lymphocyte

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Delay in getting a patient to radiology. Yeah, I'll take them down myself.

ED dumps a crashing patient on you. Don't worry, I'll sort it out. Tube, lines, done. I control their physiology now -- until I can't.

The agony of resuscitation. The art of deresuscitation. The feeling that -- this needs to happen, right now, or this person dies, so get it done. And if you need to go home, that's fine, but I'm here all night.

We're at war with death, and in the end it's a war we all lose -- but by skill and luck, not today. So let's fight this battle my friend, my patient. We fight together.

I just finished a ten day stretch and all I want is more. The rush is freaking intense. I. Love. This. Job.
 
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jdh71

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Delay getting a patient to radiology. Yeah, I'll take them down myself.

ED dumps a crashing patient on you. Don't worry, I'll sort it out. Tube, lines, done. I control their physiology now -- until I can't.

The agony of resuscitation. The art of deresuscitation. The feeling that -- this needs to happen, right now, or this person dies, so get it done. And if you need to go home, that's fine, but I'm here all night.

We're at war with death, and in the end it's a war we all lose -- but by skill and luck, not today. So let's fight this battle my friend, my patient. We fight together.

I just finished a ten day stretch and all I want is more. The rush is freaking intense. I. Love. This. Job.
Should I be the curmudgeon and foil on the second post in this thread?

You get over it. I say this kindly though.

Sometimes I wish I still had that "rush" of it all still, but I don't; however, reading your post makes me smile fondly. It's what the discipline needs more people who want to do it. You see, I'm not saying, "I don't like my job," because I do, and I'm glad I get to do what I do. I still have quaint ideas about it being a "calling" and even quainter ideas in today's secular world that this is what my God wants me to do. All I'm saying is hold onto these times, bottle them away like precious tincture for the times in the future when it isn't so glamorous any longer and at thirty minutes before the end of a long shift, all you can see is "more work" and not someone who needs your help desperately.
 

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Delay getting a patient to radiology. Yeah, I'll take them down myself.

ED dumps a crashing patient on you. Don't worry, I'll sort it out. Tube, lines, done. I control their physiology now -- until I can't.

The agony of resuscitation. The art of deresuscitation. The feeling that -- this needs to happen, right now, or this person dies, so get it done. And if you need to go home, that's fine, but I'm here all night.

We're at war with death, and in the end it's a war we all lose -- but by skill and luck, not today. So let's fight this battle my friend, my patient. We fight together.

I just finished a ten day stretch and all I want is more. The rush is freaking intense. I. Love. This. Job.
The ED isn't dumping a crashing patient on you. That’s actually why we exist.
 

gulmohr

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Delay getting a patient to radiology. Yeah, I'll take them down myself.

ED dumps a crashing patient on you. Don't worry, I'll sort it out. Tube, lines, done. I control their physiology now -- until I can't.

The agony of resuscitation. The art of deresuscitation. The feeling that -- this needs to happen, right now, or this person dies, so get it done. And if you need to go home, that's fine, but I'm here all night.

We're at war with death, and in the end it's a war we all lose -- but by skill and luck, not today. So let's fight this battle my friend, my patient. We fight together.

I just finished a ten day stretch and all I want is more. The rush is freaking intense. I. Love. This. Job.
Days meld into nights into days. Fear loses you. The ICU never sleeps so why should you? You are both manic and zen. The patient is God and you are one with the patient. Sometimes they get better and leave, sometimes they don't and leave. You will not exult. You will not mourn. You will remain present. You will remain humble in victory and in defeat. The patient is God. You will worship at the bedside. You will lose faith at times. You will question yourself. But if not you, then who? May your path always be true and your intentions always honorable.
 
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lymphocyte

lymphocyte

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The ED isn't dumping a crashing patient on you. That’s actually why we exist.
I get it.

But ED--not ED in general, my ED--wheeled down a guy on NIV with profound abdominal dyssynchrony, FiO2 climbing by the minute, eyes starting to roll into the back of his head -- honestly looked like a kid with croup, the bad kind. Dying right in front of you.

Nurses look shocked, resident keeps walking in and out of the room, nobody wants to be there. **** that. Tube now or never. Get it done. And then you make a 100 decisions all at once. Plan A, B, and C. But it really needs to be Plan A and Plan C involves a very sharp knife.

Take a deep breath, organise the crowd, work the checklist. Ready? Ketamine. Roc. Wait. You go in, great view of a very narrow glottis and even the bougie feels tight going through.

He was sold as a "COPD exacerbation" and "it's really busy here" and "he looks fine" and "can we just send him down." Turns out it's 10 till handover and everybody wants to get outta Dodge.

I may only locum in EM, but I don't think any self-respecting EM doctor would've let a patient like that be transported unescorted down a very long corridor.
 
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lymphocyte

lymphocyte

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All I'm saying is hold onto these times, bottle them away like precious tincture for the times in the future when it isn't so glamorous any longer and at thirty minutes before the end of a long shift, all you can see is "more work" and not someone who needs your help desperately.
Sage as usual. I hope I never, ever forget this feeling.
 
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TimesNewRoman

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I get it.

But ED--not ED in general, my ED--wheeled down a guy on NIV with profound abdominal dyssynchrony, FiO2 climbing by the minute, eyes starting to roll into the back of his head -- honestly looked like a kid with croup, the bad kind. Dying right in front of you.

Nurses look shocked, resident keeps walking in and out of the room, nobody wants to be there. **** that. Tube now or never. Get it done. And then you make a 100 decisions all at once. Plan A, B, and C. But it really needs to be Plan A and Plan C involves a very sharp knife.

Take a deep breath, organise the crowd, work the checklist. Ready? Ketamine. Roc. Wait. You go in, great view of a very narrow glottis and even the bougie feels tight going through.

He was sold as a "COPD exacerbation" and "it's really busy here" and "he looks fine" and "can we just send him down." Turns out it's 10 till handover and everybody wants to get outta Dodge.

I may only locum in EM, but I don't think any self-respecting EM doctor would've let a patient like that be transported unescorted down a very long corridor.
So I’m both EM and ICU. The skill set and knowledge base are, although they overlap significantly, vastly different. The value of longitudinal care is invaluable and something you can’t get in the ED or EM training. You should pride yourself as an ICU doc as the guy or gal who loves a patient coming in hot.

And trust me, a busy ED can be a mess. You ever had 20 patients check in over 2 hours when you’re the only ER doc? I have. It’s a zoo. Sometimes the best thing to do is just get them out. Don’t get me wrong, I’m not saying that the ED can do no wrong, I’m just saying you should always give them the benefit of the doubt. You don’t know that a STEMI and an 18 year old kid shot in the chest didn’t just roll in at the same time while the ER doc is thinking “get this guy to the unit, they can handle it. I gotta go keep this kid alive”
 

Siggy

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The ED isn't dumping a crashing patient on you. That’s actually why we exist.
Then why does the ED exist and why does the EM forum act like they're gods of resuscitation instead of masters of triage? I mean... a patient having an emergency surrounded by emergency physicians in an emergency department should have the emergency managed. It's like there is a common theme among the adjectives.
 

Siggy

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And trust me, a busy ED can be a mess. You ever had 20 patients check in over 2 hours when you’re the only ER doc? I have. It’s a zoo. Sometimes the best thing to do is just get them out. Don’t get me wrong, I’m not saying that the ED can do no wrong, I’m just saying you should always give them the benefit of the doubt. You don’t know that a STEMI and an 18 year old kid shot in the chest didn’t just roll in at the same time while the ER doc is thinking “get this guy to the unit, they can handle it. I gotta go keep this kid alive”
Yep... and it sounds like that's an ED where a staffing decision was made and the ED is expecting the ICU to fix their staffing decision. It's like the inpatient docs at my hospital who wants everyone in the ICU because "The nurses on stepdown are terrible and it's understaffed." Well... it's not my job to make sure that stepdown is both properly staffed with good nurses and this patient doesn't meet ICU criteria.
 

TimesNewRoman

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Then why does the ED exist and why does the EM forum act like they're gods of resuscitation instead of masters of triage? I mean... a patient having an emergency surrounded by emergency physicians in an emergency department should have the emergency managed. It's like there is a common theme among the adjectives.
There’s no winning. If we get the patient 100% tuned up, my fellows complain that the ER already did all the lines and they don’t have anything fun to do. If the patient comes up with only PIVs, people complain about them not being intubated and having a CVL or a-line. It’s about knowing each other and working together.
 

TimesNewRoman

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Yep... and it sounds like that's an ED where a staffing decision was made and the ED is expecting the ICU to fix their staffing decision. It's like the inpatient docs at my hospital who wants everyone in the ICU because "The nurses on stepdown are terrible and it's understaffed." Well... it's not my job to make sure that stepdown is both properly staffed with good nurses and this patient doesn't meet ICU criteria.
Agreed that the icu isn’t just the place that can do everyone else’s job and sometimes people feel that way. There are times where places get unexpected surges. And there are also times where really high functioning places get a slew of gunshots after a gang fight.

I’m not saying that the ER can do no wrong. I’ve worked with some excellent ER docs and at some excellent ERs. I’ve always worked with some that are incompetent and at dysfunctional places.

It’s hard to know the exact circumstances of someone else’s hospital - you might have a terrrible ED. I just know a lot of people who aren’t ER docs and don’t understand EM like to suggest how we do our job.
 
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lymphocyte

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You should pride yourself as an ICU doc as the guy or gal who loves a patient coming in hot.
Hence me saying, "don't worry, I'll sort it out." I'm not complaining, just reflecting on the week.

There is one notoriously bad EM doctor where I work -- the one that sent this patient down unescorted -- but the rest are generally pretty sensible.

I do think the "shift worker" mentality seems to afflict EM more than other specialties, but it's also extremely burnout prone, and I get how soul-crushingly busy it can be. On balance, I hold nothing against my colleagues for half-cooked patients, as long they're not being stupid dangerous and they call me early.
 

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If I'm overwhelmed with critical patients (which happens infrequently in our 150,000 volume ED), I usually call one of the intensivists and tell them I need help. I would rather them come down to the ER to help stabilize a patient than to send one upstairs that is unstable.

I have been in a situation where a stroke patient was getting TPA, a respiratory distress needed intubation, and a level 1 trauma arrived with a BP of 70. Luckily everything was set up for the intubation, I tubed then went straight to the trauma bay.

Like the OP, I love my job and can't get enough. I have worked with ER docs at other hospitals who just want to get the patient out and not deal with it. I personally love intubating and placing CVL's (placed 80 of them last year).
 
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Yep... and it sounds like that's an ED where a staffing decision was made and the ED is expecting the ICU to fix their staffing decision. It's like the inpatient docs at my hospital who wants everyone in the ICU because "The nurses on stepdown are terrible and it's understaffed." Well... it's not my job to make sure that stepdown is both properly staffed with good nurses and this patient doesn't meet ICU criteria.
Actually you do have a responsibility that a patient is taken care of. If they really cannot (not don’t want to) take care of a pt, then they should stay in your icu despite their not being critical.

I get it that you are probably dealing with more people not wanting than can’t.
 

TimesNewRoman

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If I'm overwhelmed with critical patients (which happens infrequently in our 150,000 volume ED), I usually call one of the intensivists and tell them I need help. I would rather them come down to the ER to help stabilize a patient than to send one upstairs that is unstable.

I have been in a situation where a stroke patient was getting TPA, a respiratory distress needed intubation, and a level 1 trauma arrived with a BP of 70. Luckily everything was set up for the intubation, I tubed then went straight to the trauma bay.

Like the OP, I love my job and can't get enough. I have worked with ER docs at other hospitals who just want to get the patient out and not deal with it. I personally love intubating and placing CVL's (placed 80 of them last year).
You’re doing to many CVLs, lol.
 

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I may only locum in EM, but I don't think any self-respecting EM doctor would've let a patient like that be transported unescorted down a very long corridor.
Hello again, Dunning-Kruger.

Dude, something doesn't match up with you. You graduated medical school by your own words in 2017. You quoted yourself as a PGY 2 in the neurology forum a year ago (May 2018...how is that possible btw if you graduated medical school the previous year?) At the time you were asking about your chances at getting into a US based neurology residency. I'm assuming that you couldn't match into a US residency spot.

Best case scenario...you're an Australian PGY 2 to 3. You quote yourself as an ICU "trainee" which I suppose means that you are an Australian resident.

You've quoted several times that you do "EM locums" on a regular basis. You don't even have an EM background and can't have spent more than a year in an ICU in the first place given the date of your graduation. How are you even trained enough to moonlight in a high acuity ED and who is making the mistake of hiring you? Care to come back to the EM forum and tell us a little bit more about your background? I call bull**** on your "locums" experience unless things work very differently in Australia than they do here.
 
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southerndoc

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I've been known to throw in a CVL, get a CT, pull it, and discharge the patient. If a nurse can't get a peripheral IV and I need a CTA, CVL it is.

I do a lot of them, but so do my colleagues. We're a very high acuity ER (150,000 patients/year, average ESI 2.9 overall, most lower acuity stuff handled by PA's).
 
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lymphocyte

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Hello again, Dunning-Kruger.

Dude, something doesn't match up with you. You graduated medical school by your own words in 2017. You quoted yourself as a PGY 2 in the neurology forum a year ago (May 2018...how is that possible btw if you graduated medical school the previous year?) At the time you were asking about your chances at getting into a US based neurology residency. I'm assuming that you couldn't match into a US residency spot.

Best case scenario...you're an Australian PGY 2 to 3. You quote yourself as an ICU "trainee" which I suppose means that you are an Australian resident.

You've quoted several times that you do "EM locums" on a regular basis. You don't even have an EM background and can't have spent more than a year in an ICU in the first place given the date of your graduation. How are you even trained enough to moonlight in a high acuity ED and who is making the mistake of hiring you? Care to come back to the EM forum and tell us a little bit more about your background? I call bull**** on your "locums" experience unless things work very differently in Australia than they do here.
I'm PGY-3 but got a job meant for PGY-4 and ideally PGY-5 as an ICU registrar. I do in fact locum in EM including flying solo at night in our ED. I also get slotted in as the duty FACEM during the day to help smooth out the roster from time to time. Would you like me to PM you my roster or swipe card? What about my pay slip?

One of the perks of training at a smaller hospital is building a solid reputation and working many levels higher than you normally would. I've worked extremely hard to get where I am, and by most accounts, I'm very good at what I do.

I did in fact think about neurology (with the hope of neuro-intensive care), psychiatry, and even FM. I've done a lot of thinking about a lot of different things. I imagine I could've matched just fine in the US -- but I'm pretty happy with where I am in life, including now with a family.

You remind a lot of a guy named Phloston, who also dug through my post history and chased me across forums trying to find contradiction in my personal narrative because I criticised something he wrote. I suspect you two have a similar personality structure and a general intolerance for what J.B. Holden had called "phonies." If you find me phoney, that's fine, keep attacking me or let it go. You evidently want to hurt me personally "I'm assuming that you couldn't match into a US residency spot" and " making the mistake of hiring you" -- narcissistic rage to what is probable narcissistic injury.

Now that you're in the ICU forum, would you like to talk about your understanding of AKI?
 
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jdh71

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Hello again, Dunning-Kruger.

Dude, something doesn't match up with you. You graduated medical school by your own words in 2017. You quoted yourself as a PGY 2 in the neurology forum a year ago (May 2018...how is that possible btw if you graduated medical school the previous year?) At the time you were asking about your chances at getting into a US based neurology residency. I'm assuming that you couldn't match into a US residency spot.

Best case scenario...you're an Australian PGY 2 to 3. You quote yourself as an ICU "trainee" which I suppose means that you are an Australian resident.

You've quoted several times that you do "EM locums" on a regular basis. You don't even have an EM background and can't have spent more than a year in an ICU in the first place given the date of your graduation. How are you even trained enough to moonlight in a high acuity ED and who is making the mistake of hiring you? Care to come back to the EM forum and tell us a little bit more about your background? I call bull**** on your "locums" experience unless things work very differently in Australia than they do here.
Eh. He's a registrar in Australia - poor bastard - it's a fairly different system

He's good people. And legit.

Lots of non EM people work EDs when EP's aren't available, even here, no? I spent a year moonlighting a VA ED in fellowship myself (no kids, no trauma, very few gyn issues - get that it was a bit "unique") - no one here thinks that that you can replace a trained EP with anything but.

Come on, we all know a guy, maybe two who dispos their patient out of the ED a little on the "shady" side. You don't need to circle the wagons. OP was just a reaction to one case, one night. It's not a shot at EM.
 

Groove

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I'm PGY-3 but got a job meant for PGY-4 and ideally PGY-5 as an ICU registrar. I do in fact locum in EM including flying solo at night in our ED. I also get slotted in as the duty FACEM during the day to help smooth out the roster from time to time. Would you like me to PM you my roster or swipe card? What about my pay slip?
Well thanks for finally explaining. I asked you in the EM forum after you necrobumped one of our threads and someone called you out as a troll but you went silent. I've never seen or heard of a non EM PGY 3 resident or ICU fellow moonlighting on their own in an academic teaching hospital in the ED. FACEM for you guys is what....5 years of residency? Yet, you're moonlighting on your own as a PGY 3 as the "on duty FACEM" (U.S. equivalent to ABEM) which to my understanding is after one year of specialty training? For us, that would be akin to a PGY-2 resident in their first year of "non EM" residency training, after a rotating internship, filling in as an academic EM attending. Crazy. Things must work very differently in the land down under.

Nobody is trying to "hurt you" personally. That made me chuckle and think of Chris Rock's "Bigger and Blacker" where the girlfriend is talking about people at work and goes "She's trying to destroy me!" and Chris Rock goes "Girl...nobody is trying to destroy you, you wrap bags at J.C. Penney's!" LOL
 
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lymphocyte

lymphocyte

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That made me chuckle and think of Chris Rock's "Bigger and Blacker" where the girlfriend is talking about people at work and goes "She's trying to destroy me!" and Chris Rock goes "Girl...nobody is trying to destroy you, you wrap bags at J.C. Penney's!" LOL
But that's the thing, I don't wrap bags at JC Penney's. I'm a doctor, a good one, I work at a hospital, and I'm your colleague. You can try to hurt me, but you can't, because you frankly don't matter. It's the Internet, and it's all smoke and mirrors until you figure out who knows what they're talking about.

What raised my hackles was your definition of AKI, which is nearly 15 years old. AKIN, for example, requires an optimal state of hydration be achieved and easily reversible causes like obstruction be excluded before the diagnosis of AKI can be applied. And even that definition has a lot of flaws. It's just like when I see sepsis = SIRS + infection -- not in 2019, it's not. (Or my new favourite, using qSOFA as a diagnostic tool, which it most definitely is not.)

And treating asymptomatic hypertension? Or high blood pressure with a headache? Come on. Do you really think that's critical care? I just do a proper cardio/neuro exam, ECG/UA if indicated, give them some Panadol (Tylenol) and send them home to follow-up with their GP.

So please bill however you bill critical care time (which even your own emergency colleagues in the US were openly questioning), but if you're going to argue the medicine, cite your sources. Attending or not, I don't care. Plenty of attendings, as I discover more and more, frankly don't know what they're talking about, and respect for their opinion is earned not granted.

Mehta RL, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. CritCare 2007, vol. 11 pg. R31.

José António Lopes, Sofia Jorge, The RIFLE and AKIN classifications for acute kidney injury: a critical and comprehensive review, Clinical Kidney Journal, Volume 6, Issue 1, February 2013, Pages 8–14,
 
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kimbosliced

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I’m EM-CC too. Tbh, the ER in private hospitals is a triage center in most normal hospitals. If a patient is truly sick and need critical care after the initial 2-3 hours of ED stay, the icu doc needs to come help out (it’s how my group and others in my area does it). We aren’t paid to do that stuff, we are paid to
Move the meat, keep patients happy and not screw things up. The ED is triage and immediate resus, that’s it in non academic centers. We can make the diagnoses but main job is who stays, who goes, who needs the icu/consult. You shouldn’t have patients languishing down in the ER for 6 hours like you see at these county hospitals. The ER doc doesn’t have time to deAl with that stuff, sorry we don’t. After they are stabilized send them up. If you don’t have enough time line/tube someone then call me I’ll come do it while you deal with all the crap in the ER. I’m ICU now in the community for the above reasons btw.
 
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Delay in getting a patient to radiology. Yeah, I'll take them down myself.

ED dumps a crashing patient on you. Don't worry, I'll sort it out. Tube, lines, done. I control their physiology now -- until I can't.

The agony of resuscitation. The art of deresuscitation. The feeling that -- this needs to happen, right now, or this person dies, so get it done. And if you need to go home, that's fine, but I'm here all night.

We're at war with death, and in the end it's a war we all lose -- but by skill and luck, not today. So let's fight this battle my friend, my patient. We fight together.

I just finished a ten day stretch and all I want is more. The rush is freaking intense. I. Love. This. Job.

Just finished a 14 day stretch on service in the MICU. At the risk of sounding cynical, ‘they’ are often going to die whether you do your job or not. In fact, if you think about it, you are probably just prolonging their suffering in many instances.
Still, I applaud your enthusiasm. Wish you could spread some to our housestaff.
 

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Not unusual that a PGY3 would run an ED overnight in rural Australia. But rostered as the FACEM? Unheard of.