Average Day in EM

[Medskooldude]

Hey everyone. I've been reading the forum up and down, and haven't quite found the answer to this question.

First off, a little back ground info. I'm in college, planning on heading to Medical School, and i was thinking of potential careers, and EM was one that seemed like it would intrest me, simply because of the unique cases it seems you would get.

The question is:

Can anyone give me a description about their average day in EM?

Thanks

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[dchristismi]

Um, pick up a chart, see patient, order some stuff. Pick up another chart, see patient, order some stuff or maybe just send them home - depends on your shop. Pick up another chart... rinse, lather, repeat.

Intersperse with ambulance traffic, some sick patients, some not sick patients, some procedures, chat with the nurses, you know. See patients. Pick up charts. Admit patients, send a few home. The goal is a nice smooth flow. It never happens that way, though. You'll get stuck with some sick ones or one very sick one, and you focus on that, all the while remembering that you have several more to manage, care for, disposition, and still see in the first place.

And then you go home. And you come back and repeat. It's never quite the same, so there's no real way to answer your question.

You really have to try it to know if you like it. Most people either do or don't - and you know pretty quickly if it's for you.

 

[Drawing Dead]

Organized chaos...

Seriously, I would find the county hospital closest to you, and this summer, between college and med school, ask them if you can shadow a day or two. Should give you an idea.

 

[EM_Rebuilder]

Average day... in the ER?

Arrive at 7AM... fill the water bottle, grab a donut and a coke... one bite of the donut.. new patient Trauma 1...

Intubate a gang banger that got shot 6 times, trauma is here too.... Loss of pulse.... cram a line in...direct CPR...pulse back, whisked away to the OR. Darn, hope that blood that got splashed in the eye from the chest compressing spraying chest wounds doesnt have Hepatitis or HIV in it.. (I need to pee..)

Pick up a sprained ankle in the ortho room... Dont need an xray per your medical expertise... patient insists b/c her friend had the exact same fall and had a fracture..order the xray, easier than the fight.

Psych patient in the obs hall.. they just defecated in their shoe.. they saw Elvis in the Trauma room and want to make love with the social worker... take them away to the locked up psych unit, make a call to psych...

Another Ortho patient... they have a broken leg... they were seen by another local ER...told to see a 'bone doctor'. "I called a bone doctor, but that mother f***er wanted $800 dollars just to see me. I told him no way, he said go to the university".... Xrays ordered..

Med Control: This is EMS Agent Smith, I am on scene with a 105 yr old woman, she is cold and her extremities are rigid. Her family had not seen her for about 3 days. I can auscultate no heart or breath sounds and all three leads shows asystole.. May I forgo a code and call this patient? Yes.

20 yr old diabetic girl arrives by EMS... she prefers crack over Insulin.. her sugar is >500 and the room smells like Juicy Fruit...just another DKAer. Get labs, start fluids...

22 yr old man, my stomach hurts really low and uh, I think there isnt something right in my bottom. I was at this party last night, and I passed out.. i think someone might have assualted me and it feels like there could be something 'down there'.... Umm, k. Xrays ordered.

This 34 yr old just had seizure at the Target... and the crew behind us is bringing a 72 yr old lady that DFOed (Done Fell Out) when she saw him seize. He is supposed to take Dilantin.. new patient Trauma 2...

Trauma 2... chest pain... EKG please... Yikes, call the cath lab... ST elevation MI (i.e. widowmaker). Get some labs, somebody dont forget to shave his groin... gotta have our numbers good (meaning how many minutes to get all this stuff done... compared nationally with other hospital)... dont forget the metoprolol and asprin. (I need to pee...)

Crtical labs... Diabetic girl with a pH of 6.9 and Glucose >500... Bicarb is 4.. Start the insulin infusion, call the unit

Doctor, the patient in ortho is getting mad because nobody has talked to her about her xray..

Reviewing Xray... Doctor, this patient in the hall is having a seizure.. give him some ativan.. load him with fos...

Med Control: This is EMS Agent Lacy. I am on scene with a 24 yr old whose car got rear-ended. he is refusing medical care. He is out here walking around on his cell phone. He denies any alcohol, says that nothing hurts. Are we ok to refuse medical care to this patient? Yes

DFOer is here... lordy, I saw that guy getting the shakes and I just fell out. My chest hurts to and I am short of breath.... Yes, I have HTN and DM and no, I dont take medications for these... yes, I smoke...yeah, I passed out for like 2 minutes when I fell. Yes, I have this chest pain about everytime I walk around the mall. Cardiac labs sent, EKG reviewed, CT ordered... hold in the chest pain for serial enzymes..

Med Control: Hey doc, this is EMS Agent Jimmy. I am going to pick up a guy from the pysch hospital and I have picked this guy up before and know that I need will need restraints, is it ok if I use restraints? Please do.

Reviewing Xrays... new patient Trauma 3...

Trauma 3... EMS, whats up with this guy? I dunno, some store called and said he was asleep in front of their door and he would not move when they told him to move.. he just says he vomited.. looks homeless..

Trauma 3.. GCS is 12.. no need to get an airway, not overly oriented though... CT, labs, EtOH... febrile? and he is tachycardiac.. doh.. his left foot is black and whats that..... a maggot!... hypotensive too... lets get some antibiotics.. pressors.. page surgery/vascular for me (I REALLY need to pee...)

Doctor, the lady with the hurt ankle is pacing the hallway wanting to know what her xray shows...

Radiology Calls: Yeah, doc, whats up with this 22 yr old guy? I mean, it looks like an outline of mickey mouse down low on the abdominal film. I mean, It could be in his distal colon, but you know, I mean it could be strapped to his body..or maybe if he had a hoody on when they shot the film, I have seen objects in those kangaroo pouches before show up like this. Did this guy say he put something in his rectum? Just correlate clinically; I'll get my report typed up.

Patient rolls by, full out RAPPING... whats up with this guy? He swallowed a few bags of coke....

.......and this goes one for 8, 10, or 12 hours...depending on how long your shift is. The above could have easily happened by or even before noon. If your lucky, you'll get to finish that donut. I still have a hard time drinking an entire water bottle down during a 12 hours shift..

**All of these cases were made up off the top of my head and are NOT violations of HIPPA. I do think, however, that this often makes up a typical day in a busy Level I Emergency Department...

 

[turtle md]

I think the above post nailed it!

Did you get to pee?

 

[EM2BE]

I think the above post nailed it!

Did you get to pee?

At least before passing out?

 

[dchristismi]

Brilliant commentary EM_Rebuilder!

Oh, I did forget to mention that... you ALWAYS forget to pee. And you realize it _just_ after you've called for your Etom/Sux in that little 50 second window between push and paralysis. Bladder management is important.

At my community hospital, the cardiologists shave their own groins. Geez... now THAT is scut. I just about spewed a cabernet all over my laptop at that. I'll get the ASA/BB in (and the heparin/2B/3A if they want it) and tell the patient what's going to happen, but they are OTD before I'm shaving anything!

 

[WilcoWorld]

"Patient rolls by, full out RAPPING" - that's when I lost it!

Let EM Rebuilder's post replace the angry triage nurse's List Of Rules as EM's most forwarded email...

 

[kungfufishing]

oh, we didnt all do that at UMC. EMR just likes to shave other men's groins.

 

[EC3]

Can't get any better than EM_Rebuilder's post. The imagery is so vivid.

 

[Medskooldude]

Nice nice That was an amazing post EM!

And i have already set up a date to shadow my local EM doc.., Its in about a month! I can't wait!!!!!

Anymore post are definetely welcome

 

[ineedsleep]

Nice nice That was an amazing post EM!

And i have already set up a date to shadow my local EM doc.., Its in about a month! I can't wait!!!!!

Anymore post are definetely welcome

I'd like to say all days are that interesting, but you never know with EM. Some days you are working up your 4th or 5th abdominal pain that ends up being unknown etiology and seeing another dental pain. Then you see the frequent flyer who has migranes and the only medication that ever works is " d. . d. . .d . . dilaudid". These days you don't feel like you solve any actual problems and you tend to piss people off because you will not give the 150 of percocet that they demand.

But if you have a sense of humor and a thick skin, it's fun.

 

[Aloha Kid]

I didn't pee the other night for 13 hours. Anyone beat that? Surely thought I could get the toilet to overflow. If you count pass 30 seconds and you are still peeing, you know you have excellent bladder capacity.

 

[GeneralVeers]

I didn't pee the other night for 13 hours. Anyone beat that? Surely thought I could get the toilet to overflow. If you count pass 30 seconds and you are still peeing, you know you have excellent bladder capacity.

I bet I could get my hourly RVUs up by 1 if I used a foley at work. That way wouldn't waste the 2-3 minute stop the bathroom.

 

[deleted65604]

You forgot the:

-2 different twenty-something year-old females with chronic abdominal pain who are there for their monthly ER evaluation (you never can decide whether they just want to get high once in a while, or whether they are stupid enough to think that their eighth ER evaluation is actually going to reveal pathology that is curable).

-The guy with chronic migraines that is not relieved except by 4 of dilaudid, preferably, all at once.

-The first trimester vag-bleeder that you need to do a pelvic on to make sure their isn't a fetus sitting in the os, get an ultrasound to rule in intra-uterine pregnancy, and get an RH to see if she needs rhogam.

-The vague 50 year old chest pain that you will look at EKG for, and call for admission when the trop is negative. Internal med/ Family med doctor will always say over the phone, "but it doesn't sound cardiac." Once in a while they will come down and do things like discharge 84 year old ladies with new flipped T waves in V2 through V4 because "it is reproducible" (had that happen to me 2 weeks ago).

-The psych patient who wants to be admitted because they are depressed for the 10th time this year. (Psych is 99% get labs, make sure that there isn't a medical disorder through history and physical, and call psych for admission. Very, very boring. Don't know why ER doctors are involved in the whole ridiculous process)

-Kid with a fever- follow pediatric algorithm of choice and either admit or discharge as you get results, call pediatrician if in doubt and make sure they agree.

-Altered elderly person- shotgun labs, x-ray, consider LP CT head or belly, admit no matter what, give abx if you see a source, or if they are really sick.

-The random 40 year old intelligent but paranoid guy/girl with a multitude of vague complaints that you wouldn't want to go to a clinic for, who you come out of the room thinking, "What the crap do I do with this person?" uhhhh... CBC, CMET, UA and discharge if normal, f/u with PCP.

-Pharyngitis with abnormal vitals, who didn't meet criteria for fast-track. rule out abscess, strep, consider mono, blah-blah-blah- if they are really whiny and tachycardic, give liter of fluid, toradol, and discharge looking much better.

-Finger-tip avulsion- call ortho to ronjeur(sp?) out bone.

-High-mechanism trauma- CT stem to stern for the most part and admit to surgery. (ER resident mind-set- do they need to be intubated? No? Crap. Can I put in a central-line? No? Do they need a chest -tube? No? Can I leave? Why? I have to see my 5 other patients and produce the meaningless paper-work that my 5 minute involvement in this incident necessitates. (Surgeons loath us for this attitude, but...)

The most common presenting complaints (from the CDC) to the ER nation-wide, ranked in order of frequency are:
1. Abdominal pain
2. Chest pain
3. Fever
4. Headache
5. SOB
6. Back pain
7. Cough
8. Pain
9. Laceration
10. Throat Symptoms

Note that car accidents, stabbings, and gunshots don't even show-up on the list. Residencies tend to be at level 1 trauma centers, so you will get a larger proprotion of those problems, but even at level 1 trauma centers, the above problems will occupy the vast majority of your time... not so glamorous.

 

[EM2BE]

One more for the guy who comes in with who knows which pain (back pain, neck pain, abd pain, etc) that needs the 4 of dilaudid pushed with benadryl.

 

[8744]

You forgot the:

-Altered elderly person- shotgun labs, x-ray, consider LP CT head or belly, admit no matter what, give abx if you see a source, or if they are really sick.

This kind of patient should be the official Emergency Medicine totem animal. I cannot tell you how many useless brain CTs and other studies I have ordered on demented nursing home patients who are, at baseline, only a few percentage points of oxygen saturation away from cadaver status and who have not have any meaningful interaction with the world in a decade sent in for "Altered Mental Status."

 

[dchristismi]

This kind of patient should be the official Emergency Medicine totem animal. I cannot tell you how many useless brain CTs and other studies I have ordered on demented nursing home patients who are, at baseline, only a few percentage points of oxygen saturation away from cadaver status and who have not have any meaningful interaction with the world in a decade sent in for "Altered Mental Status."

"But grandma is worse than usual"

Heh. This is my bread-and-butter. I work in Florida. I do at least 2-3 of these every shift, especially now that it's winter. That's why my description of the way was a little more vague... I don't work at a trauma center, so it's medical medical medical all day long. I had a dude dropped off by homeboy ambulance with a bullet shattered ulna. My ortho couldn't quite get his mind around the fact he was called for a gsw at 1am at our non-trauma community hospital. I repeated that part about 8 times. "Yes, a gunshot wound. No, EMS didn't bring him here, he just showed up. Yes, he got shot. Yes, his ulna is in many tiny pieces. And yes, you need to see him. Yes, now. Really, he got shot. Come see him." Ug.

 

[emtcsmith]

On the other side of the command line....

The hospital doesn't have a command line so I call the unit clerk desk and tell him to hand the phone to a doctor..."Who is this?" "Ok, were 10min away with a likely CVA onset of about 30min, get ready to work when we get there."

Next hospital command line "Doc this guy was in an mvc on the highway, got out of his car, got hit and now has an open fx to his right leg your ok with morphine right? Ok I'll see you for a trauma alert in 10min"

Different hospital, busy night in the city..."this patient took her medication orally instead of inhaled, tell me thats ok and I'll leave her in her apartment. Thanks" ...and on to the next call

If your thinking of EM or medicine at all go for it but be ready for 80% mundane and 20% of actual sick.

 

[Arcan57]

Everytime I see a trached and PEG'ed baseline GCS of 3 x yrs with cc of "change in mental status", a small part of me hopes that they've somehow woken up from their coma Hasn't happened yet.

 

[P2J]

Average day in the ED= a million times better than the average day on medicine ward

 

[Kris1]

Average day in the ED= a million times better than the average day on medicine ward

Agreed... no rounding, no call, no clinic. What more could one ask for in a specialty?

 

[WilcoWorld]

Agreed... no rounding, no call, no clinic. What more could one ask for in a specialty?

A circadian rhythm.

 

[Kris1]

A circadian rhythm.

Yeah... good point.

 

[kajunman]

did not notice who wrote this till i got to the bottom....but you sure nailed it. when we gonna go hit the boats for some poker????

Kajunman

Average day... in the ER?

Arrive at 7AM... fill the water bottle, grab a donut and a coke... one bite of the donut.. new patient Trauma 1...

Intubate a gang banger that got shot 6 times, trauma is here too.... Loss of pulse.... cram a line in...direct CPR...pulse back, whisked away to the OR. Darn, hope that blood that got splashed in the eye from the chest compressing spraying chest wounds doesnt have Hepatitis or HIV in it.. (I need to pee..)

Pick up a sprained ankle in the ortho room... Dont need an xray per your medical expertise... patient insists b/c her friend had the exact same fall and had a fracture..order the xray, easier than the fight.

Psych patient in the obs hall.. they just defecated in their shoe.. they saw Elvis in the Trauma room and want to make love with the social worker... take them away to the locked up psych unit, make a call to psych...

Another Ortho patient... they have a broken leg... they were seen by another local ER...told to see a 'bone doctor'. "I called a bone doctor, but that mother f***er wanted $800 dollars just to see me. I told him no way, he said go to the university".... Xrays ordered..

Med Control: This is EMS Agent Smith, I am on scene with a 105 yr old woman, she is cold and her extremities are rigid. Her family had not seen her for about 3 days. I can auscultate no heart or breath sounds and all three leads shows asystole.. May I forgo a code and call this patient? Yes.

20 yr old diabetic girl arrives by EMS... she prefers crack over Insulin.. her sugar is >500 and the room smells like Juicy Fruit...just another DKAer. Get labs, start fluids...

22 yr old man, my stomach hurts really low and uh, I think there isnt something right in my bottom. I was at this party last night, and I passed out.. i think someone might have assualted me and it feels like there could be something 'down there'.... Umm, k. Xrays ordered.

This 34 yr old just had seizure at the Target... and the crew behind us is bringing a 72 yr old lady that DFOed (Done Fell Out) when she saw him seize. He is supposed to take Dilantin.. new patient Trauma 2...

Trauma 2... chest pain... EKG please... Yikes, call the cath lab... ST elevation MI (i.e. widowmaker). Get some labs, somebody dont forget to shave his groin... gotta have our numbers good (meaning how many minutes to get all this stuff done... compared nationally with other hospital)... dont forget the metoprolol and asprin. (I need to pee...)

Crtical labs... Diabetic girl with a pH of 6.9 and Glucose >500... Bicarb is 4.. Start the insulin infusion, call the unit

Doctor, the patient in ortho is getting mad because nobody has talked to her about her xray..

Reviewing Xray... Doctor, this patient in the hall is having a seizure.. give him some ativan.. load him with fos...

Med Control: This is EMS Agent Lacy. I am on scene with a 24 yr old whose car got rear-ended. he is refusing medical care. He is out here walking around on his cell phone. He denies any alcohol, says that nothing hurts. Are we ok to refuse medical care to this patient? Yes

DFOer is here... lordy, I saw that guy getting the shakes and I just fell out. My chest hurts to and I am short of breath.... Yes, I have HTN and DM and no, I dont take medications for these... yes, I smoke...yeah, I passed out for like 2 minutes when I fell. Yes, I have this chest pain about everytime I walk around the mall. Cardiac labs sent, EKG reviewed, CT ordered... hold in the chest pain for serial enzymes..

Med Control: Hey doc, this is EMS Agent Jimmy. I am going to pick up a guy from the pysch hospital and I have picked this guy up before and know that I need will need restraints, is it ok if I use restraints? Please do.

Reviewing Xrays... new patient Trauma 3...

Trauma 3... EMS, whats up with this guy? I dunno, some store called and said he was asleep in front of their door and he would not move when they told him to move.. he just says he vomited.. looks homeless..

Trauma 3.. GCS is 12.. no need to get an airway, not overly oriented though... CT, labs, EtOH... febrile? and he is tachycardiac.. doh.. his left foot is black and whats that..... a maggot!... hypotensive too... lets get some antibiotics.. pressors.. page surgery/vascular for me (I REALLY need to pee...)

Doctor, the lady with the hurt ankle is pacing the hallway wanting to know what her xray shows...

Radiology Calls: Yeah, doc, whats up with this 22 yr old guy? I mean, it looks like an outline of mickey mouse down low on the abdominal film. I mean, It could be in his distal colon, but you know, I mean it could be strapped to his body..or maybe if he had a hoody on when they shot the film, I have seen objects in those kangaroo pouches before show up like this. Did this guy say he put something in his rectum? Just correlate clinically; I'll get my report typed up.

Patient rolls by, full out RAPPING... whats up with this guy? He swallowed a few bags of coke....

.......and this goes one for 8, 10, or 12 hours...depending on how long your shift is. The above could have easily happened by or even before noon. If your lucky, you'll get to finish that donut. I still have a hard time drinking an entire water bottle down during a 12 hours shift..

**All of these cases were made up off the top of my head and are NOT violations of HIPPA. I do think, however, that this often makes up a typical day in a busy Level I Emergency Department...

 

[jbar]

A circadian rhythm.

taking call doesn't help that much. If I'm going to stay up all night at least it won't come at the beginning or end of a normal day at work.

 

[andon]

how much paper work is done per shift? do you have to stay after your shift is over to do paper work?

 

[deleted65604]

I'm notoriously bad at charting, so take this with a grain of salt. ABout 1/4-1/3 of my time is doing charting.

We do T-sheets, and usually, I fill in history in the room and leave physical and labs and clinical decision-making until after the patient has left the department. In residency, we had template computer charting, where I tended to log on to the computer while in the room and type way while the patient talked.

The busier I am, the longer I have to stay after. Some people chart as they go and walk out 5 minutes after their shift. In my limited observation, those are either the people who cherry-pick easy patients, or tend not to move as much meat, or tend to have notes that would be totally useless to defend them in court. I'm a little verbose in my medical decision making (OK, I'm always verbose on paper). On some patients, with complicated stories who I feel a little nervous about, I feel I need to justify my actions.

 

[GeneralVeers]

The busier I am, the longer I have to stay after. Some people chart as they go and walk out 5 minutes after their shift. In my limited observation, those are either the people who cherry-pick easy patients, or tend not to move as much meat, or tend to have notes that would be totally useless to defend them in court. I'm a little verbose in my medical decision making (OK, I'm always verbose on paper). On some patients, with complicated stories who I feel a little nervous about, I feel I need to justify my actions.

Gotta disagree with you there. I typically pick up patients until I am saturated (8-10 patients). At that point it's not really feasible for me to manage any more, so I begin charting on those patients, and discharge the ones I am able to. Once it's down to a reasonable level I pick up another batch of patients. Rinse, repeat. I deal with admission as I have spare time, as the limiting step is waiting for the admitting doc to call back.

My RVUs compare favorably with those who sit and fill out charts at the end. The problem with charting at the end, is you may not remember everything that was done with the patient, or you may remember "Oh crap, I forgot to give antibiotics". Too late as patient is OTD already.