Equal work for equal pay

[DermViser]

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Isn't she in Canada? Path in America's hat isn't as bad as it is around here due to their much tighter control on the number of residency positions. Other specialists are hurting though, it's crazy.

http://www.royalcollege.ca/portal/p...documents/policy/employment_report_2013_e.pdf

It's a pity, path would be a great field if they weren't so hell-bent on eating their own young in every conceivable way. I could probably match a strong program (even Columbia path takes DOs), but I wouldn't want to enter a market that's that hot with big lab competition and very little opportunity for PP.

What?? She is an AMG went to med school at Columbia and is at a U.S. residency program. PP is doing fine for Path.

 

[Mad Jack]

I must have missed something, and @DermViser what is the problem with EM?

Everything but the hours. God forbid anyone point that out though, EM is becoming the golden cow of residents and premeds. Nights, weekends, and holidays till you die, ungrateful patients, high liability, low level of respect from other physicians (something that matters when you're trying to admit or transfer), Press Ganey sending you bad patient satisfaction report cards that cause your bonus pay to be cut because every drug seeker you wouldn't write a script for some fresh Percocets decided to rate you a zero. It's a lot of little things that add up. There's a reason EM has notoriously high burnout.

 

[Mad Jack]

What?? She is an AMG went to med school at Columbia and is at a U.S. residency program.

I'm probably just mixing up what was said in a Canadian pathology residency thread some time ago. She's still a resident- I'm curious to see how she feels about the job market post-graduation, as the general vibe is that it is "not good." Really hope things go well for her.

 

[DermViser]

I'm probably just mixing up what was said in a Canadian pathology residency thread some time ago. She's still a resident- I'm curious to see how she feels about the job market post-graduation, as the general vibe is that it is "not good." Really hope things go well for her.

Well she nearly completed a surgical residency, and then switched over to Path. And she is indeed very happy.

 

[Raryn]

This is a stupid discussion. Everyone knows that EM works fewer hours than every other specialty (including Derm), but anyone with half a brain acknowledges that those hours are a lot more busy for an EM provider than they are for just about anyone else. It's true we (almost) all did EM rotations as medical students and residents, but seeing 6 patients in a 12 hour shift and staffing them with someone who does nothing but EM is different than being soley responsible for 30 patients over that same shift.

The bottom line is this: An ophthalmologist can definitely treat any eye emergency better than an EM physician. A trauma surgeon can obviously treat an acute abdomen better than an EM physician. An intensivist can manage the critically ill crashing patient at least as well in the acute setting and better in the longer term. But none of that matters. There is not now and never will be an emergency room with an internist, general surgeon, pediatrician, ob/gyn, ophthalmologist, urologist, and the rest of the whole set of subspecialists sitting around waiting for the patients to come to them. There's not enough patient volume in the individual subspecialties, and if it was just the internist seeing patients you basically have a glorified urgent care with drastically more consults being called than there are now. And I say this as an IM resident who has worked with plenty of IM attendings in VA "emergency rooms."

People trained in EM are explicitly trained to be able to see any undifferentiated patient who walks through the door and figure out if they do have an emergency that merits calling one of the other people down. Sometimes, especially in academic medical centers with residents from every subspecialty, the trigger for calling can be a bit more easily pressed than other times. And we all bitch because they give us work. But they are the ones trained to manage those ophthalmalogic emergencies in the acute setting till the eye doc gets in. And the urologic emergencies. And the neutropenic fever. And the fracture. And everything else. All of us could do parts of their job better than them I'm sure, but no one could do the whole thing. They are experts in all of emergency medicine. That's why it's a specialty, and that's why they need additional training in that rather than just getting a job after any random residency.

I made fun of them for complaining about their hours and pointed out the (very) strict limitations they have earlier on in this thread, but DermViser takes it to a whole nother level. (Oh, and as a side point to one of his comments: There are EM programs where their interns rotate through IM wards too. I've rotated with EM interns before.)

 

[DermViser]

The bottom line is this: An ophthalmologist can definitely treat any eye emergency better than an EM physician. A trauma surgeon can obviously treat an acute abdomen better than an EM physician. An intensivist can manage the critically ill crashing patient at least as well in the acute setting and better in the longer term. But none of that matters. There is not now and never will be an emergency room with an internist, general surgeon, pediatrician, ob/gyn, ophthalmologist, urologist, and the rest of the whole set of subspecialists sitting around waiting for the patients to come to them. There's not enough patient volume in the individual subspecialties, and if it was just the internist seeing patients you basically have a glorified urgent care with drastically more consults being called than there are now. And I say this as an IM resident who has worked with plenty of IM attendings in VA "emergency rooms."

This was the point I was making. "Emergency" is just a temporal scenario. The appropriate specialist can handle it.

If you see most of their sections in their textbook: http://www.mhprofessional.com/product.php?isbn=0071484809, a lot of the sections can be seen by the appropriate specialist or subspecialist i.e. Obstetrics and Gynecology, Pediatrics, etc.

Maybe not Disaster Preparedness, Toxicology, Emergency Wound Management, Abuse and Neglect. Hardly means a whole another residency/specialty should be created just for that.

 

[Raryn]

This was the point I was making. "Emergency" is just a temporal scenario. The appropriate specialist can handle it.

If you see most of their sections in their textbook: http://www.mhprofessional.com/product.php?isbn=0071484809, a lot of the sections can be seen by the appropriate specialist or subspecialist i.e. Obstetrics and Gynecology, Pediatrics, etc.

Maybe not Disaster Preparedness, Toxicology, Emergency Wound Management, Abuse and Neglect. Hardly means a whole another residency/specialty should be created just for that.

The appropriate specialist can handle it if he's there. But he's not. That's the whole damn point.

Someone needs to be trained to at least be able to screen and stabilize emergencies that are in the the purview of all specialists. Or damn near close at least. Without a specialty training people to do that, there is no one else. No one else can, in the same day, treat the obstetrics emergency, the pediatric emergency, the eye emergency, and then go ahead and at least theoretically be able to do an open thoracotomy and cross clamp the aorta until the thoracic surgeon gets down there. FM are the only people who come close, and they don't get anywhere close to as much explicit training in emergency care, which is why the specialty needed to be created.

 

[Mad Jack]

Just a few... But they can be outspoken, insulting, and strangely misinformed.

I'm just not even taking this any further. Let's just say I've heard way more than a handful of physicians refer to EM docs as "the worst physicians in the hospital." Which I don't agree with, but it's a very common sentiment you have to deal with. It's kind of like the sentiment that dermatologists do nothing and ortho guys are just scalpel jocks with power tools and no brains- certainly not true, but it's there. The difference is, when you need a dermatologist or an orthopedic surgeon, you refer to them because they're the expert, whereas an EM doc is always the one that needs to defer to other physicians and seek admissions and consults. You can imagine that causes some level of problems, as everyone is always making sure your patient really needs to be admitted and people dragging their feet on consults because it's the ED so it's probably just some CYA BS that the ED doc ordered that doesn't really need to be done in the first place. Basically, you're at the mercy of everyone in the ED- your patients, administrators, and other physicians. It's a problem other specialists don't have to the same degree. But whatever, don't take my word for it, I'm just some guy.

 

[DermViser]

The appropriate specialist can handle it if he's there. But he's not. That's the whole damn point.

Someone needs to be trained to at least be able to screen and stabilize emergencies that are in the the purview of all specialists. Or damn near close at least. Without a specialty training people to do that, there is no one else. No one else can, in the same day, treat the obstetrics emergency, the pediatric emergency, the eye emergency, and then go ahead and at least theoretically be able to do an open thoracotomy and cross clamp the aorta until the thoracic surgeon gets down there. FM are the only people who come close, and they don't get anywhere close to as much explicit training in emergency care, which is why the specialty needed to be created.

So then you're pretty much saying they serve as a triage nurse as a conveyor belt to shoot patients to different specialists, while babysitting them in the meantime.

 

[DermViser]

I'm just not even taking this any further. Let's just say I've heard way more than a handful of physicians refer to EM docs as "the worst physicians in the hospital." Which I don't agree with, but it's a very common sentiment you have to deal with. It's kind of like the sentiment that dermatologists do nothing and ortho guys are just scalpel jocks with power tools and no brains- certainly not true, but it's there. The difference is, when you need a dermatologist or an orthopedic surgeon, you refer to them because they're the expert, whereas an EM doc is always the one that needs to defer to other physicians and seek admissions and consults. You can imagine that causes some level of problems, as everyone is always making sure your patient really needs to be admitted and people dragging their feet on consults because it's the ED so it's probably just some CYA BS that the ED doc ordered that doesn't really need to be done in the first place. Basically, you're at the mercy of everyone in the ED- your patients, administrators, and other physicians. It's a problem other specialists don't have to the same degree. But whatever, don't take my word for it, I'm just some guy.

I don't know anyone who says Ortho doesn't do anything. Have you seen the strength required to actually do their surgeries?

Thank you. You got my point I was driving at.

 

[Raryn]

So then you're pretty much saying they serve as a triage nurse as a conveyor belt to shoot patients to different specialists, while babysitting them in the meantime.

It should amaze me how someone smart enough to get the scores to match derm could be so obtuse, but it really doesn't.

It takes a lot of training to "triage" and "babysit" all those patients, especially when you actually send a fairly high proportion of them home. I definitely wouldn't feel comfortable evaluating a good-sized proportion of the pathology that can present in the ED even in adults, much less kids/pregnant women.

But yes, lets just replace the ED with triage nurses. That will work well.

 

[DermViser]

It should amaze me how someone smart enough to get the scores to match derm could be so obtuse, but it really doesn't.

It takes a lot of training to "triage" and "babysit" all those patients, especially when you actually send a fairly high proportion of them home. I definitely wouldn't feel comfortable evaluating a good-sized proportion of the pathology that can present in the ED even in adults, much less kids/pregnant women.

But yes, lets just replace the ED with triage nurses. That will work well.

I was using the term triage nurse as part of "glorified triage nurse". I wasn't saying an actual nurse (RN) should serve as the conveyor belt to the appropriate specialist.

 

[Mad Jack]

I don't know anyone who says Ortho doesn't do anything. Have you seen the strength required to actually do their surgeries?

Thank you. You got my point I was driving at.

Ortho wasn't the ones I was saying have the "they don't do anything" stigma, that's derm. Ortho works hard as fuark- there's a reason your bench press gets added to your Step 1 score when you're being ranked.

 

[DermViser]

Ortho wasn't the ones I was saying have the "they don't do anything" stigma, that's derm. Ortho works hard as fuark- there's a reason your bench press gets added to your Step 1 score when you're being ranked.

Yes you said, "just scalpel jocks with power tools" Their power tools don't do all the work.

 

[Mad Jack]

Yes you said, "just scalpel jocks with power tools" Their power tools don't do all the work.

Oh, I wasn't clear enough. The caveman reputation exists for a reason lol, everyone knows it's a very physical job.

 

[PL198]

Ortho wasn't the ones I was saying have the "they don't do anything" stigma, that's derm. Ortho works hard as fuark- there's a reason your bench press gets added to your Step 1 score when you're being ranked.

lol more than double my score guaranteed, applying ortho now

 

[DermViser]

lol more than double my score guaranteed, applying ortho now

You have to be at least 26 yo to apply.

 

[Mad Jack]

lol more than double my score guaranteed, applying ortho now

I don't think you understand. If your bench doesn't at least triple your score, you aren't competitive.

"Everybody wants to match ortho, but nobody wants to lift no heavy ass weights!" -Dr. Ronnie Coleman, MD, PhD, Program Director, Harvard Orthopedic Surgery Residency Program

 

[DermViser]

I don't think you understand. If your bench doesn't at least triple your score, you aren't competitive.

"Everybody wants to match ortho, but nobody wants to lift no heavy ass weights!" -Dr. Ronnie Coleman, MD, PhD, Program Director, Harvard Orthopedic Surgery Residency Program

Good lord, Ronnie Coleman wouldn't even need Ortho power tools for surgery, with those arms.

 

[PL198]

I don't think you understand. If your bench doesn't at least triple your score, you aren't competitive.

"Everybody wants to match ortho, but nobody wants to lift no heavy ass weights!" -Dr. Ronnie Coleman, MD, PhD, Program Director, Harvard Orthopedic Surgery Residency Program

lol not going to be able to hit that, maybe 405 by the time I apply to residency but I'm assuming not as I'm expecting m3 to take too much time to maintain strength(hope I don't get a 202 )

 

[Silent Cool]

 

[alpinism]

I'm just not even taking this any further. Let's just say I've heard way more than a handful of physicians refer to EM docs as "the worst physicians in the hospital." Which I don't agree with, but it's a very common sentiment you have to deal with. It's kind of like the sentiment that dermatologists do nothing and ortho guys are just scalpel jocks with power tools and no brains- certainly not true, but it's there. The difference is, when you need a dermatologist or an orthopedic surgeon, you refer to them because they're the expert, whereas an EM doc is always the one that needs to defer to other physicians and seek admissions and consults. You can imagine that causes some level of problems, as everyone is always making sure your patient really needs to be admitted and people dragging their feet on consults because it's the ED so it's probably just some CYA BS that the ED doc ordered that doesn't really need to be done in the first place. Basically, you're at the mercy of everyone in the ED- your patients, administrators, and other physicians. It's a problem other specialists don't have to the same degree. But whatever, don't take my word for it, I'm just some guy.

When I was on surgery, literally every day the GS residents would make fun of the IM residents and how they consult them for the stupidest things. There was a running joke about how the surgery NPs were better at medicine than most IM attendings.

Then when I was on IM they constantly complained about how the GS residents don't know anything about medicine and to never trust their clinical notes. One of their favorite jokes: what do you call 2 surgeons reading an EKG? a double blind study.

There are a lot of subjects that EM docs are experts on: EMS, toxicology, undersea/hyperbaric medicine, wilderness medicine, high altitude medicine, disaster medicine, ultrasound evaluation, resuscitation.

You can do fellowships in all the above except resuscitation, as you are expected to become an expert in that during residency.

The bottom line is that you won't be deferring to other physicians for any of those patients.

 

[Winged Scapula]

Well she nearly completed a surgical residency, and then switched over to Path. And she is indeed very happy.

No she did 2 Prelim years of GS followed by Transplant research; not "nearly completed".

 

[circulus vitios]

Everything but the hours. God forbid anyone point that out though, EM is becoming the golden cow of residents and premeds. Nights, weekends, and holidays till you die, ungrateful patients, high liability, low level of respect from other physicians (something that matters when you're trying to admit or transfer), Press Ganey sending you bad patient satisfaction report cards that cause your bonus pay to be cut because every drug seeker you wouldn't write a script for some fresh Percocets decided to rate you a zero. It's a lot of little things that add up. There's a reason EM has notoriously high burnout.

It's like any other shift-based job. You get some nights, weekends, and holidays off, just not all (or even many) of them.

 

[DermViser]

No she did 2 Prelim years of GS followed by Transplant research; not "nearly completed".

Oh, ok. Her sig says, "(2010-2014) Surgical Pause, UW / UCLA" So I figured it was 1 year prelim and then 3 years of categorical.

 

[DermViser]

When I was on surgery, literally every day the GS residents would make fun of the IM residents and how they consult them for the stupidest things. There was a running joke about how the surgery NPs were better at medicine than most IM attendings.

They do consult them for stupid things. That being said many times it's bc the attending is forcing them to do it. A surgeon's job is to cut. This isn't IM rounds where long discussion is the primary mode of learning. You do.

Then when I was on IM they constantly complained about how the GS residents don't know anything about medicine and to never trust their clinical notes. One of their favorite jokes: what do you call 2 surgeons reading an EKG? a double blind study.

Why would you try to learn IM stuff from GS notes? GS doesn't write long notes like IM, bc their billing works differently than IM. It's why you won't see a full ROS. I don't understand why they don't leave a note everyday though, like IM is forced to.

There are a lot of subjects that EM docs are experts on: EMS, toxicology, undersea/hyperbaric medicine, wilderness medicine, high altitude medicine, disaster medicine, ultrasound evaluation, resuscitation. You can do fellowships in all the above except resuscitation, as you are expected to become an expert in that during residency.

See what I said above.
Yes, those are the subjects that EM doctors are probably best at - the less than 10% of all medicine and in very specific circumstances. That was my point. Most of their textbook - which they allegededly learn in real life practice is actually done by specialists. Someone above mentioned neutropenic fever. EM doctors are not actually managing neutropenic fever. Heme/Onc is called and the patient is admitted to them.

 

[Winged Scapula]

Oh, ok. Her sig says, "(2010-2014) Surgical Pause, UW / UCLA" So I figured it was 1 year prelim and then 3 years of categorical.

No.

One of my best friends is Transplant faculty at UW.

BD herself has said she did the 2 year Prelim program there for personal reasons, moved to UCLA for research, had her baby and presumably a change of heart about her specialty.

 

[PL198]

No.

One of my best friends is Transplant faculty at UW.

BD herself has said she did the 2 year Prelim program there for personal reasons, moved to UCLA for research, had her baby and presumably a change of heart about her specialty.

How do you feel about the show "Rush?"

 

[Mad Jack]

When I was on surgery, literally every day the GS residents would make fun of the IM residents and how they consult them for the stupidest things. There was a running joke about how the surgery NPs were better at medicine than most IM attendings.

Then when I was on IM they constantly complained about how the GS residents don't know anything about medicine and to never trust their clinical notes. One of their favorite jokes: what do you call 2 surgeons reading an EKG? a double blind study.

There are a lot of subjects that EM docs are experts on: EMS, toxicology, undersea/hyperbaric medicine, wilderness medicine, high altitude medicine, disaster medicine, ultrasound evaluation, resuscitation.

You can do fellowships in all the above except resuscitation, as you are expected to become an expert in that during residency.

The bottom line is that you won't be deferring to other physicians for any of those patients.

Critical care physicians can resuscitate a med patient better, surgeons and anesthesiologists are better at dealing with hemodynamically unstable patients, cardiologists can crush you on EKGs, an ultrasound trained and focused radiologist will run circles around you at ultrasound diagnosis, a pulmonologist with hyperbaric training will outperform you in many hyperbaric/undersea situations. The big things they've got that they are experts in are wilderness medicine, toxicology, disaster medicine, and high altitude medicine, all super-niche areas of expertise that aren't needed on a regular basis.

 

[Winged Scapula]

How do you feel about the show "Rush?"

I've never heard of it.

 

[CrimsonKing]

All I can think while reading this thread

 

[BadHorse]

All the ill-will towards EM, people say they're the jack of all trades masters of none... but that's not true, they're the masters of emergency care. They take a patient who has had no work-up whatsoever and either come up with a diagnosis, rule out the stuff that'll kill them or get them where they need to go. Does that make them triage? I don't think so, I've never met a triage nurse that could work up a patient from scratch and keep them alive no matter what was going on. And people seem to forget that they have a fraction of the time most of us have, yeah if they can't diagnose that lesion in 20 minutes they have to get it out of the ED because they just got a call from EMS telling them to prep the CCT because they've got a pedestrian struck with a GCS of 7 coming in. People think they're the worst diagnostician but I take the opposite stance, they have 20 minutes to make a diagnosis that can be anything in medicine, surgery, derm, ortho, ophtho, whatever, and most of the time they make it, discharge the patient home with instructions to follow up or get them to the specialists that need to treat them right then. In most specialties we overlook the fact that patients come to us with significant workups already, often already with diagnoses, and we take that information and apply our specialized knowledge to the case over days or weeks and we are so, rightfully, proud of our diagnostic acumen. In the ED they have 20 minutes and the entire world of clinical presentations ahead of them. Just remember that.

 

[DermViser]

Critical care physicians can resuscitate a med patient better, surgeons and anesthesiologists are better at dealing with hemodynamically unstable patients, cardiologists can crush you on EKGs, an ultrasound trained and focused radiologist will run circles around you at ultrasound diagnosis, a pulmonologist with hyperbaric training will outperform you in many hyperbaric/undersea situations. The big things they've got that they are experts in are wilderness medicine, toxicology, disaster medicine, and high altitude medicine, all super-niche areas of expertise that aren't needed on a regular basis.

Out of 22 sections of their Tintinalli's textbook - EM is probably an expert at 3 of them. The rest are much better handled and managed by actual specialists in those areas.

Section 1 Resuscitative Problems and Techniques
1 Advanced Airway Support
2 Arrhythmia Management
3 Resuscitation of Children and Neonates
4 Fluids, Electrolytes, and Acid-Base Disorders
5 Therapeutic Approach to the Hypotensive Patient
6 Anaphylaxis, Acute Allergic Reactions, and Angioedema

Section 2 Analgesia, Anesthesia, and Sedation
7 Acute Pain Management and Procedural Sedation
8 Management of Patients With Chronic Pain

Section 3 Emergency Wound Management
9 Evaluating and Preparing Wounds
10 Methods for Wound Closure
11 Lacerations to the Face and Scalp
12 Injuries of the Arm, Hand, Fingertip, and Nail
13 Lacerations to the Leg and Foot
14 Soft Tissue Foreign Bodies
15 Puncture Wounds and Mammalian Bites
016 Post Repair Wound Care

Section 4 Cardiovascular Diseases
17 Chest Pain: Cardiac or Not
18 Acute Coronary Syndromes: Management of Myocardial Infarction and Unstable Angina Jim
19 Cardiogenic Shock
20 Low Probability Acute Coronary Syndromes
21 Syncope
22 Congestive Heart Failure and Acute Pulmonary Edema
23 Valvular Emergencies
24 The Cardiomyopathies, Myocarditis, and Pericardial Disease
25 Thromboembolism
26 Systemic and Pulmonary Hypertension
27 Aortic Dissection and Aneurysms
28 Occlusive Arterial Disease

Section 5 Pulmonary Emergencies
29 Respiratory Distress
30 Bronchitis, Pneumonia, and SARS
31 Tuberculosis
32 Spontaneous and Iatrogenic Pneumothorax
33 Hemoptysis
34 Asthma and Chronic Obstructive Pulmonary Disease

Section 6 Gastrointestinal Emergencies
35 Acute Abdominal Pain
36 Nausea and Vomiting
37 Disorders Presenting Primarily With Diarrhea
38 Acute and Chronic Constipation
39 Gastrointestinal Bleeding
40 Esophageal Emergencies
41 Peptic Ulcer Disease and Gastritis
42 Pancreatitis and Cholecystitis
43 Acute Appendicitis
44 Diverticulitis
45 Intestinal Obstruction and Volvulus
46 Hernia in Adults and Children
47 Anorectal Disorders
48 Jaundice, Hepatic Disorders, and Hepatic Failure
49 Complications of General Surgical Procedures

Section 7 Renal and Genitourinary Disorders
50 Acute Renal Failure
51 Rhabdomyolysis
52 Emergencies in Renal Failure and Dialysis Patients
53 Urinary Tract Infections and Hematuria
54 Acute Urinary Retention
55 Male Genital Problems
56 Urologic Stone Disease
57 Complications of Urologic Devices

Section 8 Gynecology and Obstetrics
58 Vaginal Bleeding and Pelvic Pain in the Nonpregnant Patient
59 Ectopic Pregnancy and Emergencies in the First 20 Weeks of Pregnancy
60 Comorbid Diseases in Pregnancy
61 Emergencies After 20 Weeks of Pregnancy and the Postpartum Period
562 Emergency Delivery
63 Vulvovaginitis
64 Pelvic Infl ammatory Disease and Tubo-Ovarian Abscess
65 Complications of Gynecologic Procedures

Section 9 Pediatrics
66 Fever and Serious Bacterial Illness in Children
67 Common Neonatal Problems
68 Common Infections of the Ears, Nose, Neck, and Throat
69 Upper Respiratory Emergencies—Stridor and Drooling
70 Wheezing in Infants and Children
71 Pneumonia in Infants and Children
72 Pediatric Heart Disease
73 Vomiting and Diarrhea in Infants and Children
74 Pediatric Abdominal Emergencies
75 Pediatric Urinary Tract Infections
76 Seizures and Status Epilepticus in Children
77 Headache and Altered Mental Status in Children
78 Syncope and Sudden Death in Children and Adolescents
79 Hypoglycemia and Metabolic Emergencies in Infants and Children
80 The Diabetic Child
81 Fluid and Electrolyte Therapy
82 Musculoskeletal Disorders in Children
83 Rashes in Infants and Children
84 Sickle Cell Anemia in Children
85 Hematologic-Oncologic Emergencies in Children
86 Renal Emergencies in Infants and Children

Section 10 Infectious and Immunologic Diseases
87 Sexually Transmitted Diseases
88 Toxic Shock
89 Septic Shock
90 Soft Tissue Infections
91 Disseminated Viral Infections
92 HIV Infections and AIDS
93 Infective Endocarditis
94 Tetanus and Rabies
95 Malaria
96 Foodborne and Waterborne Diseases
97 Zoonotic Infections
98 World Travelers
99 The Transplant Patient

Section 11 Toxicology and Pharmacology
100 General Management of the Poisoned Patient
101 Anticholinergic Toxicity
102 Psychopharmacologic Agents
103 Sedatives and Hypnotics
104 Alcohols
105 Drugs of Abuse
106 Analgesics
107 Xanthines and Nicotine
108 Cardiac Medications
109 Anticonvulsants
110 Iron
111 Hydrocarbons and Volatile Substances
112 Caustics
113 Pesticides
114 Metals and Metalloids
115 Industrial Toxins and Cyanide
116 Herbals and Vitamins
117 Dyshemoglobinemias

Section 12 Environmental Injuries
118 Frostbite and Hypothermia
119 Heat Emergencies
120 Bites and Stings
121 Trauma and Envenomation from Marine Fauna
122 High-Altitude Medical Problems
123 Dysbarism and Complications of Diving
124 Near Drowning
125 Thermal and Chemical Burns
126 Electrical and Lightning Injuries
127 Carbon Monoxide
128 Mushroom and Plant Poisoning

Section 13 Endocrine Emergencies
129 Diabetic Emergencies
130 Alcoholic Ketoacidosis
131 Thyroid Disease Emergencies
132 Adrenal Insufficiency and Adrenal Crisis

Section 14 Hematologic and Oncologic Emergencies
133 Evaluation of Anemia and the Bleeding Patient
134 Acquired Bleeding Disorders
135 Hemophilias and von Willebrand Disease
136 Sickle Cell Disease and Other Hereditary Hemolytic Anemias
137 Transfusion Therapy
138 Anticoagulants, Antiplatelet Agents, and Fibrinolytics
139 Emergency Complications of Malignancy

Section 15 Neurology
140 Headache and Facial Pain
141 Stroke, Transient Ischemic Attack, and Subarachnoid Hemorrhage
142 Altered Mental Status and Coma
143 Ataxia and Gait Disturbances
144 Vertigo and Dizziness
145 Seizures and Status Epilepticus in Adults
146 Acute Peripheral Neurological Lesions
147 Chronic Neurologic Disorders
148 Central Nervous System and Spinal Infections

Section 16 Eye, Ear, Nose, Throat, and Oral Emergencies
149 Ocular Emergencies
150 Face and Jaw Emergencies
151 Ear, Nose, and Sinus Emergencies
152 Oral and Dental Emergencies
153 Neck and Upper Airway Disorders

Section 17 Disorders of the Skin
154 Dermatologic Emergencies
155 Other Dermatologic Disorders

Section 18 Trauma
156 Trauma in Adults
157 Trauma in Children
158 Trauma in the Elderly
159 Trauma in Pregnancy
160 Head Trauma in Adults and Children
161 Spine and Spinal Cord Injuries in Adults and Children
162 Facial Injuries
163 Trauma to the Neck
164 Cardiothoracic Trauma
165 Abdominal Injuries
166 Penetrating Trauma to the Flank and Buttocks
167 Genitourinary Injuries Matthew
168 Penetrating Trauma to the Extremities

Section 19 Injuries to the Bones, Joints, and Soft Tissue
169 Initial Evaluation and Management of Orthopedic Injuries
170 Hand and Wrist Injuries
171 Forearm and Elbow Injuries
172 Shoulder and Humerus Injuries
173 Pelvis, Hip, and Femur Injuries
174 Knee and Leg Injuries
175 Ankle and Foot Injuries
176 Compartment Syndromes

Section 20 Nontraumatic Musculoskeletal Disorders
177 Neck and Thoracolumbar Pain
178 Shoulder Pain
179 Hip and Knee Pain
180 Acute Disorders of the Joints and Bursae
181 Emergencies in Systemic Rheumatic Diseases
182 Infectious and Noninfectious Disorders of the Hand
9183 Soft Tissue Problems of the Foot

Section 21 Psychosocial Disorders
184 Clinical Features of Behavioral Disorders
185 Emergency Assessment and Stabilization of Behavioral Disorders
186 Panic and Conversion Disorders

Section 22 Abuse and Assault
187 Child and Elderly Abuse
188 Sexual Assault and Intimate Partner Violence and Abuse

 

[swamprat]

Critical care physicians can resuscitate a med patient better, surgeons and anesthesiologists are better at dealing with hemodynamically unstable patients, cardiologists can crush you on EKGs, an ultrasound trained and focused radiologist will run circles around you at ultrasound diagnosis, a pulmonologist with hyperbaric training will outperform you in many hyperbaric/undersea situations. The big things they've got that they are experts in are wilderness medicine, toxicology, disaster medicine, and high altitude medicine, all super-niche areas of expertise that aren't needed on a regular basis.

A cardiologist can crush an internist on EKGs, an intensivist can crush an internist on resuscitation, a pulmonologist can crush an internist on lung disease and sure hyperbaric undersea situations I guess if they did a fellowship.. your argument is not too strong.

 

[DermViser]

All the ill-will towards EM, people say they're the jack of all trades masters of none... but that's not true, they're the masters of emergency care. They take a patient who has had no work-up whatsoever and either come up with a diagnosis, rule out the stuff that'll kill them or get them where they need to go. Does that make them triage? I don't think so, I've never met a triage nurse that could work up a patient from scratch and keep them alive no matter what was going on. And people seem to forget that they have a fraction of the time most of us have, yeah if they can't diagnose that lesion in 20 minutes they have to get it out of the ED because they just got a call from EMS telling them to prep the CCT because they've got a pedestrian struck with a GCS of 7 coming in. People think they're the worst diagnostician but I take the opposite stance, they have 20 minutes to make a diagnosis that can be anything in medicine, surgery, derm, ortho, ophtho, whatever, and most of the time they make it, discharge the patient home with instructions to follow up or get them to the specialists that need to treat them right then. In most specialties we overlook the fact that patients come to us with significant workups already, often already with diagnoses, and we take that information and apply our specialized knowledge to the case over days or weeks and we are so, rightfully, proud of our diagnostic acumen. In the ED they have 20 minutes and the entire world of clinical presentations ahead of them. Just remember that.

And you think Surgery and IM don't work up a patient and come up with stuff and rule things in and out on the things that can kill them? You don't think IM and Surgery automatically trusts what the ER thinks it is, do you? If they have too little time, EM is free to keep the patient until they figure out what it is. Oh wait, they don't actually care what it is.

 

[DermViser]

A cardiologist can crush an internist on EKGs, an intensivist can crush an internist on resuscitation, a pulmonologist can crush an internist on lung disease and sure hyperbaric undersea situations I guess if they did a fellowship.. your argument is not too strong.

Yes, and those are all subspecialty fellowships after...wait for it...Internal Medicine.

 

[swamprat]

Yes, and those are all subspecialty fellowships after...wait for it...Internal Medicine.

FYI ER doctors can do critical care fellowships.

And what exactly does your point mean? They are fellowships after internal medicine so what? Does that mean we shouldn't have internists because we have cardiologist, pulmonologist, intensivists etc?

 

[BadHorse]

And you think Surgery and IM don't work up a patient and come up with stuff and rule things in and out on the things that can kill them? You don't think IM and Surgery automatically trusts what the ER thinks it is, do you? If they have too little time, EM is free to keep the patient until they figure out what it is. Oh wait, they don't actually care what it is.

They might not trust it, but they've got it. They've got that CTA that EM ordered to rule out mesenteric ischemia and the results of the ultrasound demonstrating no AAA. They don't have to look at that stuff but they'd be fools not to take it into account. And the fact that that patient showed up on surgery's doorstep is a pretty good indication that the problem is surgical and they can handle it. No one does that for the ED doc. They take all comers, and you neglect to think about the many, many patients that they don't consult for or admit, patient's receiving all their care from the ED and following up outside. I fail to understand your hatred of ED docs, I feel this is misplaced, I think they are incredibly valuable and their interventions are often some of the most important in medicine, if only because they deal with the high acuity patients where decisive action matters. Your biases are misplaced, I wouldn't want to see a world without them.

 

[DermViser]

FYI ER doctors can do critical care fellowships.

And what exactly does your point mean? They are fellowships after internal medicine so what? Does that mean we shouldn't have internists because we have cardiologist, pulmonologist, intensivists etc?

Yes, and EM also has "Ultrasound fellowships" as well 😆. What's your point?

 

[DermViser]

They might not trust it, but they've got it. They've got that CTA that EM ordered to rule out mesenteric ischemia and the results of the ultrasound demonstrating no AAA. They don't have to look at that stuff but they'd be fools not to take it into account. And the fact that that patient showed up on surgery's doorstep is a pretty good indication that the problem is surgical and they can handle it. No one does that for the ED doc. They take all comers, and you neglect to think about the many, many patients that they don't consult for or admit, patient's receiving all their care from the ED and following up outside. I fail to understand your hatred of ED docs, I feel this is misplaced, I think they are incredibly valuable and their interventions are often some of the most important in medicine, if only because they deal with the high acuity patients where decisive action matters. Your biases are misplaced, I wouldn't want to see a world without them.

How nice. So in other words, the information might be useless, but at least they have it. Ok.

Yes, bc it's not like non-EM physicians are allowed to order imaging either.

 

[swamprat]

Yes, and EM also has "Ultrasound fellowships" as well 😆. What's your point?

Way to completely ignore my rebuttal.

And why is an ultrasound fellowship so lol?

 

[DermViser]

Way to completely ignore my rebuttal.

And why is an ultrasound fellowship so lol?

That was a rebuttal? Really? You don't see the difference?

And you can't see why an Ultrasound fellowship is funny? Ok, what if it was a CT scan fellowship. Funny now?

 

[BadHorse]

How nice. So in other words, the information might be useless, but at least they have it. Ok.

Yes, bc it's not like non-EM physicians are allowed to order imaging either.

I'm not saying it's useless, I'm saying they ruled out the life-threatening stuff, why are you so antagonistic? This information is critical, these are things that would have to be done if the ED didn't do them because the life of the patient hangs in the balance, that's what the ED does... it keeps the patient alive, that's it's primary outcome, the acuity is high and the stakes are high, too. Things have to be done immediately, the right studies have to be ordered immediately and there's nothing, no previous information guiding them. What's your problem, why are you making the idea that ER docs are important a personal attack on you?

 

[mimelim]

When I was on surgery, literally every day the GS residents would make fun of the IM residents and how they consult them for the stupidest things. There was a running joke about how the surgery NPs were better at medicine than most IM attendings.

I think the consult issue isn't so much a "its stupid" thing and more of a, "Do your job and consult us if you need our help, don't consult us because you are too lazy to workup the patient." It took a year or two to figure out, but the best question to ask the IM resident calling the consult is, "How can we help?" If they answer anything that is part of the basic workup or the classic, "because my attending said so." I tell them to call me back after a) they have actually seen the patient themselves and b) they know at least the basics of what is going on with the patient. I'm not wasting my intern's time reinventing the wheel.

Then when I was on IM they constantly complained about how the GS residents don't know anything about medicine and to never trust their clinical notes. One of their favorite jokes: what do you call 2 surgeons reading an EKG? a double blind study.

I don't think surgeon notes are any less trustworthy than anyone else's. They are just shorter and a lot is 'missing'. People in every specialty at every hospital put endless amounts of bs in their notes. Also, most physicians can't read basic chest xrays, CTs, MRs, Echos, etc. I'm not sure how a surgeon not being able to read an EKG is a big deal. Most IM guys can't either for that matter.

There are a lot of subjects that EM docs are experts on: EMS, toxicology, undersea/hyperbaric medicine, wilderness medicine, high altitude medicine, disaster medicine, ultrasound evaluation, resuscitation.

I don't know a single EM doc at the 3-4 hospitals I've been to recently that is an expert on almost any of those.

You can do fellowships in all the above except resuscitation, as you are expected to become an expert in that during residency.

The bottom line is that you won't be deferring to other physicians for any of those patients.

How many EM docs do those fellowships?

 

[swamprat]

That was a rebuttal? Really? You don't see the difference?

And you can't see why an Ultrasound fellowship is funny? Ok, what if it was a CT scan fellowship. Funny now?

Your argument is because cardiologists are better at the heart and everyone is better at everything there is no reason for EM. So going by your logic there rlly is no need for internists then ?

And you should really look into what an ultrasound fellowship in EM entails, once again you obviously don't really know what you are talking about.

 

[DermViser]

Your argument is because cardiologists are better at the heart and everyone is better at everything there is no reason for EM. So going by your logic there rlly is no need for internists then ?

And you should really look into what an ultrasound fellowship in EM entails, once again you obviously don't really know what you are talking about.

If you saw my post, you would see that I said EM is probably expert (and I'm being generous) at these sections in Tintinalli's:
-Resuscitative Problems and Techniques
-Emergency Wound Management
-Toxicology and Pharmacology
-Environmental Injuries
-Abuse and Assault

It's debatable that those alone would require an entire new ABMS specialty.

 

[DermViser]

Your argument is because cardiologists are better at the heart and everyone is better at everything there is no reason for EM. So going by your logic there rlly is no need for internists then ?

You're really going to compare the knowledge base needed to be learned for Cardiology in fellowship to that of an "Ultrasound" fellowship? Really?

 

[swamprat]

You're really going to compare the knowledge base needed to be learned for Cardiology in fellowship to that of an "Ultrasound" fellowship? Really?

What are you talking about? Read what I wrote. Those are 2 different statements that have nothing to do with one another

 

[swamprat]

1. In summary you state: There is always someone better at managing the patient than the ER doctor. For example, a cardiologist is better at dealing with MIs than the ER doctor. My counter: There is someone better at managing the patient than the internist. For example, a cardiologist is better at dealing with MIs than an internist. You are inferring that generalists should go the way of the dodo bird and everyone should be super sub-specialized.

2. You poke fun at ultrasound fellowships in EM yet it is obvious you have no idea what they are or what they entail. I won't get into it I am sure you can look it up you have plenty of time on your hands obviously.

 

[DermViser]

What are you talking about? Read what I wrote. Those are 2 different statements that have nothing to do with one another

1. In summary you state: There is always someone better at managing the patient than the ER doctor. For example, a cardiologist is better at dealing with MIs than the ER doctor. My counter: There is someone better at managing the patient than the internist. For example, a cardiologist is better at dealing with MIs than an internist. You are inferring that generalists should go the way of the dodo bird and everyone should be super sub-specialized.

2. You poke fun at ultrasound fellowships in EM yet it is obvious you have no idea what they are or what they entail. I won't get into it I am sure you can look it up you have plenty of time on your hands obviously.

Do you really not see the difference? Internal Medicine is a specialty - think of it like a tree. The subspecialties: Cards, GI, Heme/Onc, are the branches. Same with Surgery - think of it like a tree. The subspecialties: Surg Onc, CT, Plastics, Endocrine, etc. are the branches. In order to get to those branches, you have to go thru the tree. Even a generalist IM, generalist Surgeon, generalist Peds doctor has a certain unique fund of base knowledge that can't be replicated.

The fund of knowledge in EM can be easily replicated and for the longest time was.