EM Example Caseload?

[sniffingposition]

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Hello everyone,

I'm an incoming MSIII who wants to ask the EM attendings here what their average caseload is like at a hospital EM. What % would you say are acute emergencies, non-emergent complaints, drug seeking, psychiatric disorders, etc.? Even better would be a snapshot breakdown of what you saw during a shift.

Little bit of reason why I'm asking - my interest in EM was because I wanted to be in a field where you were actively saving people's lives - maybe not 100% of the time, but being there when they need acute care or else risk dying - the overglorified idea of being a hero. However, I feel like this is not an accurate view of the field, and I wanted to ask those with experience what the actual realities of working an EM shift is like.

Thank you for any advice/stories you might have!

 

[deleted547339]

I would say you truly save a life a handful of times a month. What is it they say? In medicine, a third will be better because of what you did, a third worse, and a third it doesn't matter - it's something like that.

I see about 2-2.5 patients an hour on a good shift. Most of our super low-acquity goes to fast tract (med refill, dental pain, twisted ankle, uri, abscesses etc). We have a separate Peds ED as well. Trauma goes to a seperate area, so on trauma days that's all you see. If you're in the main ED, you'll see one or two chest pains, belly pains, psych, headaches/migraines, dyspnea, vag bleed/discharge and extremity injuries. You may get a full arrest, shocky patient or respiratory failure each shift. The rest is a smattering of syncope, general fatigue, Tia/stroke, transplants, tox, gi bleed, copd, etc. We intubate about 2 patients a day (in the ED, not per person). I'll do a few procedural sedations a month (did 2 today).

 

[TooMuchResearch]

OP, this is highly dependent on practice environment. Some will intubate a few times per year, others 1+ times per day. Some see minimal trauma, others see so much they miss seeing weak and dizzy LOLs.

 

[BAM!]

Very dependent on the hospital. Some places may run 1 code per year while others will see several a day.

TimesNewRoman's post is pretty accurate/representative. But it sounds like he works at a busy trauma center. So he may see higher acuity patients. My ED is much smaller, so no separate Peds or Trauma area. That said I intubate once every couple of shifts. Did I save a life with each intubation? Probably not all of them, but probably a considerable amount of them. Maybe I'll run a code once every week or two. Of course it's variable, but I agree with TimesNewRoman. I think you have the chance to genuinely save someone's life or at least decrease morbidity a few times per month.

Here's something else. While extremely effective, after you've treated large numbers of people with supportive care and life support measures (which is how most lives are saved), the adrenaline rush decreases and the experience loses some of its original sex appeal. You'll still have cases that make you feel good about your work though.

Also, I'm assuming we're not putting things like appendicitis in the "life saved" category.

Another way of thinking about it.
2.5 patients per hour
8 hr shift
15 shifts
300 patients per month
3 lives saved per month
3/300 = 1% of patients.

hmmm, feels too high. ;D

 

[sniffingposition]

Thank you for all your responses, I have been trying to decide between EM and another specialty - EM just seems to have this allure of being able to be right there and intervening to hopefully prevent a patient from dying - I'm just not sure if I'm looking through rose-colored glasses or have an overly heroic/idealized image of the EM. I anticipate there's some bull**** you have to wade through, I just don't know how much.

 

[Perrin]

.

 

[The White Coat Investor]

Typical for me might be this:

8 hour shift, 12 patients.

2 chest pains, 3 abdominal pains, 2 vaginal bleeds, a dyspnea, a laceration, one critical patient, an SI, and an altered mental status. That's pretty typical. Maybe throw in something interesting every couple of shifts.

How many are "drug-seekers"? A lot more after midnight, that's for sure. Sometimes it feels like every other patient after midnight is a drug seeker. But even among the aforementioned 12 patients, 5 or 6 of them will be on chronic opiates.

 

[deleted547339]

Typical for me might be this:

8 hour shift, 12 patients.

2 chest pains, 3 abdominal pains, 2 vaginal bleeds, a dyspnea, a laceration, one critical patient, an SI, and an altered mental status. That's pretty typical. Maybe throw in something interesting every couple of shifts.

How many are "drug-seekers"? A lot more after midnight, that's for sure. Sometimes it feels like every other patient after midnight is a drug seeker. But even among the aforementioned 12 patients, 5 or 6 of them will be on chronic opiates.

Dang. 1.5 pph in a democratic group? Living the dream....

 

[Arcan57]

10 hr shift, somewhere between 14 and 30 patients depending on what shift and volume that day. Reliably will see 1-3 chest pain pts (STEMI every other month), 7-10 abdominal complaints, 2-3 dyspneas with hx of every possible cause of dyspnea and wheezing, crackles, and baseline mod-severe pedal edema on exam. Throw in 2 patient with either resolved neuro deficits or persistent "dizziness" without exam findings and your shift is complete. Except for the 2-3 first trimester vag bleeds,2-3 RUQ pains with hx of cholelithiasis, 2 pediatric lacs, and 3 peds fever patients the NP/PA gives you that you have to personally evaluate.

Every month or so I'll catch a STEMI, maybe 3 times a week one of those dyspnea pts gets put on BiPap, and I'll tube a septic shock or polypharmacy overdose unresponsive to Narcan every couple of months.

 

[The White Coat Investor]

Dang. 1.5 pph in a democratic group? Living the dream....

Ssshhhhh.... it's actually 1.3-1.4. We'd love to boost our volume a bit. We just opened another hospital where we averaged 0.5 the first month. Would LOVE to see that get to 1.5 ASAP.

 

[takeurmeds02]

I'm a scribe in an ER in a level I urban trauma center. On average, my doc and I will see about 20 pts on a 8/9 hour shift.

Today, we're at 15 patients with another ~2 hours left: three admits so far: elderly, complicated UTI, another CHF exacerbation, and the third, atrial flutter-acute cardioversion. One psych who will probably come in. The rest were low acuity; neck pain, HTN, eye pain, chronic pancreatitis, UTI's, etc.

I probably see 1-3 deaths a month working ~15 shifts. Most docs here work about that many.

 

[dotcb]

Urban academic trauma center - 5% critical, 50% need to see a doctor soon-ish, 45% - need us to decide if they have an urgent condition (chest pain, abd pain, swelling, joint pain, lac, psych, etc.).

 

[Angry Birds]

I would say that I have a truly critical patient every shift or every other shift. I mean a patient that you are sweating bullets over and could die in front of you if you make a mistake.

I think that's the right number of such patients. Any more and your job would be way too stressful.

Saving a life every day you work--and I mean truly saving someone from the brink--is a lot more than other specialties can claim. And it's a highly rewarding feeling.

 

[Xerxes1729]

I found my list from a eight-hour overnight a few weeks ago:

Abdominal pain - 10
Minor complaint (small burns, insect bites, URI, epistaxis, etc.) - 9
GYN issues - 3
Chest pain - 2
Cardiac arrest - 1
Headache - 1
Elderly feeling vaguely unwell - 1
Drunk - 1
Social issues - 1
Cellulitis - 1

Half were patients I saw with the PA, half were on my own.

Add to that some signouts:

Psych - 6
Drunk - 2

Plus a bunch of inpatient borders who I'm not technically responsible for, but the nurses really don't like calling the inpatient team, so they want me to order pain meds, nausea meds, etc for all of them.

 

[deleted109597]

People that will die today if I don't intervene now? 1
People that will die this week if I don't figure out what is wrong with them? 2-3
People that will die this month if I don't figure out something? 2-3
People that will die this year if I don't diagnose something? 2-3
People that will have no meaningful change in their mortality whether they come to the ED or not? 5-6
People who will die sooner as a result of misguided attempts at figuring out their problem or treating some imaginary complaint? 1-2
People that will die eventually? All of them

 

[Angry Birds]

I think some people underestimate how big of a deal it is to save one person every shift...to save them from nothing short of death. Very few occupations can claim that, and even very few specialties in medicine overall can claim that.

 

[RustedFox]

Just two shifts ago, I had an empty (completely freaking EMPTY) department from 12:30 AM to 2 AM.

At 3 AM, I had three females, all intubated and on ventilators. These were my only patients.

Patient A: 65 year old former RN charge nurse who says to me: "I'm afraid that I have a PE." She was right.
Patient B: 91 year old five-star dementia patient with idiopathic pulmonary fibrosis. She was the only one that DIDN'T have renal failure (acute, or chronic) and was looking GOOD !
Patient C: 73 year old COPD'er who coded when EMS transferred her to the ED bed. Epinephrine and chest compressions brought her back. Her first words were "Whoa! I'm here! Wow... you... are all so KIND to me." She then went into V-tach, which I broke with Amiodarone, but resulted in a junctional bradycardia causing her to go out again. Atropine, Epinephrine, Intubated. Minimal sedation, cause her pressure sucked. Husband shows up. Intubated (and showing more strength than many millennial men that I know), she answers all questions with "yes/no" gestures of the head. Husband is at bedside. I tell him to hold her hand and shout at her "Hey! This is your husband ! He loves you very much !" She nods three times affirmatively. Never makes an "extubate me!" gesture.