IM docs as ER docs

[mountaindew2006]

question...

i've been told that IM docs work as Er docs on occassion. here in lies my curiosity, is it possible to say be board certified in IM and then entired 'practice' as an ER doc? of course ER docs woudl be better trained because of their residency, but wouldnt these IM docs be just as good with experience..

Additionally, will these IM docs get paid the same amount of $$$ especially in places like chicago, etc.

of course i suppose EM docs wouldnt like this since this is in essence getting into their territory, nevertheless, is this possible?

thanks

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[DrQuinn]

You could probably find a job in an ED in a rural setting... but even for EM trained graduates, finding a job in a big city like Chicago might be tough. I think its a pretty competitive market. Anyways, you have to remember that your IM training is minimal in OB/GYN, Peds, and trauma. Every day, about 10% of my patients are OB/GYN related... and in some places without a dedicated Pediatric portion to the ED, their patient population is 25% peds. And don't forget the occasional trauma alert, MVA, assault, etc.

Assuming you could find a job (which will be tougher to get in the future), pay would be the same.

 

[PDIsani]

Can you just pick adult nontrauma patients depending on their census?

 

[gutonc]

Can you just pick adult nontrauma patients depending on their census?

Bravo on the solid necrobump bro.

And no.

 

[Raryn]

Can you just pick adult nontrauma patients depending on their census?

Sure. At the VA.

 

[Siggy]

Can you just pick adult nontrauma patients depending on their census?

The hospital that my residency is out of is single coverage in the ED overnight. We are a non-trauma center. We had a gunshot wound dropped off at the hospital by home boy ambulance service (POV). Good luck not picking the GSW up while waiting for EMS to respond to transfer to the local trauma center.

 

[Raryn]

The hospital that my residency is out of is single coverage in the ED overnight. We are a non-trauma center. We had a gunshot wound dropped off at the hospital by home boy ambulance service (POV). Good luck not picking the GSW up while waiting for EMS to respond to transfer to the local trauma center.

And breaking federal law in the meantime.

 

[ArkansasMed]

Are there any models where they have IM docs look over admissions or IM docs that do primary care within the ED? In my opinion probably 75% of what actually goes through most ED is primary care worthy. Probably would be worth doing since it would lead to reduced bs ED admissions/visits.

 

[Siggy]

Are there any models where they have IM docs look over admissions or IM docs that do primary care within the ED? In my opinion probably 75% of what actually goes through most ED is primary care worthy. Probably would be worth doing since it would lead to reduced bs ED admissions/visits.

In most hospitals calls for admission are really "consults." There's nothing forcing a hospitalist from saying, "This patient doesn't need admission." That said, at 2 in the morning it's much easier to admit, phone in basic orders, and then see the patient in the morning.

 

[IMreshopeful]

Are there any models where they have IM docs look over admissions or IM docs that do primary care within the ED? In my opinion probably 75% of what actually goes through most ED is primary care worthy. Probably would be worth doing since it would lead to reduced bs ED admissions/visits.

ED admits are a hospitalist's bread and butter. In the community the vast majority of hospitalists most likely will not turn down admits ever (unless of course the patient is critically ill and needs an ICU, not a floor bed).

Blocking admits is very much a residency/fellowship thing, because it's not affecting your paycheck.

That being said, my ED has a system where a medicine attending evaluates each admit for appropriateness (whether it can go to a nonteaching obs service vs. gen med resident staffed inpatient service - this is an academic medical center). Rarely the attending will say whether or not the patient can just be discharged with followup. Generally speaking this improves workflow significantly. The ED also has triage staffed with residents that rotate through to turn away most of the stupid stuff that shows up (my meds ran out, my toe hurts, I have no insurance but need a PCP, etc). So there are models that work which decrease less legit admits.

Also, it's occasionally nice to have BS admits to pad your team, as those patients are quickly dischargeable after their ACS r/o or syncope tele monitoring or whatever. Nobody wants to be the resident with 15 patients who aren't ever going anywhere because they need placement/guardianship or are just insanely sick and need to be inpatient.

 

[deleted547339]

Are there any models where they have IM docs look over admissions or IM docs that do primary care within the ED? In my opinion probably 75% of what actually goes through most ED is primary care worthy. Probably would be worth doing since it would lead to reduced bs ED admissions/visits.

You do realize that determining disposition is a large part of EM training, right?

 

[ArkansasMed]

You do realize that determining disposition is a large part of EM training, right?

You did not understand my question. Disposition is half the battle. EM usually does that very well. EM at works an admission up enough to get them either admitted or out of the hospital. I just don't know if there is anyone actually looking over admissions not as floor appropriate but has the work up been done to be floor ready. Like starting antibiotics early, ordering the appropriate work up for a sick patient etc? Devils advocate, any consequences for providers ordering too many tests (CT for a general headache etc.) The second half of my question is actually more of an improved care model that treats people with HTN, HLD and other conditions as PCPs assuming that high risk patients going to the ED should just have an Epic account with almost a resident clinic model (whatever resident is on sees the patient) where their primary care is done there instead of a clinic. So many high risk patients are probably released into the population daily that could and probably would benefit from a primary intervention that usually is overlooked due to either their concern not being an "emergency" or thinking someone will actually follow up to a clinic (or can make the hours of a clinic). I bet if you created such a model, it would eventually reduce morbidity of high risk, high utilizes of the ED and prevent them from coming in for real emergencies like malignant hypertension or CHF.

 

[deleted547339]

I just don't know if there is anyone actually looking over admissions not as floor appropriate but has the work up been done to be floor ready. Like starting antibiotics early, ordering the appropriate work up for a sick patient etc?

There is. It's called an ER doctor.

 

[cassrae]

You did not understand my question. Disposition is half the battle. EM usually does that very well. EM at works an admission up enough to get them either admitted or out of the hospital. I just don't know if there is anyone actually looking over admissions not as floor appropriate but has the work up been done to be floor ready. Like starting antibiotics early, ordering the appropriate work up for a sick patient etc? Devils advocate, any consequences for providers ordering too many tests (CT for a general headache etc.) The second half of my question is actually more of an improved care model that treats people with HTN, HLD and other conditions as PCPs assuming that high risk patients going to the ED should just have an Epic account with almost a resident clinic model (whatever resident is on sees the patient) where their primary care is done there instead of a clinic. So many high risk patients are probably released into the population daily that could and probably would benefit from a primary intervention that usually is overlooked due to either their concern not being an "emergency" or thinking someone will actually follow up to a clinic (or can make the hours of a clinic). I bet if you created such a model, it would eventually reduce morbidity of high risk, high utilizes of the ED and prevent them from coming in for real emergencies like malignant hypertension or CHF.

Your questions are a bit confusing.

Yes.. ER docs do the work up and determine what work up/meds are needed now before they go to the floor.. this is pretty standard... If there is something that they have not done in the ER that I would like them to do or something that I think needs to be done sooner rather than later as they might be sitting in the ER for awhile, I will ask the ER doc to order it/do it in the ER. But if a pt is sick, they are getting the treatment they need now in the ER..

And the 2nd part of your question- I do not know where you have been, but in the ED at my hospital system, there are case managers that work with the pts who do not have PCPs and set them up with a PCP to see, often making the appointment for them. Now they cannot take the patient to the appt but they do as much as they can. Also say if a pt comes in with hypertensive urgency because they ran out of BP meds, most of the times the ED docs will give them an rx for a small amount until they get into the PCP. If you start putting a PCP in the ER, pts are going to think they can just show up there when they run out of BP meds instead of establishing with an actual PCP, which defeats the whole purpose of the ER. The ER's I am familiar with want to get pts into a PCP as they do not want them to keep coming back to the ER for nonemergent things.

 

[premedk]

And no.

I'm my Er rotation I can assure you the answer is yes....at least at many community based level 2 centers outside of big cities. Where I'm at, there is always atleast 1 em boarded guy with the IM or FM guys. The IM guys only sign up for patients within their scope of practice(80-90% of pts). You have rem these centers are mostly urgent care, with a few true emergencies. But it's all demand and supply, some places only pay non em boarded guys half, other places pay the full hourly salary. It depends how badly they need docs. Non-EM boarded guys have a better concept of the healthcare system at large including the outpt and inpatient setting, I actually think they do a better job on most patients. But if a crashing 10 year comes in the door like I saw yesterday, all bets are off for the IM and FM guys.

 

[rokshana]

But if a crashing 10 year comes in the door like I saw yesterday, all bets are off for the IM and FM guys.

and the adult EM guy as well...

 

[b-real]

and the adult EM guy as well...

The adult EM guy has training in pediatric EM in residency, the FM guy has general pediatric training and the IM guy has nothing to offer.

 

[Siggy]

. I just don't know if there is anyone actually looking over admissions not as floor appropriate but has the work up been done to be floor ready. Like starting antibiotics early, ordering the appropriate work up for a sick patient etc?

You mean like the admitting physician? As an IM resident, I don't expect the ED physician to do my job. The job I'm in training to do as a specialist and get paid to do. I view the ED as the return man on a kickoff. Sure... it's great if they can do all of those things (good starting position). It's even better if they can discharge from the ED (return for touchdown). Every so often I'm stuck on the 1 yard line (ED doesn't do their job). However, 99% of the time I'm on the 20 yard line regardless of what the ED does when they admit a patient.

The second half of my question is actually more of an improved care model that treats people with HTN, HLD and other conditions as PCPs assuming that high risk patients going to the ED should just have an Epic account with almost a resident clinic model (whatever resident is on sees the patient) where their primary care is done there instead of a clinic. So many high risk patients are probably released into the population daily that could and probably would benefit from a primary intervention that usually is overlooked due to either their concern not being an "emergency" or thinking someone will actually follow up to a clinic (or can make the hours of a clinic). I bet if you created such a model, it would eventually reduce morbidity of high risk, high utilizes of the ED and prevent them from coming in for real emergencies like malignant hypertension or CHF.

Those patients need long term follow up and need to be established with a PCP, be it a resident clinic or not. Regardless, if they don't follow up then the "primary intervention" is a waste of ED resources. If they do follow up, then the primary intervention can be done at the outpatient office.

 

[premedk]

You do realize that determining disposition is a large part of EM training, right?

Whats all this online chatter of dispositions, all I'm hearing on my rotation is talk of depositions. In fact, my attending has only been in practice for a 3 years and has already been hit by a suit. The only other rotation I've hear this much talk of lawsuits is OBGYN.

 

[gutonc]

Whats all this online chatter of dispositions, all I'm hearing on my rotation is talk of depositions. In fact, my attending has only been in practice for a 3 years and has already been hit by a suit. The only other rotation I've hear this much talk of lawsuits is OBGYN.

You need a dictionary bro. Disposition and deposition. Look 'em up and get back to us.

 

[rokshana]

The adult EM guy has training in pediatric EM in residency, the FM guy has general pediatric training and the IM guy has nothing to offer.

the peds guys (esp the peds critical care guys) would beg to differ..

a month here or there isn't really training...for peds EM, you really need Peds residency with a EM fellowship..it like saying that someone trained adult IM with the required adult EM rotation in IM training is as qualified as someone trained EM...unless of course you ARE saying that the few months an adult EM guy spends in the the Peds ED qualifies them to be peds ER docs (then of course that then negates the argument EM training is necessary to work as an EM doc)...

 

[deleted547339]

the peds guys (esp the peds critical care guys) would beg to differ..

a month here or there isn't really training...for peds EM, you really need Peds residency with a EM fellowship..it like saying that someone trained adult IM with the required adult EM rotation in IM training is as qualified as someone trained EM...unless of course you ARE saying that the few months an adult EM guy spends in the the Peds ED qualifies them to be peds ER docs (then of course that then negates the argument EM training is necessary to work as an EM doc)...

So an internist shouldn't ever run a clinic, right? I mean, they only do sporadic months and a few days for continuity.

I don't understand what the goal of your argument is. EM folks spend 25% of their time training with Peds. The training is to differentiate sick from not sick and to manage basic Peds emergencies. I don't understand what the issue is.

 

[rokshana]

So an internist shouldn't ever run a clinic, right? I mean, they only do sporadic months and a few days for continuity.

I don't understand what the goal of your argument is. EM folks spend 25% of their time training with Peds. The training is to differentiate sick from not sick and to manage basic Peds emergencies. I don't understand what the issue is.

you can't have it both ways...EM is always about how it is important for one to be trained specifically for EM...that FM and IM aren't trained to handle the different and varying levels of illness that appear in the ED...but then you can't turn around and say that those trained in ADULT EM are just as qualified to handle children peds EM guys spend 100% of their time with kids...they are not just little adults...those who train in Peds EM are trained much differently to be able to manage the emergent care of children...

the issue is that for some reason EM guys seem to think that they can take care of anything and everything...you need to know what your limits are...and i have heard peds EM and peds CC peeps bemoan the way kids are managed by adult EM guys...that they treat them as if they are adults when sometimes its the worst way to manage them.

 

[deleted547339]

you can't have it both ways...EM is always about how it is important for one to be trained specifically for EM...that FM and IM aren't trained to handle the different and varying levels of illness that appear in the ED...but then you can't turn around and say that those trained in ADULT EM are just as qualified to handle children peds EM guys spend 100% of their time with kids...they are not just little adults...those who train in Peds EM are trained much differently to be able to manage the emergent care of children...

the issue is that for some reason EM guys seem to think that they can take care of anything and everything...you need to know what your limits are...and i have heard peds EM and peds CC peeps bemoan the way kids are managed by adult EM guys...that they treat them as if they are adults when sometimes its the worst way to manage them.

First off, no one trains in "ADULT EM." The ACGME residency training is Emergency Medicine, period. We aren't trained in how to manage poorly controlled, chronic hypertension, or how to diagnose MEN2 syndrome, or how to do a whipple. However, we are trained to manage all emergencies, regardless of the subspecialty. I hear lots of specialists bemoan how things are managed in the ED. That's everyone in medicine's favorite pastime - what else is new?

You're trying to speaking about a topic on which you sound poorly informed. If you're somewhere that even has Peds EM and Peds CC folks, you are, almost by definition, at a major academic center. The practice of Peds EM at a children's hospital that sees 50K children a year is vastly different than the practice of community emergency medicine that sees 25% peds - not only that, but the practice of medicine should be different. At the academic center, you have availability of all sub-specialists, you're seeing a patient population that consists of post-op congenital heart patients, advanced cancer patients, transplant recipients, kids with in-born errors of metabolism. When you work at a community shop, the kids you see have strep, a fever, a twisted ankle, etc. Sure, you see a septic kid once in a while, but the management of that at a community shop is very different. Parents of kids with transplants know to go to the academic center. You're job as a community EM doc is to 1) recognize that kid 2) perform any emergent, time-sensitive issues and 3) ship that kid as fast as humanly possible. If the kids not sick, your job is figuring out what needs to be done to keep that kid from dying between the time you see them and the time they can see their pediatrician. This is what EM residency does. It doesn't teach you to be a Peds EM attending - it teaches you how to manage a community ED where 25% of your patients are pediatric.

I am a senior resident at a major academic center - we rotate at a couple community hospital and I moonlight at another. I've seen medicine practiced differently and practiced differently depending on where I am, and that's OK. If the PICU attending doesn't approve of what I did before I ship the kid to the PICU, I don't really care - I care that the kid gets to the PICU safely. They have the benefit of being able to sit back and review the patient's history in it's entirety. I have 10 minutes to get the sick kid out safely - I have a guy who an LP, a lac that needs to be repaired, a tech handing me an EKG, notes to catch up on and a few charts in the rack; I need to recognize those beyond my ability and ship immediately - you learn to do that in a good EM training program.

 

[rokshana]

funny h

First off, no one trains in "ADULT EM." The ACGME residency training is Emergency Medicine, period. We aren't trained in how to manage poorly controlled, chronic hypertension, or how to diagnose MEN2 syndrome, or how to do a whipple. However, we are trained to manage all emergencies, regardless of the subspecialty. I hear lots of specialists bemoan how things are managed in the ED. That's everyone in medicine's favorite pastime - what else is new?

You're trying to speaking about a topic on which you sound poorly informed. If you're somewhere that even has Peds EM and Peds CC folks, you are, almost by definition, at a major academic center. The practice of Peds EM at a children's hospital that sees 50K children a year is vastly different than the practice of community emergency medicine that sees 25% peds - not only that, but the practice of medicine should be different. At the academic center, you have availability of all sub-specialists, you're seeing a patient population that consists of post-op congenital heart patients, advanced cancer patients, transplant recipients, kids with in-born errors of metabolism. When you work at a community shop, the kids you see have strep, a fever, a twisted ankle, etc. Sure, you see a septic kid once in a while, but the management of that at a community shop is very different. Parents of kids with transplants know to go to the academic center. You're job as a community EM doc is to 1) recognize that kid 2) perform any emergent, time-sensitive issues and 3) ship that kid as fast as humanly possible. If the kids not sick, your job is figuring out what needs to be done to keep that kid from dying between the time you see them and the time they can see their pediatrician. This is what EM residency does. It doesn't teach you to be a Peds EM attending - it teaches you how to manage a community ED where 25% of your patients are pediatric.

I am a senior resident at a major academic center - we rotate at a couple community hospital and I moonlight at another. I've seen medicine practiced differently and practiced differently depending on where I am, and that's OK. If the PICU attending doesn't approve of what I did before I ship the kid to the PICU, I don't really care - I care that the kid gets to the PICU safely. They have the benefit of being able to sit back and review the patient's history in it's entirety. I have 10 minutes to get the sick kid out safely - I have a guy who an LP, a lac that needs to be repaired, a tech handing me an EKG, notes to catch up on and a few charts in the rack; I need to recognize those beyond my ability and ship immediately - you learn to do that in a good EM training program.

funny how its always the EM guys that get their feelings hurt when its even hinted that the are not the best suited or have the training for something...being a jack of all trades doesn't necessarily mean that you have the expertise to handle everything...there is a reason there is Peds EM training...

 

[Daedalus]

funny how its always the EM guys that get their feelings hurt when its even hinted that the are not the best suited or have the training for something...being a jack of all trades doesn't necessarily mean that you have the expertise to handle everything...there is a reason there is Peds EM training...

And there's a reason there's EM training - it's funny how other specialties think they can do what EM docs do as well or better (or even 80-90% of what EM docs do, as some have implied in this thread).
What would be your response to a thread started by an EM doc asking how they could get into the hospitalist business - I mean, I'm sure they'd be just as good as an IM doc with experience, right?

 

[Siggy]

And there's a reason there's EM training - it's funny how other specialties think they can do what EM docs do as well or better (or even 80-90% of what EM docs do, as some have implied in this thread).
What would be your response to a thread started by an EM doc asking how they could get into the hospitalist business - I mean, I'm sure they'd be just as good as an IM doc with experience, right?

...because as an IM resident, I should be able to handle any medical emergency better than an EM physician. Why? Because I'm trained to handle medical conditions... including medical emergencies. What am I not trained to do? OB/Gyn, peds, trauma, surgical emergencies (Granted, non-trauma surgical emergencies are both generally handled the same... call a surgeon)? That's not my bag. I'm also not trained to work the volume of patients seen in the ED because my job isn't to "Stabilize and triage to admit/discharge." The ED can settle for a touch back on a patient being admitted. I've got to take the patient to the end zone. On the other hand, I'm not getting 3 new patients per hour.

 

[Daedalus]

...because as an IM resident, I should be able to handle any medical emergency better than an EM physician. Why? Because I'm trained to handle medical conditions... including medical emergencies.

EM docs are trained to handle medical emergencies as well.... why is your training in medical emergencies better than an EM doc's training?
And as you pointed out, there are pretty big chunks of EM that you simply aren't trained to handle in any way, shape or form. So... still confused on the "better" part.

 

[ArkansasMed]

Yeah I did not mean to start a war. I think ER docs are good at what they do. I was more wondering out of curiosity and had no idea. There are a lot of performance measures most of the inpatient setting gets held to, most that are involved in a hospitals rankings. I have never heard any discussion of reviewing cases in ED to make sure the correct bare bones work up was done such as were antibiotics started at a specific time for someone with sepsis etc. I know there are measures for MI but that usually involves cards with door to balloon times. More curious given the importance of this issue.

My second point is very valid and I think people are being really foolish to think just giving someone a PCP appointment is enough to establish primary care. Overutitlization of the ED is well established and plays a huge roll in overcrowding, burnout from staff and worse health outcomes for patients. I bet if you looked at patients who constantly utilize the ED annually, you'd find they have a ton of issues that could be intervened that are not because the ED doesn't do primary care. Unfortunately, the emtala of 1986 really promotes people using the ED as their surrogate primary care. I agree, ED should be about triage, stabilization and fixing emergencies. However, new models should be incorporated into our EDs that involve primary care providers that pull these overutilizers out of the ED (more than just urgent care, literally see these patients with continuity). This could theoretically be achieved by approaching them as PCPs when you see them since online records like Epic. Models like this I bet would also promote more long term health benefits once hospitals move from rembursement based on fee for service to quality measures like Medicare is going to.

 

[Siggy]

EM docs are trained to handle medical emergencies as well.... why is your training in medical emergencies better than an EM doc's training?
And as you pointed out, there are pretty big chunks of EM that you simply aren't trained to handle in any way, shape or form. So... still confused on the "better" part.

Last time I checked, I didn't need an EM physician to take care of my critical inpatients or handle my rapid responses. Strange enough, though, all of those critical medical patients that are in the emergency room? They get an internal medicine consult in order to admit them and have the hospitalist and intensivist fix the patient's problem. Why are you better at handling a medical emergency than the people you consult in order to take care of those patients?

It's funny how EM scratches the surface of every field, thus things that they're the best at everything... and yet can't think of 3 IV antibiotics besides vanc, zosyn, and levaquin.

 

[rokshana]

And there's a reason there's EM training - it's funny how other specialties think they can do what EM docs do as well or better (or even 80-90% of what EM docs do, as some have implied in this thread).
What would be your response to a thread started by an EM doc asking how they could get into the hospitalist business - I mean, I'm sure they'd be just as good as an IM doc with experience, right?

that wouldn't be a bad idea...they can see it from the other side some of the silly admissions that come from their brethren.

 

[Nivakia]

Last time I checked, I didn't need an EM physician to take care of my critical inpatients or handle my rapid responses. Strange enough, though, all of those critical medical patients that are in the emergency room? They get an internal medicine consult in order to admit them have have the hospitalist and intensivist fix the patient's problem. Why are you better at handling a medical emergency than the people you consult in order to take care of those patients?

It's funny how EM scratches the surface of every field, thus things that they're the best at everything... and yet can't think of 3 IV antibiotics besides vanc, zosyn, and levaquin.

But their approach to headache is topnotch

 

[Siggy]

But their approach to headache is topnotch

Step 1: Don't order head CT
Step 2: Medicine admits, gets CT, finds head bleed.
Step 3: ICU to ICU transfer now takes 10 hours where an ED to ED transfer would have taken less than an hour.
Step 4: Profit by keeping door to disposition times down.

 

[premedk]

My two cents is that er doctors are expected to know about essentially every specialty out there and in all age groups. But most would probably trust a medicine doc for medicine emergencies, a peds doc for peds emergencies, a surgeon for surgical emergencies, an ICU doc for patients in shock...etc. But none of those specialties can handle issues from the other specialties or are you expected to, yet the er guys can. Most ER doctors consider themselves a jack of all trades some forget that they are a master of none.

What I'm seeing with my limited time working in the ER, is that many ER doctors will openly admit that they aren't even really forming a true differential, instead just deciding whether to admit or discharge. This leads to missed diagnosis. A few days ago a young patient with acute onset lower extremity weakness was sent home with suspicion of malingering only to come back a few days later after the neurologist diagnosed him with GBS.

I've also noticed that ER docs are hypersensitive to criticism, and most of my rotation has been spent with the attending's defending their specialty to the students since noone else will listen.

 

[deleted547339]

...because as an IM resident, I should be able to handle any medical emergency better than an EM physician. Why? Because I'm trained to handle medical conditions.

That's comical.

 

[IMreshopeful]

That's comical.

More sad than comical given the number of frigging times I've had to convince the ED to start antibiotics on patients who were septic. And this is at an institution with a reputable EM residency.

I think EM starts with proper intentions for learning how to appropriately diagnose and treat serious conditions early on. Then when the residents join the real world they become jaded and don't give two ****s as long as they "dispo" the patients. Maybe there needs to be more streamlined ED triaging procedures to allow for more time to appropriately manage the patients? I dunno. But clearly if everyone thinks there's an issue, there probably is one.

 

[IMreshopeful]

Step 1: Don't order head CT
Step 2: Medicine admits, gets CT, finds head bleed.
Step 3: ICU to ICU transfer now takes 10 hours where an ED to ED transfer would have taken less than an hour.
Step 4: Profit by keeping door to disposition times down.

Step 5: lawsuit

 

[Beacopp665]

Every institution is different I'm sure, But at our place the only indication for getting a head CT seems to be having a head.

 

[Siggy]

That's comical.

Comical is running a code for the ED in the VQ scanner because they had to rule out PE in a patient with DKA and a pH of 6.9.

Comical is diagnosing a stroke in a woman where ED just chocked it up to a hypertensive emergency and gave 10 of hydralazine with a 0.2 clonodine chaser. "Because it's most likely a hypertensive emergency than a stroke." CT head already showed 2 chronic strokes.

Comical is when every drunk or druggy who tries to AMA from the ED gets placed on a psych hold... even when it's in the plain language of the law that those patients don't qualify for holds.

Comical is when the PMD actually faxes over records, the ED goes, "Oh, that's what those are? We just toss everything that comes through the fax machine."

Comical is the ED going, "But but but this is septic shock! We just don't have a source!" in the woman who is hypernatremic, putting out a liter of urine an hour, and has a prior diagnosis of central DI and is on desmopressin at home. I fixed the "septic shock" with a single dose of desmopressin.

 

[rokshana]

Comical is running a code for the ED in the VQ scanner because they had to rule out PE in a patient with DKA and a pH of 6.9.

Comical is diagnosing a stroke in a woman where ED just chocked it up to a hypertensive emergency and gave 10 of hydralazine with a 0.2 clonodine chaser. "Because it's most likely a hypertensive emergency than a stroke." CT head already showed 2 chronic strokes.

Comical is when every drunk or druggy who tries to AMA from the ED gets placed on a psych hold... even when it's in the plain language of the law that those patients don't qualify for holds.

Comical is when the PMD actually faxes over records, the ED goes, "Oh, that's what those are? We just toss everything that comes through the fax machine."

Comical is the ED going, "But but but this is septic shock! We just don't have a source!" in the woman who is hypernatremic, putting out a liter of urine an hour, and has a prior diagnosis of central DI and is on desmopressin at home. I fixed the "septic shock" with a single dose of desmopressin.

can i like this twice?

 

[IMreshopeful]

Comical is running a code for the ED in the VQ scanner because they had to rule out PE in a patient with DKA and a pH of 6.9.

Comical is diagnosing a stroke in a woman where ED just chocked it up to a hypertensive emergency and gave 10 of hydralazine with a 0.2 clonodine chaser. "Because it's most likely a hypertensive emergency than a stroke." CT head already showed 2 chronic strokes.

Comical is when every drunk or druggy who tries to AMA from the ED gets placed on a psych hold... even when it's in the plain language of the law that those patients don't qualify for holds.

Comical is when the PMD actually faxes over records, the ED goes, "Oh, that's what those are? We just toss everything that comes through the fax machine."

Comical is the ED going, "But but but this is septic shock! We just don't have a source!" in the woman who is hypernatremic, putting out a liter of urine an hour, and has a prior diagnosis of central DI and is on desmopressin at home. I fixed the "septic shock" with a single dose of desmopressin.

My personal favorite was the "low risk ACS rule out" I admitted a few months back overnight in a guy with a history of a CABG two years ago and having daily typical angina with exertion that turned into angina randomly at rest with evolving ST depressions. I tell the ED attending that this guy is more appropriate for our inpatient cardiology service who then, flat out lies and tells us cardiology didn't want the patient, then the guy requires a nitro drip a couple hours later and is sent emergently to the cath lab for possible posterior MI.

So yeah great work with that "emergency triage" guys.

 

[Siggy]

What I love now is that, apparently, there's a growing pseudo-sub-specialty (I use "pseudo" because it's a non-fellowship subspecialty in the same sense of hospitalist vs outpatient IM) of "resuscitationists" in EM where all of the sick people go to one provider. Um... isn't the resuscitation like the entire point of the specialty? http://emcrit.org/ed-intensivist-roles/

I understand that EM sees enough and gets enough critical care patients that it makes sense to allow them to go through critical care fellowship and staff the unit. However, it doesn't make sense to me to shuffle all critical care patients in the ED to a critical care EM physician and basically make the rest of the ED the very thing that EM fights against... being a glorified urgent care unit, except with the option to admit.

 

[deleted547339]

Comical is running a code for the ED in the VQ scanner because they had to rule out PE in a patient with DKA and a pH of 6.9.

Comical is diagnosing a stroke in a woman where ED just chocked it up to a hypertensive emergency and gave 10 of hydralazine with a 0.2 clonodine chaser. "Because it's most likely a hypertensive emergency than a stroke." CT head already showed 2 chronic strokes.

Comical is when every drunk or druggy who tries to AMA from the ED gets placed on a psych hold... even when it's in the plain language of the law that those patients don't qualify for holds.

Comical is when the PMD actually faxes over records, the ED goes, "Oh, that's what those are? We just toss everything that comes through the fax machine."

Comical is the ED going, "But but but this is septic shock! We just don't have a source!" in the woman who is hypernatremic, putting out a liter of urine an hour, and has a prior diagnosis of central DI and is on desmopressin at home. I fixed the "septic shock" with a single dose of desmopressin.

We get it. Our training is worthless and we're just lucky to work in your hospital.

 

[Siggy]

We get it. Our training is worthless and we're just lucky to work in your hospital.

We get it... we're just suppose to bend over and ask, "Please Sir, may I have another?" every time EM goes, "Dur, we're the best at everything because we see everything... even if our training barely scratches the surface and the sad reality is that given our workload we "stabilize" and decide disposition without regards to differentials or... you know... considering the patient's past medical history and current medications."

Actually, if you read my first couple posts on this thread, I'm supporting the scope of practice and purpose of the emergency department. You're the one that pointed out that my training, as an internist, includes handling medical emergencies (and, as I pointed out, not trauma, peds, or ob/gyn emergencies) in totality. That means the resuscitation, critical care, post critical care, and discharge portion. EM? Only training in the resuscitation portion and the critical care portion.

Also, don't fling pathetic comments like "That's comical" (which is the post, in it's entirety, while providing no actual substance) and then act surprised when you get called out on such nonsense.

 

[deleted547339]

We get it... we're just suppose to bend over and ask, "Please Sir, may I have another?" every time EM goes, "Dur, we're the best at everything because we see everything... even if our training barely scratches the surface and the sad reality is that given our workload we "stabilize" and decide disposition without regards to differentials or... you know... considering the patient's past medical history and current medications."

Actually, if you read my first couple posts on this thread, I'm supporting the scope of practice and purpose of the emergency department. You're the one that pointed out that my training, as an internist, includes handling medical emergencies (and, as I pointed out, not trauma, peds, or ob/gyn emergencies) in totality. That means the resuscitation, critical care, post critical care, and discharge portion. EM? Only training in the resuscitation portion and the critical care portion.

Also, don't fling pathetic comments like "That's comical" (which is the post, in it's entirety, while providing no actual substance) and then act surprised when you get called out on such nonsense.

No. I'm just perpetually surprised by the lack of understanding of the training of EM by other specialties. We are not mini-internists with a little extra training in peds, ob and trauma. We are specialists in emergencies. Your training in internal medicine is extraordinarily valuable, but you are not the expert in medical emergencies.

 

[Siggy]

No. I'm just perpetually surprised by the lack of understanding of the training of EM by other specialties. We are not mini-internists with a little extra training in peds, ob and trauma. We are specialists in emergencies. Your training in internal medicine is extraordinarily valuable, but you are not the expert in medical emergencies.

Which is why EM responds to rapid responses in the hospital... oh wait... they don't. If the patient on the floor is having an emergency, and the EMP is the expert in emergencies, shouldn't they be responding?

 

[Apollyon]

Which is why EM responds to rapid responses in the hospital... oh wait... they don't. If the patient on the floor is having an emergency, and the EMP is the expert in emergencies, shouldn't they be responding?

Dude, once you get into the real world, and out of the residency bubble, you'll see that, often, especially in the 90% of American hospitals that are community hospitals, where there are no residents, overnight, the emergency physician is the only doctor in the hospital (like I am right now). When I was a resident, we went to all first floor and lower codes, including in radiology. The IM guys were second floor and higher. Our relationships with IM sounded MUCH more collegial than all of the burning going on in here. In fact, just as a point, my program director was asked by the IM program director to stop working patients up so completely, because that was leaving his residents with nothing to do but chase labs and write notes. All the fun was gone, because we were taking it. Hell, I got a ceruloplasmin level (resulted) on a Sunday night!

What happens in your hospital is local; it likely can't - across the board - be extrapolated globally. In the community? Hospitalists are comfortable working floor codes. The admitting PMDs? Not so much. Where I am now, there is one IM doc that works ~2 shifts a month in the ED, and he is HORRIBLE: he knows NOTHING about Ob/Gyn, peds (he did a CT on a 3 WEEK old), or trauma, and is also culture-bound beyond that. He can't intubate, do an LP, or put in a chest tube. He WON'T do a pelvic. And he refuses to learn.

So, outside the ivory tower of residency, and outside the upper floors of IM subspecialty, in the real world, people aren't so at each other's throats. And I go to the upstairs codes.

 

[rokshana]

No. I'm just perpetually surprised by the lack of understanding of the training of EM by other specialties. We are not mini-internists with a little extra training in peds, ob and trauma. We are specialists in emergencies. Your training in internal medicine is extraordinarily valuable, but you are not the expert in medical emergencies.

oh no we get it...y'all just don't like it when we say its pretty much triage...

 

[rokshana]

Dude, once you get into the real world, and out of the residency bubble, you'll see that, often, especially in the 90% of American hospitals that are community hospitals, where there are no residents, overnight, the emergency physician is the only doctor in the hospital (like I am right now). When I was a resident, we went to all first floor and lower codes, including in radiology. The IM guys were second floor and higher. Our relationships with IM sounded MUCH more collegial than all of the burning going on in here. In fact, just as a point, my program director was asked by the IM program director to stop working patients up so completely, because that was leaving his residents with nothing to do but chase labs and write notes. All the fun was gone, because we were taking it. Hell, I got a ceruloplasmin level (resulted) on a Sunday night!

What happens in your hospital is local; it likely can't - across the board - be extrapolated globally. In the community? Hospitalists are comfortable working floor codes. The admitting PMDs? Not so much. Where I am now, there is one IM doc that works ~2 shifts a month in the ED, and he is HORRIBLE: he knows NOTHING about Ob/Gyn, peds (he did a CT on a 3 WEEK old), or trauma, and is also culture-bound beyond that. He can't intubate, do an LP, or put in a chest tube. He WON'T do a pelvic. And he refuses to learn.

So, outside the ivory tower of residency, and outside the upper floors of IM subspecialty, in the real world, people aren't so at each other's throats. And I go to the upstairs codes.

please..in the real world the EM guys are looking to see how fast they can dispo the pt out of the ED...which doesn't mean that they actually touch a patient to do so...if they are old and "dwindly" they get admitted...heck if they are just old it will get them admitted...if their SCr is 4.2 when the baseline is 4.1, they get admitted...

...and i have NEVER seen an EM resident at a code...even in the CT scanner next to the ED...

 

[deleted547339]

Which is why EM responds to rapid responses in the hospital... oh wait... they don't. If the patient on the floor is having an emergency, and the EMP is the expert in emergencies, shouldn't they be responding?

Where I moonlight, I am the rapid response team....