how many hours per month do you work?

[Alvarez13]

Exact same boat. So excited!

Yah, cocaine is great.

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[RustedFox]

And that one dick attending who makes me order CT PE on every patient with dyspnea that has ever existed. "I've seen 6 negative dimer PE patients". STFU!

Unnggh. She still works there? Lol. (And everywhere)

 

[Psai]

Unnggh. She still works there? Lol. (And everywhere)

That's weird because our d-dimer test claims to have 100% sensitivity below a certain number

 

[RustedFox]

That's weird because our d-dimer test claims to have 100% sensitivity below a certain number

My comment was more designed to say "Oh, THAT attending. I know him/her (in my shop, it was a her)".

There's always ONE r/**** that paralyzes the shop by not being able to see the forest for the trees; especially in an academic shop.

 

[deleted109597]

There's always ONE r/**** that paralyzes the shop by not being able to see the forest for the trees; especially in an academic shop.

Did I tell you about the time I ordered [unnecessary test] and found [incredibly rare and utterly irrelevant non-emergency] finding? So that tells me to keep doing it.

 

[RustedFox]

Did I tell you about the time I ordered [unnecessary test] and found [incredibly rare and utterly irrelevant non-emergency] finding? So that tells me to keep doing it.

Yep. Bullseye.

I'm all for trying to help out our brothers and sisters of humanity, but CTA chest on everyone over 50 and lactates for every tweenager getting her first ovarian cyst isn't the way to do it.

 

[WilcoWorld]

Yep. Bullseye.

I'm all for trying to help out our brothers and sisters of humanity, but CTA chest on everyone over 50 and lactates for every tweenager getting her first ovarian cyst isn't the way to do it.

Lactate!

When I trained, we got a lactate on septic patients to see just how septic they were. Now I see people getting lactates on patients to see if they're "sick". Drives me crazy. First of all, if you need a lactate to see if someone's sick, you need some better clinical skills. Second of all, people with normal lactates can be pretty sick. And what is worst for flow is when someone checks a lactate "to see if the patient's hiding something", then after the work up is negative, except that the lactate's 2.5, they sign the patient out to me to "dc if the lactate normalizes."

 

[RustedFox]

Lactate!

When I trained, we got a lactate on septic patients to see just how septic they were. Now I see people getting lactates on patients to see if they're "sick". Drives me crazy. First of all, if you need a lactate to see if someone's sick, you need some better clinical skills. Second of all, people with normal lactates can be pretty sick. And what is worst for flow is when someone checks a lactate "to see if the patient's hiding something", then after the work up is negative, except that the lactate's 2.5, they sign the patient out to me to "dc if the lactate normalizes."

I gave up this fight awhile ago, when HCA got pissy that lactates weren't being ordered, but the patient was "Septic!" as per their RR of 22. I now order a lactate with one click and watch as I waste money.

 

[BAM!]

I gave up this fight awhile ago, when HCA got pissy that lactates weren't being ordered, but the patient was "Septic!" as per their RR of 22. I now order a lactate with one click and watch as I waste money.

I agree. It's stupid how CMS requires this for the new sepsis guidelines. It's all tied to medicare reimbursements which is why the administrators get all worked up about this stuff. Sooo really it's a government problem, and the administrators are the annoying messengers.

Just have a smart phrase for your charting which reads, "Although the patient meets SIRS criteria, there is little concern for infection and/or sepsis. Therefore, fluid bolus, antibiotics, and lactate testing are unwarranted."

As for the lactate of 2.5 in a healthy patient. Easy dispo. Just discharge like we used to before all this weak-evidence, arbitrarily based CMS cutoff of 2.0 for severe sepsis came around a few years ago.

 

[BAM!]

I gave up this fight awhile ago, when HCA got pissy that lactates weren't being ordered, but the patient was "Septic!" as per their RR of 22. I now order a lactate with one click and watch as I waste money.

and tell the nurses that 18 is the new 20 for RR.

 

[deleted547339]

and tell the nurses that 18 is the new 20 for RR.

Wait, nurses are allowed to chart something other than 16? I just assumed this was precompleted.

 

[RustedFox]

Lactate!

When I trained, we got a lactate on septic patients to see just how septic they were. Now I see people getting lactates on patients to see if they're "sick". Drives me crazy. First of all, if you need a lactate to see if someone's sick, you need some better clinical skills. Second of all, people with normal lactates can be pretty sick. And what is worst for flow is when someone checks a lactate "to see if the patient's hiding something", then after the work up is negative, except that the lactate's 2.5, they sign the patient out to me to "dc if the lactate normalizes."

This $hit drives me nuts, too. The only *academic* reason that I can think of to order a lactate "to see if they're hiding something" is in the setting of mesenteric ischemia. Full disclosure: I can be wrong on this. If I have an "old vasculopath" with belly pain, or "pain out of proportion" to exam (because those SMA syndromes do exist in the young skinny person) - then yeah, I send off a lactate. At no other times would I normally do this without CMS breathing down my neck. Nowadays... eff it. CMS gets what CMS wants. Taxpayers be damned.

The setting that I described in my prior post with tweenagers and lactates actually existed. There was this ONE attending at my shop who ordered lactates, GC/Chlam, full pelvic, and *whatever else* on every well-looking tweenage girl. I got sick of telling the mother of every twelve year-old that "my attending has ordered a full pelvic exam and swabs", so I called her out one day as a senior, and (as I was wont to do at the time) said something like: "You're afraid of your own shadow; its a shame because I don't think you've ever seen it" or something else pithy and disrespectful.

This is generally the part in the parable where the storyteller says "and I was wrong. and I learned."

*** record scratch sound effect ***

I wasn't wrong. Eff her. She's probably still doing this nonsense. Running up 10K+ workups on healthy tweens and exposing all their abdomens/pelvii to 20 milliseiverts every day. Somewhere. In academia.

 

[The White Coat Investor]

This $hit drives me nuts, too. The only *academic* reason that I can think of to order a lactate "to see if they're hiding something" is in the setting of mesenteric ischemia. Full disclosure: I can be wrong on this. If I have an "old vasculopath" with belly pain, or "pain out of proportion" to exam (because those SMA syndromes do exist in the young skinny person) - then yeah, I send off a lactate.

The problem with patients is they haven't read the darn medical textbooks. I had a bizarro case I picked up last week with a CT scan. I ordered the lactate after finding mesenteric ischemia on the CT (yes, I called the surgeon before the lactate came back). I ordered the CT because the patient was acting so weird I had no other way to really evaluate her abdomen well. I probably would have ordered it for the WBC of 22, but that came back after I'd already ordered it. The patient?

Oh yea, she was 27 with portal vein thrombosis extending well into the superior mesenteric vein. Lost 130 cm of small bowel. Still need to FU to see if she made it. Non-smoker, no OCPs, no personal or fam hx of clots, no liver disease etc.

I guess she fit the "pain out of proportion" rule, but really she was just so nutty I couldn't trust her history so I went veterinary medicine mode.

The lactate was only 3.6.

You find enough of that bizarro stuff (the 16 year old stroke, the 22 year old MI, the ICH in the frequent flier migraineur) and you understand your hyperconservative attendings back in residency a little better. Still not the best way to practice in my opinion, but at least it leads to understanding. I'm certainly closer to the hyperconservative guy in residency than the cavalier guy now, whereas I was much more cavalier when I left residency, and certainly as a PGY2.

 

[deleted547339]

The problem with patients is they haven't read the darn medical textbooks. I had a bizarro case I picked up last week with a CT scan. I ordered the lactate after finding mesenteric ischemia on the CT (yes, I called the surgeon before the lactate came back). I ordered the CT because the patient was acting so weird I had no other way to really evaluate her abdomen well. I probably would have ordered it for the WBC of 22, but that came back after I'd already ordered it. The patient?

Oh yea, she was 27 with portal vein thrombosis extending well into the superior mesenteric vein. Lost 130 cm of small bowel. Still need to FU to see if she made it. Non-smoker, no OCPs, no personal or fam hx of clots, no liver disease etc.

I guess she fit the "pain out of proportion" rule, but really she was just so nutty I couldn't trust her history so I went veterinary medicine mode.

The lactate was only 3.6.

You find enough of that bizarro stuff (the 16 year old stroke, the 22 year old MI, the ICH in the frequent flier migraineur) and you understand your hyperconservative attendings back in residency a little better. Still not the best way to practice in my opinion, but at least it leads to understanding. I'm certainly closer to the hyperconservative guy in residency than the cavalier guy now, whereas I was much more cavalier when I left residency, and certainly as a PGY2.

But what you're saying different things. He's saying he had an attending who made a practice of ordered everything on everyone. You're saying you order those tests sometimes when you need them (because you're a good doctor).

We all had those attendings in residency. Ground level fall in a 20 year old - came in to get scalp lac repaired - left after ct head, neck and in a collar with pcp f/u to get an MRI, every 25 yo with BPPV getting an MRI, etc

 

[The White Coat Investor]

But what you're saying different things. He's saying he had an attending who made a practice of ordered everything on everyone. You're saying you order those tests sometimes when you need them (because you're a good doctor).

We all had those attendings in residency. Ground level fall in a 20 year old - came in to get scalp lac repaired - left after ct head, neck and in a collar with pcp f/u to get an MRI, every 25 yo with BPPV getting an MRI, etc

It's a pretty subtle difference at times.

For example, to a resident it often looks like an attending is just saying "get all the tests" when in reality he orders a CT because he's had a patient with that presentation who had an appy and a lactate because he had a patient with that presentation with mesenteric ischemia etc etc.

Like the vertigo thing- it turns out all the stuff we thought we could use clinically to rule out central causes of vertigo aren't even close to being 100% accurate. I'm ordering way more MRI on vertigo than I used to. The indications for MRI for vertigo are not set in stone by any means.

 

[WilcoWorld]

It's a pretty subtle difference at times.

For example, to a resident it often looks like an attending is just saying "get all the tests" when in reality he orders a CT because he's had a patient with that presentation who had an appy and a lactate because he had a patient with that presentation with mesenteric ischemia etc etc.

Like the vertigo thing- it turns out all the stuff we thought we could use clinically to rule out central causes of vertigo aren't even close to being 100% accurate. I'm ordering way more MRI on vertigo than I used to. The indications for MRI for vertigo are not set in stone by any means.

You picked up the young patient with mesenteric ischemia because you had a clinical suspicion of badness after evaluating the patient, not because you indiscriminately checked a lactate.

You order MRI's on vertigo, because you recognize that you don't have another equally sensitive test to rule out potentially devastating disease processes, not because you're too lazy to ambulate a patient.

This is all completely appropriate. If I am worried about a patient, I will pull out all the stops (I recently diagnosed an SMA clot by doing a CTA on a patient who had a standard contrast CT just a few hours before that was "indeterminate". The vascular surgery team blew it off because her lactate was normal. It took about 10 minutes of arguing with Radiology for me to get them to agree to repeat the CT. In the end I saved her from loosing a few feet of gut.)

I'm not railing against being very conservative (or, alternatively stated, being diagnostically aggressive) when the patient gives you reason to be concerned. I'm railing against indiscriminately ordering work ups because you had a weird case once. I'm not worried about cost, I'm only mildly concerned about radiation - what I am really worried about is the false sense of security that people get from negative indiscriminate work ups.

Here's a case I took as a transfer recently - 40's something woman has a fall and comes to the ED for shoulder pain. In spite of no risk factors and being PERC (-), a d dimer is ordered to rule out PE as a cause of syncope. D dimer is +. CT PE scan is ordered, and it shows no PE, but there's either a motion artifact or a type A dissection, so she gets transferred to my ED to see vascular surgery.

I see her, and she denies syncope - the fall was mechanical. She has no CP or back pain, and wonders when we're going to do something about her shoulder pain. I actually LOOK at her shoulder and, BAM! the diagnosis is clear - she has a dislocation.

So I guess I'm saying - be as conservative/diagnostically aggressive as you like. But do it because there is something about the patient in front of you that inclines you to do so. This is not motivated by a desire to save the US healthcare system. Ironically it's motivated by a desire to avoid the missed diagnoses that come from false reassurance.

 

[link2swim06]

I had a negative d dimer, positive cta PE the other day. Those are always fun.

I guess its what happens when the "nurse orders" a d-dimer a triage and I determine them the pt to have no other plausible diagnosis....

 

[RustedFox]

Yeah, amigo. - When your spider sense tingles, you investigate and order the test.

Ordering dimer/lactate/pelvic on EVERY tween before you even see 'em? THAT'S what we're complaining about.

 

[TooMuchResearch]

Did I tell you about the time I ordered [unnecessary test] and found [incredibly rare and utterly irrelevant non-emergency] finding? So that tells me to keep doing it.

Oh weird. I can't believe we all train(ed) in the same place. /sarcasm

 

[heroesinahalfshell]

Contracted for 14x 10 hours monthly but do about 180-200. Recent grad trying to pay off bills and save $$$ to play catch up. I did about 120-140 hours first 5 month and had too much free time so I think sweet spot is 150hours monthly until I am in "all bills paid and hit my nest egg" mode

Contracted for 120/month (mixture of 12s and 8s), most months I'm picking up a few additional shifts and averaging closer to 150

 

[deuist]

We are short at my military emergency department. Between that place and moonlighting, I usually do to 230-260 hours a month. My active duty commitment ends in July and cannot come fast enough.

 

[sonofva]

We are short at my military emergency department. Between that place and moonlighting, I usually do to 230-260 hours a month. My active duty commitment ends in July and cannot come fast enough.

I was talking to some leadership recently and they said the way to do it out of residency is to go operational out of residency for the 9-4 clinic hours and then just moonlight on all the 4 days

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[deuist]

I was talking to some leadership recently and they said the way to do it out of residency is to go operational out of residency for the 9-4 clinic hours and then just moonlight on all the 4 days

The problem with that plan is that you will quickly loose your skills, particularly if you come directly from residency. I specifically did not want to flight surgery/GMO as I wanted to work in some resemblance of an emergency physician, even if it was in one of the military's glorified urgent care centers.

 

[julie walker]

I work 48 hours per week and make far more than these ER MD's .....lolololol

 

[sonofva]

You make more than $325000 a year working 48 hours a week? Please tell me what job this is so I can go do it...

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[deleted109597]

I work 48 hours per week and make far more than these ER MD's .....lolololol

If I worked 48 hours a week at my minimum pay rate, and worked 52 weeks in a year, I would make $723840.
Thankfully, some shifts pay more, so I don't have to work 192 hours a month. I don't work half that. I do make a little over half of that obscene dollar amount though.

 

[Hercules]

You make more than $325000 a year working 48 hours a week? Please tell me what job this is so I can go do it...

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This was sarcasm I assume? There are several EM jobs where 48 hrs/week would get you just shy of 1M.


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[GeneralVeers]

If I worked 48 hours a week at my minimum pay rate, and worked 52 weeks in a year, I would make $723840.
Thankfully, some shifts pay more, so I don't have to work 192 hours a month. I don't work half that. I do make a little over half of that obscene dollar amount though.

For that amount of work I'd make $923,520 at my present rate/job. Of course if I worked 48 hours a week life wouldn't be worth living. I'll settle for my 30 hour work week.

 

[Boatswain2PA]

Last quarter we averaged 27 pts/24 hrs. It's a little over 10k a year. Sleep varies but it's really rare not to get any. Probably can count on 3-4 hrs most nights.

Are you a BC EP? How can such a low census ED afford a BC EP??

Busiest place I work 24 hr shifts at average a little over 9K a year and no way they could afford BC EP pay.

 

[emergentmd]

I work 48 hours per week and make far more than these ER MD's .....lolololol

There are not many fields in medicine where I am offered 500/hr and regularly refuse these shifts. If I was just in it for the money, I could easily work 48hr/wk=200hr/mo=2400hr/yrx500=1.2 MIL

I think you are grossly overpaid. I have not many docs who pulls in my rates.

 

[The White Coat Investor]

We are short at my military emergency department. Between that place and moonlighting, I usually do to 230-260 hours a month. My active duty commitment ends in July and cannot come fast enough.

That sounds familiar. Bet you can't wait to make twice the money working half the hours. I'm surprised the military retains any emergency docs at all. Those guys have a serious commitment to serve. Kudos to them.

 

[The White Coat Investor]

Here's a case I took as a transfer recently - 40's something woman has a fall and comes to the ED for shoulder pain. In spite of no risk factors and being PERC (-), a d dimer is ordered to rule out PE as a cause of syncope. D dimer is +. CT PE scan is ordered, and it shows no PE, but there's either a motion artifact or a type A dissection, so she gets transferred to my ED to see vascular surgery.

I see her, and she denies syncope - the fall was mechanical. She has no CP or back pain, and wonders when we're going to do something about her shoulder pain. I actually LOOK at her shoulder and, BAM! the diagnosis is clear - she has a dislocation.

Wow! That's bad. I hope I haven't had very many of that type of miss in my career.

 

[deuist]

I'm surprised the military retains any emergency docs at all.

In the last four years, the only person who stayed beyond the initial commitment went to fellowship. Other than that we are 0 for 15 for EP's on retention.

 

[DrYoda]

140-190 depending on my appetite for picking up extra shifts.