Why don't more people go into EM? Why is EM not more competitive?

[Cramster]

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[Cramster]

 

[jl lin]

Yea. Good times.

 

[Cramster]

BTW that Cache valley shooting was because the guy wanted more percocet! Patients will threaten you or will actually try to kill you if you refuse to give them their narcs. It happens all the time.

While working in the ED prior to medical school a gun WAS discharged. Had I been standing a few feet over I would have been hit. There needs to be a metal detectors and armed police offers in every ED to protect healthcare workers from the rabble that inevitably end up there. BTW, given the work rendered, stressful atmosphere, and legitimate dangers I believe that ED staff/nurses/physicians are underpaid

 

[jl lin]

I can find words that are strong enough to say how much I hate what drug and alcohol abuse and addiction do to people. So many lives severely hurt or ruined from it. The horrible, needles pain and suffering it causes.

Whatever one things about Dr. Scott Peck, the first words from his book, The Road Less Travelled, still stand true. "Life is difficult" is the first statement in this book. It's not that we don't get a hint that life is difficult. It's more of the issue of resistance to accepting the regular realities of life's difficulties. Once accepted, finding the true discipline of problem-solving serves to helps us live above the difficulties. I often think that so many engaged in drug or alcohol addiction somehow, at least to some degree, have resisted the acceptance of difficulties in all of life, and thus have sought to avoid learning the discipline of effective problem-solving. Sure, there's more to it than that, and it's straying from the topic. But ED physicians and others in the ED can become inundated and completely overwhelmed with having to, at least temporarily, solve problems of people that cannot help their predicaments, as well as having to solve the problems of those that indeed can control them.

Putting their pay aside, I can't help but wonder if those working in ED don't need a lot more downtime--more vacation time, for example. They also need more support counseling , if they are open to it. More support from administration would do wonders as well.

A number of patients that come in are very far from appreciative of the care given them there. It can be a very abusive environment. I worked with a RN that loved working the ED at a children's hospital, but eventually it wore her down. Why? It was a regional rape/abuse center for kids--and a fair amount of that abuse involved drugs and alcohol. A number of the abused kids' parents would come in and make things worse and then speak or act so abusively to the nurses and doctors. She was so beaten up by it, she ended up transferring to the cardiac unit. If ever there is need for care for the caregivers, it's in the ED.

 

[notbobtrustme]

EM sounds like a great gig, then you actually get on your EM rotation, see a burst esophageal varice and say "welp, I'm done with this".

Also, there is a relevant thread on the EM forums. It's basically disaster cases that attendings/residents have seen and the **** there is depressing. If you can stomach that kind of stuff on a near weekly basis, then go for it. Otherwise, you will flame out hard and fast.

 

[Jabbed]

EM sounds like a great gig, then you actually get on your EM rotation, see a burst esophageal varice and say "welp, I'm done with this".

Also, there is a relevant thread on the EM forums. It's basically disaster cases that attendings/residents have seen and the **** there is depressing. If you can stomach that kind of stuff on a near weekly basis, then go for it. Otherwise, you will flame out hard and fast.

I think the issue for most grads is that they go into EM expecting emergencies and acute care and then end up buried in the nightmarish sequale of chronic disease and Press Ganey.

 

[peanutsss]

.....

 

[DoctorLacrosse]

that "12 reasons" post by Jarabacoa is spot on. I obviously haven't had experience with the physician side of it, but I am a "Type A tech", and have seen enough of it over the years to know.

the ER isn't for everyone. every worker who floats down to help us once in awhile from other units literally hates it and pities our lives. it's fast-paced, jam-packed, and super stressful. if you can't handle the heat, you will be hoping to never enter that kitchen again.

 

[MU420]

EM is a very popular specialty.

However, there are 1800 EM spots each year, so that drastically brings down EM's competitiveness.

Reduce EM to 200 spots per year and see what happens. With that said, EM is still moderately competitive and has become more difficult to match into in recent few years.

 

[alpinism]

I wouldn't do EM, not because of longterm patient continuity, but because you lack the ability to follow even through a single hospital stay.

Most ED patients aren't admitted so technically you'll be the one and only doctor taking care of them from start to finish.

The majority of fractures, dislocations, lacerations, burns, headaches, rashes, URIs, UTIs, etc are usually taken care of entirely in the ED with the patient given instructions to follow up in clinic later.

 

[mehc012]

Most ED patients aren't admitted so technically you'll be the one and only doctor taking care of them from start to finish.

The majority of fractures, dislocations, lacerations, burns, headaches, rashes, URIs, UTIs, etc are usually taken care of entirely in the ED with the patient given instructions to follow up in clinic later.

Right, for things like fractures, it's the outpatient ortho who ends up following the problem to the end. For actual hospitalisation level issues, it's the hospital docs. The stuff that you get to be the sole physician on is largely stuff that didn't need to come in, with a couple of exceptions. As soon as the interest level of the problem goes up, though, the likelihood you'll get to see it to the finish goes down sharply.

That's not an issue if your primary interest is figuring out what's going on on patients. It's more of an issue if you get a lot of satisfaction out of the process of fixing it.

 

[Salt Salt]

Because it has the highest burnout of any specialty

 

[alpinism]

Right, for things like fractures, it's the outpatient ortho who ends up following the problem to the end. For actual hospitalisation level issues, it's the hospital docs. The stuff that you get to be the sole physician on is largely stuff that didn't need to come in, with a couple of exceptions. As soon as the interest level of the problem goes up, though, the likelihood you'll get to see it to the finish goes down sharply.

That's not an issue if your primary interest is figuring out what's going on on patients. It's more of an issue if you get a lot of satisfaction out of actually directly fixing it.

Yes and No.

When most patients come into the ED with a fracture its the ED doc who diagnoses it, prescribes pain management, and immobilizes the bone/joint with a cast/splint. They're actually fixing the problem.

Its the same thing with dislocations and lacerations and a ton of other problems besides what's listed above.

All they do in clinic is ask how you're doing and remove the cast/splint. I wouldn't personally describe that as being interesting or fixing anything.

The more complex fractures that require surgery are fixed by ortho, but those are a small minority. Most of the time ortho docs are doing routine elective cases (hips and knees) and following them up in clinic. I also wouldn't describe doing the same procedure on the same structure 1,000 times are being interesting either, but to each their own. Not to mention, to be honest the whole fixing part is up for debate as well since many of surgeries are totally unnecessary.

 

[mehc012]

Yes and No.

When most patients come into the ED with a fracture its the ED doc who diagnoses it, prescribes pain management, and immobilizes the bone/joint with a cast/splint. They're actually fixing the problem.

Its the same thing with dislocations and lacerations and a ton of other problems besides what's listed above.

All they do in clinic is ask how you're doing and remove the cast/splint. I wouldn't personally describe that as being interesting or fixing anything.

The more complex fractures that require surgery are fixed by ortho, but those are a small minority. Most of the time ortho docs are doing routine elective cases (hips and knees) and following them up in clinic. I also wouldn't describe doing the same procedure on the same structure 1,000 times are being interesting either, but to each their own. Not to mention, to be honest the whole fixing part is up for debate as well since many of surgeries are totally unnecessary.

Fair enough...again, though, the more 'interesting' the case, the less likely that the ED guy will be the one with the final solution.
Fractured forearm? Sure, they'll try to reduce it and throw a splint on.
Fractured hip? Admitted to the hospital (usually elderly, often they can't walk to go home), ortho consults in-house.
Serious fracture? Give them pain pills and send them to outpatient ortho. We saw people come in with GSW which had struck the bone and caused incredible fractures. The ED doc would seriously give them a couple of Norco and give them the ortho guy's number. Maybe an admit or in-house consult if it was open or unstable, or they couldn't ambulate. That's it.

The bigger the problem, the less likely the ED doc will be the one fixing it (aside from actual codes). Again, not a bad thing, just something to consider before going into the specialty. So it's not that I'm disagreeing with you...I wouldn't do that, you're spot on. Most patients don't require huge intervention. Those who do, however, typically don't get it from the ED physician. For some people, that's a downside.

 

[alpinism]

Fair enough...again, though, the more 'interesting' the case, the less likely that the ED guy will be the one with the final solution.
Fractured forearm? Sure, they'll try to reduce it and throw a splint on.
Fractured hip? Admitted to the hospital (usually elderly, often they can't walk to go home), ortho consults in-house.
Serious fracture? Give them pain pills and send them to outpatient ortho. We saw people come in with GSW which had struck the bone and caused incredible fractures. The ED doc would seriously give them a couple of Norco and give them the ortho guy's number. Maybe an admit or in-house consult if it was open or unstable, or they couldn't ambulate. That's it.

The bigger the problem, the less likely the ED doc will be the one fixing it (aside from actual codes). Again, not a bad thing, just something to consider before going into the specialty. So it's not that I'm disagreeing with you...I wouldn't do that, you're spot on. Most patients don't require huge intervention. Those who do, however, typically don't get it from the ED physician. For some people, that's a downside.

While I'm sure stuff like that happens, its not standard practice.

There are good ED docs and there are crappy ED docs just like every specialty. I could sit here and tell you crazy stories of the all incredibly dumb stuff i've seen surgeons do over the years.

I still don't completely agree with the fixing problems comment. I will admit, after having worked at and rotated at dozens of hospitals, there is a ton of variety from place to place. Some EDs tend to consult everything under the sun while others take care of almost everything on their own. That being said, at most EM residency powerhouses, you'd be surprised at all the things that get done in the ED. The last hospital where I worked at they even have their own critical care unit.

We managed the sickest patients with the biggest problems: sepsis, stroke, meningitis, PE, DKA, anaphylaxis, hypothermia, heat stroke, poisoning,
I could go on...

They're all diagnosed and treated in the ED. If there was a bed available, they were sent upstairs, if not they stayed in the ED. Sometimes >48hrs.

Either way, the immediate life threatening problems were fixed in the ED before the patient was sent upstairs. Once on the floor they basically continue the treatment we already started, provide supportive care, and monitor the patient while they recover.

If you like fixing complex chronic non emergent medical or surgical problems, then yes, EM is not the place for you.

To be honest though, I was bored to death on every other rotation 3rd year besides EM. So obviously I'm biased.

 

[mehc012]

While I'm sure stuff like that happens, its not standard practice.

There are good ED docs and there are crappy ED docs just like every specialty. I could sit here and tell you crazy stories of the all incredibly dumb stuff i've seen surgeons do over the years.

It has nothing to do with good vs bad docs. I'm sorry, but even the best ER physician is not going to fix a bone which has been shattered by a bullet. It's not a reflection on them, it's just not what the specialty is designed to do. If consulting ortho for a bone problem that they can't fix in the ER isn't standard practice, what is?

I still don't completely agree with the fixing problems comment. I will admit, after having worked at and rotated at dozens of hospitals, there is a ton of variety from place to place. Some EDs tend to consult everything under the sun while others take care of almost everything on their own. That being said, at most EM residency powerhouses, you'd be surprised at all the things that get done in the ED. The last hospital where I worked at they even have their own critical care unit.

We managed the sickest patients with the biggest problems: sepsis, stroke, meningitis, PE, DKA, anaphylaxis, hypothermia, heat stroke, poisoning,
I could go on...

Of course. For a couple of hours, and then they get sent upstairs. You might be there when they go from 'actively dying' to 'I think they are done coding for tonight' or even all the way to 'stable', but you won't be there when they get to go home. You might not even get to see if they wake up, or if the actual cause of the problem is ever figured out. And that's OK...it's just different.

They're all diagnosed and treated in the ED. If there was a bed available, they were sent upstairs, if not they stayed in the ED. Sometimes >48hrs.

Which is inefficient for both the ED and the patient. I'm not sure what the point of throwing that in there is...that's just poor floor management or inadequate resources.

Either way, the immediate life threatening problems were fixed in the ED before the patient was sent upstairs. Once on the floor they basically continue the treatment we already started, provide supportive care, and monitor the patient while they recover.

If you like fixing complex chronic non emergent medical or surgical problems, then yes, EM is not the place for you.

To be honest though, I was bored to death on every other rotation 3rd year besides EM. So obviously I'm biased.

Well yeah, clearly if you prefer non-emergent situations you won't like the emergency room.
But I'd switch the surgical side to 'any surgical problem'. I don't care how emergent it is, it's not the ER docs going in except in the rarest of circumstances.
And while you say most problems are 'fixed' in the ED, I say 'stablized', which is very different. If it's only the acutely life-threatening stuff (and I mean on an hours scale), then yeah, things are 'fixed'. But plans change from ED to floor all the time, and even when they don't, it's still not the ER physician who gets to actually see how things play out. Some people like that.

Me? I loved working in the ER, but I wanted to follow every single surgical patient out of there so damn bad it hurt. I came into my shifts hoping that my doc would check up on yesterday's patients and let me know how they were doing, if they'd improved, gone downhill, etc. Did they figure out why the patient was so hyponatremic? Etc. As energizing as I found the ER pace and environment, at the end of the day 9/10 of the patients shouldn't have been there in the first place and the last 1/10 basically teased me with the first chapter and the rest of the book was left blank. I could do it, and I could enjoy myself there, but I think there are probably better fits for me. That is likely true of a lot of people, and that's all I was trying to point out. It's not that ER docs don't fix anything, or that they don't do a good job, or whatever...it's that they focus on only a very narrow sort of problem and never get to chase the others, and unless you love their focus enough to disregard the downsides, and won't miss out on the chase, it's probably not the specialty for you, even if you could pull it off.

 

[alpinism]

It has nothing to do with good vs bad docs. I'm sorry, but even the best ER physician is not going to fix a bone which has been shattered by a bullet. It's not a reflection on them, it's just not what the specialty is designed to do. If consulting ortho for a bone problem that they can't fix in the ER isn't standard practice, what is?

Of course. For a couple of hours, and then they get sent upstairs. You might be there when they go from 'actively dying' to 'I think they are done coding for tonight' or even all the way to 'stable', but you won't be there when they get to go home. You might not even get to see if they wake up, or if the actual cause of the problem is ever figured out. And that's OK...it's just different.
Which is inefficient for both the ED and the patient. I'm not sure what the point of throwing that in there is...that's just poor floor management or inadequate resources.

Well yeah, clearly if you prefer non-emergent situations you won't like the emergency room.
But I'd switch the surgical side to 'any surgical problem'. I don't care how emergent it is, it's not the ER docs going in except in the rarest of circumstances.
And while you say most problems are 'fixed' in the ED, I say 'stablized', which is very different. If it's only the acutely life-threatening stuff (and I mean on an hours scale), then yeah, things are 'fixed'. But plans change from ED to floor all the time, and even when they don't, it's still not the ER physician who gets to actually see how things play out. Some people like that.

Me? I loved working in the ER, but I wanted to follow every single surgical patient out of there so damn bad it hurt. I came into my shifts hoping that my doc would check up on yesterday's patients and let me know how they were doing, if they'd improved, gone downhill, etc. Did they figure out why the patient was so hyponatremic? Etc. As energizing as I found the ER pace and environment, at the end of the day 9/10 of the patients shouldn't have been there in the first place and the last 1/10 basically teased me with the first chapter and the rest of the book was left blank. I could do it, and I could enjoy myself there, but I think there are probably better fits for me. That is likely true of a lot of people, and that's all I was trying to point out. It's not that ER docs don't fix anything, or that they don't do a good job, or whatever...it's that they focus on only a very narrow sort of problem and never get to chase the others, and unless you love their focus enough to disregard the downsides, and won't miss out on the chase, it's probably not the specialty for you, even if you could pull it off.

Possibly. Everyone has different interests and I agree its nice to follow through on patients to see how they ended up doing.

When you rotate on medicine you'll see that its the same for patients admitted on the floor, 9/10 shouldn't be there either. That's just a reality of modern medicine. For the most part its babysitting patients with straightforward chronic diseases like uncontrolled diabetes, COPD exacerbation, HF exacerbation, CKD exacerbation, dementia, and alcoholism. Problems that you don't fix but rather treat the symptoms they're readmitted next month. Why is Mr. Jones hyponatremic? Because he stopped taking his meds. Again. You basically spend most of your day rounding on patients and talking about their problems without actually doing anything besides the endless paperwork and social work (90% of your day is on a computer). For surgery you have to enjoy spending long hours in the OR and doing the same 10 procedures over and over again like a robot because everything is so sub specialized now.

EM definitely has some big downsides that can be deal breakers for many people. All I'm saying is that wanting to see sick patients and fix problems aren't usually mentioned as reasons to rule out the specialty for pre meds.

Stabilizing sick patients with life threatening conditions is still a fixing a problem. IMHO the most important one. You can't fix a shattered bone if the patient is already dead.

Its the EM docs job to fix acute problems not chronic problems.

 

[toutou]

IMHO the least safe place to be in the hospital is to be an "admitted" patient stuck in an ED bed waiting for an available inpatient bed.

The ED thinks their job is done since it has been dispo'ed. The ED nurse is busy running around with their 8 other new patients dealing with them.

The treatment that was "started" was usually a bag of antibiotics hanging with some fluids running at a semi-random rate. It's hardly comprehensive care and the level of monitoring and follow-up compared to an inpatient bed is a big difference.

THIS THIS THIS!! ALL OF IT.

 

[medic86]

Which is inefficient for both the ED and the patient. I'm not sure what the point of throwing that in there is...that's just poor floor management or inadequate resources.

He included that because that's what the job entails. The vast majority of the EDs in this country end up holding patients for admission/psych holds/etc. and it's doubtful that it'll get better. There's a reason ER nurses can sit for the CCRN.

IMHO the least safe place to be in the hospital is to be an "admitted" patient stuck in an ED bed waiting for an available inpatient bed.

The ED thinks their job is done since it has been dispo'ed. The ED nurse is busy running around with their 8 other new patients dealing with them.

The treatment that was "started" was usually a bag of antibiotics hanging with some fluids running at a semi-random rate. It's hardly comprehensive care and the level of monitoring and follow-up compared to an inpatient bed is a big difference.

Nail on the head. It's not the ER's fault they have to do this, though.

 

[mimelim]

I'm not blaming the ED for this. It's the nature of the workload. It's not a good place for ongoing treatment.

IMHO the least safe place to be in the hospital is to be an "admitted" patient stuck in an ED bed waiting for an available inpatient bed.

The ED thinks their job is done since it has been dispo'ed. The ED nurse is busy running around with their 8 other new patients dealing with them.

The treatment that was "started" was usually a bag of antibiotics hanging with some fluids running at a semi-random rate. It's hardly comprehensive care and the level of monitoring and follow-up compared to an inpatient bed is a big difference.

+100

On the other hand, sometimes it pisses me off to no end that, "Oh we called Vascular, we are done with the patient." is in their minds a valid excuse for abhorrent patient care. Especially when it is clearly not a vascular issue.

 

[mehc012]

Possibly. Everyone has different interests and I agree its nice to follow through on patients to see how they ended up doing.

When you rotate on medicine you'll see that its the same for patients admitted on the floor, 9/10 shouldn't be there either. That's just a reality of modern medicine. For the most part its babysitting patients with straightforward chronic diseases like uncontrolled diabetes, COPD exacerbation, HF exacerbation, CKD exacerbation, dementia, and alcoholism. Problems that you don't fix but rather treat the symptoms they're readmitted next month. Why is Mr. Jones hyponatremic? Because he stopped taking his meds. Again. You basically spend most of your day rounding on patients and talking about their problems without actually doing anything besides the endless paperwork and social work (90% of your day is on a computer). For surgery you have to enjoy spending long hours in the OR and doing the same 10 procedures over and over again like a robot because everything is so sub specialized now.

EM definitely has some big downsides that can be deal breakers for many people. All I'm saying is that wanting to see sick patients and fix problems aren't usually mentioned as reasons to rule out the specialty for pre meds.

Stabilizing sick patients with life threatening conditions is still a fixing a problem. IMHO the most important one. You can't fix a shattered bone if the patient is already dead.

Its the EM docs job to fix acute problems not chronic problems.

You have a different definition of acute than I, then. For example, a ruptured appy would generally be considered an acute problem in my book, but hey, if they're not actively coding...

There's more to fixing problems than running codes. You say stabilizing sick patients is fixing a problem...I say that their problem is whatever was making them sick. Yeah, you have to stabilize them in order to treat them, but it's like seeing step A, but not B-Z, when the 'problem' is the whole damn alphabet soup. I'm not saying it's not important, but it's not a 'fix'...if it were, you could send them home afterward. When I say 'fix problems', I mean 'see to completion', and that is something that ER docs only get to do, practically by definition, when the patient is not sick enough to warrant hospitalization (and even then a lot of times it's the outpatient provider who finishes up).

This has nothing to do with the amount of busywork on the floor, 'chronic vs acute' problems, etc. I actually prefer acute problems with more short-term solutions. I don't really have an interest in following a patient long-term throughout their life. However, I like to see an individual problem, as in 'condition requiring hospitalization' to its conclusion (problem 'fixed' to the point where the patient can go home). That doesn't happen all of the time on the floor either, but it happens a lot more than the ED (if you don't count those who never needed hospitalization to begin with).

I'm done, because at this point you're either intentionally skipping on what I'm saying or you're just never going to get it. Maybe I am the suckiest explainer that ever attempted to explain things, whatever...point is, this has gone back and forth enough that there's no point in continuing.

 

[alpinism]

You have a different definition of acute than I, then. For example, a ruptured appy would generally be considered an acute problem in my book, but hey, if they're not actively coding...

There's more to fixing problems than running codes. You say stabilizing sick patients is fixing a problem...I say that their problem is whatever was making them sick. Yeah, you have to stabilize them in order to treat them, but it's like seeing step A, but not B-Z, when the 'problem' is the whole damn alphabet soup. I'm not saying it's not important, but it's not a 'fix'...if it were, you could send them home afterward. When I say 'fix problems', I mean 'see to completion', and that is something that ER docs only get to do, practically by definition, when the patient is not sick enough to warrant hospitalization (and even then a lot of times it's the outpatient provider who finishes up).

This has nothing to do with the amount of busywork on the floor, 'chronic vs acute' problems, etc. I actually prefer acute problems with more short-term solutions. I don't really have an interest in following a patient long-term throughout their life. However, I like to see an individual problem, as in 'condition requiring hospitalization' to its conclusion (problem 'fixed' to the point where the patient can go home). That doesn't happen all of the time on the floor either, but it happens a lot more than the ED (if you don't count those who never needed hospitalization to begin with).

I'm done, because at this point you're either intentionally skipping on what I'm saying or you're just never going to get it. Maybe I am the suckiest explainer that ever attempted to explain things, whatever...point is, this has gone back and forth enough that there's no point in continuing.

Yeah I understand exactly what you're saying. You just seem to have a general lack of understanding of inpatient medicine in general or have this idealistic view of other specialties besides EM.

You're also ignoring all my previous points. Whether or not you follow a patient till they're sent home has nothing to do with fixing their problem. Most patients sent home from the floor don't have their problem fixed as I already mentioned (nearly all chronic diseases). Not to mention all the patients discharged to rehab or a nursing home that are still sick and disabled. A ton of patients are also admitted for observation or because of social issues. Just because their admitted doesn't mean they are necessarily sicker.

In addition, you're completely wrong about EM docs only fixing things when the patient is not sick enough to warrant hospitalization. What do you think will happen if we don't fix that SSTI, FBO, anaphylactic reaction, asthma attack, heat stroke, hypothermia, poisoning, overdose, or seizure?
Hint - they'll need to be hospitalized. We fix many serious problems so they don't need to be hospitalized as a result. The majority of those patients are sent home or stay in the hospital for observation only.

The patient may or may not follow up in clinic depending on whether they have insurance or a PCP and it might not be for months. In any event, the current problem was fixed. So yeah, we see many things to completion, A through Z.

 

[mehc012]

Yeah I understand exactly what you're saying. You just seem to have a general lack of understanding of inpatient medicine in general or have this idealistic view of other specialties besides EM.

You're also ignoring all my previous points. Whether or not you follow a patient till they're sent home has nothing to do with fixing their problem. Most patients sent home from the floor don't have their problem fixed as I already mentioned (nearly all chronic diseases). Not to mention all the patients discharged to rehab or a nursing home that are still sick and disabled. A ton of patients are also admitted for observation or because of social issues. Just because their admitted doesn't mean they are necessarily sicker.

In addition, you're completely wrong about EM docs only fixing things when the patient is not sick enough to warrant hospitalization. What do you think will happen if we don't fix that SSTI, FBO, anaphylactic reaction, asthma attack, heat stroke, hypothermia, poisoning, overdose, or seizure?
Hint - they'll need to be hospitalized. We fix many serious problems so they don't need to be hospitalized as a result. The majority of those patients are sent home or stay in the hospital for observation only.

The patient may or may not follow up in clinic depending on whether they have insurance or a PCP and it might not be for months. In any event, the current problem was fixed. So yeah, we see many things to completion, A through Z.

I understand all of those things. I guess I'm just not describing my point well, at all, so I give up. EM is the best specialty ever. They do everything, inpatient medicine is just 100% continuation of things EM docs start, only you have to deal with them for a longer period of time. There's absolutely no benefit in seeing the patients go home. There's nothing an EM doc can't do, except boring stuff that nobody would want to.

 

[GameTheory29]

OP...read the above and read it well. I highlighted a part that I believe you should strongly consider.

When I moonlight...I never worry about the patients I admit. Those patients are taken care of. At least one shift a day I have a patient that is on the cusp...and I decide not to admit them. You know...the guy with a lobectomy who is now presenting with pneumonia. Vitals look good...diagnosis looks straight forward. He is stable for outpatient care...until he dies in his sleep the next night. Or how about the girl with abdominal pain who doesn't have insurance that doesn't want to go to the ER because it would cost too much money. You end up doing everything in your limited ability to work the girl up. You don't have a CT/US...so you never completely know if they don't have a pelvic/abdominal emergency. The average patient you would send the patient to the ER for better diagnostics, but when they refuse due to cost...what do you do? You document the heck out of it and wish for the best.

If you don't think about your patients and don't want to think about your patients when you get home...you are probably a good fit for ER. If you do, like me, then you are a poor fit.

Docs say this all the time to me when I'm working with them. Almost all of them say they think about patients they sent home even if they feel they did the right thing.

 

[giantswing]

You have a different definition of acute than I, then. For example, a ruptured appy would generally be considered an acute problem in my book, but hey, if they're not actively coding...

There's more to fixing problems than running codes. You say stabilizing sick patients is fixing a problem...I say that their problem is whatever was making them sick. Yeah, you have to stabilize them in order to treat them, but it's like seeing step A, but not B-Z, when the 'problem' is the whole damn alphabet soup. I'm not saying it's not important, but it's not a 'fix'...if it were, you could send them home afterward. When I say 'fix problems', I mean 'see to completion', and that is something that ER docs only get to do, practically by definition, when the patient is not sick enough to warrant hospitalization (and even then a lot of times it's the outpatient provider who finishes up).

This has nothing to do with the amount of busywork on the floor, 'chronic vs acute' problems, etc. I actually prefer acute problems with more short-term solutions. I don't really have an interest in following a patient long-term throughout their life. However, I like to see an individual problem, as in 'condition requiring hospitalization' to its conclusion (problem 'fixed' to the point where the patient can go home). That doesn't happen all of the time on the floor either, but it happens a lot more than the ED (if you don't count those who never needed hospitalization to begin with).

I'm done, because at this point you're either intentionally skipping on what I'm saying or you're just never going to get it. Maybe I am the suckiest explainer that ever attempted to explain things, whatever...point is, this has gone back and forth enough that there's no point in continuing.

Nothing ever actually gets fixed in medicine. Seriously. Ever.

Now surgery...

 

[Mad Jack]

How were there armed security and police in both of these cases? I dont think I've ever seen officer in the ED unless they were the one bringing the person in.

The sorts of EDs that are at high risk for these sort of events usually have armed security. All guards at my old hospital were former police officers with full gear, gun included, specifically to deal with incidents like this.

 

[Mad Jack]

Ditto. The ED had armed guards (I think technically they were university police force - which was a commissioned police force, not "security").

They also had a lockdown protocol for when shooting victims came in, with city PD in kevlar posted at the entrances/exits.

We petitioned the city for our own commissioned police force, but they wouldn't allow it in their jurisdiction. Felt it would complicate certain cases too much.

Really wish we had a lockdown protocol that was as good as yours, given the number of shootings we saw. We would bar visitors to only the closest family members, and they would be kept in a locked unit. But all it would really take is someone saying the right things to sneak their way into the unit if they so chose. Hence why I'm a big advocate of installing metal detectors at all of the entrances.

 

[Jabbed]

Yeah I understand exactly what you're saying. You just seem to have a general lack of understanding of inpatient medicine in general or have this idealistic view of other specialties besides EM.

You're also ignoring all my previous points. Whether or not you follow a patient till they're sent home has nothing to do with fixing their problem. Most patients sent home from the floor don't have their problem fixed as I already mentioned (nearly all chronic diseases). Not to mention all the patients discharged to rehab or a nursing home that are still sick and disabled. A ton of patients are also admitted for observation or because of social issues. Just because their admitted doesn't mean they are necessarily sicker.

In addition, you're completely wrong about EM docs only fixing things when the patient is not sick enough to warrant hospitalization. What do you think will happen if we don't fix that SSTI, FBO, anaphylactic reaction, asthma attack, heat stroke, hypothermia, poisoning, overdose, or seizure?
Hint - they'll need to be hospitalized. We fix many serious problems so they don't need to be hospitalized as a result. The majority of those patients are sent home or stay in the hospital for observation only.

The patient may or may not follow up in clinic depending on whether they have insurance or a PCP and it might not be for months. In any event, the current problem was fixed. So yeah, we see many things to completion, A through Z.

Do you routinely send home heat stroke patients and overdoses? o.o

 

[medicalstadent]

what i keep hearing is that EM has the highest burn-out rates - maybe thats why?

 

[alpinism]

Do you routinely send home heat stroke patients and overdoses? o.o

After they've been treated and observed and as long as they're stable.

If their vitals and labs are all normal and they have no complications there's no reason to stay in the hospital.

 

[Jabbed]

After they've been treated and observed and as long as they're stable.

If their vitals and labs are all normal and they have no complications there's no reason to stay in the hospital.

I call BS. Unless you've got Jesus doing the fluid resus, you're getting a few days in the unit minimum. DIC, acute renal failure, rhabdo, ARDS are all huge causes of mortality that require constant monitoring and acute interventional management. As an EM physician, you can quickly recognize the problem, but the most invasive and acute management that you can do in the ER is basic cooling measures, intubate, and work the code if it comes. Maybe a lavage if you're a cowboy. You basically package them and keep them alive long enough for the ICU team to come and take over. Therein lies the lack of appeal for EM for many people: you just spent half the night working up benign belly pain complaints and one particularly foul smelling vaginal discharge when the one and only interesting patient comes through the door and all that you can do is try and stabilize them before they cruise on down to the unit where the real work begins.

I'm not at all discounting the work that EM docs do, but there's a reason why many people hate it.

 

[alpinism]

I call BS. Unless you've got Jesus doing the fluid resus, you're getting a few days in the unit minimum. DIC, acute renal failure, rhabdo, ARDS are all huge causes of mortality that require constant monitoring and acute interventional management. As an EM physician, you can quickly recognize the problem, but the most invasive and acute management that you can do in the ER is basic cooling measures, intubate, and work the code if it comes. Maybe a lavage if you're a cowboy. You basically package them and keep them alive long enough for the ICU team to come and take over. Therein lies the lack of appeal for EM for many people: you just spent half the night working up benign belly pain complaints and one particularly foul smelling vaginal discharge when the one and only interesting patient comes through the door and all that you can do is try and stabilize them before they cruise on down to the unit where the real work begins.

I'm not at all discounting the work that EM docs do, but there's a reason why many people hate it.

Except that's exactly what you and other posters are doing. Just go back and read the last sentence you wrote.

You do also realize that most heat illness/heat stroke patients don't require aggressive fluid resuscitation because they're not significantly hypovolemic. They have physiologic hypotension due to redistribution of fluid from peripheral vasodilation. Once they're cooled it should correct on its own. Having Jesus do your fluid resuscitation is a good way to put the patient cerebral/pulmonary edema and kill them. But hey that's what happens when you have non EM trained doctors try to treat patients with emergency conditions. So yeah, the most important part of definitively treating heat stroke is rapid resuscitation and cooling. After that its just careful observation and monitoring for most patients.

However, if they become unstable or develop complications, the ICU team (which may consist of EM/CC guys) will take care of them.

Listen, if you don't like doing resuscitations that's fine. But, this whole idea that EM guys don't do any "real work" is complete garbage.

 

[Jabbed]

Except that's exactly what you and other posters are doing. Just go back and read the last sentence you wrote.

You do also realize that most heat illness/heat stroke patients don't require aggressive fluid resuscitation because they're not significantly hypovolemic. They have physiologic hypotension due to redistribution of fluid from peripheral vasodilation. Once they're cooled it should correct on its own. Having Jesus do your fluid resuscitation is a good way to put the patient cerebral/pulmonary edema and kill them. But hey that's what happens when you have non EM trained doctors try to treat patients with emergency conditions. So yeah, the most important part of definitively treating heat stroke is rapid resuscitation and cooling. After that its just careful observation and monitoring for most patients.

However, if they become unstable or develop complications, the ICU team (which may consist of EM/CC guys) will take care of them.

Listen, if you don't like doing resuscitations that's fine. But, this whole idea that EM guys don't do any "real work" is complete garbage.

Again, I'm not saying that they don't do any "real work". Ideally, their role in the healthcare system is to stabilize and initiate first line treatments for acute patients and not be involved with further inpatient work-up/follow up. Functionally, a large part of their role in the healthcare system is on-demand primary care. People that can not tolerate either of these roles are just not attracted to the field or burn out faster than usual.

fwiw I'm planning on going EM/IM, which I mention to illustrate that I have obvious respect for the field. I'm just aware of the drawbacks.

 

[Jabbed]

This is why you never give the full 2 mg of Narcan. You want them to stay at least a little bit stoned.

 

[Mad Jack]

This is why you never give the full 2 mg of Narcan. You want them to stay at least a little bit stoned.

I love watching them jump up like they've risen from the dead, personally.

 

[Jabbed]

Except that's exactly what you and other posters are doing. Just go back and read the last sentence you wrote.

You do also realize that most heat illness/heat stroke patients don't require aggressive fluid resuscitation because they're not significantly hypovolemic. They have physiologic hypotension due to redistribution of fluid from peripheral vasodilation. Once they're cooled it should correct on its own. Having Jesus do your fluid resuscitation is a good way to put the patient cerebral/pulmonary edema and kill them. But hey that's what happens when you have non EM trained doctors try to treat patients with emergency conditions. So yeah, the most important part of definitively treating heat stroke is rapid resuscitation and cooling. After that its just careful observation and monitoring for most patients.

However, if they become unstable or develop complications, the ICU team (which may consist of EM/CC guys) will take care of them.

Listen, if you don't like doing resuscitations that's fine. But, this whole idea that EM guys don't do any "real work" is complete garbage.

And you don't play the odds on fluid resuscitation for heat stroke patients. You follow ICU protocols and monitor CVP.

 

[Jabbed]

I love watching them jump up like they've risen from the dead, personally.

My local EMS is notorious for giving max dose in the field, so our junkies come in stone cold sober and raring for a fight. We once had a guy jump out of the back of the ambulance and run buck naked down the street in front of the hospital during a JCAHO visit.

 

[bc65]

There doesn't need to be an argument here about whether or not the ER "cures" anyone.

First of all, the point of this thread was to explain why the people who DON'T like ER Don't like it. Threre's no reason to disagree with any of the negative posts. This thread isn't about whether anyone should or should not go into ER. To repeat, OP was asking only for the negatives. He wasn't even requiring that these reasons be accurate.

Next, it seems to me that ER patients will fall into two categories: the ones that are treated and released, and the ones who are admitted. Clearly, only the ER docs see the treated and released patients, the ones they cured, or at least, managed acutely. The other ones all required admission, and therefore will look like "failure to adequately treat" to the admitting doctors.

Now, it's true that the ER can splint a fracture. The ER doc might be happy with applying the splint, but the splint will need to be replaced and there will need to be follow up and therapy. Some will need reduction, others will need surgery. Even the ones who don't need further treatment will need to be evaluated, and probably get physical therapy. The ER doc may not be interested in providing that type of treatment, but it needs to be done as part of the care. No one should discount it as "non treatment" just because you aren't interested in providing it. Giving a hypertensive a single dose of medication and getting him out the door is not the same as managing hypertension in primary care.

Now, here are some reasons why I complain about the ER docs:

The hand laceration with a "normal " hand exam that later turn up with nerve or tendon lacerations that are now complicated by the delay and will require more complex and less successful surgery. The nerve that was debrided away in the ER, now requiring a nerve graft. The call waking me up at 3 am telling me that they are sending me a consult for a tendon laceration. Waking me up "just to let me know"!? #@!%#@. This happens about once a week, " just letting me know". Or asking if I need to come in to see it. No, I do not. Why not ask one of the 3 other ER docs there if you need to call before you wake me up?
Insisting that I come in at night to see a bad hand infection which is obviously gout in a patient with a documented history of , yes, gout.

Or waking me at 2 am to tell me about a tendon laceration in the dorsum of the foot. By the way, this is not a problem that needs to be managed acutely. Skin sutures and a follow up in the office in a week is all that it needs.

ME: Why are you calling me?
ER: Because the tendon is lacerated.
ME: But why are you calling ME?
ER: Because you're on call for hand surgery.
ME: But the laceration was in the foot!
ER: Yes, but it's a tendon laceration.
ME: But, did you not take anatomy in med school? The foot is not the hand?
ER: But it's a cut tendon.
ME: Yes, in the FOOT. You want a FOOT doctor.
ER: But the tendon is cut.
ME: Yes, in the FOOT, not the hand . I am a hand doctor, not a foot doctor. Please call podiatry, or perhaps ortho. Not hand surgery.
ER: But.......
ME: Call podiatry!
Hang up.

Not only is this an accurate transcript of my conversation, but another hand surgeon reported this exact conversation with another ER docter for the same problem the year before. So, while I respect what ER docs do, there is a lot of room for improvement.

 

[medic86]

 

[alpinism]

Again, I'm not saying that they don't do any "real work". Ideally, their role in the healthcare system is to stabilize and initiate first line treatments for acute patients and not be involved with further inpatient work-up/follow up. Functionally, a large part of their role in the healthcare system is on-demand primary care. People that can not tolerate either of these roles are just not attracted to the field or burn out faster than usual.

fwiw I'm planning on going EM/IM, which I mention to illustrate that I have obvious respect for the field. I'm just aware of the drawbacks.

Fair enough.

And you don't play the odds on fluid resuscitation for heat stroke patients. You follow ICU protocols and monitor CVP.

CVP is worthless and doesn't tell you anything about fluid status.

Meta-analysis:
http://www.ncbi.nlm.nih.gov/pubmed/18628220
http://www.ncbi.nlm.nih.gov/pubmed/23774337

Not only that, its also been associated with increased mortality:
http://www.ncbi.nlm.nih.gov/pubmed/20975548

The dagger in the heart was the ProCESS trial which just came out this year:
http://www.nejm.org/doi/full/10.1056/NEJMoa1401602

 

[FictiousForce]

Why is 66h/week considered crazy when 80-100h work weeks is a thing in surgical specialties?

Honest question.

 

[The Buff OP]

EDM rules!












And EM is pretty awesome too, if you work at a level 1 trauma hospital.
I just finished watching this the other day.

 

[DrBowtie]

Why is 66h/week considered crazy when 80-100h work weeks is a thing in surgical specialties?

Honest question.

% of time doing actual work.

 

[notbobtrustme]

Why is 66h/week considered crazy when 80-100h work weeks is a thing in surgical specialties?

Honest question.

there's basically no downtime in the ED. You are constantly seeing whatever walks in.

 

[KnuxNole]

I think the issue for most grads is that they go into EM expecting emergencies and acute care and then end up buried in the nightmarish sequale of chronic disease and Press Ganey.

This. People who expect EM to be ONLY, or half the cases to be acute cases and emergencies are delusional. They have a decent amount, but TONS of minor urgent care like stuff, back pain for 8 months but decided TODAY is the day to come to the ED, and people waiting 4 hours for nasal congestion

 

[jl lin]

This. People who expect EM to be ONLY acute cases and emergencies are delusional. They have a decent amount, but TONS of minor urgent care like stuff, back pain for 8 months but decided TODAY is the day to come to the ED, and people waiting 4 hours for nasal congestion

Seriously, I couldn't deal with waiting 2 to 6 hours or more in an ED for nasal congestion. I know. There are those w/o primary care providers who do this. It's so much easier to make an appointment at a clinic or go to see a primary. If you have insurance, it's ridiculous too; b/c the cost is too high compared with going to a clinic or seeing a PCP. These kinds of ED admissions are a huge waste of money. . .and time.

 

[mimelim]

I understand all of those things. I guess I'm just not describing my point well, at all, so I give up. EM is the best specialty ever. They do everything, inpatient medicine is just 100% continuation of things EM docs start, only you have to deal with them for a longer period of time. There's absolutely no benefit in seeing the patients go home. There's nothing an EM doc can't do, except boring stuff that nobody would want to.

The vast majority of patients do not come into the hospital via the ED. I'll just say this bluntly, you don't know anything about this topic. Forming strong opinions when in positions like this are recipe for problems down the road.

 

[NickNaylor]

Seriously, I couldn't deal with waiting 2 to 6 hours or more in an ED for nasal congestion. I know. There are those w/o primary care providers who do this. It's so much easier to make an appointment at a clinic or go to see a primary. If you have insurance, it's ridiculous too; b/c the cost is too high compared with going to a clinic or seeing a PCP. These kinds of ED admissions are a huge waste of money. . .and time.

At the risk of going down the non-PC road, if you're a person who has no insurance, no job, and survives only on benefits of various types, what's the cost to you for spending 4+ hours sitting in the ED? None.

 

[KnuxNole]

I just find it funny having to wait 4 hours for snotty noses...I mean damn. Go to Mcdonalds and flip some burgers, get that Medicaid, and see some pcps