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I've gotten the feeling that general surgeons and ER docs don't get along very well. Is this true across other specialties? And why?
Thanks.
Thanks.
Are ER docs disliked by other specialties?
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I think EM guys are respected more privately than publicly.
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Nobody "likes" anyone who continuously gives them "work." This is often the view many physicians take towards the ED physician. The reality is that it takes someone very special, dedicated, and knowledgeable to see the patients we do, 24 hours a day, 365 days a year, and keep them alive. For that, we are respected.
"Deep down in places you don't like to talk about at parties you WANT me on that wall - you NEED me on that wall...."
"Deep down in places you don't like to talk about at parties you WANT me on that wall - you NEED me on that wall...."
D
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They hate the fact that we refer patients to them between 5p and 7a.
They love the fact that we refer patients to them between 7a and 5p. In an ideal world, I could admit patients to the appropriate service after hours and have them followed up in the morning so that people could sleep. This wouldn't work for ICU patients, but the rest don't need to be seen.
Unfortunately, we live in a world where they often don't trust our ED management of patients, and feel they need to be contacted. And then they're upset about being contacted.
They love the fact that we refer patients to them between 7a and 5p. In an ideal world, I could admit patients to the appropriate service after hours and have them followed up in the morning so that people could sleep. This wouldn't work for ICU patients, but the rest don't need to be seen.
Unfortunately, we live in a world where they often don't trust our ED management of patients, and feel they need to be contacted. And then they're upset about being contacted.
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once you are in the community and are on a first name basis with your most frequently called consultants, learn their patterns (and a few of their patients), know your stuff, and have handled their patients well.... you get very little grief.
if you are demanding, rude, don't know your stuff about the problem you're calling about, or take poor care of their patients... god help ya.
if you are demanding, rude, don't know your stuff about the problem you're calling about, or take poor care of their patients... god help ya.
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Depends on the place and how "hungry" the docs are. I work with a dude who was a fellow where I did my residency. He wasnt always the nicest guy down there.. up here a phone call at 3 am and he is happy to hear from me. Keep in mind I put food on his table and gas in his Ferrari.
i'm on awesome terms with most OR docs......its ortho that don't like me and they made that clear in the softball match last year...because of a send fellowship im doing i need to be on good terms with OR docs because i have to be in the OR with them....makes things mighty uncomfortable to work in if not
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'You're a lousy stinkin' softball player, Jack!"
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Thanks for all of the responses. I had another question. How competitive is EM residency? I just want an idea of how realistic it will be for me to match into it.
I went to an interest group meeting today, and people said that EM is 'competitive'. What exactly does that mean? Like, how does it compare with other specialties?
I went to an interest group meeting today, and people said that EM is 'competitive'. What exactly does that mean? Like, how does it compare with other specialties?
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I've been in Vegas for four days; I'm at McCarran now waiting for my flight home....where I'm off till Monday.
That tends to bother counterparts who must make big arrangements and plan 6 to 12 months for 7+ days off. Whereas this happens monthly for us....
As you can guess, that causes some mixed feelings from your colleagues....
As a resident, I dislike people who call me for things that they should legitimately be able to take care of themselves, regardless of the time of day. Simple lac repairs, uncomplicated nosebleeds, straightforward peritonsillar abscesses are all things that should be handled by the ER and followup can be arranged as an outpatient. Unfortunately, those calls all tend to come from the ER.
And if I even so much as hint that this is something a competent ER physician should be able to take care of themselves, I get the snide, "Well this is a teaching institution." Goodness, their generosity warms the cockles of my heart...
And if I even so much as hint that this is something a competent ER physician should be able to take care of themselves, I get the snide, "Well this is a teaching institution." Goodness, their generosity warms the cockles of my heart...
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Cool story bro
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And where is this? Is there an EM residency? Are there medical student in the ED? I'll assume no. Based on what you have listed someone is either very lazy or is doing this to spite you.
Either way, I've never known EM docs to move these kinds of cases out of the ED. Granted I have only been in maybe 4-5 EDs for any extended period. However, there some weird policy that requires them to call you for stuff like this?
Also, what service are you? Surg? Cause it would be even more strange to have IM come down and do any procedure.
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There's a large EM residency program. And a peds EM fellowship.
I think the policy is, "because we can."
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Our EM group just had a meeting today and we talked about how ortho takes a good chunk of money from us since our group has agreed with them that they can come down and do reductions on ortho cases.
In the end when you hit the real world and get paid for your work you will tend to change your attitude. Clearly the cases described arent all coming to you. No one has ever called gen surg for a nosebleed, PTA.. perhaps you are ENT.. in which case hot damn.. those residents arent getting their training.. On the other hand what may be simple to you such as a nosebleed has been bleeding for 4 hours and a rhinorocket and a slew of other techniques and tricks hasnt worked.
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Geeze, in my residency we considered that bread and butter EM.
Yeah, I forgot to mention I'm ENT. I'm sure they don't call us for all nosebleeds... but I've been called in too many times to see a "bad nosebleed" that's "posterior" and stopped an hour before they called me after they put in a merocel. (Riight.) I'm pretty sure they call us for all peritonsillar abscesses because they, without fail, seem to have CT scans when the H&P are clear cut.
Maybe this EM residency just sucks ass. I don't know.
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name it
Would rather not. EM outnumbers ENT by like 4 or 5 to 1, I think, and I have too many years left to make that many enemies!
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That's a real shame about the PTAs and such...unless some significant circumstance, these should be handles in the ED.., especially in a residency program.
Call you in with intent of you laying some pearls on the EM residents perhaps??
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Call you in with intent of you laying some pearls on the EM residents perhaps??
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Perhaps I speak from a different perspective but where I trained there was no ENT residency and we barely had any ENT coverage at all. I think we had 1 ENT attending and like I said no residents.. Dont know how it was anywhere else but even to this day I rarely call ENT (hence it is probably the best surgical subspecialty).
Once I had them come in at 2 am for a patient who had a cancer of some sort I cant recall and he was their patient.. Long story short it was the hardest intubation in my life and the dudes cancer had eroded into his lingual artery and his carotid and the tube was a bloody freaking mess. The ENT dude was cool... he was like I cant believe you were able to tube that guy arterial bleed with this huge mass. Was a freak f---ckin show.. nailed the tube..
Anyways, sorry about your frustration with your EM residency.. perhaps the culture of your hospital is this way..
Once I had them come in at 2 am for a patient who had a cancer of some sort I cant recall and he was their patient.. Long story short it was the hardest intubation in my life and the dudes cancer had eroded into his lingual artery and his carotid and the tube was a bloody freaking mess. The ENT dude was cool... he was like I cant believe you were able to tube that guy arterial bleed with this huge mass. Was a freak f---ckin show.. nailed the tube..
Anyways, sorry about your frustration with your EM residency.. perhaps the culture of your hospital is this way..
My ED calls for PTA's, I'm sorry to say. For some reason, most of our attendings aren't trained in them. I've done 3 myself with one of our friendly ENT attendings taking me through it, so I'll at least have some ability to do it when i'm in the community.
Although I can at least say that I've never CT'd one, and have never called or heard of anyone else calling ENT for nosebleeds. The only other times I've called were at least for valid reasons, post-op tonsillectomy bleeds, r/o Tracho-Inominate fistulas.
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I'll call ENT for a PTA. When I'm the only doctor in the whole hospital, with 10 people in the waiting room and have a histrionic drunk patient with a huge PTA, I have no problem calling for some help from ENT. For me its all about resource utilization. I'm not calling these guys more than a few times a year, so if I get to the point where I need another set of hands, because the rest of the department is imploding, I don't feel at all bad talking to the guy that's on call. I'm already up working in the middle of the night, so I don't usually feel too bad about waking someone up if I need their help. Very few of the other specialties experience the chaos that we get in the ED.
Also training in PTA drainage is variable at best for EM residents. 50% of my attendings in residency would not even try to drain these. If a doctor calls you because they are uncomfortable shoving a huge needle into the back of someones throat, its probably reasonable to help them out.
Also training in PTA drainage is variable at best for EM residents. 50% of my attendings in residency would not even try to drain these. If a doctor calls you because they are uncomfortable shoving a huge needle into the back of someones throat, its probably reasonable to help them out.
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I second that.. probably half my attendings in residency would let us do them, the other half wanted us to call ENT.
As an attending.. One day I was getting ready to do one and all my new colleagues told me I was crazy taking on that liability... At my current job, nobody does them. They all say why take the liability and the time? Call ENT and let them do it. Granted, ENT is covered by general surgery PGY1s who tend to see the patient and then have them come back to clinic the next AM. I have not seen them actually drain anyone in the ED.
A good friend of mine in a different town had a daughter who sounded like she had a PTA. It was Friday evening.. I advised them to go to the ED. They ended up with labs and a CT scan and ENT came in and poked it. Their bill is almost 8K and their insurance only pays 2K for ED bills.... We dont always think about the money as much as we should, but that is eye opening to me.
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This surprises me. I've never called ENT for a PTA (or even had attending hint at that being a posibility). The "why take on the liability" argument irks me - we are ED PHYSICIANS, not the concierge/secretary of the hospital. Hell, i'd consider a PTA bread and butter EM. We start down a road like this where we refer/consult for everything and eventually there really will be an argument for PA/NP run Emergency Departments.
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I actually rarely drain PTAs. If they are not obstructing the airway, I start Decadron, Toradol, Rocephin and send them out the door with referral.
I treated one of my friends with PTA this way, and he said he felt like a million bucks within a couple hours once the Decadron kicked in.
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But what people are talking about is calling ENT in to drain PTAs (i.e. "this should probably get drained, but I don't want to do it so I'll just call ENT to do it"). Patient ends up waiting several extra hours taking up a bed/chair, possibly getting an unnecessary CT (at least if it's surgery covering for ENT), and a much higher bill, for a procedure that takes 5-10 minutes.
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True. I don't understand the CT scans. Why do so many do this for an obvious PTA. What are they looking for that the clinical exam can't demonstrate?
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Aberrant internal carotid maybe? Not likely, but possibly to rule out
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Good point about PTA drainage.
At my residency, I've made it a point to be facile with aspiration and incision of the PTA. I just don't know if my new job allows for it.
At my residency, I've made it a point to be facile with aspiration and incision of the PTA. I just don't know if my new job allows for it.
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What is the incidence of that? Is it really high enough to warrant CT on every PTA?
Also, sticking an 18 gauge into the carotid likely won't cause significant problems.
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Agree w/ Cerberus. I've wanted to drain PTAs myself, but at my program, I'm met with mealy-mouthed attendings who consult it away.
Never done one. Know how. Never done it.
Never done one. Know how. Never done it.
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It's retrospective, but the CT can show two separate, discrete pus pockets (which the ENT - an old, crusty Chinese guy - said he'd never seen). Also, looking for what that clinical exam can't demonstrate? How about size and localization? I shall say that I would be credulous if everyone said they hit every PTA on the first poke, drained them fully, and didn't hit the ICA, all from the clinical exam.
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Really? That's too bad RF...
I've done many aspirations and I've even had ENT teach me how to do an open incision and drainage so I wouldn't have to call them if I've missed with the needle.
it probably won't be in your delineation of privileges (DOP) when you get out... you'll have to check.
i did a few in residency w/o much luck. when i went to do one at my first job out of residency, my colleagues in the ED looked at me like i'd grown horns. i got the idea it would be a political issue at that hospital with a great payor mix... taking $$ from the ENT's.
i often will CALL whomever is on call to ensure f/u... especially w/ uninsured pts. this is much less of a problem where i am now that it was at my previous gig.
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If you want to know about vasculature and pus pocket location a bedside ultrasound exam can tell you what you need to know in a fraction of the time.
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Sure - when you have it available at bedside.
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If anything in my experience Emergency Medicine Physicians are quite respected; I know of some Consultants who out-and-out say "oh I could never do that"
Think about the environment in which the Emergency Physician works; its not the nicest and certainly very different from that of the GP or specialist who works in private practice on the side.
The Surgical House Officer might not like you because you called him down at 1am to review somebody for admitting but as was said previously; nobody likes anybody who gives them work!
Think about the environment in which the Emergency Physician works; its not the nicest and certainly very different from that of the GP or specialist who works in private practice on the side.
The Surgical House Officer might not like you because you called him down at 1am to review somebody for admitting but as was said previously; nobody likes anybody who gives them work!
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I don't mind that you guys call to "give me work" at 1 am. I do mind when you don't know the exam, have no studies/did no work up, and knee jerk call a consult.
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A few points:
1. First of all ER docs need to know how to drain simple PTAs, if you are not learning it in residency that is ridiculous. A big hot PTA is a chip shot.
2. Don't ever say you are consulting for the sake of the consulting resident's education. That is a great way to make people absolutely hate you. I have several attendings who do this and its such crap. They are consulting b/c they are not comfortable with something, so they get all blustery and say "well the X residents need to learn how to manage these." If you're not comfortable doing something, just say that politely to your colleague on the phone, hell maybe even thank them for helping you out with something.
3. If you really want to earn brownie points, go into the room with them. This is how I learned to do PTAs, my attendings would want to consult so I would call ENT then ask the senior to walk me through it. 5-10 PTAs later I wasn't calling ENT.
4. To AndEE: not trying to start a flame war, but be a little careful trying to delineate what another doc should or should not be comfortable with. If an EM doc who wasn't comfortable doing something tried to do it then called you 2 hours into the mess you would be even more angry. I also find that our colleagues in surgical subspecialities are laughably incompetent in basic adult medicine. What happens in University Hospital when the post op ENT patient develops chest pain? Stat cardiology consult. Simple drug eruption? Stat derm consult. Develops a bit of ARF? Stat renal consult. I've had interns from ortho/ENT come up to me panicky about things like a hemolyzed K of 5.2 or an admit EKG that the machine reads as "abnormal" because it has 2 inverted T waves. Just sayin'.
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agree 100%
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The "not knowing the exam" is indefensible. Depending on your specialty, the "no studies" part is a huge gray area. Ignoring the really time critical diagnoses (penetrating trauma with shock not responding to fluids, fx/dislocation with vascular compromise, etc), there is a huge variability in when surgeons want to be called in the work-up. Take appendicitis for example. I've been yelled at for not calling prior to examining the patient (pt was waiting in lobby and took 2 hrs to be brought back), for calling with a classic story with consistent exam (who after he finished reaming me out, took the patient to the OR before labs were even back), for calling prior to CT scan, and once for calling after the CT was done.
At my old shop, you didn't go to the OR prior to CT and at my current shop the surgeons will admit on my H&P +/- labs and sound genuinely puzzled if you bring up CT'ing a classic appy. You may be (as much as your attendings allow) internly consistent on when in the work-up you want to be notified, but the overall variability is huge. So I call when I think your involvement is going to benefit the patient.
Also, if your attending sent a stable patient over from his clinic to the ED for admission instead of making the patient a direct admit then you are getting paged as soon as my exam is done.
