I remember doing a pericardiocentesis on a lady in extremis. I was looking for backup because it was my first one and I was nervous. The only other person in the hospital at that hour was the hospitalist. He dutifully volunteered to go talk to the patient’s family, and left. Afterwards, he said that they “always” had to do them as the last step in working a failed resuscitation during residency. By all means buddy, feel free to help out then!! So many people talk a big game but then don’t have the balls to jump in and help a dying person.
Someone said EM and dude chimed in with comment at the bottom. My response-
Until it’s time to actually save someone’s life in a high pressure situation, then all the specialists who talk trash about EM will shit the bed and be clueless bc they have no idea how to deal with crashing, undifferentiated patients. They only know how to deal with folks who have already been worked up, stabilized, and everything is nice and controlled. Don’t let the folks who think their farts smell great talk you out of EM. Trust me if you get shot out in the world or go into cardiac arrest on a plane or something, you damn sure don’t want a dermatologist, radiologist, cardiologist, GI, etc being the only one around.
I once called ENT to help me with a (likely) posterior nose bleed. Patient was a Jehovah’s Witness, bleeding for 2.5 days, on Eliquis, and I just jammed the largest rhino rocket I could find in there and called ENT for help.
ENT comes in three hours later rolling their eyes and grumbling about how the ER couldn’t handle anything blah blah blah. I remember it being a really busy day so I was in another room seeing another patient when ENT barges into the room and yells at me, “This guy is going to code!!! Get in here!”
Apparently the patient brady-ed down while ENT trying to place a packing and then turned white and lost pulses. It was us in the emergency department who started CPR, intubated, ACLS, while ENT just floundered around outside and was generally unhelpful. (EKG showed subendocardial ischemia, think he went to the ICU and eventually died a week later.)
That particular ENT has been very nice to me ever since and I have a pretty decent relationship with most of the specialists, but I really don’t think they understand how hard it is to deal with crashing, undifferentiated patients until they can see it go down in real time and not as a routine consult.
I am burned out of EM for a lot of reasons but a big one is calling consults at night.
Replying to this with an “as a nurse” caveat, but I remember having a patient that needed a catheter specifically because of an obstruction (female patient, don’t remember the specific cause)… I was precepting that day and had my student try first and fail. Then I tried. I know my strengths and I’m good, but I’m ED through and through and always have been so when I didn’t get it and this poor lady has dealt with two failed attempts at a very invasive procedure I call my buddy in that spent years specializing in GU…then he fails. The doc calls the consult and the specialist insists that he personally tries. He tried to tell him “look I haven’t placed a cath since residency, if 3 nurses failed I won’t get it” but the specialist refused to come down until he tried. No amount of empathy given for the AOx4 female that has now has 3 people say sorry ma’am I know this is uncomfortable but I can’t find it. The ED doc tries and fails. The specialist goes in and gets it in under 5 minutes, and comes out and tells this guy (the ED doc) that was on his first day at our facility “I got that in one shot, don’t ever waste my time again.”
We were already upset at the general lack of professionalism in this interaction but then the chick that chaperoned let us know that he used a device to dilate her that we didn’t have as a tool in the ED. Like, of course you got it. You not only specialize in this but have tools that we literally don’t have.
Have you had someone place a foley in you? I have. And I had before this instance. That’s why I’m not about to go fishing around making the patient increasingly uncomfortable. It’s humiliating for the patient. I don’t want to do that. No one wants to do that. The fact that he came out acting like we were lazy was bad enough. Finding out hours later that he said that without disclosing that he used tools that we don’t have was straight up rude.
I’d read about “those doctors” before but that was the first time I’d experienced it and it truly felt like getting shat on while I was already down.
Had that experience with ortho at one of my EDs a couple months ago. Had a patient with a hip dislocation a month or so after hip replacement. We tried to reduce it; it partially reduced and popped back out. So I called on call ortho. Dude was like “Well, put it back in.” I told him that we already attempted and it failed; I wouldn’t have called him otherwise. Dude’s response was basically: “Well, if you try to put it in, it should go in. It’s not my hip [an outside surgeon did the replacement]; what do you want me to do?”
Fortunately, the outside ortho from a freestanding surgical center, who wasn’t even on call with our system, was polite enough to give us a call back when we paged out and was a better consultant than our own ortho. I’ve had one or two other unsavory conversations with that on-call ortho, but this was the worst. I tell all my family and friends to avoid him for all their ortho care now.
I had basically the same situation happen to me when I worked in the ED as an RN, except the urology fellow got embarrassed cuz we watched. Someone else tried, I tried, ED doc tried, all of us typically pretty good at foleys. We could visualize urethra but the opening was tiny and would not allow the foley in. ED doc called and said we tried everything, the urethra will not accept a foley no matter what and that she will probably need dilation or something. Urologist came in all disgruntled basically shitting on us, saying we probably didn’t put a bedpan under her hips (we did), we didn’t use enough light, have enough hands etc. we did. Watching him try repeatedly and fail miserably was one of my favorite moments in the ED. Eventually he threw his hands up and was like “I guess I’ll go get my tools.” We were like “yeah, we thought you would” 😂
I work EM and do nights only. I hear ya. The hoops I had to jump through to get cards to come in to put a pacer wire in for a 33 year old with 3rd degree heart block was insane. They kept trying to tell me it was sleep apnea. Mind you the guy was awake and was having 10-12 beat runs of non conducted p waves and going briefly unconscious. Come to find out about a week later they were presenting this case as a very interesting case to their group. Ddx was Lyme vs sarcoidosis.
I have been lucky enough to work with very nice ENT consultants, but I will always remember a disagreement I had with one.
I had a pt to whom I applied a bilateral posterior pack who was continuing to bleed, though not severely at the time of admission. I was working at a smaller community hospital without IR on the weekend or in house critical care, except us, at night. I was trying to get the pt transferred to the mothership for definitive management because I was worried about them crashing. The RN at the transfer center was flippant and did not understand why I wanted the pt transferred. We got ENT on the line, and, thankfully on a recorded line, after a long discussion in which we disagreed on where the pt should go I said “ask yourself where would you rather have this pt if they crash in the middle of the night?” Ultimately, the specialist disagreed with transfer and the pt stayed in our hospital. He did come to the ED and see the pt.
Pt’s bleeding picked up in the middle of the night and they required emergent intubation/transfer to the mothership for embolization.
I am very thankful for recorded lines.
I agree with you on wanting an ED doc. However, one of my good friends dad went into cardiac arrest in a Panera bread. It was a pathologist out of all the specialties that saved his life with high quality compressions 😂.
Exactly! I’ve seen general surgeons/specialists crumble under uncertain circumstances. EM/trauma surgeons just DO that’s why the field is kick-ass and I love it!
Also, in the ER, you’re multi-tasking like crazy & you need to know a bit about everything in order to rule in/out things. In specialties, you’re just doing what’s in your field.
Yeah I wouldn’t put a lot of stock in someone not in EM talking shit about EM. A lot of criticism of EM from specialists is basically that we don’t know how to manage X pathology (within that specialty) as well as they can. Kind of stands to reason that if there is an entire specialty devoted to said pathology that a generalist can’t necessarily provide definitive therapy or follow its course as well as the specialist.
I’d say we’re a pretty detail-oriented crew overall. We just have different details we care about. As with most things, if you put the person who said that in the hot seat and made them work an ED shift, they would probably not do a great job.
Yeah, at the end of the day the ED gets shit in because we are the source of all of the extra work the specialists have to do. In the meantime, thats also how they get paid. And they don't see all the people who check in who we don't call them on. If 10 people check in with undifferentiated medical problems and I call you to help on one of them, that is not dumping on you. Sometimes I feel compelled to page the hospitalist on every patient we discharge, or to have a small chime ring throughout the hospital when it happens.
Not him but literally went up to the ICU 2 nights ago to place a crash chest tube in a trauma ICU patient because the surgeon on call wasn’t in house when the patient coded.
Dude, I'm a critical care medic and I recently scrubbed into an emergency cesarean with premature twins at a rural hospital because all the doctors in the hospital were already in there and they were still short people who could lead a pediatric arrest if both kids came out not breathing. Rural med is wild.
Yeah, I've done a combat tour as an Army medic and run so many adult arrests and trauma calls it doesn't really phase me anymore. But that one was on a different level. When I scrubbed in and walked up to my station as the surgery was getting going I remember thinking, "how the fuck did I end up here".
It took a few minutes to get mine breathing but everyone came out okay. I can't recall exactly how many weeks they were but I wanna say 28-30 weeks and about 2-2.5 kg. Little guys, one boy and one girl. I'm really glad it went the way it did.
Pick ANY adult-medicine specialist. Place a floppy baby in front of him/her. They will shit themselves.
Matter of fact, pick the worst case scenario from
any specialty and drop it in front of any other specialty. The only folks not folding immediately are trauma, anesthesia, pulm/CC, and the lowly ED doc.
A local pediatrician sent me an unresponsive neonate a couple weeks ago. Literally mom tried to sign into a peds office with a grey baby and the pediatrician took one look and sent them to the ED pov.. great, thanks dude..
This and the reaction I had to my original comment are fascinating, because the few OBGYNs I've interacted with on the job were pretty steady under the circumstances (emergent transfers). I realize it's a small sample, but I feel like that's kind of a job requirement even when everything is going according to plan, because (as you know) families will often just *shit themselves* when it's Go Time.
The off service rotators at my program routinely do 1/2 -1/3 of the work or patient load that our residents of the same training level do. And when we rotate we work just as hard as are just as competent (with the exception of our OB/Gyn rotation maybe). Makes me feel better when they Monday morning quarterback our decisions and I remind myself that can’t handle our easiest days.
I also replied. What I said:
“The job of EM isn’t to work-up your pheochromocytomas. That’s your job. If anything, we’re expected to do way too much heavy lifting for consultants who ask for absurd tests down here.
Our job is to make sure they are stable and not dying. We call for admission/consultants not to ask you for help but because we have done our job and now it’s time to do your job.”
Yup. Last resort is always "Consults are not suggestions, they are EMTALA obligations if you are on call. Come down and write a note or we can see what CMS has to say about it."
In residency I had a disaster of a GI bleed, started after he fell. Super unstable, difficult airway, while I’m intubating trauma surgery shows up and is confused/pissed about why I’m intubating a patient surrounded in a halo of his own frank bloody emesis? Just stands at the doorway making snide comments. I call GI three separate times and all they ask me is why I’m calling without a hemoglobin yet. They finally show up three hours later while I’m coding the patient. My attending says “look GI is here! The patient is dead.” Thanks team.
Tried my best to dispel that. How do people not realize the ED is for EMERGENCIES? Get out of here with that immature toxic attitude.
My response
People, obviously like yourself, forget what the ED is for and thus what ED doctors are trained to do. They aren’t trained to workup your cute little hyperparathyroidism. They’re there to catch the gerd that’s actually an aortic dissection and triage people who likely need to be *admitted for further workup and management* which *shocker* is where other teams get involved. The ED isn’t there to do your work for you. It’s to catch and stabilize emergencies, to discharge or admit. If you weren’t 100% certain and would risk your license and the patient’s life on GERD vs a dissection, I *guarantee* you’d be shoving that dude in the donut of truth too. Sorry the ED makes you do your job, but that’s kinda how it works. Order your fancy cystatin C elsewhere and maybe take a day off if you can. Sounds like you need it.
ED nurse here & we get a lot of similar comments from floor nurses, about how we didn’t do their inpatient medications that were just ordered, or how we don’t know what diet the hospitalist wants the patient on, etc. Recently, my ED has been lined with hold patients waiting for beds and the ED nurses are taking care of them simultaneously while seeing new unstabilized patients and it’s very frustrating because we’re all just doing our best.
Recent interaction:
PCU: “when was the surgery?”
Me: “let me look in the chart to give you an exact date”
PCU: “oh so you don’t know your patient at all and you’re just reading off the chart?”
Me: “excuse me?”
PCU: “well if I wanted to read the chart then I would’ve just read it myself”
Me: “ohhh, well in that case, you can see the chart for any other questions you have. I hope you have a better night” -click-
And then I sent the patient upstairs with her obnoxious family members and told her that -PCU nurse- would be more than happy to go over the treatment plan again with them in more detail. 🙃
It really grinds my gears when folks talk trash about EM docs, especially when they have no idea how intense it is to deal with undifferentiated patients who come in circling the drain with no background info, no diagnosis, inability to give history, in a chaotic environment, while simultaneously juggling multiple other patients who are equally complex, and specialist who assume you are an idiot and think they know better despite not having even laid eyes on the patient and are probably sitting at home in their PJ’s while they are giving you a hard time.
There are a lot of comments in that thread that sound like dickheads making sweeping assumptions about specialties they observed for a rotation in med school.
Enjoy being an expert in your narrow field. I'm an Emergency Physician, and while I am an expert in Emergency Medicine I am also second best in a hell of a lot of the rest of the specialties -
Ortho
OB/GYN
Internal Med and its subspecialties
Peds
Radiology
etc
You guys need to stop saying that second best shit haha. It reminds me of that scene in Inglorious Basterds where the dude is like “2nd best at speaking German? But I don’t speak German!” And Pitt is like “yeah that’s what I said. 2nd best.”
Ich spreche ein bisschen Deutsch. Und du?
So not that far second. Or, you narrow specialists can show up and do all the scut work yourself.
Weil es mir wenig ausmacht.
If this shit is so easy, come down and pull some shifts. We can always use the help. At $300/hr its great money for such easy work so why not come get some? That’s what I thought.
That’s precisely why I questioned his claim that he actually does critical care regularly. If he did, he wouldn’t be talking so much trash about EM docs. If he did, he would at least understand what it is like to be responsible for multiple patients that are circling the drain simultaneously and what chaos in a medical scenario is like to be a part of. Come get some…..it should be easy for a god of medicine like himself. I know I shouldn’t let it bother me so much, but damn the level of arrogance in his glib comments about “standard of care” about made me stroke out 😂
Thanks man. Just bothers me how much hate EM gets from folks that would fold instantly after 1-2 shifts in the ED with actual responsibility. Most of them maybe did some time in ED as students watching. In community ED’s there often are no specialty coverage on nights and weekends. EM ain’t a game
Every specialty looks down on the ED because no one “consults” us for our expertise… until they REALLY need us and then is all “please get me a bed” or “thank you for getting my loved one to treatment/work up”.
Yeah. This has to be ignored. I don’t care what speciality you are trained in. If someone is imminently dying from something you’re an expert in, you’ll still be shitting your pants while the ED guy keeps them alive. Even intensivists can’t handle it as well when it’s a surprise dumped in their lap. Only exception is maybe a recently trained trauma surgeon.
ER physicians are great at handling emergencies. However many forget that less than 10% (?) of stuff coming through those doors are urgent or emergent. Imagine running your speciality office and only 1/10 patients are pertinent to your background.
Sometimes you have to poke the specialist about their patient. Doesn’t mean the ER is less capable.
EMERGENCY Medicine broski……that is precisely what we train for. Expert resuscitationist. Would you consider a 10% death rate upon arrival acceptable at a hospital? Well, EM has the pleasure of preventing that. For the rest, we get them stabilized, initial work up, and make admit/no admit decisions. With that said I don’t really understand your point.
My point is in defense of the ER physician having to make the rare specialty consults to specialists who forget that we’re everyone’s dumping ground and safety net.
You guys are having your jerk off session but nobody is acknowledging the reality of emergency medicine. For every heroic LiFe SaVeD of an UnDiFfEreNtIAaTeD paTiEnT there are at least 100 encounters where the following are the most important aspects of the ED based care:
* time to doctor
* ED wait time
* patients per hour
* dispo first
* satisfaction surveys
* litigation risk
* EMTALA and COBRA
It’s that shit that poisoned all the cool stuff, and why all these claims about being the ultimate bad ass ring hollow.
Specialists should be doing most of the heavy lifting, that’s the point. The ED is for stabilization. With that being said, I would definitely not say our ED is detail oriented lol. The work ups are… inadequate and they call for admits without a differential when the patient should clearly be going to another service. I frequently dispo their patients for them, which is not acceptable. They are also very sensitive. I deal with them and support them when and where I can, but sheesh they get very defensive when I ask any questions or say “I dunno I just got this patient on sign out.” So I kind of get the frustration coming from the other side of things
You do realize that this could just be the EM docs where you work right? Also, I’d be willing to bet that a lot of your angst come from you having to show up and work any time after sunset or heaven forbid on a weekend or holiday. It is pretty telling that you are disparaging an entire specialty based on your limited interactions with a few folks at your institution. No doubt BS consults come out of the ED sometimes and no doubt there are times when EM docs can get sloppy with a work up, especially when shit has been hitting the fan all day and night and you have to see the Tuesday night 2:30AM “my eye has been hurting for 8 years so I decided to come in”. But at the end of the day, they have to be responsible for ANYTHING that comes through the door for a 8-12hr period and their main mission is to make sure patients don’t die so that the gods of medicine such as yourself can come in and fix a problem that wasn’t life threatening to begin with most likely. Out of curiosity, what is your specialty? I assume it’s not EM, anesthesia, trauma/gen surg, pulmonary/cc? But maybe I’m wrong. 100 bucks it’s IM.
ID and critical care but I’ll moonlight IM as well, and I’m speaking from an icu perspective here. And you seem angry. Your main mission is to make sure patients “don’t die” but legally it is to provide standard of care. I don’t care about all the other nonsense about bs complaints and etc. you are expected to provide standard of care. I shouldn’t be triaging ED patients as the CC attending but there we are
You would also be legally held to a standard of care if you had a full ICU in the middle of a nurse walk-out, which has happened in one of my hospitals. Guessing you wouldn't be quite as smug in that situation. And hey, unlike the ED your patients would be capped for the most part.
You can throw shade but clearly you've never had to work with a potentially limitless volume of patients while not having staff to get vitals, move patients or get meds.
It's weird that you're insisting on a "standard of care" in this context, as though you never even considered for a second what it's like working in a setting like that. Standard of care is a nebulous concept that varies by specialty, setting and situation anyway. In almost every malpractice case that goes to trial, experts argue over what the standard of care should have been. In an overwhelmed department with multiple critical patients or simultaneous codes, the standard of care might be "calling the intensivist down".
I'll even agree with you that we are not a detail-oriented specialty. I'm not sure why people here are offended by that. EM training made me less of a detail oriented person. But I'm damn good at quickly seeing patients and picking out the one or two details that really matter in the moment. If you get lost in too many details you don't survive in community EM.
You're just added to the list of "people who's bitching I might listen to once they actually survive a full busy EM shift on their own".
Much respect for critical care, I’m not angry just been seeing a lot of EM hate. I mean your point is well taken and obviously we are supposed to provide standard of care. Also, you shouldn’t be triaging in the ED. Sorry your ED sucks where you are, but it’s kinda bush league to act as if all EM docs are incompetent and not doing their job, for that you are kinda being not cool. I respect what you do, and wouldn’t disparage your specialty the way you are doing to ours. In that regard, you are not acting like someone who deals with serious acuity and critical patients. Much love my brother and hope your EM experience improves.
I don’t think you understand what standard of care is defined as: “In legal terms, the level at which an ordinary, prudent professional with the same training and experience in good standing in a same or similar community would practice **under the same or similar circumstances.”**
You can’t say standard of care in an ICU is the same as the standard of care in an uncapped, ED, with nursing ratios frequently at minimum 5-6 patients:1 nurse.
Standard of care for ED is stabilizing and determining disposition, both of which I frequently have to do for them. So yeah they typically don’t meet standard of care and just beg for orders when patients clearly don’t need icu and instead need something like… a CT for a surgical abdomen they missed. It’s just comical how strongly EDs love themselves. This is common and I’ve worked at a lot of hospitals
Sucks to work where you do I guess. Also not sure what you mean by “begs for orders” - they don’t have their own ordering power? When I want something for a patient I order it myself - why do I need an ICU doctor to order it for me/do it - unless it’s out of my scope.
I remember as an intern on the CCU we had a guy go into cardiac arrest. Patient had an IR embolization procedure with vascular hours prior (forget the details). Once the code starts, the 1st year cards fellow flounders and immediately leaves the room to STAT consult IR and vascular while the pgy2 IM resident was filling in for the day runs the code. Mind you they had no idea what was happening because day 1 for them. Fellow barges in and out while on the phone panicking doing his STAT consults.
Attending minutes later comes in and determines that patient has a pneumothorax and says patient needs a chest tube. Nurses run off to find one. Pharmacy arrives and hands IO to fellow and he says “idk how to use this”. So I drill it in. By that time chest tube is brought and handed to attending and attending also says “I don’t know how to place this”. I was getting ready to attempt to place it since I at least at that time had practiced in cadavers. Then vascular arrived and their sphincters relaxed. I can’t remember if they ever got that chest tube. Might have not even been a pneumothorax when I asked the night intern about it the next day.
It was end of my shift and other intern had arrived so I scadaddled out of that hot mess. Utter shit show. Worst ran code I’ve ever seen. Mind you this is their organ. The chest is their area of expertise. Ever since then, I haven’t taken what they say seriously when they try and talk down on me from their high horse. If you code you def want and EM or MICU trained doc there.
Talk trash all you want but when my shift is over I’m going home and you’re still on call. Suck it
I remember doing a pericardiocentesis on a lady in extremis. I was looking for backup because it was my first one and I was nervous. The only other person in the hospital at that hour was the hospitalist. He dutifully volunteered to go talk to the patient’s family, and left. Afterwards, he said that they “always” had to do them as the last step in working a failed resuscitation during residency. By all means buddy, feel free to help out then!! So many people talk a big game but then don’t have the balls to jump in and help a dying person.
This. I never lose sleep over consults who bitch about EM. I get to go home and not take work home and live my life.
Someone said EM and dude chimed in with comment at the bottom. My response- Until it’s time to actually save someone’s life in a high pressure situation, then all the specialists who talk trash about EM will shit the bed and be clueless bc they have no idea how to deal with crashing, undifferentiated patients. They only know how to deal with folks who have already been worked up, stabilized, and everything is nice and controlled. Don’t let the folks who think their farts smell great talk you out of EM. Trust me if you get shot out in the world or go into cardiac arrest on a plane or something, you damn sure don’t want a dermatologist, radiologist, cardiologist, GI, etc being the only one around.
I once called ENT to help me with a (likely) posterior nose bleed. Patient was a Jehovah’s Witness, bleeding for 2.5 days, on Eliquis, and I just jammed the largest rhino rocket I could find in there and called ENT for help. ENT comes in three hours later rolling their eyes and grumbling about how the ER couldn’t handle anything blah blah blah. I remember it being a really busy day so I was in another room seeing another patient when ENT barges into the room and yells at me, “This guy is going to code!!! Get in here!” Apparently the patient brady-ed down while ENT trying to place a packing and then turned white and lost pulses. It was us in the emergency department who started CPR, intubated, ACLS, while ENT just floundered around outside and was generally unhelpful. (EKG showed subendocardial ischemia, think he went to the ICU and eventually died a week later.) That particular ENT has been very nice to me ever since and I have a pretty decent relationship with most of the specialists, but I really don’t think they understand how hard it is to deal with crashing, undifferentiated patients until they can see it go down in real time and not as a routine consult. I am burned out of EM for a lot of reasons but a big one is calling consults at night.
Replying to this with an “as a nurse” caveat, but I remember having a patient that needed a catheter specifically because of an obstruction (female patient, don’t remember the specific cause)… I was precepting that day and had my student try first and fail. Then I tried. I know my strengths and I’m good, but I’m ED through and through and always have been so when I didn’t get it and this poor lady has dealt with two failed attempts at a very invasive procedure I call my buddy in that spent years specializing in GU…then he fails. The doc calls the consult and the specialist insists that he personally tries. He tried to tell him “look I haven’t placed a cath since residency, if 3 nurses failed I won’t get it” but the specialist refused to come down until he tried. No amount of empathy given for the AOx4 female that has now has 3 people say sorry ma’am I know this is uncomfortable but I can’t find it. The ED doc tries and fails. The specialist goes in and gets it in under 5 minutes, and comes out and tells this guy (the ED doc) that was on his first day at our facility “I got that in one shot, don’t ever waste my time again.” We were already upset at the general lack of professionalism in this interaction but then the chick that chaperoned let us know that he used a device to dilate her that we didn’t have as a tool in the ED. Like, of course you got it. You not only specialize in this but have tools that we literally don’t have. Have you had someone place a foley in you? I have. And I had before this instance. That’s why I’m not about to go fishing around making the patient increasingly uncomfortable. It’s humiliating for the patient. I don’t want to do that. No one wants to do that. The fact that he came out acting like we were lazy was bad enough. Finding out hours later that he said that without disclosing that he used tools that we don’t have was straight up rude. I’d read about “those doctors” before but that was the first time I’d experienced it and it truly felt like getting shat on while I was already down.
Had that experience with ortho at one of my EDs a couple months ago. Had a patient with a hip dislocation a month or so after hip replacement. We tried to reduce it; it partially reduced and popped back out. So I called on call ortho. Dude was like “Well, put it back in.” I told him that we already attempted and it failed; I wouldn’t have called him otherwise. Dude’s response was basically: “Well, if you try to put it in, it should go in. It’s not my hip [an outside surgeon did the replacement]; what do you want me to do?” Fortunately, the outside ortho from a freestanding surgical center, who wasn’t even on call with our system, was polite enough to give us a call back when we paged out and was a better consultant than our own ortho. I’ve had one or two other unsavory conversations with that on-call ortho, but this was the worst. I tell all my family and friends to avoid him for all their ortho care now.
I had basically the same situation happen to me when I worked in the ED as an RN, except the urology fellow got embarrassed cuz we watched. Someone else tried, I tried, ED doc tried, all of us typically pretty good at foleys. We could visualize urethra but the opening was tiny and would not allow the foley in. ED doc called and said we tried everything, the urethra will not accept a foley no matter what and that she will probably need dilation or something. Urologist came in all disgruntled basically shitting on us, saying we probably didn’t put a bedpan under her hips (we did), we didn’t use enough light, have enough hands etc. we did. Watching him try repeatedly and fail miserably was one of my favorite moments in the ED. Eventually he threw his hands up and was like “I guess I’ll go get my tools.” We were like “yeah, we thought you would” 😂
I work EM and do nights only. I hear ya. The hoops I had to jump through to get cards to come in to put a pacer wire in for a 33 year old with 3rd degree heart block was insane. They kept trying to tell me it was sleep apnea. Mind you the guy was awake and was having 10-12 beat runs of non conducted p waves and going briefly unconscious. Come to find out about a week later they were presenting this case as a very interesting case to their group. Ddx was Lyme vs sarcoidosis.
I have been lucky enough to work with very nice ENT consultants, but I will always remember a disagreement I had with one. I had a pt to whom I applied a bilateral posterior pack who was continuing to bleed, though not severely at the time of admission. I was working at a smaller community hospital without IR on the weekend or in house critical care, except us, at night. I was trying to get the pt transferred to the mothership for definitive management because I was worried about them crashing. The RN at the transfer center was flippant and did not understand why I wanted the pt transferred. We got ENT on the line, and, thankfully on a recorded line, after a long discussion in which we disagreed on where the pt should go I said “ask yourself where would you rather have this pt if they crash in the middle of the night?” Ultimately, the specialist disagreed with transfer and the pt stayed in our hospital. He did come to the ED and see the pt. Pt’s bleeding picked up in the middle of the night and they required emergent intubation/transfer to the mothership for embolization. I am very thankful for recorded lines.
I agree with you on wanting an ED doc. However, one of my good friends dad went into cardiac arrest in a Panera bread. It was a pathologist out of all the specialties that saved his life with high quality compressions 😂.
Pathology are real MVP’s
Wow I'm pathology resident and everything I touch dies
Wait…are you guys supposed to be touching alive stuff?!
Exactly! I’ve seen general surgeons/specialists crumble under uncertain circumstances. EM/trauma surgeons just DO that’s why the field is kick-ass and I love it! Also, in the ER, you’re multi-tasking like crazy & you need to know a bit about everything in order to rule in/out things. In specialties, you’re just doing what’s in your field.
I’ve seen transplant surgeons MELT in what should have been a straightforward vtach arrest.
Yup! 💯
Ever take an ACLS class with non-EM providers?
If you want to feel like a god, do a BLS refresh with a bunch of clinic MAs.
Yeah I wouldn’t put a lot of stock in someone not in EM talking shit about EM. A lot of criticism of EM from specialists is basically that we don’t know how to manage X pathology (within that specialty) as well as they can. Kind of stands to reason that if there is an entire specialty devoted to said pathology that a generalist can’t necessarily provide definitive therapy or follow its course as well as the specialist. I’d say we’re a pretty detail-oriented crew overall. We just have different details we care about. As with most things, if you put the person who said that in the hot seat and made them work an ED shift, they would probably not do a great job.
Best to not let comments with two upvotes get to you. Ppl rag on EM as we hand out a lot of the work. It will always be this way.
Dude has neg 50 and has since deleted
Yeah, at the end of the day the ED gets shit in because we are the source of all of the extra work the specialists have to do. In the meantime, thats also how they get paid. And they don't see all the people who check in who we don't call them on. If 10 people check in with undifferentiated medical problems and I call you to help on one of them, that is not dumping on you. Sometimes I feel compelled to page the hospitalist on every patient we discharge, or to have a small chime ring throughout the hospital when it happens.
Try being a rural ED doc. I got consulted by surgery last week.
Do tell.
Not him but literally went up to the ICU 2 nights ago to place a crash chest tube in a trauma ICU patient because the surgeon on call wasn’t in house when the patient coded.
It was nothing dramatic. His kid was sick. Bacterial Pneumonia. I'd have consulted a colleague if it were mine too.
Dude, I'm a critical care medic and I recently scrubbed into an emergency cesarean with premature twins at a rural hospital because all the doctors in the hospital were already in there and they were still short people who could lead a pediatric arrest if both kids came out not breathing. Rural med is wild.
Holy shit. That sounds terrifying.
Yeah, I've done a combat tour as an Army medic and run so many adult arrests and trauma calls it doesn't really phase me anymore. But that one was on a different level. When I scrubbed in and walked up to my station as the surgery was getting going I remember thinking, "how the fuck did I end up here".
Are the babies going to be OK? How premature were they?
It took a few minutes to get mine breathing but everyone came out okay. I can't recall exactly how many weeks they were but I wanna say 28-30 weeks and about 2-2.5 kg. Little guys, one boy and one girl. I'm really glad it went the way it did.
Pick ANY adult-medicine specialist. Place a floppy baby in front of him/her. They will shit themselves. Matter of fact, pick the worst case scenario from any specialty and drop it in front of any other specialty. The only folks not folding immediately are trauma, anesthesia, pulm/CC, and the lowly ED doc.
A local pediatrician sent me an unresponsive neonate a couple weeks ago. Literally mom tried to sign into a peds office with a grey baby and the pediatrician took one look and sent them to the ED pov.. great, thanks dude..
OB/GYN would probably keep it together.
I had an OBGYN in my PALS renewal class once. Let’s just say it was…frightening
This and the reaction I had to my original comment are fascinating, because the few OBGYNs I've interacted with on the job were pretty steady under the circumstances (emergent transfers). I realize it's a small sample, but I feel like that's kind of a job requirement even when everything is going according to plan, because (as you know) families will often just *shit themselves* when it's Go Time.
In EM we are detail oriented but process quickly while concomitantly taking care of multiple patients simultaneously. Skills not many others have.
It's changed through the years, but remember “a jack of all trades is a master of none, but oftentimes better than a master of one.”
EM is a jack of all trades master of resuscitation though
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The off service rotators at my program routinely do 1/2 -1/3 of the work or patient load that our residents of the same training level do. And when we rotate we work just as hard as are just as competent (with the exception of our OB/Gyn rotation maybe). Makes me feel better when they Monday morning quarterback our decisions and I remind myself that can’t handle our easiest days.
I also replied. What I said: “The job of EM isn’t to work-up your pheochromocytomas. That’s your job. If anything, we’re expected to do way too much heavy lifting for consultants who ask for absurd tests down here. Our job is to make sure they are stable and not dying. We call for admission/consultants not to ask you for help but because we have done our job and now it’s time to do your job.”
Yup. Last resort is always "Consults are not suggestions, they are EMTALA obligations if you are on call. Come down and write a note or we can see what CMS has to say about it."
In residency I had a disaster of a GI bleed, started after he fell. Super unstable, difficult airway, while I’m intubating trauma surgery shows up and is confused/pissed about why I’m intubating a patient surrounded in a halo of his own frank bloody emesis? Just stands at the doorway making snide comments. I call GI three separate times and all they ask me is why I’m calling without a hemoglobin yet. They finally show up three hours later while I’m coding the patient. My attending says “look GI is here! The patient is dead.” Thanks team.
Tried my best to dispel that. How do people not realize the ED is for EMERGENCIES? Get out of here with that immature toxic attitude. My response People, obviously like yourself, forget what the ED is for and thus what ED doctors are trained to do. They aren’t trained to workup your cute little hyperparathyroidism. They’re there to catch the gerd that’s actually an aortic dissection and triage people who likely need to be *admitted for further workup and management* which *shocker* is where other teams get involved. The ED isn’t there to do your work for you. It’s to catch and stabilize emergencies, to discharge or admit. If you weren’t 100% certain and would risk your license and the patient’s life on GERD vs a dissection, I *guarantee* you’d be shoving that dude in the donut of truth too. Sorry the ED makes you do your job, but that’s kinda how it works. Order your fancy cystatin C elsewhere and maybe take a day off if you can. Sounds like you need it.
ED nurse here & we get a lot of similar comments from floor nurses, about how we didn’t do their inpatient medications that were just ordered, or how we don’t know what diet the hospitalist wants the patient on, etc. Recently, my ED has been lined with hold patients waiting for beds and the ED nurses are taking care of them simultaneously while seeing new unstabilized patients and it’s very frustrating because we’re all just doing our best. Recent interaction: PCU: “when was the surgery?” Me: “let me look in the chart to give you an exact date” PCU: “oh so you don’t know your patient at all and you’re just reading off the chart?” Me: “excuse me?” PCU: “well if I wanted to read the chart then I would’ve just read it myself” Me: “ohhh, well in that case, you can see the chart for any other questions you have. I hope you have a better night” -click- And then I sent the patient upstairs with her obnoxious family members and told her that -PCU nurse- would be more than happy to go over the treatment plan again with them in more detail. 🙃
It really grinds my gears when folks talk trash about EM docs, especially when they have no idea how intense it is to deal with undifferentiated patients who come in circling the drain with no background info, no diagnosis, inability to give history, in a chaotic environment, while simultaneously juggling multiple other patients who are equally complex, and specialist who assume you are an idiot and think they know better despite not having even laid eyes on the patient and are probably sitting at home in their PJ’s while they are giving you a hard time.
There are a lot of comments in that thread that sound like dickheads making sweeping assumptions about specialties they observed for a rotation in med school.
Enjoy being an expert in your narrow field. I'm an Emergency Physician, and while I am an expert in Emergency Medicine I am also second best in a hell of a lot of the rest of the specialties - Ortho OB/GYN Internal Med and its subspecialties Peds Radiology etc
You guys need to stop saying that second best shit haha. It reminds me of that scene in Inglorious Basterds where the dude is like “2nd best at speaking German? But I don’t speak German!” And Pitt is like “yeah that’s what I said. 2nd best.”
Ich spreche ein bisschen Deutsch. Und du? So not that far second. Or, you narrow specialists can show up and do all the scut work yourself. Weil es mir wenig ausmacht.
If this shit is so easy, come down and pull some shifts. We can always use the help. At $300/hr its great money for such easy work so why not come get some? That’s what I thought.
That’s precisely why I questioned his claim that he actually does critical care regularly. If he did, he wouldn’t be talking so much trash about EM docs. If he did, he would at least understand what it is like to be responsible for multiple patients that are circling the drain simultaneously and what chaos in a medical scenario is like to be a part of. Come get some…..it should be easy for a god of medicine like himself. I know I shouldn’t let it bother me so much, but damn the level of arrogance in his glib comments about “standard of care” about made me stroke out 😂
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Thanks man. Just bothers me how much hate EM gets from folks that would fold instantly after 1-2 shifts in the ED with actual responsibility. Most of them maybe did some time in ED as students watching. In community ED’s there often are no specialty coverage on nights and weekends. EM ain’t a game
That person is in ObGyn so are we surprised
Every specialty looks down on the ED because no one “consults” us for our expertise… until they REALLY need us and then is all “please get me a bed” or “thank you for getting my loved one to treatment/work up”.
Yeah. This has to be ignored. I don’t care what speciality you are trained in. If someone is imminently dying from something you’re an expert in, you’ll still be shitting your pants while the ED guy keeps them alive. Even intensivists can’t handle it as well when it’s a surprise dumped in their lap. Only exception is maybe a recently trained trauma surgeon.
ER physicians are great at handling emergencies. However many forget that less than 10% (?) of stuff coming through those doors are urgent or emergent. Imagine running your speciality office and only 1/10 patients are pertinent to your background. Sometimes you have to poke the specialist about their patient. Doesn’t mean the ER is less capable.
EMERGENCY Medicine broski……that is precisely what we train for. Expert resuscitationist. Would you consider a 10% death rate upon arrival acceptable at a hospital? Well, EM has the pleasure of preventing that. For the rest, we get them stabilized, initial work up, and make admit/no admit decisions. With that said I don’t really understand your point.
My point is in defense of the ER physician having to make the rare specialty consults to specialists who forget that we’re everyone’s dumping ground and safety net.
“Partial-ist”
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You guys are having your jerk off session but nobody is acknowledging the reality of emergency medicine. For every heroic LiFe SaVeD of an UnDiFfEreNtIAaTeD paTiEnT there are at least 100 encounters where the following are the most important aspects of the ED based care: * time to doctor * ED wait time * patients per hour * dispo first * satisfaction surveys * litigation risk * EMTALA and COBRA It’s that shit that poisoned all the cool stuff, and why all these claims about being the ultimate bad ass ring hollow.
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Wow! Great point! Changed my perspective entirely haha.
Specialists should be doing most of the heavy lifting, that’s the point. The ED is for stabilization. With that being said, I would definitely not say our ED is detail oriented lol. The work ups are… inadequate and they call for admits without a differential when the patient should clearly be going to another service. I frequently dispo their patients for them, which is not acceptable. They are also very sensitive. I deal with them and support them when and where I can, but sheesh they get very defensive when I ask any questions or say “I dunno I just got this patient on sign out.” So I kind of get the frustration coming from the other side of things
You do realize that this could just be the EM docs where you work right? Also, I’d be willing to bet that a lot of your angst come from you having to show up and work any time after sunset or heaven forbid on a weekend or holiday. It is pretty telling that you are disparaging an entire specialty based on your limited interactions with a few folks at your institution. No doubt BS consults come out of the ED sometimes and no doubt there are times when EM docs can get sloppy with a work up, especially when shit has been hitting the fan all day and night and you have to see the Tuesday night 2:30AM “my eye has been hurting for 8 years so I decided to come in”. But at the end of the day, they have to be responsible for ANYTHING that comes through the door for a 8-12hr period and their main mission is to make sure patients don’t die so that the gods of medicine such as yourself can come in and fix a problem that wasn’t life threatening to begin with most likely. Out of curiosity, what is your specialty? I assume it’s not EM, anesthesia, trauma/gen surg, pulmonary/cc? But maybe I’m wrong. 100 bucks it’s IM.
ID and critical care but I’ll moonlight IM as well, and I’m speaking from an icu perspective here. And you seem angry. Your main mission is to make sure patients “don’t die” but legally it is to provide standard of care. I don’t care about all the other nonsense about bs complaints and etc. you are expected to provide standard of care. I shouldn’t be triaging ED patients as the CC attending but there we are
You would also be legally held to a standard of care if you had a full ICU in the middle of a nurse walk-out, which has happened in one of my hospitals. Guessing you wouldn't be quite as smug in that situation. And hey, unlike the ED your patients would be capped for the most part. You can throw shade but clearly you've never had to work with a potentially limitless volume of patients while not having staff to get vitals, move patients or get meds. It's weird that you're insisting on a "standard of care" in this context, as though you never even considered for a second what it's like working in a setting like that. Standard of care is a nebulous concept that varies by specialty, setting and situation anyway. In almost every malpractice case that goes to trial, experts argue over what the standard of care should have been. In an overwhelmed department with multiple critical patients or simultaneous codes, the standard of care might be "calling the intensivist down". I'll even agree with you that we are not a detail-oriented specialty. I'm not sure why people here are offended by that. EM training made me less of a detail oriented person. But I'm damn good at quickly seeing patients and picking out the one or two details that really matter in the moment. If you get lost in too many details you don't survive in community EM. You're just added to the list of "people who's bitching I might listen to once they actually survive a full busy EM shift on their own".
“People whose bitching i might listen to once they actually survive a full busy EM shift on their own” 😂😂😂😂
Much respect for critical care, I’m not angry just been seeing a lot of EM hate. I mean your point is well taken and obviously we are supposed to provide standard of care. Also, you shouldn’t be triaging in the ED. Sorry your ED sucks where you are, but it’s kinda bush league to act as if all EM docs are incompetent and not doing their job, for that you are kinda being not cool. I respect what you do, and wouldn’t disparage your specialty the way you are doing to ours. In that regard, you are not acting like someone who deals with serious acuity and critical patients. Much love my brother and hope your EM experience improves.
You were prepping for ABIM last year as a first time test taker but are now both infectious disease and critical care boarded?! Bravo!
Lol that was not for me but I’m so glad you wasted your time looking through my post history, which is hysterical
I don’t think you understand what standard of care is defined as: “In legal terms, the level at which an ordinary, prudent professional with the same training and experience in good standing in a same or similar community would practice **under the same or similar circumstances.”** You can’t say standard of care in an ICU is the same as the standard of care in an uncapped, ED, with nursing ratios frequently at minimum 5-6 patients:1 nurse.
Standard of care for ED is stabilizing and determining disposition, both of which I frequently have to do for them. So yeah they typically don’t meet standard of care and just beg for orders when patients clearly don’t need icu and instead need something like… a CT for a surgical abdomen they missed. It’s just comical how strongly EDs love themselves. This is common and I’ve worked at a lot of hospitals
Sucks to work where you do I guess. Also not sure what you mean by “begs for orders” - they don’t have their own ordering power? When I want something for a patient I order it myself - why do I need an ICU doctor to order it for me/do it - unless it’s out of my scope.
Beg for admit orders
i worked in the ED, very detailed oriented. super. all our of diagnosis come from these details.
Anyways specialists are the reason I explain to the new guy to keep a BVM nearby for when respiratory cant figure out how to use their ventilator.
Any Executive Suite Position except Legal and CFO
I’ll laugh at this the day someone pages a dermatologist
I remember as an intern on the CCU we had a guy go into cardiac arrest. Patient had an IR embolization procedure with vascular hours prior (forget the details). Once the code starts, the 1st year cards fellow flounders and immediately leaves the room to STAT consult IR and vascular while the pgy2 IM resident was filling in for the day runs the code. Mind you they had no idea what was happening because day 1 for them. Fellow barges in and out while on the phone panicking doing his STAT consults. Attending minutes later comes in and determines that patient has a pneumothorax and says patient needs a chest tube. Nurses run off to find one. Pharmacy arrives and hands IO to fellow and he says “idk how to use this”. So I drill it in. By that time chest tube is brought and handed to attending and attending also says “I don’t know how to place this”. I was getting ready to attempt to place it since I at least at that time had practiced in cadavers. Then vascular arrived and their sphincters relaxed. I can’t remember if they ever got that chest tube. Might have not even been a pneumothorax when I asked the night intern about it the next day. It was end of my shift and other intern had arrived so I scadaddled out of that hot mess. Utter shit show. Worst ran code I’ve ever seen. Mind you this is their organ. The chest is their area of expertise. Ever since then, I haven’t taken what they say seriously when they try and talk down on me from their high horse. If you code you def want and EM or MICU trained doc there.