What's the deal with the frigging telephone in EM??

[Toadkiller Dog]

Allright, I just got done with a month in the ER as part of my internship (I am not going into EM). It was, I must say, the most miserable month of my internship.

There were many things about which I could complain, but what bugs me the most is how much time we spend on the dang phone! For every flippin' person that comes in, whether it's a heart attack, "not feeling well", or a hangnail, we have to call some other doctor, and generally beg them to treat the patient (either admit or agree to do it as an outpatient). As you can imagine, most docs are not thrilled to hear from an intern in the middle of the day or (or worse, the middle of the night) when their patient (or worse, not their patient) comes in for blah, blah, blah. Sheesh, the stress!

Examples:
-Renal transplant patient comes in with high sugars and unexplained vomiting and a host of other nonspecific complaints = call the nephro, discuss it, listen to a lecture on how busy he is, get yelled at a little, then have him tell you to call his family doc and adjust his diabetes meds. Yay! another call.

-A 28 year old woman with a h/o anxiety and GERD comes to the ER with chest pain. EKG, enzymes, etc, are all negative. ER doc (who is known to be very conservative) makes you call the cardiologist on call and try to convince him to admit

And my personal favorite:
-34 yo male in a barfight has a teeny SAH, radiologist says it could be artifact. NS on call is a known jackass. It's 2 AM.

Just a warning to all med students considering this specialty: it's most definitely NOT what you see on TV. Maybe one in a hundred patients is something exciting. The rest are aggravating, and the rest of the doctors in the hospital all hate you.

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[GeneralVeers]

Hmm...Troll?

It can be frustrating, but one thing a successful ER doc must do is foster good relationships with the residents on other services. When one of my conservative attendings makes me call in a BS consult, I call the consultant, apologize profusely for the consult, and make sure to thank them for any help they give. If you're polite and considerate, generally you can get them to do the right thing for your patients.

Emergency isn't for everyone. If you don't have a thick skin, and can't take a little abuse from off-service attendings/residents then it's definitely not for you. Most EM residents can brush off the criticism because they KNOW that they are the most skilled, confident, and highly trained residents in the hospital.

Allright, I just got done with a month in the ER as part of my internship (I am not going into EM). It was, I must say, the most miserable month of my internship.

There were many things about which I could complain, but what bugs me the most is how much time we spend on the dang phone! For every flippin' person that comes in, whether it's a heart attack, "not feeling well", or a hangnail, we have to call some other doctor, and generally beg them to treat the patient (either admit or agree to do it as an outpatient). As you can imagine, most docs are not thrilled to hear from an intern in the middle of the day or (or worse, the middle of the night) when their patient (or worse, not their patient) comes in for blah, blah, blah. Sheesh, the stress!

Examples:
-Renal transplant patient comes in with high sugars and unexplained vomiting and a host of other nonspecific complaints = call the nephro, discuss it, listen to a lecture on how busy he is, get yelled at a little, then have him tell you to call his family doc and adjust his diabetes meds. Yay! another call.

-A 28 year old woman with a h/o anxiety and GERD comes to the ER with chest pain. EKG, enzymes, etc, are all negative. ER doc (who is known to be very conservative) makes you call the cardiologist on call and try to convince him to admit

And my personal favorite:
-34 yo male in a barfight has a teeny SAH, radiologist says it could be artifact. NS on call is a known jackass. It's 2 AM.

Just a warning to all med students considering this specialty: it's most definitely NOT what you see on TV. Maybe one in a hundred patients is something exciting. The rest are aggravating, and the rest of the doctors in the hospital all hate you.

 

[JackBauERfan]

I agree, even if this isn't really 'trolling' the OP is definitely showing a biased opinion...which is ok on any forums, but to say to future medical students that a profession just isn't what its advertised as is making blank statements. And everyone has different opinions and likes about any field, and thats why everyone can choose different things to be happy in. Its like me saying, ob/gyn just sucks really bad, and all the glory of delivering babies is just on tv, the rest (delivering placentas), so don't go into that field. But just as I love EM, there are folks that love ob, folks that love surgery, so it works out great. so for the future students interested in EM, just see for yourself (as you probably would anyway, I doubt anyone would make career decisions based on what folks say on message boards!)

Hmm...Troll?

It can be frustrating, but one thing a successful ER doc must do is foster good relationships with the residents on other services. When one of my conservative attendings makes me call in a BS consult, I call the consultant, apologize profusely for the consult, and make sure to thank them for any help they give. If you're polite and considerate, generally you can get them to do the right thing for your patients.

Emergency isn't for everyone. If you don't have a thick skin, and can't take a little abuse from off-service attendings/residents then it's definitely not for you. Most EM residents can brush off the criticism because they KNOW that they are the most skilled, confident, and highly trained residents in the hospital.

 

[kungfufishing]

"...Sorry kids, your dad is dead. I wish there was more that could've been done, but it was 2 in the morning and the Neurosurgeon on call might have yelled at me. I think it worked out better for everyone this way..."

 

[tiger_lily]

Ok, I've seen it on other SDN threads but I guess I'm just not forum-savvy. What's a Troll? (Other than the scary hairy guy who lives under the bridge...)
Thanks
Sorry for the post hijack, but I'm curious!

 

[odoreater]

If that is the way emergency medicine is practiced in your institution I would not want to go into it either. Calling cardiology to make ED clinical decisions? Leaving admissions up to consults? My friend the ED must simply have absolute admitting privileges wherever your residency is done.

Allright, I just got done with a month in the ER as part of my internship (I am not going into EM). It was, I must say, the most miserable month of my internship.

There were many things about which I could complain, but what bugs me the most is how much time we spend on the dang phone! For every flippin' person that comes in, whether it's a heart attack, "not feeling well", or a hangnail, we have to call some other doctor, and generally beg them to treat the patient (either admit or agree to do it as an outpatient). As you can imagine, most docs are not thrilled to hear from an intern in the middle of the day or (or worse, the middle of the night) when their patient (or worse, not their patient) comes in for blah, blah, blah. Sheesh, the stress!

Examples:
-Renal transplant patient comes in with high sugars and unexplained vomiting and a host of other nonspecific complaints = call the nephro, discuss it, listen to a lecture on how busy he is, get yelled at a little, then have him tell you to call his family doc and adjust his diabetes meds. Yay! another call.

-A 28 year old woman with a h/o anxiety and GERD comes to the ER with chest pain. EKG, enzymes, etc, are all negative. ER doc (who is known to be very conservative) makes you call the cardiologist on call and try to convince him to admit

And my personal favorite:
-34 yo male in a barfight has a teeny SAH, radiologist says it could be artifact. NS on call is a known jackass. It's 2 AM.

Just a warning to all med students considering this specialty: it's most definitely NOT what you see on TV. Maybe one in a hundred patients is something exciting. The rest are aggravating, and the rest of the doctors in the hospital all hate you.

 

[docB]

Ok, I've seen it on other SDN threads but I guess I'm just not forum-savvy. What's a Troll? (Other than the scary hairy guy who lives under the bridge...)
Thanks
Sorry for the post hijack, but I'm curious!

In this case it's the guy under the bridge with a computer and a axe to grind.

 

[ERMudPhud]

Ok, I've seen it on other SDN threads but I guess I'm just not forum-savvy. What's a Troll? (Other than the scary hairy guy who lives under the bridge...)
Thanks
Sorry for the post hijack, but I'm curious!

http://en.wikipedia.org/wiki/Internet_troll

In this case though I think the correct response is Fatty McFattypants not troll.

 

[SanDiegoSOD]

If that is the way emergency medicine is practiced in your institution I would not want to go into it either. Calling cardiology to make ED clinical decisions? Leaving admissions up to consults? My friend the ED must simply have absolute admitting privileges wherever your residency is done.

Hmmm... I worked at a hospital where EPs had to beg the internists to admit a patient. Good to see that doesnt happen everywhere!

 

[MD Dreams]

If that is the way emergency medicine is practiced in your institution I would not want to go into it either. Calling cardiology to make ED clinical decisions? Leaving admissions up to consults? My friend the ED must simply have absolute admitting privileges wherever your residency is done.

Couple of questions

1. How does one find out which residency programs have admitting priveleges?

2. What about private practice ER's?

3. Why don't all institutions have direct admitting priveleges?

Thanks

 

[GeneralVeers]

I've never seen a program where the ED physician has carte blanche to admit whomever they wish. Most places you call up their PMD who says "Admit them and I'll see them in the morning", then you go ahead and write the orders and admit to that physician.

My hospital has an "EMC" which is a 3rd year medicine resident who screens who gets admitted and writes all the admission orders. Unfortunately when we get a sucky one who doesn't feel like working, patients clog up our E.D. for 8 hours or more without being admitted.

 

[sweetfynesse]

I've never seen a program where the ED physician has carte blanche to admit whomever they wish. Most places you call up their PMD who says "Admit them and I'll see them in the morning", then you go ahead and write the orders and admit to that physician.

My hospital has an "EMC" which is a 3rd year medicine resident who screens who gets admitted and writes all the admission orders. Unfortunately when we get a sucky one who doesn't feel like working, patients clog up our E.D. for 8 hours or more without being admitted.

interesting...at my residency the ED physician has final say on who gets admitted. we give courtesy calls to PMDs if the pt has a private, but ultimately it's still our decision. we call up the med resident on call and give them signout, and they either come down and write admit orders or they write admit orders when the patient gets to the floor. we never hold up admissions waiting for the medicine admit note.

 

[Squad51]

I've never seen a program where the ED physician has carte blanche to admit whomever they wish. Most places you call up their PMD who says "Admit them and I'll see them in the morning", then you go ahead and write the orders and admit to that physician.

My hospital has an "EMC" which is a 3rd year medicine resident who screens who gets admitted and writes all the admission orders. Unfortunately when we get a sucky one who doesn't feel like working, patients clog up our E.D. for 8 hours or more without being admitted.

Actually ACEP has a policy statement against EPs writing orders. Most places hae EPs able to admit without anyone else's permission.

 

[bulgethetwine]

interesting...at my residency the ED physician has final say on who gets admitted. we give courtesy calls to PMDs if the pt has a private, but ultimately it's still our decision. we call up the med resident on call and give them signout, and they either come down and write admit orders or they write admit orders when the patient gets to the floor. we never hold up admissions waiting for the medicine admit note.

I wonder if we're all really just debating semantics? Consider that at my institution, EPs don't, by the letter, admit directly. But the general medicine team is obligated to accept all admissions.

If a particular patient might be better suited for a specialty admission -- e.g. cardiology -- we might call them first and that service can refuse. But in the end, even if cardiology doesn't want them, if we in the ED have made the decision that the patient is coming into the house, general medicine cannot refuse the admission. So I suppose we do have de facto direct admission privileges.

And for the record, if any real medical student is taking the OPs post at face value (which I doubt), I can tell you that the so-called "fight" to get patients admitted gets better as you get to know other residents in the hospital through off-service rotations and as one improves the succinctness of your presentations. Both of these are difficult to do and/or master with a one-month rotation but are much improved by even your 2nd or 3rd month in the ED. Plus, many services are great from day 1 because they are staffed by more senior residents, fellows, or attendings. These services are less apt to be resistant to admissions due to probably two factors. First, they have an appreciation for the fact that at a teaching institution is it just that -- and are more likely to coach you on improving your presentation but still facilitating an easy admit overall. Second, and probably the more relevant factor, the more senior the person authorizing the admit, the less likely they are actually involved in the grunt work of the admission (H&P, admit orders, initial assessment on the floor at 3:25 am).

Finally, although the OP hated the phone work, I can say that it can actually be a cool aspect of the job if the admit is a slam dunk due to your presentation being so tight that the accepting physician was appreciative and supportive of the admission right from the start. You will find that if your ability to communicate is good (and again, it will improve very quickly in your first few months of residency regardless of what your baseline was coming in) it is beneficial for you, your patient, and the admitting service as you and the admitting resident/fellow will work increasingly better together in getting all the aspects of the preliminary workup complete and the patient moved out of the ED.

 

[southerndoc]

Just a warning to all med students considering this specialty: it's most definitely NOT what you see on TV. Maybe one in a hundred patients is something exciting. The rest are aggravating, and the rest of the doctors in the hospital all hate you.

Yea, we usually don't let the interns see critical patients. Sorry for your bad month Toadkiller. Some places are like that and call the patient's PMD on every single visit, whereas others only call for admissions or to relay important discharge information (i.e., following up on things).

 

[NinerNiner999]

"...Sorry kids, your dad is dead. I wish there was more that could've been done, but it was 2 in the morning and the Neurosurgeon on call might have yelled at me. I think it worked out better for everyone this way..."

Besides, it was only a "teeny SAH." Other specialties may let you pontificate on diagnoses, treatment options, and tests to order. EM requires a decision actually be made in a reasonable amount of time and the proper admitting team be called. Sure, if we needed to we could manage our patient on the floor, but unfortunately, we also have to rely on other "doctors" to do this for our patients.

 

[turtle md]

I am at a community hospital, so when we admit, majority of the time it is to a private group, not to a resident. So my phone call means more money for the admitting doc, not just more work for a tired resident. Occasionally, we get a PMD who doesn't want to admit, but usually by saying that I don't feel comfortable discharging the patient, and the PMD can either come in and do it him/herself or let me admit solves the problem.

We also keep a list of problem docs who give us a hard time about admitting. The president of the medical staff is one of our attendings, so this list usually remains short.

Regarding admit orders, who don't write them. We can post a patient w/o them, and let the admitting doc do them via telephone. I don't want to be responsible for a patient admitted and on the floor, so would rather the admitting orders were not from me.

 

[Dunce]

. . . how much time we spend on the dang phone! For every flippin' person that comes in, . . .

You sound like you have been watching Napoleon Dynamite

 

[totalbodypain]

You sound like you have been watching Napoleon Dynamite

The real question is whether the moonboots are fashionable with blue or green scrubs or with tie and slacks only.

 

[AmoryBlaine]

We also keep a list of problem docs who give us a hard time about admitting. The president of the medical staff is one of our attendings, so this list usually remains short.

That's awesome. Do you publish a "Top 10" in the cafeteria each month?

 

[EctopicFetus]

Nuff said..

 

[SanDiegoSOD]

Nuff said..

Haha... thats supposed to be someone feeding a troll? Interesting graphic, that's for sure

 

[Homunculus]

looks more like a leprechaun to me. i thought they liked lucky charms, but maybe they have a taste for turkey as well.

--your friendly neighborhood magically delicious caveman

 

[Jeff698]

There was something that struck me as incredibly funny about reading the wiki entry on 'troll'.

Take care,
Jeff

 

[bartleby]

There are two issues here: 1) The final say of the ED physician to determine admission or discharge (a very good thing) and 2) Whether or not you write the initial set of inpatient orders (a bad thing).

#1 is a great option to have in your back pocket, and is written into the bylaws in one of our residency's clinical sites, and in the other there is a verbal agreement of similar substance with the medicine service. Sure, you're better off using the carrot with your consultants. You don't want them to feel like they're being abused or that you're admitting gratuitously, which is bad for them, the hospital and ultimately, the patient. However, when push comes to shove, it's good patient care to be able to say that the patient is admitted to their service until they are physically examined by the attending of record. If they want to come in at 10pm and evaluate the patient or see them on rounds in the morning, it's their problem at that point.

#2 is bad because you are essentially writing orders and taking legal responsibility for a patient who is no longer under your care. It's easy to order a beta blocker in the ED when you're around to at least indirectly make sure the patient isn't getting an additional dose of metoprolol when her HR is 33, and you're around to deal with the consequences. Do you want to play liability hot potato with a cardiologist when the patient with chest pain admitted to their service on your orders codes or has an adverse event from a med administered on the floor? I sure don't. There's a good reason why ACEP has a position statement against this practice. The only good thing about it is that it can get the patient out of your overcrowded ED quicker compared to waiting for your doc to come in from home to see them. But it isn't worth the trouble.

I've never seen a program where the ED physician has carte blanche to admit whomever they wish. Most places you call up their PMD who says "Admit them and I'll see them in the morning", then you go ahead and write the orders and admit to that physician.