How dangerous is EM?

[trevagandalf]

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So, how dangerous is it to be an EM doctor? It is like the first line of defense and I'm sure that it is very easy to get exposed to some really weird contageous diseases. I just learned in clinical practice that to do a physical exam you should not use gloves, so how do EM doctors protect themselves?

I was just wondering because I'm trying to find something to do during the summer and I guess now it is the time to start contacting mentors and deciding what I should be doing. First year has gone by and my grades aren't the best. So I figure whatever I'm doing wrong now, I should make up by doing research and getting some connections?

Also, I'm not dead set on being an EM doc, just pondering the possibilities? How am I supposed to decide what kind of research I want to do if I don't have the slightest idea what specialty I want to get into???

 

[ZagDoc]

I just learned in clinical practice that to do a physical exam you should not use gloves, so how do EM doctors protect themselves?

Never heard this one. Anything involving biological fluids you're pretty much required to wear gloves. Everything else the standard hand wash/sanitizer regimen does the trick.

People in medicine get sick just like anyone else, but if anything I seem to observe a trend of less people getting sick than other avenues of work simply by the emphasis on sterility and sanitation.

 

[AmoryBlaine]

a) Not dangerous enough to disregard it as a career possibility. If someone were to "come in" with a sufficiently "wierd" disease to put the ED attending in danger more than likely they would be admitted so even if you were IM/Peds/Surg you could still be exposed.

b) Considering that EM docs don't use knives/needles as often as their surgical, obstetric, and anesthesia colleagues do it is probably a less "risky" field than those.

c) IMHO the risks of EM come more from psych and trauma patients than from infectious disease.

 

[PeepshowJohnny]

It's pretty dangerous. I've seen a doctor get abducted by gang members, someone lose their arm in a helicopter blade, and two people get knifed by a schizophrenic (one of whom died)...

...no wait, that was ER the TV show. Nevermind.

 

[smq123]

So, how dangerous is it to be an EM doctor? It is like the first line of defense and I'm sure that it is very easy to get exposed to some really weird contageous diseases.

All doctors are at risk. I've heard that in the "old days" (i.e. before universal precautions), almost 100% of pulmonologists developed latent TB through the course of their careers. A lot of surgeons got Hep B at some point in their careers as well.

You just need to be careful.

I just learned in clinical practice that to do a physical exam you should not use gloves, so how do EM doctors protect themselves?

I hope that whoever told you that was not being serious. You should DEFINITELY use gloves, especially if there's any chance of touching bodily fluids.

I was told that you should be consistent. If you don't like using gloves, then consistently don't use gloves (unless the situation calls for it). If you use gloves, then always use gloves. That way you can become accustomed to one way or the other.

I pretty much always use gloves. 😀

Also, I'm not dead set on being an EM doc, just pondering the possibilities? How am I supposed to decide what kind of research I want to do if I don't have the slightest idea what specialty I want to get into???

That's okay. If you have a good opportunity to do research in EM, then do it - that won't stop you from matching into radiology later on. PDs understand that people change their minds.

Plus, research early on can be useful - it helps you "rule out" or "rule in" different specialties.

 

[AmoryBlaine]

By the way, the OP gets 2 points for his sweet avatar.

 

[cofcemt]

a) Not dangerous enough to disregard it as a career possibility. If someone were to "come in" with a sufficiently "wierd" disease to put the ED attending in danger more than likely they would be admitted so even if you were IM/Peds/Surg you could still be exposed...IMHO the risks of EM come more from psych and trauma patients than from infectious disease.

Would have to agree here, working EMS for the last several years, usually if we have some sort of decon situation, they are decon'ed and "clean" before the ED physicians get to them or you would have been given information on TB or other airborne infectious agents via radio prior to our arrival. (of course this is all for a EMS response).

Also agree with the psych and/or trauma patients being the worse...nothing worse than a behemoth 300 pound crazy person with a head injury swinging at you telling you to get away from them or they'll ...

So many crazy stories from EMS, I love it and thats why I'm looking as EM as a possibility. Truth is there are so many people working around and with you, the odds of your health really being at risk is minimal in the ED.

 

[RxnMan]

When I saw the title I thought it was a question of patients abusing health workers. While not directly the OP's question, I'll tell in my limited experience we're pretty good in the US about restraining patients who are dangers to themselves and others. Also, security is pretty good - i.e. nobody is going to come into the dapartment with weapons.

I hear in the UK that things are different.

I agree 100% with SMQ. All of medicine is dangerous because you're exposing yourself to people who are sick. Don't AIDS patients get surgery too? Do Hep B+ women give birth? You don't go into medicine and not expect to get dirty from time to time.

On research - if you don't know have an idea of what you want to specialize in, then you can do work on one of the condions that touches on many systems - diabetes, hypertension, atherosclerosis, inflammation. Almost every doc is going to deal with hypertensive patients at some time, so you can spin that to fit any speciality down the road.

 

[DogFaceMedic]

I just learned in clinical practice that to do a physical exam you should not use gloves, so how do EM doctors protect themselves?

Kevlar-Nitrile gloves and a flak jacket.

 

[Drogba]

When I saw the title I thought it was a question of patients abusing health workers. While not directly the OP's question, I'll tell in my limited experience we're pretty good in the US about restraining patients who are dangers to themselves and others. Also, security is pretty good - i.e. nobody is going to come into the dapartment with weapons.

I hear in the UK that things are different.

I agree 100% with SMQ. All of medicine is dangerous because you're exposing yourself to people who are sick. Don't AIDS patients get surgery too? Do Hep B+ women give birth? You don't go into medicine and not expect to get dirty from time to time.

On research - if you don't know have an idea of what you want to specialize in, then you can do work on one of the condions that touches on many systems - diabetes, hypertension, atherosclerosis, inflammation. Almost every doc is going to deal with hypertensive patients at some time, so you can spin that to fit any speciality down the road.

Didn't someone go into a detroit ER with a grenade not too long ago?

 

[RxnMan]

Didn't someone go into a detroit ER with a grenade not too long ago?

I wouldn't let a one-time extreme example dictate my choice of speciality.

 

[Jeff698]

My job as an emergency physician is MUCH safer than my job as a field paramedic.

Fortunately, the lessons and 'spidey sense' I picked up as a paramedic help make my job as a physician even safer.

Take care,
Jeff

 

[docB]

Didn't someone go into a detroit ER with a grenade not too long ago?

Yup.
http://forums.studentdoctor.net/showthread.php?t=484360

Here's my take, EM isn't more dangerous than other specialties when it come to BBP like HIV, HepC, etc. Sure stuff gets flying and chaotic but spending 8 hours up to your elbows in an abdomen while using a knife is risky too.

In terms of highly virulent communicable diseases like SARS, yeah we'll get it first but the critical care guys will be right behind us. And when people start to get symptoms they're likely to go to their PMDs first so no one will be totally safe. The odds that some EP will get killed by a SARS like thing in the near future are high but the odds that it will be you individually are low. I'm more at risk than most being in Vegas and it doesn't keep me up at night.

Physical violence is your most likely way to get hurt as an EP. I get assaulted about every 2 months. Our system is bad in that we hold the psychs in the ED indefinitely and we get all the drunks and druggies. I've been lucky in that I've never been significantly injured by a patient. The main ways to stay safe are to be cautious and use common sense, ie. don't try to restrain a patient if you don't know how, don't let them get between you and the door, take someone with you to eval the psychy and intoxicated and always listen to the little voice when it says "This ain't right!"

 

[jazz]

if a person walks into the ER and is diagnosed with SARS, highly resistant active TB, s/he has probably already exposed a ton of people in the community....
(think the case of the atlanta man who had resistant TB who flew on commerical airline back from italy through canada and entered US via car...)

also, in the case of a "really weird contagious disease" the pt may be evaluated in the ER and then admitted to the ICU/MICU in which case the risk of prolonged exposure to the virus/bacteria, etc is higher for the internists/critical care specialists.... (think the las vegas ricin case -- supposedly the guy with ricin is in the ICU "unconscious".... and has been there for weeks without a diagnosis. at least he was only in the ER for a few hours...

you can't spend your life worrying about these things -- if you're a hypochondriac, avoid medicine all together....

you have a much higher chance getting killed in a car accident, crossing the street, etc than catching the "weird" contagious disease...

 

[Apollyon]

c) IMHO the risks of EM come more from psych and trauma patients than from infectious disease.

That said, I am now on Rifampin prophylaxis (because I'm allergic to quinolones) after tubing a guy without a mask on who had an atypical case of meningococcemia. Petechiae slowly from neck down, no fever, apparent GI bleeding, and never purpura. God's honest truth, I was worried about measles first, and I'm up to date on my MMR. Patient is critically ill but stable and still alive.

 

[Drogba]

Yup.
http://forums.studentdoctor.net/showthread.php?t=484360

Here's my take, EM isn't more dangerous than other specialties when it come to BBP like HIV, HepC, etc. Sure stuff gets flying and chaotic but spending 8 hours up to your elbows in an abdomen while using a knife is risky too.

In terms of highly virulent communicable diseases like SARS, yeah we'll get it first but the critical care guys will be right behind us. And when people start to get symptoms they're likely to go to their PMDs first so no one will be totally safe. The odds that some EP will get killed by a SARS like thing in the near future are high but the odds that it will be you individually are low. I'm more at risk than most being in Vegas and it doesn't keep me up at night.

Physical violence is your most likely way to get hurt as an EP. I get assaulted about every 2 months. Our system is bad in that we hold the psychs in the ED indefinitely and we get all the drunks and druggies. I've been lucky in that I've never been significantly injured by a patient. The main ways to stay safe are to be cautious and use common sense, ie. don't try to restrain a patient if you don't know how, don't let them get between you and the door, take someone with you to eval the psychy and intoxicated and always listen to the little voice when it says "This ain't right!"

Wow. What, exactly, do you mean assaulted?

 

[deleted109597]

Saw a case report recently of an ED doc who go MRSA pneumonia superinfection from the flu. Don't know that he was at any more risk than anyone else with the flu.
Was pretty sick from it though.

As a student, I got to tackle a large naked man under the influence of recreational pharmaceuticals. It was actually kinda fun.

Some crazy guy shot people in a Lane Bryant recently, does this mean being a large woman is more dangerous than being skinny? (other than the obvious, you clowns)

 

[DrQuinn]

Been an attending in the ED 1.7 years, haven't been assaulted (I am at a Level 1 trauma center, inner city) or threatened. HOld that, I've been threatened, but its usually by coke head females that threaten everyone. No one has tried to attack me . But I'm 6'1 205# so that might help.

Q

 

[Febrifuge]

As a student, I got to tackle a large naked man under the influence of recreational pharmaceuticals. It was actually kinda fun.

I got to hip-check a guy who was trying to escape the ER. My associate, a tiny female, was the one who tackled him.

To the OP, remember that the ED is a little chaotic, but every single staff member has a role to play, and a share of the responsibility for everyone else's safety. If you think the team moves quickly when the trauma pagers go off, you should see them race to assist a compatriot who winds up in a dangerous situation.

Plus, our security guys are the best - and biggest - in the hospital.

 

[roja]

Been an attending in the ED 1.7 years, haven't been assaulted (I am at a Level 1 trauma center, inner city) or threatened. HOld that, I've been threatened, but its usually by coke head females that threaten everyone. No one has tried to attack me . But I'm 6'1 205# so that might help.

Q

Well, Q, you do have *quite* a reputation, being world famous and all. 😀


Seriously, you can get 'assaulted'. However, its usually 'attempted assault'. I remember in med school being told to trust your gut if you feel uncomfortable being alone in a room. And definately trust it. If your gut starts going off, mind it and get some help. don't be afraid of having your security guys get involved. And do NOT argue with these people. My process: verbally or physically trying to get at people- safe to kick out? Yes= they get a security consult and get escorted out. No? they get held down (I regularly teach how to appropriately hold someone down), IV and sedation. Period.

 

[EM2BE]

if a person walks into the ER and is diagnosed with SARS, highly resistant active TB, s/he has probably already exposed a ton of people in the community....
(think the case of the atlanta man who had resistant TB who flew on commerical airline back from italy through canada and entered US via car...)

also, in the case of a "really weird contagious disease" the pt may be evaluated in the ER and then admitted to the ICU/MICU in which case the risk of prolonged exposure to the virus/bacteria, etc is higher for the internists/critical care specialists.... (think the las vegas ricin case -- supposedly the guy with ricin is in the ICU "unconscious".... and has been there for weeks without a diagnosis. at least he was only in the ER for a few hours...

you can't spend your life worrying about these things -- if you're a hypochondriac, avoid medicine all together....

you have a much higher chance getting killed in a car accident, crossing the street, etc than catching the "weird" contagious disease...

Also, if you're not a hypochondriac and feel you may have a health problem, trust your gut (like roja said) and have someone else evaluate you before it becomes a bigger problem (not that I've learned this from my own experiences or anything 😉 )

 

[docB]

Wow. What, exactly, do you mean assaulted?

Hit, shoved, grabbed, spit on, something thrown at, physical contact. I get threatened about twice a week. The problem here in Vegas is that all drunks and druggies go to the ED no matter what. That and we have to board the psychs in the ED for weeks on end. Drunks and psychs and frequently drunk psychs create a hostile work environment.

 

[NYgirl2]

Hit, shoved, grabbed, spit on, something thrown at, physical contact. I get threatened about twice a week. The problem here in Vegas is that all drunks and druggies go to the ED no matter what. That and we have to board the psychs in the ED for weeks on end. Drunks and psychs and frequently drunk psychs create a hostile work environment.

Seriously, how do you not dread going to work every day? How do you stay passionate/positive about your job (or at least not hate it)? (Need motivation and inspiration for my bad days)

 

[AmoryBlaine]

That said, I am now on Rifampin prophylaxis (because I'm allergic to quinolones) after tubing a guy without a mask on who had an atypical case of meningococcemia. Petechiae slowly from neck down, no fever, apparent GI bleeding, and never purpura. God's honest truth, I was worried about measles first, and I'm up to date on my MMR. Patient is critically ill but stable and still alive.

Inasmuch as you are an attending/resident (I can't remember) and I am a student it is good a good chance to emphasize the importance of wearing masks w/ faceshields!

Seriously, I made the mistake of sewing a hand lac one time w/o a mask. The nylon suture kind of slipped down as I was tying it and I got a nice drop of blood on my lower lip. Pt was a 41 y/o suburban mother of 3 who cut herself at a pottery class so I didn't freak out but I haven't made the same mistake again!

 

[JackBauERfan]

It's pretty dangerous. I've seen a doctor get abducted by gang members, someone lose their arm in a helicopter blade, and two people get knifed by a schizophrenic (one of whom died)...

...no wait, that was ER the TV show. Nevermind.

you forgot about all those times we get our arms chopped off on the helipad and sometimes we get crushed by helicopters that go wild.

 

[JackBauERfan]

Inasmuch as you are an attending/resident (I can't remember) and I am a student it is good a good chance to emphasize the importance of wearing masks w/ faceshields!

Seriously, I made the mistake of sewing a hand lac one time w/o a mask. The nylon suture kind of slipped down as I was tying it and I got a nice drop of blood on my lower lip. Pt was a 41 y/o suburban mother of 3 who cut herself at a pottery class so I didn't freak out but I haven't made the same mistake again!

mask every time you suture?? yeah I guess you had a bad experience, but I've never even thought about masks when suturing, I guess if it was a big wound...

 

[docB]

Seriously, how do you not dread going to work every day? How do you stay passionate/positive about your job (or at least not hate it)? (Need motivation and inspiration for my bad days)

I gave up trying to be positive a long time ago. I've settled into a sort of comfortable grumpiness. Oddly the tussels with drunks and psychs don't bother me anywhere near as much as fighting with consultants and lack of subspecialty coverage.

 

[docB]

Inasmuch as you are an attending/resident (I can't remember) and I am a student it is good a good chance to emphasize the importance of wearing masks w/ faceshields!

Seriously, I made the mistake of sewing a hand lac one time w/o a mask. The nylon suture kind of slipped down as I was tying it and I got a nice drop of blood on my lower lip. Pt was a 41 y/o suburban mother of 3 who cut herself at a pottery class so I didn't freak out but I haven't made the same mistake again!

I wear safety glasses all the time in the ED now. And I don't mean "frequently." I mean all the time. I got splashed about 3 times in a 2 year span and just decided I was more comfortable wearing the glasses. I don't wear a mask (unless it's a high risk situation like tubing a GI bleeder) but I probably should.

 

[AmoryBlaine]

mask every time you suture?? yeah I guess you had a bad experience, but I've never even thought about masks when suturing, I guess if it was a big wound...

This particular one was tiny, but you know the way that nylon kinds of slips on itself quickly? I'm probably not describing it that well, the best analogy would be if you had a taught string with water on it and plucked the string.

Anyway, yes, every time. Mask with shield.

 

[enfuegoEP]

The last few months I've been at a hospital with a very high HIV population and a few attending have shared stories about having to go on antiretrovirals for exposure. It's made made me extra cautious. Not too worried about physically threatening patients. We have a detail officer assigned to the ED at all times and they usualy have an itchy tazer trigger finger.

 

[JackBauERfan]

This particular one was tiny, but you know the way that nylon kinds of slips on itself quickly? I'm probably not describing it that well, the best analogy would be if you had a taught string with water on it and plucked the string.

Anyway, yes, every time. Mask with shield.

I just bought some medical glasses things and I think i'll wear those all the time when i do procedures/intubations....we'll see how long before i lose or someone steals them haha.

 

[Hayduke]

Regarding safety in terms of assault, the solution is having a dog in the dept. I worked in a place where security was accompanied by some big-@ss dutch shepherds. Rowdy folks got curiously quiet when they showed.

In terms of danger in the ED, I feel emperiled more by the constant threat of litigation. In my current place I am treated once every week or so to a version of "if __________doesn't happen, I'm going to sue you". I am training and have redundant layers of back up to look for slips, but bad outcomes don't care. I worry more about catching a supoena bullet when I get out than any BBP (I can protect against) or some thug who does a little hassling.

 

[docB]

In terms of danger in the ED, I feel emperiled more by the constant threat of litigation. In my current place I am treated once every week or so to a version of "if __________doesn't happen, I'm going to sue you". I am training and have redundant layers of back up to look for slips, but bad outcomes don't care. I worry more about catching a supoena bullet when I get out than any BBP (I can protect against) or some thug who does a little hassling.

I totally agree with this.

 

[WestcoastMedicine]

The department I felt "least safe" in was by far inpatient psych. I have never seen so many patients tackled in a day. Several times in the month I saw patients get mad and put there fists through panes of glass. Several times that month I walked in on people jerking each other off. Several times a week during that month I had patients spit at me, verbally abusive, and attempted physical abuse if I would have been dumb enough to isolate myself in a room with them. Granted this was in Elizabeth, NJ...............

 

[enfuegoEP]

I had a patient threaten to "punch me in the nose" if I hurt her while suturing up the lack over her eye because she drank too much and tripped over something (probably a straw or piece of paper) I didn't feel threatened, but got a little angry. I was there to suture up her lac that was caused by her stupidity and she's threatening to hit me?

 

[tkim]

I had a patient threaten to "punch me in the nose" if I hurt her while suturing up the lack over her eye because she drank too much and tripped over something (probably a straw or piece of paper) I didn't feel threatened, but got a little angry. I was there to suture up her lac that was caused by her stupidity and she's threatening to hit me?

You should have stopped and told her that unless she decides to stop threatening you, she can leave.

 

[docB]

I had a patient threaten to "punch me in the nose" if I hurt her while suturing up the lack over her eye because she drank too much and tripped over something (probably a straw or piece of paper) I didn't feel threatened, but got a little angry. I was there to suture up her lac that was caused by her stupidity and she's threatening to hit me?

I understand that you're a student and it's not easy to take a stand like this but I think you can make a good argument for not suturing that patient. I would document:

"Patient has threatened to punch me if she feels any pain while suturing her lac. Pain is an expected and unavoidable part of this procedure even with the use of LET followed by local anesthesia which I have offered this patient. The patient still felt compelled to threaten me. This places me, other ED staff and the patient in danger of significant injury. As suturing this laceration is primarily indicated for cosmesis the risks in this case outweigh the benefit to the patient. Therefore I have dressed the wound to the degree the patient will allow and am discharging the patient with instructions to follow up with a plastic surgeon within 24 hours."

 

[Febrifuge]

I like DocB's advice, but I just know my impulse would be to pull back a little, look the patient in the eyes, and quietly and matter-of-factly say "if you punch me in the nose, you will go to jail as soon as we're done here. Okay?"

My guess is that this drunk person is either trying and failing to make a joke because she's nervous about being sewn, or else she has an inflated sense of her power in this interaction. Either way, my response serves to re-establish the rules governing our next several minutes together.

Would you advise that this would be an indiscreet thing for a rotating student to say?

(I know, I know, "if you have to ask..." etc., but I'm interested in opinions.)

 

[enfuegoEP]

I told her if she struck me the detail officer would take her to jail. Her response was that "I'm just tellin ya...just in case." I guess she thought she was doing me a favor by forwarning me. It's not the threat of violence that's so annoying...It's the threat of violence when you're trying to help someone you've never met before and the first thing out of their ungrateful mouth is that they may punch you in the nose.

 

[tkim]

I told her if she struck me the detail officer would take her to jail. Her response was that "I'm just tellin ya...just in case." I guess she thought she was doing me a favor by forwarning me. It's not the threat of violence that's so annoying...It's that threat of violence when you're trying to help someone you've never met before and the first thing out of their ungrateful mouth is that they may punch you in the nose.

Your response should be "Well, maybe we shouldn't go on then, because although I will do my best to numb up the site, there might be an area or two that might still hurt, and I don't really want to be punched."

Won't change what she said, but perhaps the next time they'll think before saying such a jackass thing.

 

[bartleby]

People who say stuff like this to me get my, "I'm going to step out of the room for 10 minutes to give you a chance to think about why it is a bad idea to threaten the guy who is going to determine how your face looks for the rest of your life" speech. This is usually enough of a buzzkill for them that they STFU, or at least their slightly more appropriate friend apologizes for them and promises to help keep them still.

 

[crewmaster1]

I always wear a face mask suturing for several reasons. Splashes are a definite risk of things like nylon throwing fluids or when you inject with lido and as you are pulling out you get a little squirt in the air. I also think it helps reduce the patient's risk of infection as you sit there and breath over the lac you are sewing. Don't know if there is much research on this reducing infection, but it cant hurt. It always reinforces me to look at the mask when I'm done doing whatever I was doing to see what the hell is on the mask that would have been on my face, you would be surprised! Try wearing white in the ER for a couple of shifts and you'll see why gowning and personal protection is important. However, with regards to gloves on all patients. I feel strongly that without obvious risk of infection (wounds, rashes, body fluids) gloves imparts a message to your patient that doesn't foster a good relationship. But, this is a personal opinion that many people differ on. Just wash good before and after and you're fine.