Ah, the ED ...

[Spiff]

Maybe it's just me but, on the whole my interactions with the ED people have been pretty good. They have done a pretty good job of sorting out things like clinically likely appendicitis which doesn't need a CT and fuzzier cases which warrant CT evaluation. I was especially greatful to the ER attending last night who saw me walk in with consult sheets jammed in every pocket and two of my three pagers going off at once who took the new consult sheet from the resident about to hand it to me and said, "you know what, I think we can handle this one down here."

Residency is a different animal from the real world. In residency, consults mean no sleep. In the real world, consults often mean more money. For those of us in specialties, the ED docs and PMDs are going to be the people that help put food on our tables and put our kids through college. Having good relationships with the PMDs and the ED docs is often going to mean the difference between getting good consults and getting pain. I was talking to an FP doc last year who was showing me all the flyers for complimentary dinners from GenSurg and Orthopedics groups advertising for referrals. "These are the same people who used to yell at me over the phone during residency" she said.

With that said, the only part I have had a real problem with is all of the "curbside" consulting that goes on.... the whole "hey since you're down here, we really don't think this guy has anything but could you just lay your hands on him..." type stuff. I have pretty much cased the ED to ensure maximum stealth when consulting so that I don't get nailed by ED residents who are unsure about their physical exams. My stealth is enhanced by the fact that my white coat says "Otolaryngology," but it still baffles me that the ED people would curbside the Oto PG1 about belly pain just because that PG1 is on a GenSurg rotation.

The last comment has to do with ERMDPhD's comments about complications, which I think was unfair. I think ER physicians should tread particularly lightly on this topic because it is somewhat of a sore spot. As has been mentioned, every specialty has its set of complications, and I am sure it is annoying to see a bounceback because of a mistake or other problem, however, other than stabilization, if any, the service that caused the problem usually ends up dealing with the problem. Every service except one that is. That would be the ED, of course. ED docs cause pneumos too when they are putting in lines, over narcotize patients and cause any amount of medical havoc at times, but they don't manage those things. Those problems go to Medicine or Surgery or some other specialty. So I think it is probably a little brash for the ED docs to start moaning about handling other peoples problems.

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[FoughtFyr]

My stealth is enhanced by the fact that my white coat says "Otolaryngology," but it still baffles me that the ED people would curbside the Oto PG1 about belly pain just because that PG1 is on a GenSurg rotation.

You need to start with the understanding that you are in residency. For the "ED people", residency has it's own little issues that lead to what you are describing. What do I mean? Well, for example, we have some general surgery chiefs who absolutely will not, under any circumstances, go to the OR with a suspected appy without getting a CT. We have others who will insist on "their" intern seeing the patient prior to CT to ascertain if a CT is needed. Unfortunately, my call sheet only lists the intern and the staff, I don't know which chief is on. So I have to ask the GS intern "do I need a CT?" Now I know this is not always the case, and it definitely isn't in PP. But, almost every regularly consulted service in our ED (except medicine because we admit to them directly, they don't come down) including GS, TS, NS, Ortho, Neuro and ENT have these little "rules" about who sees what, and when, and what tests must be ordered first. I'm not bi*ching, it is fine by me, but it does have me asking some seemingly stupid questions of these services' interns...

- H

 

[Spiff]

I understand what you are saying, and I have no problem playing within all of the protocols for passing things up the line. I have absolutely no problem with bonafide consults. An I don't think that I am lacking in exam skills just because my coat says Oto. What I am referring to is "curbside consulting" ... that is "unofficially" consulting. In other words, these are patients that the ED people think don't have a surgical issue, and would not even talk to a surgeon were it not for the fact that someone from surgery happens to be down there. They just want someone to unofficially "bless" their patient before the patient gets sent home.

The surgery department got fed up with this a while back and put down the law that there is no such thing as an "unofficial consult." It is a huge liability issue and frankly unprofessional practice to have some ED doc note addendum stating that a "surgeon" looked at the patient, but there be no documentation from surgery and the surgery staff not know about the patient.

So what ends up happening is that they ask me "since you're already down here can you just lay eyes on the guy in room 4... we're about to send him home." Then I ask " is this a consult?" And then I get something like, "Oh no, you happened to be here and we just thought it might be nice if you could just bless that guys belly." And then I say "we'll I can't go in and examine a patient without doing a full consult and workup." And then inevitably I get "Wait a sec, let me talk to my staff.... oh, sure, what the heck, we'll just do this as an official consult." Gee thanks a lot.

 

[mikecwru]

I understand what you are saying, and I have no problem playing within all of the protocols for passing things up the line. I have absolutely no problem with bonafide consults. An I don't think that I am lacking in exam skills just because my coat says Oto. What I am referring to is "curbside consulting" ... that is "unofficially" consulting. In other words, these are patients that the ED people think don't have a surgical issue, and would not even talk to a surgeon were it not for the fact that someone from surgery happens to be down there. They just want someone to unofficially "bless" their patient before the patient gets sent home.

The surgery department got fed up with this a while back and put down the law that there is no such thing as an "unofficial consult." It is a huge liability issue and frankly unprofessional practice to have some ED doc note addendum stating that a "surgeon" looked at the patient, but there be no documentation from surgery and the surgery staff not know about the patient.

So what ends up happening is that they ask me "since you're already down here can you just lay eyes on the guy in room 4... we're about to send him home." Then I ask " is this a consult?" And then I get something like, "Oh no, you happened to be here and we just thought it might be nice if you could just bless that guys belly." And then I say "we'll I can't go in and examine a patient without doing a full consult and workup." And then inevitably I get "Wait a sec, let me talk to my staff.... oh, sure, what the heck, we'll just do this as an official consult." Gee thanks a lot.

That's exceptionally weak practice and I would be ashamed as an emergency physician to do that. The only time I call a surgeon when the problem to my eyes seems to be garbage, is when they're a postop patient, as it's considered a common courtesy. Please understand this is not how most residency trained docs and decent residents operate. (no pun intended)

mike

 

[Blade28]

With that said, the only part I have had a real problem with is all of the "curbside" consulting that goes on.... the whole "hey since you're down here, we really don't think this guy has anything but could you just lay your hands on him..." type stuff. I have pretty much cased the ED to ensure maximum stealth when consulting so that I don't get nailed by ED residents who are unsure about their physical exams.

That happens all the time during my current rotation (peds surg). I never really thought about it and realized it was curbsiding, but it's true. Your last post really hits home - many times they'll stop and ask you for a quick check on their patient with no surgical issue, but just because you're in the ER and they spot you as you try to walk out. Since you have to fill out documentation and all, it becomes an official consult. This month, that means surgery sees a lot of viral/infectious gastroenteritis, fever of unknown origin, etc.

 

[Blade28]

Why the bump?

 

[ERMudPhud]

Why the bump?

http://forums.studentdoctor.net/showthread.php?t=227641

 

[Spiff]

By the way, if it helps any, I havent been on the board long enough to get to know some of the personalities around here. My apologies if I have contributed something less than meaningful, and I am sorry if you are having difficulties with your local ENTs. Like I mentioned in my initial post, my experiences with the ED folks have been very positive.

I mentionend the curbsiding thing, because I think it isn't anything that is done maliciously or by incompetent people. I think it is mainly just a bit of insensitivity. And no I don't think it is endemic to emergency departments, but it just so happens that the place where I have experienced it happened to be in the ED. My purpose in mentioning it wasn't to trash anyone, but just to put it out there. We're all about improving practices, right? If my post was taken in any other fashion than as something constructive, then I have done a poor job.

As for the complications issue... well, they are complications, which means controversy. Again,my apologies for strirring the pot that shouldn't be stirred.

In any case, I appreciate the responses, and it certainly wasn't my intention to suck anyone back into an old flame fest.

 

[mmmmdonuts]

what's funny is that if the er acts like a-holes long enough, then when they act nice you guys all lick their feet. why are you happy that they took back a consult? the question should be: if you don't really need a consult why are you calling one and then dealing with it on your own out of pity later? and why are we pretending that the er doesn't try to pass off patients with lame curbsides at whim? it's easy to tell someone else to handle the problem, which is why lazy bums love er.

all the er docs are always talking about how they never do all the things that everyone always sees er docs doing, which is strange, isn't it?

 

[FoughtFyr]

all the er docs are always talking about how they never do all the things that everyone always sees er docs doing, which is strange, isn't it?

So about six months ago, while doing my IM rotation, I am upstairs in a resident work area and I overhear someone bi**hing about the ED. Seems that a patient was admitted for cellulitis who really was encephalopathic. When I look over, it is a resident I know well (graduated a few years before me from my medical school). So, I ask her more about the patient. Together we look up who saw the patient in the ED (I was thinking M&M). Except it turned out to be an IM third year who was doing an elective month. Sp, then and there I challenged all of the IM residents to bring me their ten "BS admits" from the ED. Of the ten, only one was actually seen by an EM resident (an intern) and that one was a multiple problem patient that I would still defend was properly admtted, but by the "rules" of my challenge she was included. Maybe the reason that, as a resident or medical student, you fell like "all the er docs are always talking about how they never do all the things that everyone always sees er docs doing" is because the "er docs" you are watching are notEM trained physicians but rather IM, FP, or Surgery residents fufilling the requirements of their own residencies (and often not happily). And if you think that "er docs" are "lazy", pm me. I'd be happy to have you work a shift (or shadow on one, as I suspect would be more appropriate to your level of training) at our facility.

- H

 

[mmmmdonuts]

Except it turned out to be an IM third year who was doing an elective month.

nice try, except:

a) er isn't an elective month for any specialty. if they're there, it's because it's a requirement.

b) you obviously haven't rotated through the ed as a resident or you'd know that you still have to do what the attending wants, which is to call someone else. i had a guy come in with a 'broken leg' and i asked the attending to wait until i had gotten lower extremity plain films, but she told me to call ortho...stat!! so i called them up and was like, ok, listen, i know you guys are going to kick my ass for this, but we have a guy with a broken leg that we want you to see and no we don't have films. and note that the attending will never make that call because they know what's coming.

c) i'm not totally denying your anecdote, however, just saying that you fail to grasp the point, that when you throw an individual into a 'culture,' they must and do adapt to it. i've had er residents have to rotate through non-er services and they start bitching about the pathetic workups of the er within one week. it's hilarious. so, yeah, what you say may happen, but it's because of the culture of the er.

 

[TheFatMan]

b) you obviously haven't rotated through the ed as a resident or you'd know that you still have to do what the attending wants, which is to call someone else. i had a guy come in with a 'broken leg' and i asked the attending to wait until i had gotten lower extremity plain films, but she told me to call ortho...stat!! so i called them up and was like, ok, listen, i know you guys are going to kick my ass for this, but we have a guy with a broken leg that we want you to see and no we don't have films. and note that the attending will never make that call because they know what's coming.

So, did you get your ass chewed out?

 

[mmmmdonuts]

So, did you get your ass chewed out?

yep

 

[TheFatMan]

I love it.

Personally, I will go ape**** whenever I personally start getting calls like that. Really, as if I don't have enough work to do on my own, I've now got to start taking care of another department's as well.

 

[FoughtFyr]

nice try, except:

a) er isn't an elective month for any specialty. if they're there, it's because it's a requirement.

Umm, no. Nice try yourself. The PGY-3 in question was heading for a pulm./CC fellowship and did an elective month in the department. But you are right, the other residents in the cases I listed above were there because it was a requirement.

b) you obviously haven't rotated through the ed as a resident or you'd know that you still have to do what the attending wants, which is to call someone else.

To quote you "nice try". I am a PGY-2 in Emergency Medicine. I have rotated through the ED quite a few months as a resident. And, my "attendings", almost all of whom themselves trained in emergency medicine, want me to do a complete workup before handing off any patient. To be fair, I have seen them "push along" patients being cared for by "off-service" (non-EM) residents, but usually because those residents were so far off base in their diagnosis or management that damage control became necessary.

i had a guy come in with a 'broken leg' and i asked the attending to wait until i had gotten lower extremity plain films, but she told me to call ortho...stat!! so i called them up and was like, ok, listen, i know you guys are going to kick my ass for this, but we have a guy with a broken leg that we want you to see and no we don't have films. and note that the attending will never make that call because they know what's coming.

In my experience this hapens when an off-service resident isn't able to describe even a basic exam to the EM attending. You know, little things like: is distal CNS intact?, is the overlying skin intact?, or is their pain under control? Yes, if the EM attending feels the off-service resident is utterly imcompetant at managing that patient, the proper referral service will be called in "Stat". Sorry to hear you performed so poorly in your ED month...

c) i'm not totally denying your anecdote, however, just saying that you fail to grasp the point, that when you throw an individual into a 'culture,' they must and do adapt to it. i've had er residents have to rotate through non-er services and they start bitching about the pathetic workups of the er within one week. it's hilarious. so, yeah, what you say may happen, but it's because of the culture of the er.

Yep, I too have bitched about ED workups. And I have always looked into it. In every case it was either a) an off service resident, usually far outside their area (e.g., a PM&R prelim working up a complicated oncology patient) who saw the patient in the ED, b) a "turf war" between consulting services (e.g., the patient with a-fib and the broken hip who ortho refuses since, while in pain she had RVR), or c) a patient evaluated in the ED during a perod when our "over-capacity" protocol was activated. This is a local protocol (but growing nationally) that most EM residents hate, where patients are expidited through the ED when the department is "too full" (by pre-defined parameters). Notifications are sent out hospital-wide, and we, as residents, are not give the opporitunity to work up our patients as fully as we'd like. Unfortuately that means we miss out on some prcedures, but it also means some of the "initial" workup is done upstairs (which s**ks for everybody!).

As for the residents "thrown" into the culture, as I said above, the problem usually is that the culture can't throw them back! Not everyone belongs in the ED. And, if an attending cannot trust that a patient is going to be well served by the resident treating them, then yes, consults are going to be called quickly and often. But when the resident is an EM resident, usually consults are held off as long as possible to afford that resident every opporitunity to learn from that patient. Lazy my a$$!

- H

 

[mmmmdonuts]

The PGY-3 in question was heading for a pulm./CC fellowship and did an elective month in the department.

this isn't a big point, but i've never heard of anyone planning to be a fellow or who is a fellow who has done an er 'elective.' mostly because the er is absolutely irrelevant and useless to fellowship. that has nothing to do with ripping on the er. it's just fact. cc fellows would take icu months, procedural months, or even pulm months, but not er months.

And, my "attendings", almost all of whom themselves trained in emergency medicine, want me to do a complete workup before handing off any patient.

this is more of er docs who are running around saying "i've never seen anyone who ever does any of the stuff you guys are talking about because that's poor practice and any er doc would be ashamed to be practicing medicine that way." you can say it, but who cares? everyone here has interacted with the er, which supposedly "never" does any of this stuff.

To be fair, I have seen them "push along" patients being cared for by "off-service" (non-EM) residents, but usually because those residents were so far off base in their diagnosis or management that damage control became necessary.

hey, everyone, listen up! foughtfyr is telling us that the only time er docs push patients out of the er is when non-er residents rotating through the er are so incompetent that the er is trying to save the patient's life. hee hee hee!

In my experience this hapens when an off-service resident isn't able to describe even a basic exam to the EM attending. ...Sorry to hear you performed so poorly in your ED month...

and more of the same. hey, everyone, foughtfyr is saying that i can't describe even a basic exam to the er attending! a) assume this is 100% true -- so what, the er attending should examine and see each patient ...i thought, but apparently they just sit around eating donuts (mmmmdonuts) while residents tell them stuff. b) does anyone want to tell stories of how er attendings and residents do patient presentations? it's like listening to someone with no medical training at all, often. hee hee hee.

Yep, I too have bitched about ED workups. And I have always looked into it. In every case it was either a) an off service resident etc etc

yeah, everyone, the er is awesome!

 

[mmmmdonuts]

i'll start. here's an er "awesome" presentation when the attending consulted us. i know i can't present as well as this, but i hope to one day if my training permits it:

er: "hey, i have a patient here and his belly, you know ...uh, it hurts."

long pause.

i realize that's it.

me: "what's the patient's name?"

er: "i ...he, he's in room 4. do you really need the name?"

me: "have you seen the guy?"

er: "i ...uhhhhhhh, yeah. yeah. i can get you the name."

long pause.

me: "you know what, never mind."

er: "so you'll see the guy?"

me: "click."

 

[FoughtFyr]

i'll start. here's an er "awesome" presentation when the attending consulted us. i know i can't present as well as this, but i hope to one day if my training permits it.

Yep, you are right. The ABMS was completely wrong to ever allow emergency medicine to become a specialty. All EM physicians are incompetant (and the ones at your institution, wherever that is are, in fact, the best that EM has to offer). There are no other viewpoints to anything except those of surgeons. I am right now preparing my letter of resignation so I can go back to honest work for the fire department.

{Note to self: never argue with an idiot, he'll only drag you down to his level and then beat you with experience...}

- H

 

[mmmmdonuts]

All EM physicians are imcompetant (and the ones at your institution, wherever that is are, in fact, the best that EM has to offer).

more of the same "yeah, er docs happen to be awesome, just not at your particular institution." somewhere, there are apparently er docs who actually know something, but it's like the holy grail of the medical field to find them.

 

[odoreater]

more of the same "yeah, er docs happen to be awesome, just not at your particular institution." somewhere, there are apparently er docs who actually know something, but it's like the holy grail of the medical field to find them.

Just couldn't keep yourself confined to rSDN could you Kinetic?

 

[odoreater]

i'll start. here's an er "awesome" presentation when the attending consulted us. i know i can't present as well as this, but i hope to one day if my training permits it:

er: "hey, i have a patient here and his belly, you know ...uh, it hurts."

long pause.

i realize that's it.

me: "what's the patient's name?"

er: "i ...he, he's in room 4. do you really need the name?"

me: "have you seen the guy?"

er: "i ...uhhhhhhh, yeah. yeah. i can get you the name."

long pause.

me: "you know what, never mind."

er: "so you'll see the guy?"

me: "click."

Yes, I am sure that this was an ATTENDING presentation to you. I am quite sure that this is actually a true story.

 

[Severus]

Just couldn't keep yourself confined to rSDN could you Kinetic?

Someone just couldn't help but bump one of his threads, huh?

Besides, he doesn't come here anymore. There are lots of people here who apparently had poorly run EDs or incompetent docs working in them. Not all of them are kinetic, and there is little to no reason to suspect Mmmmdonuts of being him either.

 

[odoreater]

Someone just couldn't help but bump one of his threads, huh?

Besides, he doesn't come here anymore. There are lots of people here who apparently had poorly run EDs or incompetent docs working in them. Not all of them are kinetic, and there is little to no reason to suspect Mmmmdonuts of being him either.

1) I didn't bump his thread---read back

2) Odd that you his biggest defender just happened to pop up after his name was mentioned.

3) We all know it's him----try not to patronize-----funny that this person lurked until his kinetic-esque diatribe in this thread (I would also bet dollas to donuts that fatman is him as well as he has done this in the past----that person just popped up today too)

I am done with this nonsense, I am actually in a residency unlike our histrionic prez-o-dent therefore I have better ways to spend my free time.

 

[Severus]

1) I didn't bump his thread---read back

Maybe you didn't, but since you're fond of troll-posting-conspiracy theories, I'll give you one of my own:

13-9-2005: Some dude name "Fedor" bumps this thread.
14-9-2005: You, odoreater, show up at rebel SDN and immediately start taking pot shots at kinetic.

Hmmmmmmmm.....

2) Odd that you his biggest defender just happened to pop up after his name was mentioned.

Not really. I'm usually here on any given day under another name I use when asking/answering questions on the professional forums. As too many people know me personally as "Severus", I only bring it out when I want people to know I said something. In this case, I don't really mind that people know I'm calling you a coward and a loser for berating someone who isn't here to defend himself.

3) We all know it's him----try not to patronize-----funny that this person lurked until his kinetic-esque diatribe in this thread (I would also bet dollas to donuts that fatman is him as well as he has done this in the past----that person just popped up today too)

God, what a paranoid little fothermucker you are. I suppose that everyone in this thread that feels the same way is kinetic as well? Grandma, what excellent time management skills you have!! Puhleeze.

I am done with this nonsense, I am actually in a residency unlike our histrionic prez-o-dent therefore I have better ways to spend my free time.

Obviously not, since you not only followed him over to rebel to instigate a flame war, you seem to scan the horizon over here for any news or hint of him as well.

 

[odoreater]

Maybe you didn't, but since you're fond of troll-posting-conspiracy theories.......Blah Blah Blah Blah

This is stupid. This thread got bumped after it was brought up in the EM forum, I read it and Kinetic appeared----I responded---plain and simple----if you are so sure it is not Kinetic (which I don't think you are) feel free to ask a mod to comment.

I do not care to take up a professional forum with this kind of nonsense, if you wish to continue make a lounge/everyone thread where we can continue this “discussion.”

 

[Severus]

This is stupid. This thread got bumped after it was brought up in the EM forum, I read it and Kinetic appeared----I responded---plain and simple----if you are so sure it is not Kinetic (which I don't think you are) feel free to ask a mod to comment.

I do not care to take up a professional forum with this kind of nonsense, if you wish to continue make a lounge/everyone thread where we can continue this “discussion.”

Odoreater is so great, he even knows what I'm thinking!!! Man, he's so on it. What am I thinking now, Cleo?

I'd love to hear what a moderator has to say.

No, I do not wish to continue this discussion elsewhere, but it's mainly because people like you turn it into a huge TOS violation**, deciding to make your posts personal attacks rather than discuss the topic at hand.

Reading through this thread, however, I am reminded, more than anything else, that actions do indeed speak louder than words. Having been a member of this site for many, many years (in one form or another) I never cease to be amazed at how the people on here can continually claim such great compassion and love for humanity, and yet fail every time to demonstrate such qualities when the opportunity presents itself.

During the course of his membership here, kinetic always owned his mistake and recognized his actions as being in poor form. Unfortunately, his humility and openness about his past and his application cycles got him little else around here than kicked in the balls. Kinetic has paid for his mistake dearly (although I would argue it was more their loss than his), and he most certainly does not need our censure.

**Not that anything would be done about it. Unlike other cases when moderators swoop in from every angle to close/delete an offending thread which bashes a particular poster, very little (oddly enough) was ever done to the threads, which ripped on kinetic, or to the posters who started them. Hmmmmmm...

 

[mmmmdonuts]

all odor has said is that he's in residency. well, i guess since you're in residency, therefore the er doesn't suck. i think i follow.

oh, plus you statement that you're sure it wasn't an attending presentation. if you're so sure, why don't you ask people to tell you their favorite er presentations? i'm sure it would be quite entertaining.

 

[DrMom]

you guys need to stop making this a personal issue
thx

 

[daveshnave]

mmmdonuts/kinetic/whatever you want to call yourself... why are you so bitter? Clearly you have an agenda, and the fact you've had it for a year and a half raises questions.

Then again I should have known you had an agenda when you begin a thread with a poll asking people to rate the quality of their ED, and said poll is anything but PC. I can assure you the wording and phrasing in your poll would not be used in a Gallup poll.... hmmm. Please try to tell me you wouldn't be insulted by a similiar poll with "EM" replaced with "surgery."

Look... at the end of the day we're all trying to do the best for our patients. I'm sorry you've seen what you've seen, and based on what you write, it's unacceptable ER practice. At the same time, I'm sure you're
not seeing the whole picture. It's interesting actually. When I started medical school I thought I wanted to go into ER, only to hit third year internal medicineand get called down for the millionth chest pain R/O, or COPD exacerbation, or "abdominal pain" during my surgery clerkship. After 3rd year, I had changed paths toward surgery, but figured since EM was my initial thought, I'd better at least try an EM sub-I in addition to my surgery sub-I. The funny thing was, once I was working in the ER, I realized how many interesting and/or complex cases were seen that were discharged, never to be seen by the likes of someone like you. Some were critical, others were not. My point here is that my perception of EM was completely false until I actually was a part of it, as opposed to an admitting hospital service, be it surgery, medicine, ortho, whatever....

Since you'll probably refute that you've worked in an ER, great. But come to me when you've carried 15-20 or more active patients at once (and when I say active, I differentiate this from 15, 30, 60, etc. FLOOR patients where there are only active issues on a handful). Active patients tear you in 15-20 different directions simultaneously, unlike any floor patient can do. Also unlike many of the unit patients. Not that I can't deal with this. But on top of their minor complaints, and the TIME needed for minor easy procedures (spliniting, suturing, LPs, etc), I also need to complete charts, fill out discharges, etc... and yes, we actually fill out our charts. Again, completely unacceptable ER practice to do otherwise, especially before calling in a consult. Oh yeah, and I also have to spend time harassing some of you guys (whether it be medicine/surgery/radiology/ortho/you name it) to come see the patient you should have seen hours ago, but that you think is stable enough that they can wait, because you're busy. Interesting how you can make that decision when YOU'VE never seen the patient (as opposed to you getting so upset about some of the patients you say that we've never seen before you come down). Hmmm.... Oh, and by the way, you just made my ER waiting room patient census jump to 45-50. Oh, and by the way again, going by statistics, 25% of those are chest pain patients. Whose to say which of those are going to be legitimate, but they can't even be evaluated yet because my ER's full of sick, but LESS sick patients already brought into rooms before the chest pains came in, but they're waiting on their consultants to come see them, who I called over two hours ago. Oh, and by the way, I'm legally responsible for them since they're in my waiting room. And yes, because of patient back ups in the ER we've had patients wait just in the WAITING ROOM for over 24 hours. Hmmm... sounds like a bad deal all around.

If you're not realizing here that my time is of the essence, well, that is my point, just as I'm sure your time is too. So we work our hardest to make a diagnosis before calling in a consult. The vast majority of the time this happens. OCCASIONALLY, however, when you have a patient who you KNOW is going to be admitted, and you have 35-40 patients waiting in your
waiting room, which is often the case where I work, you get labs going, and you get the consulting team to come evaluate the patient to get the ball rolling, and prevent that number of people waiting to hit 45-50. It doesn't matter if labs aren't back yet. Some patients you just KNOW are going to be admitted because of their story/recent past medical hx, and these patients need to be expedited to the floors. Unfortunately, when I call you on the phone for the consult, you seem to think otherwise until you get your *ss down here 2-3 hours later. And then I know I know I didn't do my job properly because the patient deserved faster care to the floors and it's my fault you didn't get down here sooner.
I'm sorry that we call you guys at what seems like busy times, but if you haven't noticed, we're ALL (you guys and us) pretty much busy 24/7. I'll give you my presumed working diagnosis, AND I will have seen the patient. Again, to do otherwise is completely unacceptable EM practice. I'll give you my labs that are back too, albeit not all of them may be on rare occasions.
You know why I do this...? Because it's the care my patients deserve. It's not becuase I'm trying to shirk my duties and get out of doing work. It's insulting that you even insinuate this, but again I can't speak to your past personal experiences with EM docs. Who made you so high and mighty to begin to think you REALLY know what is going on with how any ER is managed? As a surgeon, you get called down for at best 3-5% of our daily patient census typically. Bet you didn't know that. Frankly, if you want to bitch about all the extra work you get from the ER, talk to the medicine doctors, who see much more of our census, especially for potential surgical issues that you guys refuse to admit because you call it medical. Of course the irony here is that the medicine guys get annoyed with US, not you, for those admits. Again, tell me how you think I should manage my ER, since you seem to think it's all a no-brainer and that we're lazy idiots.

To mention the MICU again... I believe I am in a unique position to accurately compare the ER and MICU. My residency has us spend 8 months of our 3 years in the MICU. Further, it is OUR MICU (ie only staffed by EM residents... the only IM trained people are the attendings). 4 of those months are during our intern year. The remaining 4 are divided between 2nd and 3rd year. True many of the unit patients in our 20 bed MICU have serious life-threatening conditions, unlike most of the ER patients,
but it's rare where two have to be coded at once, including line placement, intubations, etc.... we run the whole gamit of procedures in our MICU. And BTW, when this does happen overnight, our senior resident every other night is a PGY-2 EM resident. That's a great level of responsibility, and to be honest with you, when I do it next year it scares the bejeezus out of me. But after 4 months in the MICU this year as an intern, I think I'll be capable, albeit scared. Funny, but I don't see this going on in our SICU. The most senior SICU resident on any given night is a PGY-4. So I think I do know what it's like to work 30 hours and be tired, only to get a page from those crazy ER docs that we have another MICU admission. Damn chest pain rule outs... (okay we don't really get these since they go to tele, haha).

To be compleltely fair, I know there are some EM residents out there like the people you describe. I know some people from my school who sought out "cush" EM programs, the idea of which completely disgusted me. In my opinion, residency should push you to your limits, because that's how you learn and excel. Don't think all EM docs are like how you stereotype. They're not. I don't think all surgeons are dim-witted pompous jack*sses, another common stereotype. I even defend them when necessary, a practice I'm sure of which isn't reversed on your part. Don't presume to understand a specialty you're not part of, and I won't do the same. And find a better use of your time than trashing EM.... really, it's getting a bit tired kinetic.

 

[tupac_don]

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.[/QUOTE]

Hahahaha, you are hilarious, now that's funny. You gave me a good chuckle.

p.s. I would of paid to see you do it

 

[mmmmdonuts]

come to me when you've carried 15-20 or more active patients at once (and when I say active, I differentiate this from 15, 30, 60, etc. FLOOR patients where there are only active issues on a handful).

so you had to make 15-20 phone calls?