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ER: my thoughts

Discussion in 'Emergency Medicine' started by Jason26, Nov 24, 2005.

  1. Jason26

    Jason26 Member
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    I'm an IM resident finishing off an ER rotation at a New York City Community Hospital and I have to say that the ER residents and attendings are a cool group to work with and the work can be difficult in that the pace may be hectic and you have to know how to multi-task. But, its a cinch in the sense that you never have to fully figure out whats going on w/ a patient for yourself as long as you can effectively rule out the top 4 or 5 diagnoses that can kill someone and if you haven't ruled them out or sometimes even if you have, you turf them off to surgery, gyn, or medicine and they figure it out. And 90% of the time its a cinch to rule things out. Too much belly pain and abnormal labs, get a CT Abdomen/Pelvis. Someone altered and/or slurring speech, get a CT Head. I'm not sure that med school even needs to be a prerequisite to do this job; maybe PA school or a 1 year course in emergency medicine. It is interesting to see a patient when they first present and I can definitely understand why people go for this field: good money and not having to have one's own practice w/ all the pains that come with that and shift work.
     
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  3. EctopicFetus

    EctopicFetus Keeping it funky enough
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    :rolleyes: Troll alert? :laugh: yes thankfully my ivy league education wasnt really necessary. i should have done a correspondence class at my community college rather than all this work I have been through. :thumbdown: :rolleyes:

    Maybe you should have been smarter and picked a different field. thankfully for you we will be there to see the patients you mismanaged at 3 am while you sleep.
     
  4. OSUdoc08

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    Don't internists, peds, and family physicians turf patients to specialists if it isn't something very common as well?

    Maybe all we need is PA's there as well.

    :rolleyes:
     
  5. bulgethetwine

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    I LOVE when one of these jack asses shows up!!! :laugh:

    Thanks for the holiday chuckle, Turkey. Gotta go. I just had a patient with a headache.... ruled out the top 5 causes with a CT head and LP, but now, you've inspired me, so I've just sent off another repeat CBC, Chem 7, coags, and added on a thyroid, kidney and hematological panel including full anemia workup (the results won't be back for a couple of weeks, but by then, BY GOD, I'll have found SOMETHING to explain why the patient is here in hospital, and I'll be glad I had those results!). I'm also ordering some rare, extremely expensive endocrine indices...
     
  6. AlienHand

    AlienHand Member
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    Emergency physicians must be prepared to handle 90% of the emergencies that occur across all medical specialties. In some situations, the diagnoses we make, and the initial treatment we provide, determine whether the patient lives or dies. And even if ruling out serious conditions is easy 90% of the time, there are some truly sick people in the remaining 10%, and in the real world, a consultant isn't always going to get out of bed or interrupt his/her golf game to evaluate even 10% of pts that come to the ED. If you've drawn different conclusions regarding emergency medicine during your brief stint as an off-service intern in a community hospital, then I guess you didn't have the opportunity to see what EM is really all about.
     
  7. EctopicFetus

    EctopicFetus Keeping it funky enough
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    Come on guys... lets be honest. We are in this to become highly paid PA's right.. It is so true. I am glad I wasted all that education. It could have really come into great use in Medicine. Oh well I guess I can shut my brain off now. Later..The tryptophan and EtOH are starting to set in..
     
  8. mfrederi

    mfrederi Senior Member
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    you can say the samething about almost every speciality. In fact, I challenge you to name more than a few medical spcialities where the dx is not pretty much clear cut 90% of the time. Cardiology- ummm, MI, must cath. GI- polyp, must remove. Surgery- GB hurts, must remove. FP- runny nose, virus, no Abx. EM- probably more DDX sorting than all the above. For example, a pt comes in with altered LOC- is it a bleed, a CVA, drug tox, DKA, diabetic coma. Or pt comes in with the feared "abominable" pain- what is it? The DX does really matter, because you may call GI, you may call surg, you may call nephro / uro, or you may tx and street.
     
  9. corpsmanUP

    corpsmanUP Senior Member
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    Wow, I guess I should have just stayed a PA. What was I thinking? ;)
     
  10. Jason26

    Jason26 Member
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    In ER, you are basically a glorified triage nurse. It doesn't matter who you call because the basic idea is to cover your ass and admit them and hope they will be properly cared for by the real docs who you turf the patient off to. Oftentimes, services are pan-consulted. If I had a nickel for every time both GI and Surg are called, I'd be a rich man.
     
  11. Jason26

    Jason26 Member
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    Go ahead and be my guest; you need to send off many tests because you are unable to think of what the diagnosis could plausibly be on your own. And even on the off chance one of your "tests" came back positive, you would never see the result nor care because your busy taking a dog**** history and turfing patients to the real docs.
     
  12. bulgethetwine

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    I assume you meant "you're" busy taking a dog**** history..." as opposed to the word 'your', which when used properly might look like this: 'your' road is fraught with professional misgivings and confrontation ahead...

    Grammar aside, best of luck in your chosen specialty, Jason.
     
  13. emmd2b

    emmd2b Junior Member
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    enough said.
     
  14. fedor

    fedor gunning like the NRA
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  15. Hawk22

    Hawk22 Senior Member
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    Wow Jason, I'm sure you were a popular guy in the ED. I'd love to hear what a "real doc" actually means.

    You're an internist right? So what would you do if you had a 2 year old or a pregnant patient? What about a psych patient? Surgical issue?

    You wouldn't know the first thing to do with most of these patients, so does that make you any less of a doctor? No, it just means that these things are outside your area of expertise. ED docs are trained to handle all types emergencies in all ages, as well as certain nonemergent care (not just adults, your specialty of choice).

    Perhaps you'd like a world in which no ED docs existed. Once you're out of residency, you'd have to come in and see ALL of the patients in your practice during your call night, no matter why they are there. And in the real world, the "turfing to real docs" instead becomes how you get a sizeble chunk of patients and make money. In the real world outside of residency, you'll develop a greater appreciation for EM because we keep you from having to come in all the time and direct patients to your practice for treatment (i.e. $$$ for you).
     
  16. kungfufishing

    kungfufishing Senior Member
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    Always nice to get some fresh, original material on this board.
     
  17. OSUdoc08

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    Enjoy working with old people all day on the floors.

    I hope writing scripts excites you, since it will be the most action you'll see. By the way, we'll be the ones feeding you diagnoses. You won't have to come up with one on your own.

    :thumbdown:
     
  18. Hawkeye Kid

    Hawkeye Kid Senior Member
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    Of course he drew different conclusions because they either didn't let him take the "non-medicine" pts or he didn't want to (or both).

    There's a resident in every non-EM department that feels this way, but as has been discussed before and as Hawk mentioned, residency and real-world are two completely different medical beasts. During my first medicine rotation at the VA I couldn't figure out why consultants always wrote "thank you for this interesting consult..." because we were just creating work for them. Then I rotated at a community hospital and figured out that it really said "you are an excellent general internest for realizing that this is beyond the scope of your practice and getting an expert opinion was the best thing for your patient. Aside from stroking your ego, I'd like to thank you for making the payment on my kid's BMW..." We'll see how long this dude keeps this attitude when he's in practice and needs the EP for emergency backup, convenience, or cash flow.
     
  19. hyperbaric

    hyperbaric Cool under pressure.
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    :thumbup:
     
  20. Homunculus

    Homunculus SDN Caveman Administrator
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    i think jason may have had a bad ED experience :laugh: :)

    i think some of the problem is that most of the people on this board are somewhere *in* their education, be it in medical school, residency, staff attendings, etc. folks who completed their residency 20 years ago and have beeen in private practice learning bad habits aren't here. but they do exist, like in every specialty. so don't be too hard on him. :D

    jason was attempting (poorly) to troll, and nothing gets the feathers rankled faster in this forum that the "triage nurse" gambit. the only other thing that comes close is criticising ED management . . .

    at any rate, continue with the barbecue. just keep it civil. :)

    --your friendly neighborhood rankle-avoiding caveman
     
  21. EctopicFetus

    EctopicFetus Keeping it funky enough
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    They thank you for the help in making a payment on their Benz.
     
  22. Jambi

    Jambi Caldari
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    Maybe this was just the OP's way of helping us +pad+

    Thanks!
     
  23. tiene dolor?

    tiene dolor? ...for me to POOP on!
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    I'm impressed. An IM resident that can get to the point in under 3 hours. :thumbup: :smuggrin:
     
  24. tiene dolor?

    tiene dolor? ...for me to POOP on!
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    :laugh: :smuggrin: :p
     
  25. EctopicFetus

    EctopicFetus Keeping it funky enough
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    Nice.... Pretty funny stuff. It always astounds me how much wasted time there is in IM. That being said I respect the job they do since it is not something I would ever want to do.
     
  26. roja

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  27. EctopicFetus

    EctopicFetus Keeping it funky enough
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  28. roja

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    Feeding them only makes them bigger. :D
     
  29. AzMichelle

    AzMichelle Member
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  30. bartleby

    bartleby Senior Member
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    Right. When I did an IM floor month as a intern I was forced to request more consults in one week than I did in an entire month in the ED. Knee pain? Call ortho. Belly pain? Call surgery. Platelets 50k over the high end of normal? Better get heme-onc involved. Epistaxis? You can't pack that anterior bleed yourself! Make that ENT resident come in from home!

    Somewhere in ENYCE, a bridge is missing its troll.

     
  31. GeneralVeers

    GeneralVeers Globus Hystericus
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    Why do internists alway frown upon us? Emergency medicine doctors have to know EVERYTHING that internal medicine doctors know, plus they have to have a good general knowledge of pediatric, GYN, orthopedics, neurology, surgery, sports medicine, nephrology, cardiology, infectious disease, and critical care, not to mention EMS and toxicology. When Internists have mastered all of those topics, then, and only then are they allowed to criticize our knowledge base.

    I'd gladly put up a good Emergency physician's internal medicine knowledge against any internist in the country. The ER doc would more than hold his own, plus he'd see 10 patients, sew up a few lacs, and write some scripts in the time the internist takes to write his pedantically verbose progress note.
     
  32. roja

    7+ Year Member

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    bezoars!
    def:
    A hard indigestible mass of material, such as hair, vegetable fibers, or fruits, found in the stomachs or intestines of animals, especially ruminants, and humans. It was formerly considered to be an antidote to poisons and to possess magic properties.

    also from Buffy the Vampire Slayer: a prehistoric parasite
     
  33. tonem

    tonem Senior Member
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    funny story about "real" doctors

    During his surgery month during intern year, one of my classmates was pre-rounding when he passed a room with a couple of "real" doctors frantically trying to get an ABG. The patient was guppy breathing...so he popped in told the nurse to get the code cart. He intubated the patient, ran the code, then finished pre-rounds. It was one of the surgery residents that told me the story...the punchline? The ABG showed the patient was hypoxic

    Luckily for the patient there was a glorified triage nurse around...

    Anyway, it always amazes me how otherwise intelligent people can have so little insight...
     
  34. Dr.MISHKA D.O.

    Dr.MISHKA D.O. Senior Member
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    Can't we all just get along? :laugh:

    This post in no way is meant to boost us past path - it has real content :D

    I just have a quick question. Say you and your family are trapped on a desert island and you can pick one kind of doctor to have with you the rest of your life, which do you pick?
    A) OB/GYN
    B) Urologist
    C) Internist
    D) Emergency Doc

    (correct answer is D - only one who can handle any situation in any patient demographic and is someone you would actually like to be around for more than 10 minutes. :D ) - the real, real answer is actually a IM/EM doc with a fellowship in pediatric EM (sigh - its gonna be a long residency) ;)

    Speaking as someone interested in IM/EM I understand the pros and cons of each speciatly, but in the end EM is probably the best- and the EM chicks (and wives of EM docs - love you darling) are always hotter! (coincidence - I think not!) And that is why IM (although quite smart docs) will always be back seat to EM!
    (thats why we go into EM - for the hot cars and fast women - don't tell my wife :laugh: )

    Best Wishes

    The Mish :luck:
     
  35. southerndoc

    southerndoc life is good
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    Triage is a big part of the job, and it shouldn't ruffle any EP's feathers.

    Every specialty has its own pitfalls and gets its own criticism. If any GP, internist, pediatrician, etc. thinks he/she is immune from errors, over workups, or criticism by someone with more specialty training, then I've got news for him or her: open your eyes.

    Medicine is full of back biting, criticism, etc. from someone more specialized in care of a patient. The EP admits a patient to an internist... the internist whines about the care and criticizes the EP for being so ignorant of the condition. The internist consults GI, and the gastroenterologist whines about the care provided by the internist and criticizes the internist for being so ignorant of the condition. The internist sends to the ED a patient who was mistreated for a number of weeks and never had the proper diagnosis made. The EP criticizes the internist.

    You see, the criticism and judgment isn't only on the EP.
     
  36. southerndoc

    southerndoc life is good
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    This may not be attributable to training, but to the fact that emergency medicine usually attracts applicants with higher board scores, grades, etc. since it's more competitive.
     
  37. bulgethetwine

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    You know who I would also add to this list? A good family practice doctor. No kidding, I know many of us, perhaps, eschewed the FP route out of medical school owing to a perceived lack of procedures, interesting and challenging cases, the 'ol "I want to avoid Johnny's stuff nose x 5 per day" syndrome. But I have been frequently amazed by the FP residents who rotate through EM at my institution. Other than their lack of experience with codes and truly emergency cases, they also have an amazing knowledge base, and they do MUCH better than the hotshot internal med residents.

    And you know what? It's damn TOUGH to be a good FP! The good ones, in my opinion, are held back (from a reputation standpoint) by the lazy ones who seek to "hide" in FP, just sort of drift along. But that is true of almost any specialty, and the ones who are truly good are reading a GIGANTIC quantity of material in the form of journals, practice updates, and current trends.

    Props to the FPs over IM anyday.
     
  38. Dr.MISHKA D.O.

    Dr.MISHKA D.O. Senior Member
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    Yeah, I agree that FP is quite versed in many forms of med and I therefore left it out as an option to avoid ruffled feathers.

    Best wishes

    The Mish
     
  39. GeneralVeers

    GeneralVeers Globus Hystericus
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    I agree with that assessment. We have FPs, Pediatrics residents, and IM residents rotating with us in the ED. The IM residents view it as a joke, and often go sleep in the lobby during a shift (a swift kick by one of us interns usually wakes 'em up). The FP residents usually work hard, and love to do procedures. The continuum for our ED is thus:

    FP > Peds > IM
     
  40. colforbinMD

    colforbinMD "Thanks, I'm very funny"
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    I heard that EM doctors have the smallest "packages" (except the female ones who are usually freakishly endowed. That's why they like the fast cars. They are compensating. Also explains the obsession with baggy scrubs......


    OK I'm ready to be fed now :wow:
    ....
    ...
    ..
    .
    TWO DAYS LATER:
    :barf: You guys feed the trolls too much around here

    Worthless daily +pad+ out!
     
  41. Ralph05

    Ralph05 Junior Member
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    AMEN Tiene Dolor!

    He obviously put this crap on here to stir everyone up...for some reason he had to use the outlet to have some excitement in his life (likely the super exciting world of IM isn't keeping his interest!). Whatever JASON...you made your speciality choice and don't need to bash EM because you're unhappy with your choice!
     
  42. colforbinMD

    colforbinMD "Thanks, I'm very funny"
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    P.S. OUR KIDS ARE THE CUTEST!!!!!!!!!!!!!!!
     
  43. GeneralVeers

    GeneralVeers Globus Hystericus
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    EM residents are usually physically fit and have a tan. Versus the pasty, beer-gut IM residents.
     
  44. Jeff698

    Jeff698 EM/EMS nerd
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    Two pages on this and still no Fatty McFattypants?

    I'm so disappointed.

    BTW, at my program all the off service residents are interns. This puts them and their knowledge base roughly.....with mine. We're all interns and struggling to kill as few patients as possible.

    There is SO much more variability between individual residents than there is between specialties at this stage that it truly is pointless to compare. Other than the EM guy's fiendishly stylish hairdos, of course.

    Take care,
    Jeff
     
  45. Annette

    Annette gainfully employed
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    Yeah, but the IM people won't end up with skin cancer!

    But I have to admit the EM guys tend to have much cooler shoes. Must be all that time you have to shop as well as getting the tan . . . :laugh:
     
  46. GeneralVeers

    GeneralVeers Globus Hystericus
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    They may not die of skin cancer, but they'll die of CHF secondary to the hypertension their job produces. Not to mention the non-stop sitting and eating they do all day.
     
  47. fourthyear

    fourthyear Senior Member
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    You actually make diagnoses??? I thought you just decided "admit vs. send home" and "surgery vs. medicine admit".

    At least once a week I get a "this person has belly pain and we can't figure it out, can you come admit him?"...which really means the ED did a 2 second history and exam, then ordered a CT scan that the radiologist read as normal - that's real diagnostic skills, lemme tell you. Majority of the time we (surgery) can spend a whole 10 minutes actually taking a full history and careful exam and come up with either a real diagnosis or reason the patient doesn't even need to be a admitted - like, he feels better now, but nobody in the ER knows it b/c no one has checked in with the patient since last shift's resident left 2 hours ago and gave the new resident the checkout that CT scan and surgery consult were pending, then the new resident just calls us up "aren't you gonna come see/admit this guy?" without re-assessing the patient - seriously!

    Maybe your ED's are better than mine, but most of the ER residents in my hospital just seem to want to work their shift time and leave - most really don't seem truly interested in using thier diagnositic skills on any challenging cases. Oh, and they love to try to put in all the trauma chest tubes but they're afraid to put a knife into an abscess - must call surgery for that!
     
  48. OSUdoc08

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    Congrats, you're a winner!

    :thumbup:
     
  49. Jambi

    Jambi Caldari
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    Got your Peanuts here, peanuts!

    (Jambi buys a bag of peanuts from the vendor and makes himself comfy)
     
  50. Apollyon

    Apollyon Screw the GST
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    Why don't you "nut up" (uh, excuse me, "ovary up") and tell us where you are (or even the area)? A vague, "ER guys suck!" post about some hospital somewhere (which is not my hospital, since you'd be in the lab now) doesn't lend credence. This isn't the first time you've bashed EM - why don't you fix things where you are? Also, the "no diagnosis = doesn't need to be admitted" card is a weak one to play.

    I don't need to bash surgery because we have a collegial, good working relationship. Our surgeons fought - hard - to send a guy home 2 weeks ago - that came back the next day with a perfed appy. It happens. But I don't anonymously ding them online for it. I would trust them with my life.

    It's a lot easier to admit patients, but a real gut check to send them home. Every so often, a hospital will have a push to have a surgeon lay hands on every belly of a pt complaining of abd pain, or on whom the EP has ordered a CT-abdomen. That lasts somewhere from 2-5 days - every time.

    You don't make mention of how frequently you are appropriately (in your eyes) consulted. If these "BS" cases are rare, then you are being disingenuous. If they are frequent, and you are not getting consults that meet your standard, anonymously on SDN isn't the way to go - you need to contact the ACGME and the ACS, because you are not getting the cases you need. (Where do your emergent cases come from - the PMD's office?)

    And, finally - if you are going into GS community practice, like it or not, you will have to cultivate good relationships with the EPs at the hospitals you will be at, because there is NOTHING illegal or unethical about the EP calling one group time and again, and never calling the other, when a consult is needed. And, how can you object to, as an attending, laying hands on the belly, saying "nothing surgical here", and collecting your $200?
     
  51. odoreater

    odoreater Cybernetic Ghost
    15+ Year Member

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    Excellent post!!! :thumbup:
     

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