For those thinking about jumping ship

[eefen]

A little background: I wanted to do EM since before medical school, "liked everything," worked as a scribe, did the EMT thing, etc. Was 100% confident EM was for me. Toyed briefly with surgery and very very briefly with med-peds (ha) and applied for residency in 3rd year. In early 4th year I did my first ICU rotation and really liked it. I ended up going to an EM residency with a strong EM/CCM presence.

Long story short, realized a lot of the things I liked about EM (taking care of sick patients, broad knowledge of medicine, procedures, etc.) were present in ICU without the constant dredge of complaints that shouldn't even be in the hospital. I really enjoyed where I trained - we took pride in holding the sick patients downstairs, intervening to change their course/stave off an intubation, and getting any procedures done and delivering them to the ICU/floors in a wrapped-up package. But that's just not generally EM in the real world, and even in residency after you were done in the sick patient's room now you had several back-hall patients to go slog through and discharge that had built up while you were in there. For that and other reasons, I started getting some "buyer's remorse" for EM. Also, all we ever hear about is how the market is getting worse, pay is getting worse, conditions are getting worse, etc.

So I applied for CCM. I thought about other potential outs, including pain. But I really do enjoy medicine and taking care of sick patients. At that point, I was married and we had kids, so we prioritized getting close to home and I only applied to a few programs. Got into one near home (so my wife had some support/extra hands with the kids) and it was a brutal two years (really the first year, second year was more manageable). It was a bit of a change going from an easy third year EM chief schedule to routine 70-80 hour weeks. But the pace was different, more predictable, and you usually get lunch.

I graduated this past summer and took a job a few months ago in a small community teaching hospital with small IM/FM residency programs. Schedule is week on/week off. Week on you are on 24/7, there during the day and home at night- sometimes fielding phone calls, rarely have to go in, NP in house to take care of the silly things. Home for dinner essentially every night and can leave whenever work is done (went home early yesterday afternoon and watched a TV show with my wife) and show up in the mornings whenever it makes sense based on the current acuity level. Pay is not the best in CCM but pretty good - MGMA median for my area, which is north of mid-400s. Average census is 4-6 patients and we have good step-down unit that will take most of the softer stuff. Once I'm done, I sign a patient out and the hospitalists take over before they even physically move out of ICU. Acuity is decent with lots of bread-and-butter critical care problems, and none of the tertiary/quaternary care center disasters that aren't really there to see you anyways. Get to work with residents (although for the once that aren't interested in ICU we'll do some quick teaching then I'll kick them out after rounds or any procedures they want to take a stab at to go enjoy their afternoon). And the weeks off are fantastic.

I'm new at this and probably in the honeymoon phase to some degree, but am incredibly happy I did a fellowship. I think EM provides a great foundation for CCM. My job isn't perfect, but it checks most of the boxes I was hoping for and I like it (and I think if you fixate on finding the "perfect" job you'll find yourself frustrated pretty quickly). With CCM, I have some control over who I see (can refuse an admit if I think it's dumb, or transfer out a patient for the rest of their social issues to be addressed once their ICU needs are over), have a good working relationship with the rest of the hospital (rather than just giving people work whenever I call them), get do some occasional cool things and have more time to develop a relationship with patients (which, in a smaller town/hospital actually can be quite enjoyable).

EM has the potential, in the right practice environment and with a supportive group/hospital, to be a great field. I think there are unfortunately many things (obviously) wrong with the current widespread practice of EM and what's rewarded/tracked/etc. and what's not. And critical care is not impervious to a lot of those forces/private equity/etc. It's not a world of roses and sunshine over here - I don't think anywhere in medicine is perfect - but for me it's been a great fit and there are lots of different practice environments in CCM depending on what you want to do/not do or what kind of patients you want to take care of.

But if you are thinking about making the switch - it's not a small thing to get through fellowship, but I'm glad I did it. If it makes sense for your situation and interests... do it.

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[cyanide12345678]

4-6 average census with mid 400k income. That sounds likely a pretty good gig you have there.

 

[WilcoWorld]

Congratulations! I'm very glad for you - finding a good fit in your career ain't easy...but I wouldn't call doing a residency and then a fellowship that expands on those skills "jumping ship".

I could be accused of just arguing semantics here, but I think it's more substantial than that. The fact that this forum has a growing number of posters who have used their EM training as a launching pad to a satisfying career that includes more than putting in shifts in the pit is not an indictment of EM training IMO.

 

[Rekt]

Congratulations! I'm very glad for you - finding a good fit in your career ain't easy...but I wouldn't call doing a residency and then a fellowship that expands on those skills "jumping ship".

I could be accused of just arguing semantics here, but I think it's more substantial than that. The fact that this forum has a growing number of posters who have used their EM training as a launching pad to a satisfying career that includes more than putting in shifts in the pit is not an indictment of EM training IMO.

I mean, his entire post is an indictment of EM and what he said is true.

Sounds like a dream OP. I wish I had done CCM. My spouse would probably murder me if I went back to fellowship.

 

[EthylMethylMan]

Congratulations! I'm very glad for you - finding a good fit in your career ain't easy...but I wouldn't call doing a residency and then a fellowship that expands on those skills "jumping ship".

I could be accused of just arguing semantics here, but I think it's more substantial than that. The fact that this forum has a growing number of posters who have used their EM training as a launching pad to a satisfying career that includes more than putting in shifts in the pit is not an indictment of EM training IMO.

I agree that it's not necessarily an indictment of the training. However, with all due respect, how is it not a very direct indictment of EM as a field? I'd wager that the vast majority of people who go into residency wanting to do CCM start in IM as opposed to EM. I guess you might have a few people who would rather train in the ED first, but IM has so many more options after residency. I really don't think a lot of people would apply to residency with the EM-CCM path in mind. Then you have fields like pain and palliative that are so different from EM that I can't see anyone starting in EM with the intention of transitioning to them. Overall, this generally paints the picture that these people are going into EM residency, realizing they made a mistake, and then bailing via these fellowships. This isn't to say that this is damning evidence that EM is in dire straits. In my opinion, it's one of many small issues reflective of the current state of our specialty.

OP, congrats, sounds like you landed a real unicorn of a gig. I hope you have many fulfilling years there.

 

[emergentmd]

CCM with 4-6 pt making 400K would be like finding an EM job seeing 1/2 pph making 400K.

Both jobs would be amazing.

 

[EMhawkeye]

Surprised an ICU with that volume can support an intensivist.

 

[CCM-MD]

450k is average pay for critical care these days, there are better paying jobs out there. But wow getting paid that much for a 4-6 patient census is sweet af.

Edit: just saw you're on 24/7 for an entire week. thats probably not for everyone.

 

[eefen]

Yeah it's a smaller hospital. Staffing is one of the limiting supposedly-temporary-but-really-permanent factors for patient capacity, but even when/if that is ever fixed this ICU probably would still run at maybe 6-8 patients on average. Which is fine with me, and still obviously very doable.

And yes, what I earn is very average for CCM. Definitely the opportunity to make more out there if you want it, but the workload and work/life balance here have been good. Overall have been pretty happy with the acuity/opportunity for procedures. One of my worries about going to a smaller place was that it would be a sleepy ICU where nothing happened, but I've been pleasantly surprised.

Absolutely - 24/7 isn't for everyone. But with this current set up and someone in house over night to put out fires, plus the flexibility to leave/show up whenever it makes sense (since you just need to be available by phone and able to respond in a reasonable time), it hasn't been too bad. I wasn't sure how I'd feel about the week on/week off schedule, but honesty by the end of the week I'm ready for some time off and by the end of the week off I almost forget I'm a doctor.

Again, only a few months into this, and the schedule and location I'm in wouldn't be for everyone, but my family and I love where we are at, we're enjoying being close to family, and so far at least we are really enjoying being on the other side of things.

 

[BulgeDaTwine]

A little background: I wanted to do EM since before medical school, "liked everything," worked as a scribe, did the EMT thing, etc. Was 100% confident EM was for me. Toyed briefly with surgery and very very briefly with med-peds (ha) and applied for residency in 3rd year. In early 4th year I did my first ICU rotation and really liked it. I ended up going to an EM residency with a strong EM/CCM presence.

Long story short, realized a lot of the things I liked about EM (taking care of sick patients, broad knowledge of medicine, procedures, etc.) were present in ICU without the constant dredge of complaints that shouldn't even be in the hospital. I really enjoyed where I trained - we took pride in holding the sick patients downstairs, intervening to change their course/stave off an intubation, and getting any procedures done and delivering them to the ICU/floors in a wrapped-up package. But that's just not generally EM in the real world, and even in residency after you were done in the sick patient's room now you had several back-hall patients to go slog through and discharge that had built up while you were in there. For that and other reasons, I started getting some "buyer's remorse" for EM. Also, all we ever hear about is how the market is getting worse, pay is getting worse, conditions are getting worse, etc.

So I applied for CCM. I thought about other potential outs, including pain. But I really do enjoy medicine and taking care of sick patients. At that point, I was married and we had kids, so we prioritized getting close to home and I only applied to a few programs. Got into one near home (so my wife had some support/extra hands with the kids) and it was a brutal two years (really the first year, second year was more manageable). It was a bit of a change going from an easy third year EM chief schedule to routine 70-80 hour weeks. But the pace was different, more predictable, and you usually get lunch.

I graduated this past summer and took a job a few months ago in a small community teaching hospital with small IM/FM residency programs. Schedule is week on/week off. Week on you are on 24/7, there during the day and home at night- sometimes fielding phone calls, rarely have to go in, NP in house to take care of the silly things. Home for dinner essentially every night and can leave whenever work is done (went home early yesterday afternoon and watched a TV show with my wife) and show up in the mornings whenever it makes sense based on the current acuity level. Pay is not the best in CCM but pretty good - MGMA median for my area, which is north of mid-400s. Average census is 4-6 patients and we have good step-down unit that will take most of the softer stuff. Once I'm done, I sign a patient out and the hospitalists take over before they even physically move out of ICU. Acuity is decent with lots of bread-and-butter critical care problems, and none of the tertiary/quaternary care center disasters that aren't really there to see you anyways. Get to work with residents (although for the once that aren't interested in ICU we'll do some quick teaching then I'll kick them out after rounds or any procedures they want to take a stab at to go enjoy their afternoon). And the weeks off are fantastic.

I'm new at this and probably in the honeymoon phase to some degree, but am incredibly happy I did a fellowship. I think EM provides a great foundation for CCM. My job isn't perfect, but it checks most of the boxes I was hoping for and I like it (and I think if you fixate on finding the "perfect" job you'll find yourself frustrated pretty quickly). With CCM, I have some control over who I see (can refuse an admit if I think it's dumb, or transfer out a patient for the rest of their social issues to be addressed once their ICU needs are over), have a good working relationship with the rest of the hospital (rather than just giving people work whenever I call them), get do some occasional cool things and have more time to develop a relationship with patients (which, in a smaller town/hospital actually can be quite enjoyable).

EM has the potential, in the right practice environment and with a supportive group/hospital, to be a great field. I think there are unfortunately many things (obviously) wrong with the current widespread practice of EM and what's rewarded/tracked/etc. and what's not. And critical care is not impervious to a lot of those forces/private equity/etc. It's not a world of roses and sunshine over here - I don't think anywhere in medicine is perfect - but for me it's been a great fit and there are lots of different practice environments in CCM depending on what you want to do/not do or what kind of patients you want to take care of.

But if you are thinking about making the switch - it's not a small thing to get through fellowship, but I'm glad I did it. If it makes sense for your situation and interests... do it.

Cool Story. I did the same. Now over a decade out and even the ICU jobs are scant and are now shift-work gigs from USACS, Sound, or whatever big box bought my group. Hell, even some of the hospital-employed gigs are ****, at least in California. No more continuity of care, everyone is a shift worker. PRIME healthcare came in to one ICU I know in Los Angeles and fired all the doctors and replaced the whole program with NPs. One doc comes in and "runs the list" for $200/hr, while the NP fields all the nurses calls for potassium and antibiotic renewals, calls the anesthesiologist or ER for lines and tubes, and generally is a detriment to patinet care.

Sure - can work as a nocturnist in most places, but is that really critical care? Multidisciplinary rounding, continuity of care of treatment plan... ahhhh no, not if you're a nocturnist.

But ... but... but... i get Locums offers to my inbox at $400/hr all the time!
Yep, sure do. But I don't fancy years of one to two week gigs all over the country like a nomad away from my family, usually in rural places, and/or malignant environments, do you?

Trust me. ICU fellowship is no panacea to what is happening in medicine. It's all corporate from here....

 

[GonnaBeADoc2222]

Cool Story. I did the same. Now over a decade out and even the ICU jobs are scant and are now shift-work gigs from USACS, Sound, or whatever big box bought my group. Hell, even some of the hospital-employed gigs are ****, at least in California. No more continuity of care, everyone is a shift worker. PRIME healthcare came in to one ICU I know in Los Angeles and fired all the doctors and replaced the whole program with NPs. One doc comes in and "runs the list" for $200/hr, while the NP fields all the nurses calls for potassium and antibiotic renewals, calls the anesthesiologist or ER for lines and tubes, and generally is a detriment to patinet care.

Sure - can work as a nocturnist in most places, but is that really critical care? Multidisciplinary rounding, continuity of care of treatment plan... ahhhh no, not if you're a nocturnist.

But ... but... but... i get Locums offers to my inbox at $400/hr all the time!
Yep, sure do. But I don't fancy years of one to two week gigs all over the country like a nomad away from my family, usually in rural places, and/or malignant environments, do you?

Trust me. ICU fellowship is no panacea to what is happening in medicine. It's all corporate from here....

I'll never understand the concept of EM doctors being forced to leave the ED to line and tube floor / ICU patients. Hire the people you need to staff the units you want. Like seriously **** off.

 

[sylvanthus]

I'll never understand the concept of EM doctors being forced to leave the ED to line and tube floor / ICU patients. Hire the people you need to staff the units you want. Like seriously **** off.

Cool Story. I did the same. Now over a decade out and even the ICU jobs are scant and are now shift-work gigs from USACS, Sound, or whatever big box bought my group. Hell, even some of the hospital-employed gigs are ****, at least in California. No more continuity of care, everyone is a shift worker. PRIME healthcare came in to one ICU I know in Los Angeles and fired all the doctors and replaced the whole program with NPs. One doc comes in and "runs the list" for $200/hr, while the NP fields all the nurses calls for potassium and antibiotic renewals, calls the anesthesiologist or ER for lines and tubes, and generally is a detriment to patinet care.

Sure - can work as a nocturnist in most places, but is that really critical care? Multidisciplinary rounding, continuity of care of treatment plan... ahhhh no, not if you're a nocturnist.

But ... but... but... i get Locums offers to my inbox at $400/hr all the time!
Yep, sure do. But I don't fancy years of one to two week gigs all over the country like a nomad away from my family, usually in rural places, and/or malignant environments, do you?

Trust me. ICU fellowship is no panacea to what is happening in medicine. It's all corporate from here....

No rounding sounds great to me, partly why I work pure nights. I take admits, put out fires, and follow my admitted patients. Less drama at night, less admin around, no jcaho or doh to worry about, few families are present if at all. Ive accepted that I am largely there to put out fires and noone really gives a crap about my treatment plan as it can often get changed during the day in rounds. Im the beaaacchh of the icu. Whatevs, my ego crashed years ago. Ill take the 410k for writing 3 notes a night and taking maybe 10 admits in a week.

 

[CCM-MD]

No rounding sounds great to me, partly why I work pure nights. I take admits, put out fires, and follow my admitted patients. Less drama at night, less admin around, no jcaho or doh to worry about, few families are present if at all. Ive accepted that I am largely there to put out fires and noone really gives a crap about my treatment plan as it can often get changed during the day in rounds. Im the beaaacchh of the icu. Whatevs, my ego crashed years ago. Ill take the 410k for writing 3 notes a night and taking maybe 10 admits in a week.

Do you work 7 on/off (182 shifts) for 410k? That's really low for pure nights...

 

[Kryptocoin]

I'll never understand the concept of EM doctors being forced to leave the ED to line and tube floor / ICU patients. Hire the people you need to staff the units you want. Like seriously **** off.

The funny thing is that there's nothing in your contract stating you're contractually obligated to do any of these things. Yet, the nurses and floor staff expect you to do it.

I was once called to put a central line on an OB patient in active labor on the floor. I flat-out told them no. Unless a patient is actively dying, I'm not leaving the ER.

 

[BoardingDoc]

The funny thing is that there's nothing in your contract stating you're contractually obligated to do any of these things. Yet, the nurses and floor staff expect you to do it.

I was once called to put a central line on an OB patient in active labor on the floor. I flat-out told them no. Unless a patient is actively dying, I'm not leaving the ER.

Even if they are actively dying, you still don't leave the ER. You have a department to run. If a pediatric arrest rolls in the door and you're upstairs doing a fem line, do you really think you're not going to get absolutely crucified for not being in the dept?

This is precisely the reason why our group no longer intubates outside the ED at my hospital. If the patient is actively dying and needs to be intubated well before the on-call anesthesiologist can get into the hospital: the patient gets brought to the ED. We will happily do it there.

 

[Kryptocoin]

Even if they are actively dying, you still don't leave the ER. You have a department to run. If a pediatric arrest rolls in the door and you're upstairs doing a fem line, do you really think you're not going to get absolutely crucified for not being in the dept?

This is precisely the reason why our group no longer intubates outside the ED at my hospital. If the patient is actively dying and needs to be intubated well before the on-call anesthesiologist can get into the hospital: the patient gets brought to the ED. We will happily do it there.

Unfortunately, I'm the only doc in the entire hospital at night. The ER is supposed to respond to RR and codes. It's not my contract, but I assume it's in the hospital bylaws. We basically subsidize the labor market for these hospitals.

 

[NYEMMED]

Unfortunately, I'm the only doc in the entire hospital at night. The ER is supposed to respond to RR and codes. It's not my contract, but I assume it's in the hospital bylaws. We basically subsidize the labor market for these hospitals.

This falls to your Medical Director. This is not the norm anymore and we should not be leaving the ED. Your director need to push back on this practice and force the other services to cover their own departments.

 

[Kryptocoin]

This falls to your Medical Director. This is not the norm anymore and we should not be leaving the ED. Your director need to push back on this practice and force the other services to cover their own departments.

Most CMG medical directors are basically all yes men. They just tow the company line and do whatever the CMG/hospital tells them to do.

 

[Rekt]

This falls to your Medical Director. This is not the norm anymore and we should not be leaving the ED. Your director need to push back on this practice and force the other services to cover their own departments.

I think you have a skewed view of what kind of hospital he's talking about. This is exceptionally common across the country at tiny hospitals.

I actually never understood why ED docs are so lazy and combative about this. I'd much rather respond to something critical upstairs intubating, tossing a central line, dropping a chest tube, etc than seeing some mind numbing dizzy 90 year old or 6 years of ankle pain. I did this is residency sometimes and at some jobs even with the department on fire it's still fun.

I get the argument if you're (inappropriately) single coverage. If you're RVU, drop a note with CCT and bill for it and the procedure.

 

[BoardingDoc]

I think you have a skewed view of what kind of hospital he's talking about. This is exceptionally common across the country at tiny hospitals.

I actually never understood why ED docs are so lazy and combative about this. I'd much rather respond to something critical upstairs intubating, tossing a central line, dropping a chest tube, etc than seeing some mind numbing dizzy 90 year old or 6 years of ankle pain. I did this is residency sometimes and at some jobs even with the department on fire it's still fun.

I get the argument if you're (inappropriately) single coverage. If you're RVU, drop a note with CCT and bill for it and the procedure.

I'd also much prefer to do a tube upstairs than see a vaguely dizzy nonagenarian. I would like legal protection if doing so. If the hospital has bylaws stating that the ED doc is required to leave the ED to respond to codes/rapid responses, I would not take issue with that. Ours did not and did not want to put into writing that the hospital required the ED doc to leave the dept to respond to those events. The compromise was that we would still help out if needed but that the patient would need to be brought to the ED.

Our shop is also one where leaving in the middle of the night isn't really an option. I routinely see between 12 (slow) and 25 (busy) patients on a 9 hr overnight shift.

 

[RustedFox]

I think you have a skewed view of what kind of hospital he's talking about. This is exceptionally common across the country at tiny hospitals.

I actually never understood why ED docs are so lazy and combative about this. I'd much rather respond to something critical upstairs intubating, tossing a central line, dropping a chest tube, etc than seeing some mind numbing dizzy 90 year old or 6 years of ankle pain. I did this is residency sometimes and at some jobs even with the department on fire it's still fun.

I get the argument if you're (inappropriately) single coverage. If you're RVU, drop a note with CCT and bill for it and the procedure.

At my shop; it is verboten to do procedures upstairs because insurance and credentialing reasons.

Bring em downstairs.

 

[NYEMMED]

I think you have a skewed view of what kind of hospital he's talking about. This is exceptionally common across the country at tiny hospitals.

I actually never understood why ED docs are so lazy and combative about this. I'd much rather respond to something critical upstairs intubating, tossing a central line, dropping a chest tube, etc than seeing some mind numbing dizzy 90 year old or 6 years of ankle pain. I did this is residency sometimes and at some jobs even with the department on fire it's still fun.

I get the argument if you're (inappropriately) single coverage. If you're RVU, drop a note with CCT and bill for it and the procedure.

There is huge liability here.
You are getting involved in a decompensating patient, which typically carry higher levels of litigation.
They are admitted by somebody, they are being followed by somebody, if in the ICU they have a intensivist following, they can all intervene and keep the liability.

It annoys me that hospitals and other departments think they can just pawn this off on ED docs. Create contracts/pay competent medical staff for 24/7 coverage. Stop paying some unskilled mid-level and pay a physician.

 

[EMhawkeye]

There is huge liability here.
You are getting involved in a decompensating patient, which typically carry higher levels of litigation.
They are admitted by somebody, they are being followed by somebody, if in the ICU they have a intensivist following, they can all intervene and keep the liability.

It annoys me that hospitals and other departments think they can just pawn this off on ED docs. Create contracts/pay competent medical staff for 24/7 coverage. Stop paying some unskilled mid-level and pay a physician.

Good point. Why should I put my name on a chart and now assume liability for someone else’s management?

 

[GonnaBeADoc2222]

Good point. Why should I put my name on a chart and now assume liability for someone else’s management?

Too often we are expected to unquestioningly absorb someone else's liability, and do it with a smile.

At one of my shops, they call it "helping out the ICU."

**** you, pay me.

 

[WilcoWorld]

Too often we are expected to unquestioningly absorb someone else's liability, and do it with a smile.

At one of my shops, they call it "helping out the ICU."

**** you, pay me.

Extra points for the Goodfellas reference

 

[RustedFox]

Can anyone find an example of a case like this?

I find it very hard to believe this could actually happen.

"I was called to the ICU to intubate a patient at the discretion of the patients primary provider that decompensated. Patient was intubated without difficulty. I had no role in the medical decision making or clinical course for the patient and was only here for the procedure".

Bro, I've been sued while I was at home for a PLP case.

 

[NYEMMED]

Can anyone find an example of a case like this?

I find it very hard to believe this would actually happen.

"I was called to the ICU to intubate a patient at the discretion of the patients primary provider that decompensated. Patient was intubated without difficulty. I had no role in the medical decision making or clinical course for the patient and was only here for the procedure".

If your name goes anywhere on the chart you will be sued. Lawyers name everybody.
It might get dropped 5-8 years later, but it’s not worth the stress and hassle.

 

[Mount Asclepius]

This all just depends if you are paid. A long time ago when we were smaller we responded throughout the hospital to codes. We were paid for any care provided. Now though that falls on the code blue/rapid response teams that includes an ICU fellow, which makes sense because if the patient survives they usually end up under the care of the intensivist.

If you are paid for your services and not single coverage, then I’d think you’d be happy to respond throughout the hospital. I’d much rather take care of a sick patient than an ankle sprain. If you aren’t paid, then not worth it nor the liability.

 

[johhnybgood]

Bro, I've been sued while I was at home for a PLP case.

You work in Florida and for worst cmg ever. What did you think would happen!

 

[RustedFox]

You work in Florida and for worst cmg ever. What did you think would happen!

I wasn't working for "them" at the time.

For realsies, though - the chart even names OtherDoc as the one involved with the case. Was I dropped? Sure. Still, a giant pain in the ass.

PLP sent home a nec.fasc in the groin. "Redness to groin" was the only physical exam finding documented. Nothing else.

The PLPs, maaaaan. This one either (1) never even did a physical exam, or (2) didn't recognize the pathology, because "the eye does not see what the mind does not know".

 

[thegenius]

Even if they are actively dying, you still don't leave the ER. You have a department to run. If a pediatric arrest rolls in the door and you're upstairs doing a fem line, do you really think you're not going to get absolutely crucified for not being in the dept?

This is precisely the reason why our group no longer intubates outside the ED at my hospital. If the patient is actively dying and needs to be intubated well before the on-call anesthesiologist can get into the hospital: the patient gets brought to the ED. We will happily do it there.

I kind of like this

 

[Apollyon]

(2) didn't recognize the pathology, because "the eye does not see what the mind does not know".

I don't know if I said this one to you, brother, but, that is verbatim what I say!

 

[RustedFox]

I don't know if I said this one to you, brother, but, that is verbatim what I say!

Yep. I'm 100% sure that I took it from you.

Credit goes to Apollyon.

 

[Janders]

I kind of like this

It took extended efforts to achieve this, though it is logical.

In tiny hospitals, I think it’s reasonable for the ED doc to help w/ floor codes overnight. I mean the type of place where they see 4-6 ED patients overnight, and there are 30 inpatient beds. CLEARLY they need to be paid for it, but the risk of being one corridor away when an unannounced ED patient shows up is reasonably low in small/low volume places and they’ll never have overnight ICU/anesthesia coverage.

On the other end of the spectrum, some places are big enough to have overnight ICU, or overnight anesthesia, or double-ED coverage overnight and ergo its much less of an issue.

In the small-to-mid-sized ED it is an issue though. ED sees 90-100/day, can see 20+ overnight, 100 floor beds in hospital w/ 6-8 bed ICU. Thats enough volume for an overnight ED doc and an overnight hospitalist, but tough to have sleep-in anesthesia or ICU financially, without the hospital tossing money at it. However, the ED is busy enough and the acuity high enough that if you keep leaving for 20 minutes you’re gonna have an issue…

Hypothetical occurrences such as—
—Hospitalist/Rn upstairs call down for immediate airway assistance while simultaneously a 45yo checks in w/ CP at 0300. ED doc declines to run upstairs until EKG performed; EKG is massive anterior tombstones… but ED MD gets massive shade / complaints for “not helping upstairs”
— ED doc runs up to ICU to get airway, runs back down (gone for 5-10 minutes) to find a new patient, thrown in a room by BLS crew, off monitor, minimal respiratory effort… it turns out to be a tricyclic OD in a wide complex tach.
— ED doc runs up to ICU to get airway, as passing tube ED RN calls up having locked herself in med room b/c EMS dropped off a violent combative psych patient who is now beating the staff senseless, can they have an order for Haldol and restraints? Oh one of the nurses is now injured and now out of work…

Clearly its a game of Russian Roulette at some point. But you want to help those dying patients upstairs; but you CANNOT abandon your ED.

There are some options—
(1) Hospital, pay for an ICU PA/NP to help the hospitalist and train them for rudimentary airway skills to hold the fort until anesthesia drives in
(2) Hospital, pay for an ED PA to be on all night, and the ED MD may be less scared to walk away for 15 minutes.
(3) Train the upstairs hospitalist / RTs to use LMAs (basic ACLS) for codes; any other airway cases can be wheeled down to the ED so the ED MD can help with them while still managing incoming ED volume. Same with the rare chest tube.

Now (3) triggers actual retrograde flow of patients (floor patient returns to the ED!) but honestly its fine, you have them as an ICU boarder in the ED under the same hospitalist attending and the ED MD can write a critical care consult note and procedure note and once stabilized the patient can be wheeled back up to the ICU, and you can bill for your services. The hospitalist comes down with the patient and maintains continuity. We all help each other and are friends and better teammates for it, but we don’t get screwed b/c we abandoned our ED patients. There can be some pushback— “these patients are too sick to transport through the hospital!”— but just remind them how many dying patients two 19yo BLS EMTs bring in the back of ambulances from miles away everyday!

Anyway, for those of you in awkwardly sized places, I highly recommend the “bring them to me, I’ll do anything in my own walls!” Line of helping out on inpatients

{There may actually be a secondary effect where the burden of packing the patient up to move them to the ED is annoying to the inpatient team and they call ICU / anesthesia in to deal with it… cool cool if so}

 

[Groove]

Unfortunately, I'm the only doc in the entire hospital at night. The ER is supposed to respond to RR and codes. It's not my contract, but I assume it's in the hospital bylaws. We basically subsidize the labor market for these hospitals.

I feel you. I work some of my shifts at one of our community sites and get called to code people on the floor/ICU with regularity because I'm the only doc at night. I also hate getting called to pronounce pts. House sup and floor nurses will start harassing me in the ED to pronounce some dead person while I'm getting slammed in the ED and I just will drag it out and refuse as long as I can. I waited until 6am during one of my overnights and then told them to get the hospitalist who will no doubt be rounding in a few mins to do it; walked out. CNO bypassed our FMD and called one of the execs of my CMG and complained about it because they had been asking me since 10pm that night. I didn't care. They need to hire a NP at night instead of farming out non ED hospital responsibilities to the ER doc and abusing us.

 

[Siggy]

Too often we are expected to unquestioningly absorb someone else's liability, and do it with a smile.

At one of my shops, they call it "helping out the ICU."

**** you, pay me.

While I agree that the ICU at anything but the smallest of hospitals should have 24/7 in house coverage (perferably physician, but at least a PLP with the intensivist on call), reimbursement is between you and your company.

If you're putting out fires in the ICU then you should be generating 99291s plus procedure codes that your company should be collecting on. It's up to your company to share the wealth on the billing for those patients.

 

[namethatsmell]

There is huge liability here.
You are getting involved in a decompensating patient, which typically carry higher levels of litigation.
They are admitted by somebody, they are being followed by somebody, if in the ICU they have a intensivist following, they can all intervene and keep the liability.

This is correct. Even if you just go to put in a line on a coding patient and pt/family sues you'll be named and forced to suffer through the ensuing mess/stress (know of a recent case). One of the worst parts of our crappy broken system.

What else sucks? The moral injury of knowing that a critical patient in the building needs help, being the only person on-site available to help, and then not helping--because we're not supported in a way that makes it feasible to actually do so (also usually unjust that we're put in that situation to begin with, but that's a different story). It's a quiet form of damage we suffer that's rarely acknowledged.

This may be reason #342 to work at a place that self-insures and protects their docs and/or has sovereign immunity. Not a cure-all, but really does go a long way.

 

[Birdstrike]

Code Liability Shock Story

Floor code is called. Doc 1 responds to code. He walks into room. He sees another attending (floor) physician in the room at the head of the bed, intubating a young person. Doc 1 says, "Do you all need me?" Doc 2 at the head of the bed says, "No. I'm running this. We're good." Doc 1 turns around and walks out of the room.

Two years later he gets a notice that he's been sued for malpractice. He has no recollection of the patient and there are no records of the "encounter." It turns out that the nurse that was writing down what happened, doses and who was in the room wrote down, "Doc 1 present in room." Ultimately the patient was esophageally intubated by Doc 2 and died.

He calls his med-mal insurance company confident it's a mistake and he'll be dropped quickly and easily. To his shock, he was told that since his name is in the chart the case must proceed and defended as any other case. He was also told that since he created no medical record to defend that they essentially can't defend him. He has no proof or recollection of anything so whatever the plaintiff says, will likely stand. That, combined with the fact that it was a death case with an obvious mistake on the defense side, if he doesn't settle, all of the other defendants will settle, because they know they're likely to lose. This would leave him as the only remaining defendant who would then be liable for all of the money lost at trial ("jointly and severally liable").

"I don't care. I did nothing wrong. I'm going to fight it!" he says indigently.

"No you're not. We're settling on your behalf," his med-mal team says. "This case is a loser and we're not about to be stuck holding the grenade that this jury award would amount to. In this state, the law says that if you want to go to trial and we want to settle, we have the right to settle as your representatives. We're only discussing this with you as a courtesy. You can't say no. Otherwise we abandon you and the case and you fight on your own, pay for your own lawyers and pay the award yourself."

He was forced to agree to a settlement, which was reported to the National Practitioner Databank.

 

[NYEMMED]

Code Liability Shock Story

Floor code is called. Doc 1 responds to code. He walks into room. He sees another attending (floor) physician in the room at the head of the bed, intubating a young person. Doc 1 says, "Do you all need me?" Doc 2 at the head of the bed says, "No. I'm running this. We're good." Doc 1 turns around and walks out of the room.

Two years later he gets a notice that he's been sued for malpractice. He has no recollection of the patient and there are no records of the "encounter." It turns out that the nurse that was writing down what happened, doses and who was in the room wrote down, "Doc 1 present in room." Ultimately the patient was esophageally intubated by Doc 2 and died.

He calls his med-mal insurance company confident it's a mistake and he'll be dropped quickly and easily. To his shock, he was told that since his name is in the chart the case must proceed and defended as any other case. He was also told that since he created no medical record to defend that they essentially can't defend him. He has no proof or recollection of anything so whatever the plaintiff says, will likely stand. That, combined with the fact that it was a death case with an obvious mistake on the defense side, if he doesn't settle, all of the other defendants will settle, because they know they're likely to lose. This would leave him as the only remaining defendant who would then be liable for all of the money lost at trial ("jointly and severally liable").

"I don't care. I did nothing wrong. I'm going to fight it!" he says indigently.

"No you're not. We're settling on your behalf," his med-mal team says. "This case is a loser and we're not about to be stuck holding the grenade that this jury award would amount to. In this state, the law says that if you want to go to trial and we want to settle, we have the right to settle as your representatives. We're only discussing this with you as a courtesy. You can't say no. Otherwise we abandon you and the case and you fight on your own, pay for your own lawyers and pay the award yourself."

He was forced to agree to a settlement, which was reported to the National Practitioner Databank.

This is real life, and also why I won’t touch a patient that is not mine.

Also this is what Lawyers cause.

 

[RustedFox]

Think: if only uselessnurse wasn't there writing down dumb things that did not matter.

Would have saved a doc who didn't do anything from being sued.

 

[Mount Asclepius]

Sometimes you have to take a stand. I would have in that case even if it meant losing. I just don’t believe that a jury of 12 people would find you in fault if you weren’t there, and held everything to the fact that some nurse wrote your name down incorrectly. I know suits aren’t personal in theory and are just about money, but I’m not going to have that on my record when I wasn’t even present. One thing if you felt your care was right and settle to just get rid of the suit, another when you weren’t even providing care or remotely involved. I’d also potentially consider counter suing the nurse for damages even if a lost cause.

 

[RustedFox]

They do this all the time (write dumb things down, because write them down), too.

Dr. x is in room
The clock is round.
My shoes are blue.

 

[namethatsmell]

Sometimes you have to take a stand. I would have in that case even if it meant losing. I just don’t believe that a jury of 12 people would find you in fault if you weren’t there, and held everything to the fact that some nurse wrote your name down incorrectly. I know suits aren’t personal in theory and are just about money, but I’m not going to have that on my record when I wasn’t even present. One thing if you felt your care was right and settle to just get rid of the suit, another when you weren’t even providing care or remotely involved. I’d also potentially consider counter suing the nurse for damages even if a lost cause.

The sentiment is noble, and part of me wants to tell myself I'd do the same. But you have to ask yourself: do I have six figures lying around to self-fund my defense (and potentially way more cash to pay the other side in the event I lose) and excess spare time available I want to spend on this instead of other things? I suspect that's the calculus the doc in question was up against.

 

[Mount Asclepius]

The sentiment is noble, and part of me wants to tell myself I'd do the same. But you have to ask yourself: do I have six figures lying around to self-fund my defense (and potentially way more cash to pay the other side in the event I lose) and excess spare time available I want to spend on this instead of other things? I suspect that's the calculus the doc in question was up against.

I agree and understand the calculus. I just think physicians have bent over backwards sometimes too much to the detriment of the profession. I’m more mad at the medmal system in this scenario (case if real).

 

[johhnybgood]

I agree and understand the calculus. I just think physicians have bent over backwards sometimes too much to the detriment of the profession. I’m more mad at the medmal system in this scenario (case if real).

For this, it’s dumb, but who cares. We all know the doc did nothing wrong but it’s all a money grab and exchange cash from insurance to patient.

 

[sylvanthus]

Do you work 7 on/off (182 shifts) for 410k? That's really low for pure nights...

140 shifts

 

[Kryptocoin]

Code Liability Shock Story

Floor code is called. Doc 1 responds to code. He walks into room. He sees another attending (floor) physician in the room at the head of the bed, intubating a young person. Doc 1 says, "Do you all need me?" Doc 2 at the head of the bed says, "No. I'm running this. We're good." Doc 1 turns around and walks out of the room.

Two years later he gets a notice that he's been sued for malpractice. He has no recollection of the patient and there are no records of the "encounter." It turns out that the nurse that was writing down what happened, doses and who was in the room wrote down, "Doc 1 present in room." Ultimately the patient was esophageally intubated by Doc 2 and died.

He calls his med-mal insurance company confident it's a mistake and he'll be dropped quickly and easily. To his shock, he was told that since his name is in the chart the case must proceed and defended as any other case. He was also told that since he created no medical record to defend that they essentially can't defend him. He has no proof or recollection of anything so whatever the plaintiff says, will likely stand. That, combined with the fact that it was a death case with an obvious mistake on the defense side, if he doesn't settle, all of the other defendants will settle, because they know they're likely to lose. This would leave him as the only remaining defendant who would then be liable for all of the money lost at trial ("jointly and severally liable").

"I don't care. I did nothing wrong. I'm going to fight it!" he says indigently.

"No you're not. We're settling on your behalf," his med-mal team says. "This case is a loser and we're not about to be stuck holding the grenade that this jury award would amount to. In this state, the law says that if you want to go to trial and we want to settle, we have the right to settle as your representatives. We're only discussing this with you as a courtesy. You can't say no. Otherwise we abandon you and the case and you fight on your own, pay for your own lawyers and pay the award yourself."

He was forced to agree to a settlement, which was reported to the National Practitioner Databank.

How do you kill someone that's already dead? Was this a code blue or a rapid response? Running a code is probably one of the least riskiest thing I can do as an ER doc.

 

[Dr. Texas]

Code Liability Shock Story

Floor code is called. Doc 1 responds to code. He walks into room. He sees another attending (floor) physician in the room at the head of the bed, intubating a young person. Doc 1 says, "Do you all need me?" Doc 2 at the head of the bed says, "No. I'm running this. We're good." Doc 1 turns around and walks out of the room.

Two years later he gets a notice that he's been sued for malpractice. He has no recollection of the patient and there are no records of the "encounter." It turns out that the nurse that was writing down what happened, doses and who was in the room wrote down, "Doc 1 present in room." Ultimately the patient was esophageally intubated by Doc 2 and died.

He calls his med-mal insurance company confident it's a mistake and he'll be dropped quickly and easily. To his shock, he was told that since his name is in the chart the case must proceed and defended as any other case. He was also told that since he created no medical record to defend that they essentially can't defend him. He has no proof or recollection of anything so whatever the plaintiff says, will likely stand. That, combined with the fact that it was a death case with an obvious mistake on the defense side, if he doesn't settle, all of the other defendants will settle, because they know they're likely to lose. This would leave him as the only remaining defendant who would then be liable for all of the money lost at trial ("jointly and severally liable").

"I don't care. I did nothing wrong. I'm going to fight it!" he says indigently.

"No you're not. We're settling on your behalf," his med-mal team says. "This case is a loser and we're not about to be stuck holding the grenade that this jury award would amount to. In this state, the law says that if you want to go to trial and we want to settle, we have the right to settle as your representatives. We're only discussing this with you as a courtesy. You can't say no. Otherwise we abandon you and the case and you fight on your own, pay for your own lawyers and pay the award yourself."

He was forced to agree to a settlement, which was reported to the National Practitioner Databank.

Do you remember which state this happened in?

 

[CoolDoc1729]

If your name goes anywhere on the chart you will be sued. Lawyers name everybody.
It might get dropped 5-8 years later, but it’s not worth the stress and hassle.

My director somehow got named on a case even though he had no involvement and Wasn’t even in the department that day. I think it was because the nurses often put his name on protocol orders that they place. He got off the suit but he first was required to be deposed. How stupid.