had a couple busy months taking call q2 in the unit. That definitely compares to the workoad that attending EM physicians see during every one of their shifts for the rest of their lives. I totally see your point.

    As for cooperation, I'm all for it.

    Kinetic, you seem to forget all the patients that are seen, treated, and discharged from the ED without ever seeing a specialist. At the 11 places I interviewed, this averaged about 2/3 of patients seen in the ED.

    Sure, most patients aren't dying, but unless you're working in the unit I'll bet that the EM physician in a busy ED has seen more critical care patients in a shift than most other staff in a day. These days when even critical patients are spending several hours in the ED waiting for a bed to say that EM docs are inept at treatment shows an obvious misunderstanding of the duties of EM docs and the extent of their training.

    C
     
  27. Apollyon

    Apollyon Screw the GST
    Physician Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Nov 24, 2002
    Messages:
    19,269
    Likes Received:
    3,678
    So when I hang dopamine for a septic patient and get antibiotics on board (after cultures), (initiating the right treatment, that is, despite cultures being a waste), and call the MICU to follow up, am I a dilettante?

    I did IM, so I can tell you - every field has some people who care, and some who don't. I had a senior IM resident call from on vacation (for a weekend) asking about her patients. I had another who only worried about her golf game - couldn't give a damn about her patients, but how she looked to the chief residents.

    Frankly, there are few people in medicine - globally - who are so sanguine or vexed by clinical decisions and patient welfare.
     
  28. DoctorDoom

    DoctorDoom Witch King
    10+ Year Member

    Joined:
    Mar 11, 2003
    Messages:
    963
    Likes Received:
    5
    Status:
    Attending Physician
    Thanks for explaining it ace, I knew who you were directing that comment to. I was echoing Neuron's sentiment. My point is that there are places in the hospital that are as busy as the the ED, for the attending and the resident, which you obviously missed. And I'm glad to see that your vast experience as a 4th year medical student means that you can be a smartass and entitle you to the mantle of busiest doctor in the hospital. Have fun with that.

    I'll be with the rest of the surgery people and medicine people, eating bonbons and drinking lattes... yawn...
     
  29. Neuron

    Neuron Aequanimitas.
    7+ Year Member

    Joined:
    Jan 1, 2004
    Messages:
    1,005
    Likes Received:
    1
    Of course not. I was talking outta my ass. I have never, ever even imagined working one of those tough ER shifts - the stress of continually doing so much high-order thinking would just kill me.

    In fact, if you graduated from medical school anywhere in the US or Canada, there is a very high likelihood that you have never, ever been required to do shifts in the ER even as a student, let alone resident. Indeed, you've really caught onto something here, you smart, clever MS4 you: it's a great big secret - none of us has even been to the ER! We're just talkin **** because we're totally green with envy at EM residents who are so cool!!

    The work in the ER is continuously, horrendously challenging - there's just no let up in the pressure man. Not like in the CV ICU, another place where I've never, ever worked -just talkin outta my ass as usual! - where, for instance, all you have to do is manage a dozen hemodynamically unstable patients for, oh, nothing really, maybe 38 measely hours. And all those other units too -neuro, MICU - pieces of cake.

    The easiest are the other services I've never rotated on - Neurosurg at a Level I trauma center, General surg... why any kind of surgery really. All of them pale so much in comparison to the intense work all those smart ER docs do all the time in the ER... just wows me man, you know what I'm saying?

    Of course I'm not even gonna mention the medical services - after all, what do they do, right? Nuuuthin...
     
  30. Seaglass

    Seaglass Quantum Member
    10+ Year Member

    Joined:
    Jul 25, 2003
    Messages:
    1,614
    Likes Received:
    6
    Status:
    Attending Physician
    I'm sorry, I came here thinking I could have a serious conversation. I see I was wrong. Enjoy.
     
  31. Neuron

    Neuron Aequanimitas.
    7+ Year Member

    Joined:
    Jan 1, 2004
    Messages:
    1,005
    Likes Received:
    1

    Hey Kinetic,

    Good posts. I completely understand where you're coming from. I agree that people who claim the regard and monetary rewards bestowed on physicians -but don't do anywhere near the work we expect them to (and display the professionalism we expect them to) are a complete pain. And yes, it can be especially painful when one is on the other side, perhaps even underappreciated. And no, I'm not going to tell you life can be unfair - you already know that. ;)

    I guess my philosophy is just that there'll always be situations and people out there like that. It doesn't suck for me because I guess I try to look at it differently - my happiness comes from doing my job as best I can. If I get consulted suboptimally - I go out there and do the best goddamn workup I can, because I love what I do, I love the thought processes, the reasoning, I love that the patient may somehow in some small way be helped, despite everything we medical (small m) people say and do because we think we know so much...and, who knows, if you do the best you can for your patients, your team mates, your consulting services, it can rub off.

    PS. I read about your personal situation on one of these threads. Really sorry to hear what happened. I really hope you pull through and resume work - medicine needs people who are idealistic, now more than ever. ;)

    PPS. Guys, this'll be my last post here - this thread is at risk of completely degenerating into a pissing match. I've always had the opportunity of working, MOSTLY, with great ER docs, and that's always been a pleasure. They're people in every service who work suboptimally, and if you're in medicine long enough I'm sure we'll all meet them. In some places I guess there may be a higher concentration of these folks in EM, which is unfortunate. But heck, nothing's perfect.
     
  32. DoctorDoom

    DoctorDoom Witch King
    10+ Year Member

    Joined:
    Mar 11, 2003
    Messages:
    963
    Likes Received:
    5
    Status:
    Attending Physician
    LOL... thanks for the negative karma.
     
  33. Neuron

    Neuron Aequanimitas.
    7+ Year Member

    Joined:
    Jan 1, 2004
    Messages:
    1,005
    Likes Received:
    1
    Then perhaps try starting with a serious question.

    I disagreed with another poster's statement that "nothing comes close" to EM (in intensity). I said that's generally incorrect - though in some institutions it may be true (I doubt it). You yourself agreed to this - after DoctorDoom pointed out unit hours and problems. Asking me whether I have worked in an ED was ridiculous - especially from a med student. I gave you the answer your question deserved.
     
  34. Seaglass

    Seaglass Quantum Member
    10+ Year Member

    Joined:
    Jul 25, 2003
    Messages:
    1,614
    Likes Received:
    6
    Status:
    Attending Physician
    It was a serious question. Many surg residencies do not require a rotation in the ED, and neither do many medical schools. So it is completely possible that you or anyone else could go through their medical career having never worked a shift in the ED. So have you ever done a month in the ED? You didn't give me a straight answer.
     
  35. Seaglass

    Seaglass Quantum Member
    10+ Year Member

    Joined:
    Jul 25, 2003
    Messages:
    1,614
    Likes Received:
    6
    Status:
    Attending Physician
    LOL, from the first post in this thread

    This thread started as a "Let's piss on the ED" thread, so please don't hold it against us if we want to stick up for ourselves.
     
  36. kinetic

    kinetic Membership Revoked
    Removed

    Joined:
    Mar 17, 2004
    Messages:
    14,514
    Likes Received:
    3
    You really want to say that an ED shift is like call in the unit? I don't even have to argue with you - that says it all. What, did you do an ICU rotation as an MSIV or something? Because that's really similar to being the senior in the unit, so I can see where you're coming from. It's great when someone says something dumb and then is forced to ride that statement to its conclusion because they don't want to admit they might be wrong.

    Actually, at my institution, ED doctors even made IM and Surgery come and fill out consults saying that people could leave. They were "consults for discharge" (no joke here). You had to go down there and do an H&P, call your attending, round on the patient, and have the attending write that the patient was medically cleared to leave. Then, unless your attending put his foot down for you, you'd get paged an hour later by the ED telling you that "your" patient needs an outpatient appointment scheduled.
     
  37. kinetic

    kinetic Membership Revoked
    Removed

    Joined:
    Mar 17, 2004
    Messages:
    14,514
    Likes Received:
    3
    We don't hold it against you that you want to stick up for yourself. We hold it against you that you're doing such a lousy job of sticking up for yourself.

    By the way, if you actually read my OP, you will see that a) I ask if my opinion is unjustified and b) I gave a wide spectrum of choices in the poll, including one where you can call me a ****** (and I think all the ED people took that choice). I could have easily made the choices a) They suck. b) They blow. c) They suck THEN blow. d) It's like a two-cent ***** on Sunset Blvd.

    The fact of the matter is, moron, if you actually READ the posts, you'd see that people were being nice to the ED - they said that MOST of the docs were decent; I may disagree, but that's just me. But you even turned THOSE people against you because you just started yelling at them about how they don't know what they're talking about and you ED guys are really supermen. :laugh:
     
  38. neutropeniaboy

    neutropeniaboy Blasted ENT Attending
    10+ Year Member

    Joined:
    Feb 10, 2002
    Messages:
    948
    Likes Received:
    190
    Status:
    Attending Physician
    This is rich! Really. And it obviously reflects your distinct lack of experience.

    I train at a quartenary referral center, and we have a large ED/trauma program, and when I'm on call, I spend a lot of time in the ED seeing consults. So, I spend a lot of time looking at the board for what comes in through our doors. And I guarantee you, it ain't this critical care bullsh*t you seem to think ED attendings deal with day-in and day-out. In fact, a good 75% of it is primary care for the poor. Most of the consults I receive are garbage (lump in throat, "make sure he's SOB isn't laryngeal stenosis," "he's got a nosebleed but isn't bleeding anymore..."). Only on a rare occasion do I get those juicy consults that interest your average ENT resident.

    You, however, haven't carried any burden of responsibility in a MICU or SICU; that much is clear. Try handling a roomful of patients with liver failure, ARDS, and abdominal sepsis.

    I'm not saying that EDs aren't busy, as they clearly ARE. And that alone would probably drive me insane. But, please, just stop talking about critical care. . ..
     
  39. Apollyon

    Apollyon Screw the GST
    Physician Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Nov 24, 2002
    Messages:
    19,269
    Likes Received:
    3,678
    One point of note - it seems like every EM basher ("at my hospital the ER is crap, they're idiots, etc.") does so anonymously; how can we value which ED sucks and which isn't, if we don't know which one it is?

    Moreover, that might color your responses - if you're a surgeon in a place where surgery rules the roost, no department is going to measure up. What's especially chilling is when people say there's an EM program there. From some of the things people post, it would appear that some of these EDs were SERIOUSLY falling short of the standard of care.

    And I didn't vote in the poll - I'm not eligible.
     
  40. Tenesma

    Tenesma Senior Member
    10+ Year Member

    Joined:
    Jun 11, 2002
    Messages:
    5,332
    Likes Received:
    127
    Status:
    Attending Physician
    i am not in a position to judge the ED...

    well except for when they send a grade 4 liver lac and multi-ortho trauma in a 340lbs. pt with ONE 20 gauge IV.... way to go...

    or even better when they send a ruptured thoraco with a central line in the subclavian artery... way to go...

    or when they call us down because they tried intubating somebody they shouldn't even have tried to intubate, and in the process have torn three long holes in the posterior pharynx that now require a major thoracic repair...

    i think ED is tough because you have to send patients home when you aren't quite sure whether they will sue or not when their brain tumor is misrecognized as a sinusitis....

    yes, there are great ED attendings out there, and there are EM residents who work their ass off... and yes, it is easy to pick on EM complications...

    but don't start telling me that in the ED there is more critical care!!! in fact, as soon as a patient is recognized as being critical, they can't wait to dump the patient (with a 20 gauge IV of course)...
     
  41. ERMudPhud

    ERMudPhud Back for a visit
    10+ Year Member

    Joined:
    Feb 24, 2003
    Messages:
    1,086
    Likes Received:
    23
    When this thread first appeared I was happy to note that even though it was posted in the surgical forum, a place probably second only to IM for having reasons to hate the ED, the response to it was mostly benign neglec t and it looked like it would sink below the horizon fairly quickly. Then kinetic started cross posting links to it and it developed a life of its own. Now there are a lot of angry and grandiose claims being made on both sides of the argument.


    First of all to Kinetic: I think you probably were in residency some where similar to where I went to medical school or where I did my medicine training. I thought the ED's there were disasters staffed by a mix of some of the worst and a few of the best docs I had ever met. You are right that there is no excuse for having a chart with no vitals or any other information on it but I think you do a grave disservice to the field of EM by assuming that the whole country is like that.(I recall another post of yours about some informal surveying you did during your recent job hunt that found that the ED was incompetent everwhere you interviewed.) Academic ED's do breed a huge reliance on consults for a variety of reasons. Some of those reasons are because the ED docs might be lazy, scarred, or incompetent but it can go beyond that. If you aren't sure exactly how to manage a specific problem in an academic center you can at least call the consulting service and talk to someone hopefully above the intern level who can give you some advice. This may be done for the patients own good like a patient I once saw with truly the worst case of psoriasis I had ever seen. It seemed to cover nearly his whole body and he was so miserable I nearly wanted to cry. He was indigent, didn't speak english, and his chance of ever actually seeing a dermatologist was virtually nil. I called the Derm resident at around 6:00 p.m. and was lambasted for interupting his dinner. After I chewed him out for being an arrogant and compassionless bastard we managed to come up with a treatment plan for the patient. The lazy thing to do would have been to just send him home with instructions to follow up in derm clinic (if he could ever get in). Other services get consulted because that's what their attending's want. When I was a resident every belly pain that got a CT also got a surgical consult. The surgery residents hated it and we hated it but we couldn't change it because the surgical attendings felt very strongly that learning to evaluate belly pain without just looking at the CT scan was an important part of their residents education. I don't consult anywhere near as much as an attending in private practice, partly because I can't and mostly because I don't usually need to but when I do consult the consultants know its for a good reason

    The other thing people who complain about unnecessary admits miss is that there is a certain value in longitudinal observation of a patient. I only have a certain window of time in which to observe a patient and make a diagnosis (more on the make a diagnosis point later). At some point I either have to say to the patient, "I can't find anything seriously wrong with you. Go home and follow up with your PCP. If it gets worse come back to the ED" or I have to admit them. It doesn't happen often but a few times per year I admit an unexplained belly pain to surgery with a negative workup. Its usually older people with intractable pain and negative workups except for maybe a positive white count. The interesting thing is that the surgical residents at the teaching hospital raise hell over these saying, "The CT is negative, I'm not taking him to the OR, what do you want me to do with him?" The attendings at the private hospital say," Fine, if he gets worse I'll exlap him, if he's not better by tomorrow I might still exlap him, if he gets better I'll send him home tomorrow." Some of this difference in attitude is because the private attendings are paid by the patient(not working as indentured servants) and some is due to their increased level of experience. They've seen initially negative CT's turn into abdominal disasters. Syncope in high risk medical patients is similar. I try to send as many syncopes home as I can but its much easier to tell some old guy that his syncope is no big deal after he has had a more complete inpatient workup and 24 hours of monitoring on tele than it is after an hour or two on my ED monitor with an EKG and a few labs. To the medicine residents everything was either vasovagal or micturation syncope(even when it wasn't). To the private attendings it isn't as clear.

    Thats right, and without shouting, that judgement is mine, the ED attending, and not a grumpy intern or R2 with too little sleep, too much work, and too little experience.

    Just remember that when you become an attending you may see the same ED you are pissing on now in a different light. We see everyone else's mistakes and mismanagement when they present to the ED and we know who responds in a conscientous and competent manner and who doesn't. We also refer paying patients your way. More importantly when your patient calls you at 11:00 p.m on a friday with a problem you can't address by phone you will tell him,"go to the ER" not "I'll meet you in my office in 15 minutes."

    Finally, the types of ED's you've described are more common at big academic usually east coast medical centers where EM has very little respect or power. It's not surprising that the best EM docs don't want to work in that kind of environment.

    Now some other issues:

    Every specialty has its good docs and bad docs. EM is in the unique position of having many of their patients seen later by people who are more expert in whatever the problem is. On the other hand we get to see their mistakes bounce back to the hospital. Just a sample from my own experiences. The postop bleeds, infections, bile duct leaks etc... from some surgeons. The surgical resident who somehow managed to thread a central line down the subclavian artery, up the carotid, and then left it there for a few hours. The surgical attending I watched using a cautery for an SICU trach who burned through the ET tube(100% FiO2) thus setting the patient and the bed on fire. The medicine residents who D/C'd a syncope patient shortly after admission with a diagnosis of "vasovagal syncope" on her original meds(including several that prolong the QT) who then had to readmit her when she presented in pulseless V-tach. The medicine attending who first asked me,"what's TTP?" then allowed said patient with clearly altered mental status(a component of TTP) to sign out AMA. The medicine attending who apparently had their patient on two different ACE inhibitors at max doses while telling them one was a calcium channel blocker. I can only assume it was because one didn't end in 'Pril. The ortho residents who kept insisting their patient didn't have Nec Fasc and kept trying to send her home until she got septic, crumped, and was taken to the OR and admited by general surg. The ENT residents who sat on a patient with chest pain for more than 12 hours post esophagoscopy until he was completely septic. Cardiothoracic surgery actually found chunks of chicken meat in his mediastinum which had apparently been pushed there by very zealous efforts to remove his esophageal obstruction. The OB residents who misread their u/s from a few day before and insisted a patient had an IUP despite a belly full of blood on my u/s. General surgery took her to the OR too. Their are plenty of clown suits to go around.
    As for saving lives. I now work at a community trauma center and surgery response times at night could approach half an hour. So, the first half of the "golden hour" is mine and anything that is going to get done is done by me. Similarly, there are no inhouse docs for the ICU. I do plenty of lines, intubations, and other procedures either in the ED before they go upstairs or on patients that have been in the ICU for days because the hospitalists cover multiple hospitals and might be 1/2 hour away. I've seen questionable management there too. How do you have an intubated ICU patient on multiple pressors with no central access? In any event I may not be the one to finally completely fix what was wrong with the patient but they would still be dead if I hadn't done my part.

    continued...
     
  42. ERMudPhud

    ERMudPhud Back for a visit
    10+ Year Member

    Joined:
    Feb 24, 2003
    Messages:
    1,086
    Likes Received:
    23
    ...continued


    This whole argument is off base on both sides. First of all, cg1155 asks a legitimate question. Many med schools do not require an ED rotation, the medicine residents where I trained no longer do ED rotations and the surgeons do only a few as interns(we assign them the same work load that we do to med students doing an elective). So, many people in other field criticizing how the ED functions have never worked there. The most telling thing for me is that several of my colleagues did all or most of other residencies (both IM or surgery) before switching to an EM residency. They quickly realized how hard the work was and more importantly developed many of the same behaiviors and habits that they despised in us before. Not because we had made them lazy or stupid but because they were doing the best they could. Now as for what is harder I did my medicine training before many of the current work limits and I have also done a few months of q2-q3 SICU call (working in place of a surgery R3 with a chief in house but usually in the OR) and been the sole resident (R2 and again as an R3) in house for a large MICU. Was I absolutely exhausted after those shifts? yes. Did I still have time to eat, watch a little TV, and if I was lucky sleep a few hours. usually. My ED shifts are more like a sprint than a marathon. In an eight hour night shifts I see sometimes more than 30 patients. The PA I supervise sees an additional 10-20 which does lighten my work load but since much of what they see is the ankle sprains, minor lacs, and chronic back pain cases that means my 30 primary patients are already preselected for higher acuity. I also cover cardiac arrests in the rest of the hospital, and am often asked to go to the ICU for intubations and lines. I've even covered near respiratory arrests on peds. By the end of my eight hours I'm completely spent. I probably couldn't do a few more hours if I had to. So, no its not a grueling endurance race like a 36 hour SICU shift but I'm every bit as wiped out at the end of it. In the end trying to compare who works harder is pointless since your are exhausted at the end of either shift but on a per minute basis my time in the ED is clearly more tiring(at least to me).

    This post is made either from arrogance or naivete. I worry about every patient I admit and I lose sleep over them. Did I miss something important? Did I do everything I could for them while they were in the ED?
    This isn't because I'm worried about reinforcing the stereotype that all ED docs are fools but because I want the patient to get better and because even if the patient was discharged 4 days later with a missed diagnosis after an extensive workup I can and will still be sued for my part in not making the right diagnosis. I worry so much that I have read the discharge summary for nearly every patient I have admitted in the last 3 years. I worry more about the ones whose inpatient workups seemed inadequate. I worry most about the ones (>75%) that you never see because I sent them straight home.

    Now, lest you think I am completely one sided in my views.

    "Its not our job to figure out what is wrong" is an aphorism in EM that drives me crazy. I've heard it plenty but vehemently disagree with it for many reasons. First, we went to med school and spent a long time getting trained so use it. If you act like this you can't complain when the rest of the world sees you as a triage monkey. We won't always get the diagnosis right but we should be right most of the time and should have narrowed the differential quite a bit the rest of the time. Second, good patient care depends on it. Much as they hate to admit it the admitting teams are swayed by initial workups and if you send them on a wild goose chase it takes time to get back on track. Also, for many diseases correct diagnosis and time to treatment is key. If you admit a pneumonia as heart failure the delay in antibiotics is life threatening. Likewise a subtle MI on the EKG that isn't diagnosed until the second troponin is positive cost somebody some myocardium. Remember when you admit somebody without a diagnosis and intitiation of treatment you are making it that much longer before they get treated. They may have to run the whole academic pyramid from intern to resident to attending before a decision to treat is made. Third, when you are out of the academic environment you won't be able to call consults at the drop of a hat and some of your patients may not be seen by any doc other than you until the next morning so you better be able to get it right and fly on your own in many cases. Finally, figuring out what is wrong with somebody and how you can fix it is in many ways the essence of medicine and I think the funnest, most rewarding part of the job. Don't deny yourself that opportunity

    After this very long winded post I have to say there are good docs and bad docs in every field, without exception. You just have to do your best to work with the good ones and around the bad ones.

    P.S.
    I voted B on your stupid poll but I might have preferred to append "you ******" to the end of "They have some problems, but on the whole they get the job done."
     
  43. fourthyear

    fourthyear Senior Member
    7+ Year Member

    Joined:
    May 29, 2002
    Messages:
    449
    Likes Received:
    4
    ERMudPhud,
    You are clearly one of the EM docs who truly cares, and I do appreciate that. I'm truly impressed that you check out the discharge summaries of patients you admitted - what a great way to learn from your experiences.

    My earlier post was in retaliation to BeyondAllHope's ridiculous post - this person truly does seem to be beyond all hope of ever being a responsible doctor if these attitudes are kept. Unfortunately the few EM people out there like that one are the ones who make a bad name for the good ones like you.
     
  44. Masonator

    Masonator Senior Member
    10+ Year Member

    Joined:
    Oct 30, 2000
    Messages:
    330
    Likes Received:
    2
    Daaammmmnnn!! Oh it's on now! I'm a moderate on this topic. Although as a future surgical resident the leaks, post op bleeds and infections kind of go with the territory and are expected. No surgeon claims to be immune to these types of complications. Even superb, meticulous technique can't circumvent all bacteria, and poor friable tissue. Your stories are pretty amusing in a scary sort of way. This forum is turning into anecdotal M&M for the specialties we don't like. You should give some props to Gen Surg, they were the ones who finally took all of your mismanage ortho and OB/GYN patients to the OR.
     
  45. kinetic

    kinetic Membership Revoked
    Removed

    Joined:
    Mar 17, 2004
    Messages:
    14,514
    Likes Received:
    3
    To ERMudPhud: you may not like me voicing an opinion regarding ED physicians (I assume that's why you want to call me a "******" so badly) but in my opinion my post was fairly non-inflammatory to begin with - like I said, I even gave people the option of calling me an idiot.

    You're right - it is unfair to generalize. I've been told by others that I've been mischaracterizing the ED with blanket statements. But I interviewed at fourteen large medical centers - granted, on the East Coast, where you say the ED is not a good - and at 100% of them, the physicians said that their stories were the same as mine, so I'd have to accept that level of poor performance. I guess until I visit EVERY hospital in America, you can technically argue that I don't have a leg to stand on, but it's an OPINION based on my experiences.

    You know what? Again, you're right - people should not be yelling at the ED people no matter WHAT they think of them. I did, and it's something I regret and I have said on this forum PLENTY of times that I was acting immature. But a couple of things (and realize I'm far from being a supporter of Dermatologists, either): ED physicians are the LAST people who should be surprised that people are going off on them. Why? ED people are never called at home; once their shift is done, it's over. There are no pagers or interruptions. And even when they are calling people in the hospital, you're someone working 8-10 hours TOPS calling someone who (at least in the past) may have been there for over 30 hours straight ...and, at least in my case, calling them to do the ED's work.

    Also right on this point, too. But realize that, while ED guys DO get patients thrown at them by private docs, it's not just you guys who are getting hit, it's us too. A lot of times, the patients end up with the people on non-ED services (rightfully so) - but don't act like you're getting the hit in isolation. And by the way, I've gotten MANY a call from the ED with "Dr. So-and-so's patient is in the ED. *click*"

    Again, correct. Nobody is expecting perfection from ANYONE. We're all human. Some of us (like me) are dumber than others. Some of us (hopefully not me) are lazier than others. And so on. And mistakes will happen no matter what for whatever reason. But at least at my institution, EVERY specialty knew that the ED was a disaster and composed of slackers, idiots, and fools. Is that every institution and every ED doctor? NO. But it's every one in MY limited experience, as well as the case in other places I've been to. Whereas with other specialties incompetent physicians are the standouts and exceptions, it seems like it's the reverse in the ED - again, that's just my opinion.

    As for what is harder - the ICU or the ED - it's apples and oranges, but if you HAVE to compare them, it's ICU hands down. Why? First of all, you're there longer - it's NOT an eight-hour shift. My personal opinion is that doing anything for over fifteen hours straight - even leaning against a wall - is torture. Second of all, the patients are uniformly disasters - a large percentage of ED patients are either not sick at all or bread and butter. So what does that mean? I don't know - I can't see why you would feel angry or threatened that someone brings this up.

    ERMudPhud, you do seem like someone who, at the very least, is reasonable and not reactionary. We'll just have to say that we don't agree on the subject.
     
  46. Masonator

    Masonator Senior Member
    10+ Year Member

    Joined:
    Oct 30, 2000
    Messages:
    330
    Likes Received:
    2
    I think its funny that a Dermatologist who gets one page per month yelled at him for interrupting dinner. You have to admit kinetic, your rebuttal only counts for surgeons and medicine. None of the other "cush" specialties have a right to get short. I think ER MudPHud should join us in our derm bashing playa hata war !!
     
  47. DoctorDoom

    DoctorDoom Witch King
    10+ Year Member

    Joined:
    Mar 11, 2003
    Messages:
    963
    Likes Received:
    5
    Status:
    Attending Physician
    I think your evaluation of the conversation is the one that is a bit off base here, ERMDPhD. I for one was not arguing that the SICU is far and away more busy than the ER, and certainly in a busy ER you often have more tasks per hour of an 8 hour shift than the minute to minute of a normal day in the SICU (where I responded to every code in the hospital and do a bunch of intubations and saw consults...), but not necessarily. I agree that the busy-ness and acuity are different because the responsibilities in each department are different, but task density is not necessarily higher and just because you are able to eat and sleep as a resident in the unit doesn't mean the experience can be generalized to include senior residents. I was responding to the idea that the ER is always far more busy than every other dept. in the hospital. Not so. I'm not even sure why busy-ness is so important as a badge of honor. Different rates for different jobs is how I look at it. The point is that busy-ness as an excuse for palming patients off to other services is no excuse at all. There is a difference between being busy and doing the best one can, as you stated, and making a habit of dishing patients off because it makes your workload lighter. Fortunately the vast majority of ER docs I've worked with did not do that.

    More than anything else I was responding to cg1155's impudent and supercilious attitude, the snide tone in the posts, and the fact that as a 4th year student for him/her to condescend to me is ridiculous. I don't react well to smart asses.

    *EDIT TO ADD: Whomever you are, if you don't want me to be haughty, sign your little karma comments, you coward.
     
  48. ERMudPhud

    ERMudPhud Back for a visit
    10+ Year Member

    Joined:
    Feb 24, 2003
    Messages:
    1,086
    Likes Received:
    23
    Somebody (perhaps his friend kinetic) please teach masonator how to cut and paste when he quotes. The last thing I want to see is my own ramblings twice.
     
  49. ERMudPhud

    ERMudPhud Back for a visit
    10+ Year Member

    Joined:
    Feb 24, 2003
    Messages:
    1,086
    Likes Received:
    23
    Your right, I actually really like and admire the surgeons I work with. However, I could just as easily have mentioned the appendicitis admitted to me as a medical resident because the surgery resident said there was nothing wrong with the patient and refused to admit him.
     
  50. ERMudPhud

    ERMudPhud Back for a visit
    10+ Year Member

    Joined:
    Feb 24, 2003
    Messages:
    1,086
    Likes Received:
    23
    The point I was trying to make, badly, was first that comparing work loads across departments is a mistake since you are right there is a different pace for different jobs. However, responding to "ever worked in an ED" with "Yes, I have. Ever take q2 call in the SICU as the senior resident? Oh riiiight..." doesn't really advance your argument since the EM folks respond, "ever single cover a 40 bed ER as the sole attending on for a friday overnight? Oh riiight..." We both know the answer to both questions. The unfortunate fact is that EM people do rotate through other services while many residents never actually work a shift in the ER. Our rotating off service is a good thing for two reasons. First, if we are given real responsibilities we learn a ton. Second, we see life on the other side of the phone. That 's why I, for example, try like hell not to consult from 3:00 AM to 6:00 AM. I know that is the best chance for many of my consults to sleep. I fax notes to their offices, leave messages with their services, or sit on patients for a few hours if at all possible during that time. My old program used to have the R3's from medicine try to run half the ER (the EM R4's routinely manage the whole ED) but finally had to quit doing it. They hated it and they sucked at it.
     
  51. ERMudPhud

    ERMudPhud Back for a visit
    10+ Year Member

    Joined:
    Feb 24, 2003
    Messages:
    1,086
    Likes Received:
    23
    Some of my best friends do really cool Derm/immuno research--sorry
     

Share This Page