Day in the life of EM attending (article)

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BarryMarshall

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Here is an interesting article I found regarding a typical day in the life of a busy EM attending:

ER Doc Faces Complex Decisions
Patients could be admitted or sent home... but which?​
HARRISBURG, PA--Dr. Jerry Baylor's been making decisions that affect people's lives since seven this morning, and his day isn't over yet. It's only 4 PM, and he's got three hours left to go.

But Baylor, an emergency physician at Harrisburg's Mt. Holyoke Hospital, isn't thinking about going home. He's preoccupied with the tough choices he's facing for the six patients currently under his care.


erflow.jpg
E.R. Decision-Making Guide​

"In Bed 3," he says, "we've got a woman with a cough and a fever. If her X-Ray comes back positive for pneumonia, I'm admitting her. Otherwise, she might be able to go home. We'll see how she does."

"Then, in Bed 8, there's this guy with some pain in his leg. If the ultrasound shows a DVT, he may get admitted. Otherwise, I'll probably send him home."

And on it goes. Baylor, who prefers to be called an "emergentologist," says he's become accustomed to the challenging dilemmas he encounters every day.

"At first, it was a little daunting," he says. "The first time I had to decide whether a patient should be admitted or not, I almost cried. It was that stressful."

"But after a while, I began to realize that, for the patients that were sick enough to be admitted, most of the real work would be done by the doctors who actually did the admitting - the ones who would actually be taking care of the patient and making them better."

"Also," he adds, "it helps that I don't need to decide which lab tests to order - we just get a full panel for everyone, including cardiac enzymes, troponin levels, thyroid studies, and cholesterol, no matter what they present with."

He says the decision-making skills he's been honing at work has helped him in other areas of his life too.

"When my daughter has a cold, for instance, I instantly fall back on my medical training to make the decision: go to school, or stay home? I can make that determination in about twenty minutes now... ten, if I can get a stat chest film."

But there's one choice Baylor never has any difficulty making.

"When signout's over at 7:15 PM, I'm faced with either staying a bit and helping out with the patients I was seeing, or heading out the door ASAP," he explains.

He pauses to laugh. "And that, my friend, is the easiest decision of all."
 
'I almost cried'
Thanks for fixing the graphic link. That's funnier than the story.

I think the graphic should be modified for the discharged patients. There should be two options after discharge: Work Note or No Work Note. (Can also substitute Percs or No Percs.)
 
This could be made into a hilarious decision tree

admit
-> social, annoying, no real pathology -> medicine floor
-> patient not talking -> MICU
-> patient talking too much -> psych consult
-> needs emergent OR -> admit, surgery will see in AM
-> patient with surgical problem but has remote hx HTN on HCTZ-> page surgery, await turf battle

Discharge
-> annoying -> 10 Percocet
-> really annoying -> ibuprofen
-> hungry, polite -> turkey sandwich
-> hungry, not polite -> Crackers
 
Do most EM attendings really leave after their shift, without helping out at all when there are a lot of patients, like in this article?
 
Do most EM attendings really leave after their shift, without helping out at all when there are a lot of patients, like in this article?
Yep, that's the beauty of EM. You take other attending's patients when you start your shift, and they take your patients when you leave. Every patient has a plan (e.g., labs pending, CT scan (since we scan everything and they haven't implemented the CT scanner in triage yet), x-rays, etc.).

It's not just emergency medicine. Many private critical care and hospitalist groups practice the same way.
 
Do most EM attendings really leave after their shift, without helping out at all when there are a lot of patients, like in this article?

What patients? the attendings I work with dont even see patients, they just count their cash and admit people based on vitals and their desire to get admitted.
 
"But after a while, I began to realize that, for the patients that were sick enough to be admitted, most of the real work would be done by the doctors who actually did the admitting - the ones who would actually be taking care of the patient and making them better."

"Also," he adds, "it helps that I don't need to decide which lab tests to order - we just get a full panel for everyone, including cardiac enzymes, troponin levels, thyroid studies, and cholesterol, no matter what they present with."


Wouldn't it be cute if this were true?😉
 
My experience has been that many EM attendings/residents DO use the 'shotgun' approach toward making a 'diagnosis.' Would anyone really disagree that this practice occurs much more often than it probably should in most ED's?
 
My experience has been that many EM attendings/residents DO use the 'shotgun' approach toward making a 'diagnosis.' Would anyone really disagree that this practice occurs much more often than it probably should in most ED's?

oh quit digging and trying to get people worked up.

You are officially FMF'ed.
 
My experience has been that many EM attendings/residents DO use the 'shotgun' approach toward making a 'diagnosis.' Would anyone really disagree that this practice occurs much more often than it probably should in most ED's?

The shotgun is a great approach. It's the machine gun you want to avoid.
 
"Also," he adds, "it helps that I don't need to decide which lab tests to order - we just get a full panel for everyone, including cardiac enzymes, troponin levels, thyroid studies, and cholesterol, no matter what they present with."

That's so untrue . . . we never check cholesterol in the ED.
 
It is very effective with those highly annoying patients who you just want OUT of the ED.

I mean, I prefer a machete but I keep cutting myself.
 
So you actually do advocate the 'shotgun' approach in your practice?
Not really. I might actually diagnose a patient if I used the shotgun approach. I prefer the admit all patients approach. It's best to let the real docs upstairs (you know, the really smart ones) diagnose the patient.
 
So you actually do advocate the 'shotgun' approach in your practice?

Maybe I'm missing something, but I always thought the analogy doesn't fit. You can only fire one round at a time from most shot-guns. A machine gun, now that's a different story.
 
Maybe I'm missing something, but I always thought the analogy doesn't fit. You can only fire one round at a time from most shot-guns. A machine gun, now that's a different story.

Have you seen Metal Storm? http://www.metalstorm.com . Seems like it gives all the benefits of the shotgun approach with a significant fraction of machine gun. Plus it is electronically controlled, so it would fit in with EMRs.
 
Sure, this article comes from a medical humor site. But if you think about it, it is not really that far from the truth; well except for the cholesterol comment. Everything else is pretty true, no?
 
Sure, this article comes from a medical humor site. But if you think about it, it is not really that far from the truth; well except for the cholesterol comment. Everything else is pretty true, no?

Really? Yeah I mean I barely look at the patient myself and I am still a resident. The best part is that at my hospital we have a 100% admit rate so the real docs can care for the patients. I function as nothing more than a signature. The nurse orders all the labs (shotgun, if you will) and I just sign it. The docs upstairs have a pager that goes off as soon as some of the labs come back so they can admit the pt. Whats weird is that I will make 25% more once we all finish residency. Luckily for me I cant work this hard and am planning no more than 8 shifts a month.

Thank god for this being the best specialty EVER.
 
Sure, this article comes from a medical humor site. But if you think about it, it is not really that far from the truth; well except for the cholesterol comment. Everything else is pretty true, no?

Absolutely. Its all true.




😴
 
Sure, this article comes from a medical humor site. But if you think about it, it is not really that far from the truth; well except for the cholesterol comment. Everything else is pretty true, no?
I just call a surgeon. They can figure out anything. Got a chest pain? Call a surgeon. They'll diagnose your MI. Got a headache? Call a surgeon. They'll diagnose your migraine. Got a rectum? Call a surgeon. They'll do your rectal exam.
 
The docs upstairs have a pager that goes off as soon as some of the labs come back so they can admit the pt. Whats weird is that I will make 25% more once we all finish residency. Luckily for me I cant work this hard and am planning no more than 8 shifts a month.

Do EM docs really make 25% more money than all of the doctors upstairs?
 
Shhhhh. its a secret. We actually make 250% more.
 
No. Lots more.

Unless you mean 25% more than all of them combined. In which case, yeah, it is pretty close.

Sorry I let the cat out of the bag a little bit..

I doubt the OP is smart enough to figure it out since we all use our free time designing secret handshakes and codes to keep our good info from the rest.
 
DocB. I keep telling you that if you keep giving our secrets away you will be kicked out of the club!!!!!
 
I set up this really cool triage protocol last night.

Basically I told the triage nurse to circle everything on the order sheet after she gets the vital signs. If anything comes back abnormal on the labs or on the CT, she is to immediately call the hospitalist and also to request a tele bed. I showed her how to write some basic admit orders. I told her not to worry if anyone looked bad. Just bolus them some saline and put them on a non-rebreather. If they really looked bad she could call me and I might or might not intubate them as well as place bilateral chest tubes, and a cordis line in the neck and an IO in the leg for good measure. You never know.

I told her to keep the numer for general surgery, anesthesia, CT surgery, ENT, GI, plastics, cardiology, dermatology and bariatric surgery close by because you never know when we might need a consult. Especially after 2 a.m.

She knows I'll be busy in the back online getting my *** kicked in HALO or NCAA football by a couple of anonymous high school drop outs. That or texting my boys about how fuc0king drunk where going to get this weekend.


We'll see how it works out.
 
I set up this really cool triage protocol last night.

Basically I told the triage nurse to circle everything on the order sheet after she gets the vital signs. If anything comes back abnormal on the labs or on the CT, she is to immediately call the hospitalist and also to request a tele bed. I showed her how to write some basic admit orders. I told her not to worry if anyone looked bad. Just bolus them some saline and put them on a non-rebreather. If they really looked bad she could call me and I might or might not intubate them as well as place bilateral chest tubes, and a cordis line in the neck and an IO in the leg for good measure. You never know.

I told her to keep the numer for general surgery, anesthesia, CT surgery, ENT, GI, plastics, cardiology, dermatology and bariatric surgery close by because you never know when we might need a consult. Especially after 2 a.m.

She knows I'll be busy in the back online getting my *** kicked in HALO or NCAA football by a couple of anonymous high school drop outs. That or texting my boys about how fuc0king drunk where going to get this weekend.


We'll see how it works out.

This triage system should go in the "Reason's I love EM" thread.

Sounds like the perfect job.
 
This triage system should go in the "Reason's I love EM" thread.

Sounds like the perfect job.

I almost get the feeling that some EM docs actually dont want to provide any 'real' patient care. In one door and out the other (as quickly as possible), please. Is a system in which there is absolutely minimal medical practice actually to be idealized by the EM physician?
 
I almost get the feeling that some EM docs actually dont want to provide any 'real' patient care. In one door and out the other (as quickly as possible), please. Is a system in which there is absolutely minimal medical practice actually to be idealized by the EM physician?

Yes, this allows for more time to make fun of other specialties and think about getting back to our yachts and model wives.
 
Yes, this allows for more time to make fun of other specialties and think about getting back to our yachts and model wives.

Let's not forget about the Supermodel girlfriends and our Bentleys. 😀
 
I almost get the feeling that some EM docs actually dont want to provide any 'real' patient care. In one door and out the other (as quickly as possible), please. Is a system in which there is absolutely minimal medical practice actually to be idealized by the EM physician?


Wow, I am surprised that anyone in this thread admits to actually sending labs and working a patient up. What a nonsense waste of time. My approach is generally to let the triage nurse get the patient's chief complaints and vitals----I then read the front of the chart and call the admitting services. This whole "lab thing" and "CT thing" and "shotgun approach" are outdated wastes of my time. They would require me to see a patient. Do you realize what a giant waste of my time that is?!!?? I merely do a chart triage and call the appropriate consult to see the patient without seeing him myself.
 
If you people don't stop giving away all our trade secrets, I am reporting you to the board! These are serious offences!

How are we to keep our glamorous lifestyles out of the media and thus allowed to manipulate the system if you keep giving away all the secrets?
 
I almost get the feeling that some EM docs actually dont want to provide any 'real' patient care. In one door and out the other (as quickly as possible), please. Is a system in which there is absolutely minimal medical practice actually to be idealized by the EM physician?
The article you posted mocking EPs was marginally humorous but venturing into another specialty's forum to post something like that could be considered inflammatory. The fact that you have since then posted 7 times trying to get someone to engage you on these subjects is even worse.

If you would like to have an actual discussion about EM workups that is not predicated on a satirical, stereotypical view of EPs I suggest starting a new thread. If you are here to vent about what you consider bad practices of EM as a specialty then you would get better responses elsewhere.
 
I almost get the feeling that some EM docs actually dont want to provide any 'real' patient care. In one door and out the other (as quickly as possible), please. Is a system in which there is absolutely minimal medical practice actually to be idealized by the EM physician?
Yea, if the crap hits the fan or if I really want to consult a genius in the hospital, I call surgery. I'm talking surgeons are like Gods. They really know everything there is to know about medicine. They even know the history of medicine very well!
 
Yea, if the crap hits the fan or if I really want to consult a genius in the hospital, I call surgery. I'm talking surgeons are like Gods. They really know everything there is to know about medicine. They even know the history of medicine very well!

SD, you crack me up. I got a chuckle and thought of you today. I am on medicine and had this jacked up medicine patient with hyponatremia and lytes and such that we just couldn't put the picture together... talk to neph and all. I piped up and said to the attending, maybe we should consult Surgery?

I kind of got a blank stare; I had to try hard not to bust out laughin. It was good...
 
SD, you crack me up. I got a chuckle and thought of you today. I am on medicine and had this jacked up medicine patient with hyponatremia and lytes and such that we just couldn't put the picture together... talk to neph and all. I piped up and said to the attending, maybe we should consult Surgery?

I kind of got a blank stare; I had to try hard not to bust out laughin. It was good...
I'm telling you, they should wear capes with a big S (for surgeon) on their chest.

We should worship them for the Gods they are!
 
I'm telling you, they should wear capes with a big S (for surgeon) on their chest.

We should worship them for the Gods they are!

Why are you putting down the surgeons?
 
Time of Death: 12:40

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