Some newbie questions re: gas & EM

[Veritas]

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Hi everyone, I've been lurking on this forum for awhile, but have a few questions now. I've read through all the old posts and stuff. I'm an MS3 that just recently "discovered" this whole gas thing, but throughout undergrad and pre-clinicals, I thought emergency med was the way to go.

I'm wondering if there's anybody else out there that was considering EM, and eventually decided on gas. If you could kinda describe your thought process, that'd be really great. I thought I'd love EM (and no, not because of the TV show), and I do love the 10-20% of cases that are real emergencies, but I think I'm starting to realize that the other 80-90% would drive me just a little insane. Also, not being able to truly run trauma at some (or most?) hospitals is something I never really thought about either, which is another turn-off, since that was one of the reasons I was interested in it in the first place.

Gas, on the other hand, is something I never thought was fast-paced enough, but I've always liked physio, and for reasons I can't really even explain, this just seems like a really cool specialty. You have the interesting things going on in the OR, but without the grief of a surgery lifestyle. The intense (albeit short) patient interaction, the procedures, the immense wealth of knowledge you need, and hey, the $$ isn't too shabby either. Sounds real nice, except for the whole sit around for hours and monitor part (and I know how much thinking goes on during this time, but still). But hey, as far as cons go, that sure beats rounding, or surgery hours, or drug-seekers in the ER, etc.

Any thoughts on gas & EM from the enlightened docs on this forum would be most appreciated. Thanks.

 

[PiPhiDoc]

I did 3years of a 4 year EM residency before changing to anesthesiology, so I can probably add my 2 cents to this question!
As far as why I left EM - lots of reasons. Very similar to what you touched upon -- I found that the "social disease" that predominates in many of the ED population of patients drove me crazy -- mainly because I felt so frustrated that there was nothing that I could do about many of the problems such as drug/alcohol abuse, homelessness, lack of access to care, ect ect. I also found the unique death and dying issues that the EM doc faces nearly every day overwhelming -- unlike many other specialties where people are ill in the hospital for a time and then die, so their families are somewhat prepared, the EM doc has to face a family who either have no idea that their loved one is really that critically injured, or the last time they saw them they were perfectly well. The violent dealths, particuarly of children, also really got to me when I worked at our trauma center.
I also found that I HATED the endless stream of nights/weekends/holidays -- who cares if its shift work if all of your time off is Mon-Fri when your spouse/family/friends are at work? And the "move the meat" pressure of constantly trying to get people out of the ED, which is becoming more and more important as our ED's become overrun with patients was stressful. All of this added up to me becoming cynical and resentful of patients at times, and I really did not want to become some toxic, burned out doc who hates patients and is generally a real jerk to be around. So I changed to Anesthesiology -- and let me tell you, I could not be happier!!!! I come home every day and tell my husband how much I love my job. I feel like I actually have a significant impact on patients - I have to immediately form a relationship with a patient who is quite anxious, and get their trust that I will take care of them during what they perceive as a frightening experience. I also find it very rewarding on the other end of things to see them wake up comfortable, or find out on my post-op visit that their epidural or nerve block has kept them comfortable. I also love the amount of procedures that we do, and I find the daily use of physiology/pharmacology facinating. It is also just a lot of fun to be in the OR, but heck -- I get to leave and have lunch/use the bathroom/go HOME!!!!
My hours are also TONS better -- early mornings, but a lot more weekend/evening time with my family, which is huge to me.

Hope that answers some of your questions - good luck!

 

[chicamedica]

Veritas, I'm also an MS-3. I was also very interested in EM throughout preclinical years (based on a 1-afternoon shadowing experience, my impression that EM residents are very friendly and collegial, and also my interest in being on the front lines of traumas and critical patients). I also just discovered after doing 1 week of an EM rotation, that I feel EXACTLY the way you do. And hearing experiences of people like you and Phiphidoc makes me even more sure that anesthesia is the way to go for me. . .

I've always been bored by primary care clinic stuff, like family practice--and EM is mostly (80-90% like you said) just an endless stream of fast BAD primary care with no longitudinal follow-up, which makes it even LESS interesting than FP. All the interesting stuff goes to the trauma team (surgery), ortho, the CCU, the ICU, etc etc, unless there's an overload. I started realizing that although EM requires a lot of PHYSICAL energy, the mental brainwork is minimal, meaning that you feel burned out but you're still bored. If I had to choose between the two I would now actually prefer doing family practice over EM (and as I said, FP is not at the top of my list. . .), because at least it's more relaxing and you get to find out the whole story about the pt. And like PhiPhidoc said, those shifts seem endless. . .both within each shift, and in number of shifts.

After I realized this truth about EM, I had a couple of weeks of surgical subs (ENT, Ophtho), and I got observe some of those surgeries in the OR. Truthfully, I was fascinated by what the anesthesia team did, more so than the actual surgeries (especially in ENT--how boring!!). But even during one surgery that was pretty cool in ophtho that involved a total eye removal, the anesthesia resident (who was SUCH a sweet guy, as most of them are) was all hyped about observing the surgery with us med students. So even though there was a period of time when all he had to do was monitor the pt, he was still having tons of fun watching the surgery (he was more enthusiastic than the surgeons!!).

More than once, I've also noticed that the anesthesia residents are usually the ones that break the ice and relax the strict up-tightness in the air imposed by the surgeons.
I really love that.

I still haven't had my anesthesia rotation though, and since I tend to be more of an intuitive decision maker, I should wait until I experience anesthesiology more to make my decision for sure.
But right now it's anesthesia/critical care ALL THE WAY, BABY!!!!
😍 😍 😍

 

[powermd]

I'm an M4 applying for anesthesiology residencies and I can echo many of the comments made so far. There were aspects of EM that I liked in my third year- that "whole doctor" thing, being able to do both primary and acute care, life-threatening problems, lifestyle.. but I discovered that the truth behind these supposed benefits leaves much to be desired (addressed in previous posts). I like IM and cardiology, but the duration of training is obscene. I liked surgery initially, but eventually found it to be tedious drugery. I also hate it when I am scrubbed in and can't friggin scratch my nose.

I have done two months of outside rotations in anesthesiology and I am absolutely hooked. I love how laid back and cool many anesthesiologists are, yet when problems arise, they spring into action and take care of business. I love the fact that anesthesiology challenges you to think on your feet, anticipate problems, and deal with things that have to be fixed immediately. You get to be an expert in a number of critically important disciplines. I love having the OR be my office- to me that's where all the action of the hospital is centered. The long, uneventful stretches of a well-run case are actually satisfying- because the anesthetic is being done well, and relaxing, because no one is bothering you with annoying tasks. If you are at a hospital that operates on sick patients, many cases do not afford much opportunity to relax, so I learned to appreciate the ones that went smoothly. If you get lonely in the OR, you can have students with you and teach. The days start early, and can run long, but your schedule is controllable, and you are well paid. I really wish I were starting my CA-1 year instead of my internship!

 

[Gator05]

Write on, fellow future gassers!

One of the coolest parts of my elective was a pretty lengthy neuro case, when I looked back and saw the patient's vitals perfectly horizontal (or at least nearly so), despite a rather eventful case hemodynamically. The process of anticipation, action and then satisfaction was an awesome experience, even though it made for what some would call a "boring" case!

 

[Veritas]

I just wanted to say thanks for all the great replies so far- this is really reaffirming what I've been thinking. I'm feeling exactly the same way it seems you guys did too. I was also an EMT, and just figured that it would be a natural progression to EM, but I wasn't expecting all these hidden cons.

As far as the hours- I agree that who cares about shift work if your shift doesn't allow you to see your family. I don't mind getting up early in the morning if it means I get to spend the afternoons, weekends and holidays with my wife and kids! Also, like someone said, I can see how it must be great to be able to just concentrate on your case without having to worry about any other bull$hit. Your pt is your pt, and you can devote all your thought and energy towards the case without any distractions. I really like that. And all the gas people I've met so far, from attendings to residents, have been very friendly, laid-back, and down to earth. The more I learn about this specialty, the more it seems like the perfect thing for me to get into.

Like chicamedica said, I guess I'll eventually end up doing rotations in both just to make my eventual decision as informed as possible, but from the informal observing that I've done in both departments so far, I'm pretty convinced that gas is the way to go.

Thanks so much for the input, and keep it coming!

 

[gaslady]

I'm in anesthesia and my husband is in EM. The two fields are similar is some ways, but the personalities that go into the 2 fields are pretty different. I just finished an ED rotation and while there I noticed that many of the ED docs tend to have a short attention span and are easily able to move from patient to patient. You have to be good at multitasking. You do that in the OR as well, but it's different b/c you only have 1 patient. You can't be the kind of person who continually second guesses yourself and takes a long time to make a decision. If you do that you'll get buried in the ED. Sometimes you have to make quick assessments and action in the OR but it's a more controlled, predictable situation because you only have 1 patient (with equally as serious consequences though). There are different cons to the 2 fields. In the ED you have to deal with a lot of social & psych issues, trivial complaints, and sad situations as previously mentioned in this discussion. You get to see first hand many of the ills of our society on a regular basis. In the OR you are often under appreciated as the patients tend to consider the surgeon to be "their doctor" and some of the surgical personalities are hard to deal with. I believe anesthesia is best for people who get satisfaction from within, not from external validation. The ED doc more often has the opportunity to be the hero to the patient. The OR has an element of routine that I find satisfying and rely on, but others find it to be boring.
Good luck!

 

[Matty]

This is good stuff........anyone from the EM side have any input?
(hint, hint, Moderator) 😉

 

[bryanboling5]

I'm a pre-med student who works in the ER of a busy Trauma center and I'm also confused about EM vs. anesthesia. I love them both! What I really want to do is critical care/Trauma but I don't really want to be a surgeon. I've talked to some folks who do EM/Critical Care (at Pitt) and some folks who did EM but then did a Trauma fellowship (they've got one at Maryland for EM grads) and now split their time in the ER and the Trauma ICU/Trauma resus team. I agree with the previous post, I'd like to hear something from EM folks on this subject. Can anyone else offer really good advice on the best route to take to do Trauma/Critical care other than surgery? Here, our EM and Anesthesia depts neither one do a lot with those. Our EM residents share initial trauma duties with the Trauma surg team (on a week to week rotation) but that's about it.

I read an article not long ago arguing that surgery really shouldn't be the team to run Trauma because a larger percentage of traumas DON'T go to the OR right away. This article argued that Anesthesia should do it, but I would think that EM (with proper additional training in Critical care and some OR experience similar to Anesthesia) would be just as suited. Any thoughts on that?

Like I said, around this area, most EM and Anesthesia folks are more interested in the "bread-and-butter" stuff because it equates to more time off. Not that there's anything wrong with that! But that's not what I'm drawn to and so it's hard to get an accurate portrait of what kind of career I COULD have.

 

[emtp2pac]

henry ford in detroit now has a 6 yr em/im/critical care residency leading to triple board certification. that might be the way to go...

 

[omarsaleh66]

I'm at ms1 at texas tech that is interested in anesthesia and em. I have shadowed anesthesiologists in the OR and it seemed really cool. They were really happy with their job, their shifts and the money they were making.

the anesthesiologists were making like 300,000 dollars working 40-50 hours a week, and said that they could make up to 500,000 dollars if they worked 70-80 hrs a week.

They also loved their job, and the hours were real nice.

that was anesthesia in the OR.

Then, i went to see how anesthesiologist work in private practice and I became even more impressed. I shadowed a doctor that did anesthesia relating to pain. this was really cool. In this type of work, i got to see people who were in pain for years get treated. It was really gratifying to see how thankful they are.

Anesthesiologists do alot of interventional procedures to treat pain, and problems dealing with nerves and muscles that neurologists or other physiicians cant treat and one has to realize that anesthesia isnt just the OR. There is a wide turf for one to do all types of cool stuff.

In terms of the hours, in a private practice, the anesthesiologist , i guess had partners so they had shifts like ER docs and were only on call about 3-4 days a month.

The pay is much better and the work is similar and is not just limited to OR. As an anesthesiologist doing fellowship in pain management, one can do really well in private practice as well, and get to treat patients and get gratification in other ways. Also u can have the challenge of doing interventional surgical procedures as well. I got to see some really cool stuff so right now, i am kinda leaning towards anesthesia more than EM.

however, i am just a 1st year so there';s alot of time

peace

Omar

 

[juddson]

This is one of the best threads I have read on this forum for a long time. I feel like I am getting a good idea about what it means to do Gas and EM. AND, there's been no petty turf-fighting, which has been good.

Wondering if you can answer me a question (which might take us off topic--but I'm not sure): What sort of docs make up the ICU teams (the NICU teams, for that matter). Are these people IM or something else? Are these people called "intensivists" (a term I read somewhere) and is it shift-work where you are tied down to that unit, or is it something different? It seems to me that an MDA is well suited to do physiologically intensive sorts of work. Am I wrong about this?

And what is pain management anyway? Is this primarily private "pain clinic" sort of work? What sort of patient's need pain management care? Is this acute care, or do these sorts of patients need this kind of treatment forever?

Thanks
Judd

 

[Skrubz]

to answer a couple questions to the best of my knowledge...

in adult ICUs, intensivists tend to be board-certified internists, surgeons, or anesthesiologists. i think NICU/PICU tend to have pediatricians who specialize in critical care but i don't think there's an actual certification process for it.

regarding pain management, there are two major aspects to pain management, acute and chronic. the acute pain service typically deals with inpatients who are in pain for various reasons (post-op, various infections, malignancy, whatnot) and includes a lot of PCA and epidurals. in the clinic, pain specialists see a lot of people with chronic pain (malignancy, degenerative joint/disc disease, complex regional pain syndrome, and much more). there's a lot of medication (NSAIDS and COX-2, some anti-depressants, some anti-seizure, and, of course, opiates) prescribed in the clinic, and you always have to be on the lookout for malingerers and drug-seekers. i'd say most of your patients in clinic end up becoming chronic. there are some interesting procedures for pain specialists to do as well (various nerve blocks, epidural steroid injections, spinal cord stimulator placement, etc). but, a lot of the procedures require fluoroscopy and therefore lots of lead. and the results vary widely. i hear there are some people contracting with hospitals to be interventional pain specialists (just do the cool procedures and skip the clinic).

i personally thought i wanted to go into pain... but after doing it, the only way i'd be able to do pain is just interventional because being clinic just aggravates me. thankfully, i'm also interested in critical care. 🙂

 

[gaslady]

In terms of ICU there are many paths and specialties that cover the units. The neonatal ICU (NICU) is covered by neonatologists. This is a fellowship after peds. The majority of critical care doctors go through IM and then do a pulmonary and critical care fellowship. There is a wide range of practice for these docs from outpt pulmonary private practice, asthma clinic, to a mix or only working in the ICU as an intensivist. Intensivist is the ICU equivalent of a hospitalist. Hospitalist is generally an IM doctor who only takes care of patients in the hospital.
Some ICUs are open which means that private doctors can take care of their patients when in the ICU. Others are closed meaning that when a patient comes they get taken care of by the ICU team even if they have a private doctor.
Anesthesiologists also work in ICUs but make up a small percentage of critical care doctors. There is a critical care fellowship however, you don't necessarily have to do it to work in an ICU depending on where you practice.

In terms of picking between alternate routes to get to the same point (EM vs. Surgery vs. anesthesia to get to do trauma), it is essential that you look at the basic differences of the various residencies and pick the one that best suits you overall. You may chose one path thinking you will take it to get to a certain specialized point but absolutely hate the path you have to take to get there. Then you could wind up with a specialty choice that you don't like. If you niche that you have selected ahead of time doens't turn out to be what you thought it would be, you've put yourself in a bad situation.

Anesthesiologists don't really run traumas. They can run codes. Generally for trauma they may come to the ED to manage the airway, but they don't even do that everywhere. At a lot of places respiratory therapy, surgery, or EM intubates, with anesthesia being called for difficult airways. As a student you have the false perception that trauma is very challenging. In reality it's an algorithm that you have to go through that many EM docs find routine once they have learned it. It is very exciting though and can be difficult because of the injuries that you see on a regular basis.