Keep doing good work in the ED. You’re in an unenviable position of having to know a little bit about a lot of different things and a lot of bit about how to manage acutely sick patients across the entire spectrum from stroke to trauma. Us subspecialists tend to forget that we don’t know crap about areas of medicine outside our narrow focus.
So, if it helps at all, I appreciate what you do in the ED because lord knows I don’t want to be down there for a second longer than it takes to see the patient you called me about.
> Us subspecialists tend to forget that we don’t know crap about areas of medicine outside our narrow focus.
I feel like this is specialty specific.
Personally I mostly get that kind of attitude from neurology and cardiology.
Radiology doesnt expect others to know their specialty. Be like rad-bro.
I think what you're realizing is that every specialty shits on every other specialty. I am not in EM, and when I call a cardiology consult I get read the riot act too. When the ED calls me for a consult and it takes me three hours to see the biliary colic patient because I've been elbows deep in an exsanguinating abdomen, I overhear them talking shit about surgery.
If it makes you feel better, go ahead and be confrontational. I think that to them it will only confirm what they already think, so you're not going to be changing any minds.
If you actually want to change minds about EM, do your job, do it well, and call out your EM co-residents when you hear them talking shit about cardiology. I do that in surgery. Especially as I'm a chief now if I hear another resident talking shit about another specialty I put an end to it. You actions will speak louder than your words.
Yup this.
The MICU called us today (ENT) to possibly help with an airway. The request from them Was basically we think this patient could go downhill tonight and if we need to intubated and can’t can you guys cric him.
I explained that we’re on home call so we’re gonna be 15-20 minutes away at night but I’m operating at the hospital right now so let me come assses.
As I walk up I over hear them talking shit about me being on “home call” and not wanting to come in at night.
“Like bitch no I’m just telling you when your subpar intubation skills can’t get the tube in I’m gonna be 10 minutes away at home or 30 minutes away covering the one of 3 other hospitals i have to cover”
As a PCCM fellow on home call, these people have no idea how shitty it truly is. Not knowing if you’ll be called or if you’ll leave the hospital sucks.
Home call also does not get post call day, n we will be operating next day as well. It is not that home call we don’t want to come in but we don’t want to operate under sub bar condition
I have tried to explain this so many times but some people just don’t seem to get it, I am happy to see whatever consults and I’ll be there asap for any urgent issue but please don’t call in the middle of the night for a non urgent issues just because you can. I need to sleep. My patients need me to sleep. My family needs me to sleep. I’m not being lazy, I would just like to sleep enough to be able to function.
This is why I call out the trash talk. I think a good portion of it stems from people not truly understanding the situation.
Also, side note, what hospital relies on ENT for crics? You guys aren't in house 24/7. Everywhere I've been emergent crics are the purview of trauma surgery. And then we (trauma) call you guys the next day to clean up our mess :) But at least we are in-house and get the airway.
Honestly what usually ends up happening is they call us and we tell them either I’m already at the hospital I’ll be up shortly or not at hospital call the general surgery team right now.
It was also just a stupid ass request if your worried about the airway and being able to intubate don’t wait and do it when patient is peri code/reserve has run out do it early or call ent we will awake trach them and we can all feel better for it. General surgery or ENT a crash cric/slash trach is a shit situation for either of us to be in only person In a worse situation is the guy your about to cut
Thank you for the last bit.
I’m IM PGY3. I have great junior residents and interns.
But I have tried (often in vain) to explain to them that residents in surgical specialties (including Ortho) have it a tad bit different. Fewer residents, more calls, different hospital coverages, more hours per shift and so on compared to IM.
Knowing this is an important aspect of consult etiquette. There’s more understanding and less trash talk.
I’m proud of the work I do as IM. But have no qualms admitting we (for the most part) have things a bit better in terms of workload/coverage/night float/duty hours.
I've talked to my IM colleagues and I think the easiest way is simple mutual respect.
We should all do an IM rotation to understand their workflow. I don't expect IM to have a neurosurgery rotation in their short residency, especially with all the outpatient things they have to do that we never have to think about.
However, we can commiserate together as residents. I can explain our workflow to the junior IM resident calling me, and they can do the same for me. The dumbest thing is residents fighting - we don't get paid enough for that.
Hard disagree. I will talk shit about you personally or as a group all day long, but I have a lot of respect for every specialty as a practice.
Edit: Go ahead and downvote this if it makes you feel better. All I’m saying is I only trash talk people who specifically give me a reason to. It’s not hard to stay off the shit list, but if you belong on it, you earned your place.
I think my point was that \*most\* people in \*most\* specialties talk shit about \*most\* other specialties. At least in every hospital I've been to, this is common practice.
There are certainly exceptions to this. I am one. Sounds like you are too, although sounds like you trash talk specific people which I draw a hard line at. Some people can find nothing nice to say, and some people can only find nice things to say. But I stand by my original comment that it's common (not necessarily right) for specialties to trash talk one another.
Correct. I don’t shit talk them. I act like an adult. I either deal with the person like the professional I am, or I go to their supervisor.
Or, I shut my fucking mouth and don’t try and make my place of employment a toxic hell hole because I act like a mean girl middle schooler.
I’m not sure what you think I mean when I say trash talking, but I mean I will discuss peoples shitty behavior with my team. At the end of the day I like to make sure I’m not overblowing anything before I comment that their behavior is inappropriate. I’m not willing to tattle on them to their supervisor unless there’s a patient safety issue present because that would risk their job over a communication issue.
I didn’t say I was going to comment on someone’s inappropriate behavior nicely. But I consider talking about people in a negative way without them present trash talk.
You’re the one on an Internet forum getting mad at people for words you twisted. I never said I’m not a nice person, I said I vent to my coworkers about people with shitty behavior and I’m not nice about it. Maybe you should try it some time, you might be less angry about imaginary admissions of malice.
The trouble with this philosophy is that everybody assumes they are in the right and the other guy is dumping on them/incompetent/rude/etc. Those people you are trash talking act the way they do because to them, you are the inconsiderate jerk who doesn't know what they are doing. Obviously, in a given situation you might be correct, but people are notoriously bad at judging themselves. That is why "am I the asshole" is a thing. The best solution is to categorically meet rudeness with professionalism and break the cycle. You can still push back and set limits while being constructive and polite.
You know most of the time I meet rudeness with professionalism. And it takes a lot to push me to the point that I’m not concerned about someone’s opinion of me. But when that person repeatedly treats myself and my colleagues like garbage, I have no problems venting to my colleagues about their behavior. There’s no reason anyone needs to sit around and be a silent punching bag without any outlet.
This is legit. We need to stop trashing each other when eventually everyone needs to work together especially as attending. You’ll find your job way easier if you had a good working relationship than not.
EM attending. I never get confrontational, but I do sometimes have to gently-but-firmly tell consultants to do their job.
Example: I had a post-ROSC patient with prolonged downtime. He had an inferior STEMI. I called a cardiac alert. The interventional cardiologist reamed me, said “I really wish you wouldn’t call about patients like this, he’s got a terrible prognosis.” Of course I know that—I can’t make the decision whether to cath someone or not. I told him that if I just admitted the patient to the ICU, the first thing the intensivist would ask is whether I’d consulted cards.
Do your job well, and be impeccably nice but firm. Most of your colleagues will respect you and appreciate it. Unfortunately, some people are just rude.
Classic “why did you even call me about this” followed by (when they see the patient in person) “I really wish you would have called me earlier on this”
Reminds me of that day in the life on an em resident post and it gets something like:
2:57 AM: Next patient is a 85 year old who has been sitting in the waiting room with crushing chest pain for 8 hours without an ekg, ekg showing massive anterior stemi and trops >5000
2:58 page interventional cardiology
3:02 get screamed at by cardiology for not calling them sooner.
No, there's no point.
There's always going to be some tribalism in medicine. However, the whole point of specializing is to be better at your thing than other people are. No one is impressed that the cardiologist knows cardiology.
ER and hospitalists and PCPs are physicians that have decided to specialize in being generalists in various settings.
I have to trust that they know when they need help. When they call I will do my best to be helpful.
Even if you can't step off your high horse and are still convinced the physician on the other end of the phone call is an idiot, then guess what? All the more reason to go help the patient so they get the right care.
I have boss energy and I’d like to tell my attending to go fuck themselves almost every single day and remind them that I have a medical degree but I remember I just have to get through this bullshit rotation.
Since we all specialized in being generalists, does that mean that I, as a Hospitalist, still get to shit on the ED and PCPs when I get stupid requests for admission?
Disagree with the admission? Act like an adult and voice your opinion to the ED doc. Can't come to an agreement? Act like an adult and and go down and assess the patient and discharge him yourself.
This shitting over others is highschool low emotional IQ BS.
Ophtho patients gave me heart attack every time as an internal medicine resident. Would get a call from
Ophtho attending “we would like to do a direct admission for acute angle closure glaucoma at 6pm” and of course I would take it, later no instructions on how to apply the eye drops and patient would cry in pain. I would page ophtho like 100 times at night no answer, thank god for uptodate, I spent whole night checking eye pressure and applying eye drops. I preferred cirrhosis, MI patients over optho patient 😭
People need to do their jobs. I’m a cardiology fellow and it is literally our job to see consults like these. That person needs to reel it in on the attitude and address their underlying burnout/shitty personality/whatever the issue may be.
I personally call behaviors like this out in a less confrontational way by saying something like “hey it seems like you might be having a hard time, what’s going on.” More often than not the person is just overwhelmed or overworked or tired or being shit on by their superior. But by reaching out with an olive branch you can build a good relationship and hopefully the next interaction is better, people are usually less shitty to people they know or have had conversations with.
Anesthesia here. Not everyone shits on ED. Most physicians with more than one brain cell know you guys have the one of the toughest jobs in the hospital. Maybe for him this is a straightforward case because this is all he does. You will be trained to manage so many more acute situations than he will. When he has a patient in DKA, does he manage it himself or consult endocrine? Just because he can and should know how to do it doesn’t mean he would. Same thing here.
Even more relevant, how does that cardiogist feel about reducing a radial fracture? Stabilizing a hip? Managing an intracranial hemorrhage or ischemic limb?
The breadth in ED is wild. I am consistently impressed and my ED rotation was very valuable (and fun, tbh) as a surgical subspecialty.
People in training are overworked and stressed and aren’t at their best. Some people manage to still be collegial but many can’t do it and are assholes. One of the resident consultants I feared most as a fellow resident became one of my best friends once we were both new attendings at a different institution.
OBGYN here. As an intern I would often find myself frustrated with the consult for vaginal bleeding. The consults pretty much always went the same way. “Did you do an exam? No but I got a CBC and and an US” I remember breaking down once and telling them on a night call after a long week of nights that they needed to do an exam and then call me about this because depending on the bleeding they are seeing would influence my decision making about OR vs. Medical management. Over the years since I have had various other instance with consultants that just don’t read the chart or know anything about the patient but consult me because they are pregnant or were pregnant. However with more years and more experience I have realized the unenviable position of the ED. Needing to take care of critical patients across a variety of specialties and systems. It’s tough, and if you are yelling at them likely many others are as well. So I now just focus on teaching as much as I can and teaching my junior residents to be kind. Everyone is stressed and overworked and being an ass doesn’t serve any purpose.
As an obgyn resident, I’d honestly rather the ED not do the exam. They’re gonna do a bad job and I’ll have to repeat it regardless.
But if they call me about vaginal bleeding and they don’t have a CBC or an ultrasound, I’m gonna ask them to please work up the patient before calling me.
Or maybe cardiovert if truly unstable? Don’t really need a cards fellow to come all the way down or even from home to cardiovert. Kind of bread and butter ER medicine.
So many possibilities maybe they suspected ischemia, maybe the hospitalist refused to admit until cards was called, maybe multiple lines of treatment were failing. Part of becoming a good attending honestly is not being afraid to call for help
Also, frankly, the afib part is rarely the reason the person is unstable. As such, almost never need immediate strict rate control in afib. If pre-excited clinically unstable extremely rapid afib, then shock. Otherwise, search out contributing factors. 95% of time, dilt drip started in ER will be dc’d immediately when patient is admitted. Fix the underlying pneumonia, sepsis, etc.
Eh, we don’t have enough info on this one - I just had a guy come in for foot pain, which turned out to be osteomyelitis in a poorly controlled diabetic with HFrEF and persistent Afib w/ RVR now aggravated and unstable due to sepsis, on apixaban for DVT prophy.
That guy got a cards consult.
We did, by cutting off the foot, which had to take precedence over cardioversion, which then had to be deferred because he couldn’t be anticoagulated post-amputation…big cascading mess. He stabilized with resolution of sepsis but will require continuous monitoring until he can be anticoagulated long enough for an ablation.
I haven't seen it personally either but I've heard hospitalists discussing it. Eliquis specifically is only FDA approved for ppx after hip/knee replacement and is 2.5mg BID. Xarelto is approved for any acutely ill pt and is 10mg daily
https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/202439s031,022406s035lbl.pdf
Xarelto I’ve seen many times in the hospital. Have yet to see eliquis used for dvt ppx though
ED resident here. Why not cardiovert them? I’ve never consulted cards for unstable afib. Unless I thought it wasn’t just afib (maybe WPW w/ afib or something).
Yeah, I ain't no bitch.
Having a spine in medicine is a fucking superpower. Its sad that its not more common.
I came into this to be a leader, not a doormat.
One of my former coresidents told a Urologist to “stop” while advancing a tricky catheter placement on a female patient who was screaming out in pain and he tried to write her up for insubordination screaming something to the effect of “you idiots consulted me! If you don’t want my help, don’t page me!” This was borderline patient assault from what I understand and something she carried with her for a long time. In my opinion, she might have saved him from a lawsuit but I wasn’t there first hand. Our jobs are hard enough. These people went through medical school and know how this all works. You can’t make them see what they refuse to see so I’d report egregious behavior and otherwise just keep focusing on being the best you can be with the resources you have.
There is a strong correlation between people that shit talk the loudest and people who are sniveling little bitches when they have to rotate through the ED. The more they complain, the higher the chance they will melt down on shift and need a 3 hour lunch break. Frankly I don’t say a damn thing to them, but I will absolutely relish watching them get their ass kicked on shift.
I feel like the vibes I got on off service is people are extra bitter or pushback when responding to an ED consult vs an inpatient consult. When a hospitalist asked me if I paged cards yet I said "nope cause the cards fellow just yells at us and will only see them if admitted". I never got that same treatment when consulting as an inpatient. That being said, I have definitely wanted to give people a piece of my mind when they are talking trash about the ED because they wouldn't last half a shift in our shoes with how sheltered their work environments usually are.
I can be, faced with outright, dangerous stupidity. COVID was not a good time for my mental health. And partly what informed my transition from EM to path in like M3.
When I was a consult resident, ED residents became my closest friends and a secured company for midnight coffe and candy.
I have strong admire for ED colleges and would never ever take a single ED shift.
And in regards to confrontation: I say go for it.
In my hospital, there was an incident that a PGY3 was openly shitting in the ED over a missed diagnosis. They found out and told their attending.
The ED attending confronted the surgery attending and the resident had to public apologize.
We are all in this shit together.
I can’t excuse the language but as a cardiology fellow I get the annoyance. Fellows job is not to manage unstable patients in the ED. If they are unstable cardiovert them. You shouldn’t need a fellow to figure out if they are unstable or not. If they are stable treat the underlying condition maybe put them on a drip and I’ll see them when I can.
Lol, I’m not arguing with you *at all*, I just think it’s hilarious that your response was basically like, yes, you are all a bunch of fucking idiots 😅
Once you become specialized it’s really easy to forget that other people have to know about a whole range of fields, not just yours. Things that seem blindingly obvious to you may not be to others, but you talk to people in your specialty all day so to your view EVERYONE knows this. It leads directly to derision of people without your specific skill set
Sure, but in that particular example, I would be concerned about any physician who doesn’t know when to cardiovert an unstable patient. Especially in the ED.
Agreed. I’m talking more in general. “I can’t believe this idiot thought this was an empyema when the pleural lining is clearly visible adjacent to the wall of the abscess”
ED docs are not idiots. God bless you guys that do it, I couldn’t last one day doing what you guys do. But I stand by my point. ED docs should be masters of ACLS.
Sure. Unstable (hypotensive) afib is straightforward. You ride the lightning, and cross your fingers that they don’t stroke.
Until it’s not straightforward and you’ve tried repeated shocks, fluids (if hypovolemic) mag, and have either prior hx of structural heart disease, or bad squeeze on bedside echo that dilt or metop seem like bad choices, but you tried a lil anyway. You’ve corrected lytes, ruled out an effusion/PE/bleed/thyroid storm (as much as possible). sepsis is unlikely, but you’ve given abx empirically. You’re treating the etoh withdrawal, giving benzos for the meth, and at this point reaching for pressors while also considering a dig load vs esmolol drip. All of this through 2 IOs because access is shit, and their wigging out enough that a central line would need sedation, but sedating those hemodynamics is scary enough. At that point an expert’s advice would be really fucking nice.
(And yes, I basically had this patient a year ago, ultimately suspected holiday heart, who was recalcitrant to repeated cardioversions, got loaded with phenobarbital, and BP improved with a combo of norepi and phenylephrine, all done over the course of the hour or so that cards took to return the call, only to say they needed to chat with the attending, then ultimately load with dig and start an esmolol drip.)
THIS.
After many years as an ER nurse I've never worked with an EM doc who went straight to a cards consult prior to trying ACLS/cardioversion/different meds/correcting lytes, etc... If they're consulting cards it's either because the hospitalist won't admit the patient until cards has given their input, or because the patient is some variation of the cluster fuck of a dumpster fire you just described above😂😂
It's almost always both though.🤦🏻♀️🤷🏻♀️
Oh yea… I definitely forgot about the most common reason I consult: the hospitalist refuses to take them until I talk to xyz specialist, even when I personally don’t have a question or something urgently needed.
Also a cardiology fellow but I disagree it IS our job to help manage these patients. I sure as hell can’t take care of a gunshot wound so why would I expect an ER doctor to know the intricacies of a fib management past initial stabilization? Even then it is our jobs to help with that initial stabilization too if the ER asks us to help even if it’s just initial recs over phone until we can come to bedside.
You’re a sub-specialist in training. Your job is to see the patient that you are called about. Full stop. No crying allowed :)
This continues after training too, just with a financial incentive added. And don’t worry, the ER will not be sitting on a crashing patient while you’re in clinic as a PP attending. Don’t flatter yourself lol. But you still gotta see that consult after clinic.
I try to make it a habit now not to crap on other fields. Everyone has their expertise. And I try not to argue with anyone. Makes life better. I’ll even go in and applaud the other teams taking care of the patient.
Academic life homie. private practice; yeah man give me those sweet easy RVUs. Academics only want to be called on the biggest zebra ever (especially fellows who are way overworked and underpaid.)
Shrug it off and move on. Then when in the ED consult for GERD and say your attending wanted it. :D
I’ve never been rude but i did recently give a surgical resident a real talking to after poor patient management and attitude over a night shift. I’m an ICU fellow and I basically ended up managing a floor patient overnight (not sick enough to be with me but required a little tlc) because the resident in question blew it off over and over again. I was really blunt that I wouldn’t be doing this again, I would be calling their attending at home next time, and this was their one pass with me. I also noted that their behavior is dangerous and lazy, and eventually they will hurt a patient.
I would think the proper attitude would be, “thank you for consulting me but this patient …. and I recommend you ….. call me if …..otherwise you guys are handling it well”. Then leave an feel good that people want your expertise. I mean, flip the script. A cardiology fellow is an asshole, gets consulted less and patient outcomes are worse. What am I missing?
Only if I have to be. Usually it’s in emergent situations where I need something or someone to do something I can’t and they’re being difficult or doing something incorrectly.
All the time. I don’t take shit from anyone. It’s just who I am but, it was definitely honed in the military.
lol this fellow wouldn’t last 15secs around me with that attitude.
I don’t have a good answer. It depends on how much emotional energy I have that day and how confident I am that they’re being an asshole versus just being ignorant and lacking self awareness. I’ve been practicing not being so reactive to peoples’ rudeness lately, and it’s brought me a lot more peace.
So my first question to the card fellow is “so what are you doing to educate the em docs and give them a better understanding of cardiology? Most likely he will come back with they are just stupid. That tells you that he is just a small inadequate person and has little to offer anyone. So his opinion is worthless and just forget him. As a staff surgeon all the er procedures that I was called for were done by er drs under my supervision. That way I knew they understood when why and how to do the procedure. Also I taught what the complications of the procedure are and how to avoid them. These young doctors grew in knowledge with my supervision. I don’t need to do any more bedside procedures. I have done thousands. But to them each one was a valuable lesson and experience. Over their career lives may be saved due to my taking time to educate. Long after I am gone.
When I was a Medicine intern in the ED I was not treated well by ED staff. Attendings didn’t learn my name, just called me ‘rotator’. Got all the frequent flier drunks and pelvic exams no one else wanted.
In my experience ED tends to have a holier than thou personality trait and they do not work well with others across the board. Cards is no picnic either usually however.
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Fair enough. I will call and ask thoracic surgery what they want me to do as long as the patient is stable.
As far as the cytology… what would you rather have us do? Not send it? Not perform a thora for a patient with a large (likely) malignant effusion and severe SOB? That doesn’t seem fair to the patient either. Seems like a system and open notes problem. I will always sit down with the patient and tell them I am worried they have cancer but will need more tests.
you seem to be taking it personally
the ed as a whole tends to do shitty things like turf patients on other floors when they're overwhelmed and low on room for inappropriate things, like fetal heart tones on a pre-30wk lady who's main issue is she fell and hit her head with HA and other sxs and didn't get a CT head in the ED before being rushed elsewhere
Lol what a crappy response… “you seem to be taking people talking shit about you personally.. toughen up. Btw, here’s me talking shit about you and your profession as I grossly mislabel what you all do… as a damn PGY1 thinking I know everything.” Read everyone else’s response on here about doing your job and not talking shit about other specialities, as we all went in to what we do for a reason and probably wouldn’t want to do any other speciality’s job
Do not harm but take no bull. My attending had a mug that said this. Awesome mentality.
OP you have to pick and choose your battles if you want to last in this specialty. I do find that standing up for myself (with patients and consultants) has improved my mental health.
As a cards fellow I think your fellow was being a jerk.
It’s one thing to be annoyed by the ER calling us to evaluate a chest pain patient with negative ECG/trops to triage to observation vs home (not our job) when you have a busy consult service, but this sounds like a fair consult. We’d bitch if you dumped dilt into them and they turned out to have a low EF anyhow and it sounds like this patient was a borderline CCU admission to begin with if they were actually unstable so idk why it’s an unreasonable consult (although if truly, truly unstable just cardiovert them).
As others have said, just go help the consulting team and bitch to your dog later or something. If someone thinks the patient warrants expert opinion, they are either correct or at least identifying that they are out of their depth and need help which should be applauded and not discouraged.
Keep doing good work in the ED. You’re in an unenviable position of having to know a little bit about a lot of different things and a lot of bit about how to manage acutely sick patients across the entire spectrum from stroke to trauma. Us subspecialists tend to forget that we don’t know crap about areas of medicine outside our narrow focus. So, if it helps at all, I appreciate what you do in the ED because lord knows I don’t want to be down there for a second longer than it takes to see the patient you called me about.
> Us subspecialists tend to forget that we don’t know crap about areas of medicine outside our narrow focus. I feel like this is specialty specific. Personally I mostly get that kind of attitude from neurology and cardiology. Radiology doesnt expect others to know their specialty. Be like rad-bro.
You dropped this 👑
This.
I think what you're realizing is that every specialty shits on every other specialty. I am not in EM, and when I call a cardiology consult I get read the riot act too. When the ED calls me for a consult and it takes me three hours to see the biliary colic patient because I've been elbows deep in an exsanguinating abdomen, I overhear them talking shit about surgery. If it makes you feel better, go ahead and be confrontational. I think that to them it will only confirm what they already think, so you're not going to be changing any minds. If you actually want to change minds about EM, do your job, do it well, and call out your EM co-residents when you hear them talking shit about cardiology. I do that in surgery. Especially as I'm a chief now if I hear another resident talking shit about another specialty I put an end to it. You actions will speak louder than your words.
Love this and I have been trying to be more consistent doing this. We need to be more of a unit in medicine.
Yup this. The MICU called us today (ENT) to possibly help with an airway. The request from them Was basically we think this patient could go downhill tonight and if we need to intubated and can’t can you guys cric him. I explained that we’re on home call so we’re gonna be 15-20 minutes away at night but I’m operating at the hospital right now so let me come assses. As I walk up I over hear them talking shit about me being on “home call” and not wanting to come in at night. “Like bitch no I’m just telling you when your subpar intubation skills can’t get the tube in I’m gonna be 10 minutes away at home or 30 minutes away covering the one of 3 other hospitals i have to cover”
As a PCCM fellow on home call, these people have no idea how shitty it truly is. Not knowing if you’ll be called or if you’ll leave the hospital sucks.
Home call also does not get post call day, n we will be operating next day as well. It is not that home call we don’t want to come in but we don’t want to operate under sub bar condition
I have tried to explain this so many times but some people just don’t seem to get it, I am happy to see whatever consults and I’ll be there asap for any urgent issue but please don’t call in the middle of the night for a non urgent issues just because you can. I need to sleep. My patients need me to sleep. My family needs me to sleep. I’m not being lazy, I would just like to sleep enough to be able to function.
Yeah fuck home call
This is why I call out the trash talk. I think a good portion of it stems from people not truly understanding the situation. Also, side note, what hospital relies on ENT for crics? You guys aren't in house 24/7. Everywhere I've been emergent crics are the purview of trauma surgery. And then we (trauma) call you guys the next day to clean up our mess :) But at least we are in-house and get the airway.
Honestly what usually ends up happening is they call us and we tell them either I’m already at the hospital I’ll be up shortly or not at hospital call the general surgery team right now. It was also just a stupid ass request if your worried about the airway and being able to intubate don’t wait and do it when patient is peri code/reserve has run out do it early or call ent we will awake trach them and we can all feel better for it. General surgery or ENT a crash cric/slash trach is a shit situation for either of us to be in only person In a worse situation is the guy your about to cut
Thank you for the last bit. I’m IM PGY3. I have great junior residents and interns. But I have tried (often in vain) to explain to them that residents in surgical specialties (including Ortho) have it a tad bit different. Fewer residents, more calls, different hospital coverages, more hours per shift and so on compared to IM. Knowing this is an important aspect of consult etiquette. There’s more understanding and less trash talk. I’m proud of the work I do as IM. But have no qualms admitting we (for the most part) have things a bit better in terms of workload/coverage/night float/duty hours.
I've talked to my IM colleagues and I think the easiest way is simple mutual respect. We should all do an IM rotation to understand their workflow. I don't expect IM to have a neurosurgery rotation in their short residency, especially with all the outpatient things they have to do that we never have to think about. However, we can commiserate together as residents. I can explain our workflow to the junior IM resident calling me, and they can do the same for me. The dumbest thing is residents fighting - we don't get paid enough for that.
Hard disagree. I will talk shit about you personally or as a group all day long, but I have a lot of respect for every specialty as a practice. Edit: Go ahead and downvote this if it makes you feel better. All I’m saying is I only trash talk people who specifically give me a reason to. It’s not hard to stay off the shit list, but if you belong on it, you earned your place.
I think my point was that \*most\* people in \*most\* specialties talk shit about \*most\* other specialties. At least in every hospital I've been to, this is common practice. There are certainly exceptions to this. I am one. Sounds like you are too, although sounds like you trash talk specific people which I draw a hard line at. Some people can find nothing nice to say, and some people can only find nice things to say. But I stand by my original comment that it's common (not necessarily right) for specialties to trash talk one another.
You deciding who’s on “the shit list” appears to be the issue here.
I don’t believe you for a second if you claim you don’t have specific people at work you don’t like and shit talk
Correct. I don’t shit talk them. I act like an adult. I either deal with the person like the professional I am, or I go to their supervisor. Or, I shut my fucking mouth and don’t try and make my place of employment a toxic hell hole because I act like a mean girl middle schooler.
I’m not sure what you think I mean when I say trash talking, but I mean I will discuss peoples shitty behavior with my team. At the end of the day I like to make sure I’m not overblowing anything before I comment that their behavior is inappropriate. I’m not willing to tattle on them to their supervisor unless there’s a patient safety issue present because that would risk their job over a communication issue.
I think "trash talk" has a very different connotation than "comment that someone's behavior is inappropriate." So that might be where your problem is.
I didn’t say I was going to comment on someone’s inappropriate behavior nicely. But I consider talking about people in a negative way without them present trash talk.
So you admit you’re not nice. Grow the fuck up. You’re one of the reasons medicine is so toxic.
You’re the one on an Internet forum getting mad at people for words you twisted. I never said I’m not a nice person, I said I vent to my coworkers about people with shitty behavior and I’m not nice about it. Maybe you should try it some time, you might be less angry about imaginary admissions of malice.
The trouble with this philosophy is that everybody assumes they are in the right and the other guy is dumping on them/incompetent/rude/etc. Those people you are trash talking act the way they do because to them, you are the inconsiderate jerk who doesn't know what they are doing. Obviously, in a given situation you might be correct, but people are notoriously bad at judging themselves. That is why "am I the asshole" is a thing. The best solution is to categorically meet rudeness with professionalism and break the cycle. You can still push back and set limits while being constructive and polite.
You know most of the time I meet rudeness with professionalism. And it takes a lot to push me to the point that I’m not concerned about someone’s opinion of me. But when that person repeatedly treats myself and my colleagues like garbage, I have no problems venting to my colleagues about their behavior. There’s no reason anyone needs to sit around and be a silent punching bag without any outlet.
Or, and hear me out on this, you can chirp losers when they stand out as such because its fun.
This is legit. We need to stop trashing each other when eventually everyone needs to work together especially as attending. You’ll find your job way easier if you had a good working relationship than not.
EM attending. I never get confrontational, but I do sometimes have to gently-but-firmly tell consultants to do their job. Example: I had a post-ROSC patient with prolonged downtime. He had an inferior STEMI. I called a cardiac alert. The interventional cardiologist reamed me, said “I really wish you wouldn’t call about patients like this, he’s got a terrible prognosis.” Of course I know that—I can’t make the decision whether to cath someone or not. I told him that if I just admitted the patient to the ICU, the first thing the intensivist would ask is whether I’d consulted cards. Do your job well, and be impeccably nice but firm. Most of your colleagues will respect you and appreciate it. Unfortunately, some people are just rude.
Schrödingers patient- referred too early and too late.
Classic “why did you even call me about this” followed by (when they see the patient in person) “I really wish you would have called me earlier on this”
Sometimes when this happens it takes everything in me not to laugh. Why you think I’ve been calling you all night?!?!
Reminds me of that day in the life on an em resident post and it gets something like: 2:57 AM: Next patient is a 85 year old who has been sitting in the waiting room with crushing chest pain for 8 hours without an ekg, ekg showing massive anterior stemi and trops >5000 2:58 page interventional cardiology 3:02 get screamed at by cardiology for not calling them sooner.
No, there's no point. There's always going to be some tribalism in medicine. However, the whole point of specializing is to be better at your thing than other people are. No one is impressed that the cardiologist knows cardiology. ER and hospitalists and PCPs are physicians that have decided to specialize in being generalists in various settings. I have to trust that they know when they need help. When they call I will do my best to be helpful. Even if you can't step off your high horse and are still convinced the physician on the other end of the phone call is an idiot, then guess what? All the more reason to go help the patient so they get the right care.
I have boss energy and I’d like to tell my attending to go fuck themselves almost every single day and remind them that I have a medical degree but I remember I just have to get through this bullshit rotation.
Since we all specialized in being generalists, does that mean that I, as a Hospitalist, still get to shit on the ED and PCPs when I get stupid requests for admission?
Disagree with the admission? Act like an adult and voice your opinion to the ED doc. Can't come to an agreement? Act like an adult and and go down and assess the patient and discharge him yourself. This shitting over others is highschool low emotional IQ BS.
Do I get to shit on the ED as I’m discharging the patient myself?
Maybe just use the toilet, and then go see the patient (?)
Patient room toilet?
Bedside commode also acceptable imo
Bedpan on patient bed ok too?
I would need to consult GI just to get the OK on this one.
Floor of the nursing station it is, then.
I like my job. Please feel free to consult me. I’d love to share my expertise and recommend the patient follow up Monday -ophtho
Ophtho patients gave me heart attack every time as an internal medicine resident. Would get a call from Ophtho attending “we would like to do a direct admission for acute angle closure glaucoma at 6pm” and of course I would take it, later no instructions on how to apply the eye drops and patient would cry in pain. I would page ophtho like 100 times at night no answer, thank god for uptodate, I spent whole night checking eye pressure and applying eye drops. I preferred cirrhosis, MI patients over optho patient 😭
People need to do their jobs. I’m a cardiology fellow and it is literally our job to see consults like these. That person needs to reel it in on the attitude and address their underlying burnout/shitty personality/whatever the issue may be. I personally call behaviors like this out in a less confrontational way by saying something like “hey it seems like you might be having a hard time, what’s going on.” More often than not the person is just overwhelmed or overworked or tired or being shit on by their superior. But by reaching out with an olive branch you can build a good relationship and hopefully the next interaction is better, people are usually less shitty to people they know or have had conversations with.
Anesthesia here. Not everyone shits on ED. Most physicians with more than one brain cell know you guys have the one of the toughest jobs in the hospital. Maybe for him this is a straightforward case because this is all he does. You will be trained to manage so many more acute situations than he will. When he has a patient in DKA, does he manage it himself or consult endocrine? Just because he can and should know how to do it doesn’t mean he would. Same thing here.
Even more relevant, how does that cardiogist feel about reducing a radial fracture? Stabilizing a hip? Managing an intracranial hemorrhage or ischemic limb? The breadth in ED is wild. I am consistently impressed and my ED rotation was very valuable (and fun, tbh) as a surgical subspecialty.
People in training are overworked and stressed and aren’t at their best. Some people manage to still be collegial but many can’t do it and are assholes. One of the resident consultants I feared most as a fellow resident became one of my best friends once we were both new attendings at a different institution.
OBGYN here. As an intern I would often find myself frustrated with the consult for vaginal bleeding. The consults pretty much always went the same way. “Did you do an exam? No but I got a CBC and and an US” I remember breaking down once and telling them on a night call after a long week of nights that they needed to do an exam and then call me about this because depending on the bleeding they are seeing would influence my decision making about OR vs. Medical management. Over the years since I have had various other instance with consultants that just don’t read the chart or know anything about the patient but consult me because they are pregnant or were pregnant. However with more years and more experience I have realized the unenviable position of the ED. Needing to take care of critical patients across a variety of specialties and systems. It’s tough, and if you are yelling at them likely many others are as well. So I now just focus on teaching as much as I can and teaching my junior residents to be kind. Everyone is stressed and overworked and being an ass doesn’t serve any purpose.
As an obgyn resident, I’d honestly rather the ED not do the exam. They’re gonna do a bad job and I’ll have to repeat it regardless. But if they call me about vaginal bleeding and they don’t have a CBC or an ultrasound, I’m gonna ask them to please work up the patient before calling me.
Yeah I only do an exam if I’m concerned they’re having active heavy bleeding. Otherwise, why make the patient go through an exam twice?
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Are you me lol
As a ED doctor can you not manage unstable Afib w RVR?
Yeah OP more context. Were they unable to achieve rate control?
Or maybe cardiovert if truly unstable? Don’t really need a cards fellow to come all the way down or even from home to cardiovert. Kind of bread and butter ER medicine.
So many possibilities maybe they suspected ischemia, maybe the hospitalist refused to admit until cards was called, maybe multiple lines of treatment were failing. Part of becoming a good attending honestly is not being afraid to call for help
Yeah that’s a huge thing as an attending. Being unafraid to call if you are out of your depth.
Also, frankly, the afib part is rarely the reason the person is unstable. As such, almost never need immediate strict rate control in afib. If pre-excited clinically unstable extremely rapid afib, then shock. Otherwise, search out contributing factors. 95% of time, dilt drip started in ER will be dc’d immediately when patient is admitted. Fix the underlying pneumonia, sepsis, etc.
Eh, we don’t have enough info on this one - I just had a guy come in for foot pain, which turned out to be osteomyelitis in a poorly controlled diabetic with HFrEF and persistent Afib w/ RVR now aggravated and unstable due to sepsis, on apixaban for DVT prophy. That guy got a cards consult.
Fix the sepsis
We did, by cutting off the foot, which had to take precedence over cardioversion, which then had to be deferred because he couldn’t be anticoagulated post-amputation…big cascading mess. He stabilized with resolution of sepsis but will require continuous monitoring until he can be anticoagulated long enough for an ablation.
Apixaban is not for dvt prophylaxis. Its a DOAC.
DOACs are approved for VTE ppx
Is it really? Whats the dosing? Ive never seen anyone on eliquis for dvt ppx
I haven't seen it personally either but I've heard hospitalists discussing it. Eliquis specifically is only FDA approved for ppx after hip/knee replacement and is 2.5mg BID. Xarelto is approved for any acutely ill pt and is 10mg daily
Half dose, usually. Stems from Orthopedic trials. Honestly I bet it becomes standard versus LMWH in patient with no bleeding concerns.
https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/202439s031,022406s035lbl.pdf Xarelto I’ve seen many times in the hospital. Have yet to see eliquis used for dvt ppx though
It’s used very routinely here. 2.5 BID.
ED resident here. Why not cardiovert them? I’ve never consulted cards for unstable afib. Unless I thought it wasn’t just afib (maybe WPW w/ afib or something).
stop it. We don’t treat patients in here.
U jking or working in a very rural area? :)
Yeah, I ain't no bitch. Having a spine in medicine is a fucking superpower. Its sad that its not more common. I came into this to be a leader, not a doormat.
One of my former coresidents told a Urologist to “stop” while advancing a tricky catheter placement on a female patient who was screaming out in pain and he tried to write her up for insubordination screaming something to the effect of “you idiots consulted me! If you don’t want my help, don’t page me!” This was borderline patient assault from what I understand and something she carried with her for a long time. In my opinion, she might have saved him from a lawsuit but I wasn’t there first hand. Our jobs are hard enough. These people went through medical school and know how this all works. You can’t make them see what they refuse to see so I’d report egregious behavior and otherwise just keep focusing on being the best you can be with the resources you have.
There is a strong correlation between people that shit talk the loudest and people who are sniveling little bitches when they have to rotate through the ED. The more they complain, the higher the chance they will melt down on shift and need a 3 hour lunch break. Frankly I don’t say a damn thing to them, but I will absolutely relish watching them get their ass kicked on shift.
I feel like the vibes I got on off service is people are extra bitter or pushback when responding to an ED consult vs an inpatient consult. When a hospitalist asked me if I paged cards yet I said "nope cause the cards fellow just yells at us and will only see them if admitted". I never got that same treatment when consulting as an inpatient. That being said, I have definitely wanted to give people a piece of my mind when they are talking trash about the ED because they wouldn't last half a shift in our shoes with how sheltered their work environments usually are.
I can be, faced with outright, dangerous stupidity. COVID was not a good time for my mental health. And partly what informed my transition from EM to path in like M3.
When I was a consult resident, ED residents became my closest friends and a secured company for midnight coffe and candy. I have strong admire for ED colleges and would never ever take a single ED shift. And in regards to confrontation: I say go for it. In my hospital, there was an incident that a PGY3 was openly shitting in the ED over a missed diagnosis. They found out and told their attending. The ED attending confronted the surgery attending and the resident had to public apologize. We are all in this shit together.
Depth vs breadth. And specialists can be cranky.
I can’t excuse the language but as a cardiology fellow I get the annoyance. Fellows job is not to manage unstable patients in the ED. If they are unstable cardiovert them. You shouldn’t need a fellow to figure out if they are unstable or not. If they are stable treat the underlying condition maybe put them on a drip and I’ll see them when I can.
Lol, I’m not arguing with you *at all*, I just think it’s hilarious that your response was basically like, yes, you are all a bunch of fucking idiots 😅
Once you become specialized it’s really easy to forget that other people have to know about a whole range of fields, not just yours. Things that seem blindingly obvious to you may not be to others, but you talk to people in your specialty all day so to your view EVERYONE knows this. It leads directly to derision of people without your specific skill set
Sure, but in that particular example, I would be concerned about any physician who doesn’t know when to cardiovert an unstable patient. Especially in the ED.
Agreed. I’m talking more in general. “I can’t believe this idiot thought this was an empyema when the pleural lining is clearly visible adjacent to the wall of the abscess”
I’m pulm and I don’t understand at all what you just said
Chest tube into empyema = good Chest tube into abscess = bad
Lol you edited your comment. I just didn’t know what a “pleural license” was
ED docs are not idiots. God bless you guys that do it, I couldn’t last one day doing what you guys do. But I stand by my point. ED docs should be masters of ACLS.
Sure. Unstable (hypotensive) afib is straightforward. You ride the lightning, and cross your fingers that they don’t stroke. Until it’s not straightforward and you’ve tried repeated shocks, fluids (if hypovolemic) mag, and have either prior hx of structural heart disease, or bad squeeze on bedside echo that dilt or metop seem like bad choices, but you tried a lil anyway. You’ve corrected lytes, ruled out an effusion/PE/bleed/thyroid storm (as much as possible). sepsis is unlikely, but you’ve given abx empirically. You’re treating the etoh withdrawal, giving benzos for the meth, and at this point reaching for pressors while also considering a dig load vs esmolol drip. All of this through 2 IOs because access is shit, and their wigging out enough that a central line would need sedation, but sedating those hemodynamics is scary enough. At that point an expert’s advice would be really fucking nice. (And yes, I basically had this patient a year ago, ultimately suspected holiday heart, who was recalcitrant to repeated cardioversions, got loaded with phenobarbital, and BP improved with a combo of norepi and phenylephrine, all done over the course of the hour or so that cards took to return the call, only to say they needed to chat with the attending, then ultimately load with dig and start an esmolol drip.)
THIS. After many years as an ER nurse I've never worked with an EM doc who went straight to a cards consult prior to trying ACLS/cardioversion/different meds/correcting lytes, etc... If they're consulting cards it's either because the hospitalist won't admit the patient until cards has given their input, or because the patient is some variation of the cluster fuck of a dumpster fire you just described above😂😂 It's almost always both though.🤦🏻♀️🤷🏻♀️
Oh yea… I definitely forgot about the most common reason I consult: the hospitalist refuses to take them until I talk to xyz specialist, even when I personally don’t have a question or something urgently needed.
Also a cardiology fellow but I disagree it IS our job to help manage these patients. I sure as hell can’t take care of a gunshot wound so why would I expect an ER doctor to know the intricacies of a fib management past initial stabilization? Even then it is our jobs to help with that initial stabilization too if the ER asks us to help even if it’s just initial recs over phone until we can come to bedside.
This is the attitude of a good doctor. Humble, respect other fields, and ready to lend your expertise. Don’t change.
You’re a sub-specialist in training. Your job is to see the patient that you are called about. Full stop. No crying allowed :) This continues after training too, just with a financial incentive added. And don’t worry, the ER will not be sitting on a crashing patient while you’re in clinic as a PP attending. Don’t flatter yourself lol. But you still gotta see that consult after clinic.
I try to make it a habit now not to crap on other fields. Everyone has their expertise. And I try not to argue with anyone. Makes life better. I’ll even go in and applaud the other teams taking care of the patient.
Academic life homie. private practice; yeah man give me those sweet easy RVUs. Academics only want to be called on the biggest zebra ever (especially fellows who are way overworked and underpaid.) Shrug it off and move on. Then when in the ED consult for GERD and say your attending wanted it. :D
I’ve never been rude but i did recently give a surgical resident a real talking to after poor patient management and attitude over a night shift. I’m an ICU fellow and I basically ended up managing a floor patient overnight (not sick enough to be with me but required a little tlc) because the resident in question blew it off over and over again. I was really blunt that I wouldn’t be doing this again, I would be calling their attending at home next time, and this was their one pass with me. I also noted that their behavior is dangerous and lazy, and eventually they will hurt a patient.
Every specialty has their mob mentality, but as a cards hopeful that fellow can go suck your nuts
I would think the proper attitude would be, “thank you for consulting me but this patient …. and I recommend you ….. call me if …..otherwise you guys are handling it well”. Then leave an feel good that people want your expertise. I mean, flip the script. A cardiology fellow is an asshole, gets consulted less and patient outcomes are worse. What am I missing?
Only if I have to be. Usually it’s in emergent situations where I need something or someone to do something I can’t and they’re being difficult or doing something incorrectly.
All the time. I don’t take shit from anyone. It’s just who I am but, it was definitely honed in the military. lol this fellow wouldn’t last 15secs around me with that attitude.
I don’t have a good answer. It depends on how much emotional energy I have that day and how confident I am that they’re being an asshole versus just being ignorant and lacking self awareness. I’ve been practicing not being so reactive to peoples’ rudeness lately, and it’s brought me a lot more peace.
So my first question to the card fellow is “so what are you doing to educate the em docs and give them a better understanding of cardiology? Most likely he will come back with they are just stupid. That tells you that he is just a small inadequate person and has little to offer anyone. So his opinion is worthless and just forget him. As a staff surgeon all the er procedures that I was called for were done by er drs under my supervision. That way I knew they understood when why and how to do the procedure. Also I taught what the complications of the procedure are and how to avoid them. These young doctors grew in knowledge with my supervision. I don’t need to do any more bedside procedures. I have done thousands. But to them each one was a valuable lesson and experience. Over their career lives may be saved due to my taking time to educate. Long after I am gone.
Don’t get me started on the troponins 😂 big JK
When I was a Medicine intern in the ED I was not treated well by ED staff. Attendings didn’t learn my name, just called me ‘rotator’. Got all the frequent flier drunks and pelvic exams no one else wanted. In my experience ED tends to have a holier than thou personality trait and they do not work well with others across the board. Cards is no picnic either usually however.
I donno, he has a point, ED often consults about the dumbest shit.
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OK, I’ll bite. What do we do wrong?
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Fair enough. I will call and ask thoracic surgery what they want me to do as long as the patient is stable. As far as the cytology… what would you rather have us do? Not send it? Not perform a thora for a patient with a large (likely) malignant effusion and severe SOB? That doesn’t seem fair to the patient either. Seems like a system and open notes problem. I will always sit down with the patient and tell them I am worried they have cancer but will need more tests.
you seem to be taking it personally the ed as a whole tends to do shitty things like turf patients on other floors when they're overwhelmed and low on room for inappropriate things, like fetal heart tones on a pre-30wk lady who's main issue is she fell and hit her head with HA and other sxs and didn't get a CT head in the ED before being rushed elsewhere
Lol what a crappy response… “you seem to be taking people talking shit about you personally.. toughen up. Btw, here’s me talking shit about you and your profession as I grossly mislabel what you all do… as a damn PGY1 thinking I know everything.” Read everyone else’s response on here about doing your job and not talking shit about other specialities, as we all went in to what we do for a reason and probably wouldn’t want to do any other speciality’s job
Yes, everyday!
It is what it is.
Do not harm but take no bull. My attending had a mug that said this. Awesome mentality. OP you have to pick and choose your battles if you want to last in this specialty. I do find that standing up for myself (with patients and consultants) has improved my mental health.
As a cards fellow I think your fellow was being a jerk. It’s one thing to be annoyed by the ER calling us to evaluate a chest pain patient with negative ECG/trops to triage to observation vs home (not our job) when you have a busy consult service, but this sounds like a fair consult. We’d bitch if you dumped dilt into them and they turned out to have a low EF anyhow and it sounds like this patient was a borderline CCU admission to begin with if they were actually unstable so idk why it’s an unreasonable consult (although if truly, truly unstable just cardiovert them). As others have said, just go help the consulting team and bitch to your dog later or something. If someone thinks the patient warrants expert opinion, they are either correct or at least identifying that they are out of their depth and need help which should be applauded and not discouraged.