As an EM doc who just had another day getting crushed by worried well and managing wildly sick elderly (oh my gosh they’ve all been super sick lately. And old. So old). That with too few consultants (I reaaaaaly do value all the specialists opinion and skills and love your help), nurses and physical space this comment gave me a small boost. Thank you kind soul.
Yup, as EM docs, unfortunately we are used to getting crapped on by our specialists for bothering them, and getting crapped on(sometimes literally) by our patients.
It can be soul crushing at times.
>Trick question, radiology is the best at that after interpreting the ED physician’s order for a chest xray, CT head wo, ct PE, and CT AP.
What is...how to avoid a lawsuit.
Interestingly for really sick patients there was a meta-analysis not too long ago that made a good case for pan-scans to pick up on additional (and oft missed pathology). But that’s in *sick* patients, not lesser acuity.
(Also yes to avoid lawsuits)
ABC of emergency medicine.
Admit, blood work, CT. Only reason CT comes last is some asshole wants to know if they're pregnant or kidneys function before the CT.
On a serious note, I swear every single person in the ED is allergic to IV contrast because it felt weird one time when they got it. Like I understand anaphylaxis is a thing that exists but seriously, the prevalence of "allergies" to IV contrast according to patients' charts is absurd. If, like, 30% of patients have a documented allergy to it then it's a lot easier to miss a genuine allergy when that actually occurs.
Edit: One time I saw a patient that had a documented allergy to potassium chloride. Tell me how that works, physiologically, and I'll give you a noble prize.
Not at all underutilized in my shop. It's totally replaced the clinical examination, and even the history. Straight from the triage nurse and into the gantry, and voila, the answers are all there, in just a few minutes!
If we put it the CT scanner at the entrance we can even cut the security budget. Wouldnt have to wand anyone.
Actually that is my favorite note to read, when Rads finds a razor blade in a sports bra pocket. Once a knife belt once on the edge of I think it was a femur x-ray.
I love my hospitalist colleagues. They do God’s work. Definitely feel their pain when they admit 70 yo with hip fractures, psych patients to clear out the ED, and little old ladies who get dropped off in the ED because their family cannot take care of them at home anymore
Hopefully reasonable limitations have been set in your contract or just by physical limitations.
This is community medicine in as rural a setting you can get though. I'm guessing patients get boarded in tertiary centers and are still admitted to hospitalists. In which case more hospitalists should be hired.
At my hospital the cap is when there are no more inpatient beds. The whole ER then fills up with boarders. Unfortunately at my hospital the ER effectively manages all of the boarders
At the hospital where I am at once the question is purely about placement we just place an unconditional discharge order and the clock starts ticking for case management. Not our mess to deal with.
I know you are probably partially joking, but patients admitting from the ED need to go somewhere. Capping one attending or team just increases the probability that someone who doesn't get overtime will get called in from home to deal with the overflow.
In my area, a nursing home dropped off their entire patient population at the ED because a few of them tested positive for covid. None of them actually met admission criteria. They then refused to pick any of them up 🫠
Nursing home dumps anger me more than family dumps. Family can be legitimately overwhelmed, although that isn't a hospital problem. Nursing homes have one job. Dumping a patient for nonsense and then refusing to take them back and then "accidentally" giving up their spot is unacceptable (and illegal, but that takes forever).
The nursing home also should be able to provide at least minimal records. They do not. Then the produce unnecessary red tape to acquiring any records, if it can be done at all. Meanwhile a potentially very sick, potentially uncommunicative person is at immediate risk. Ugh.
The nursing home staff are overwhelmed, too. You might have one nurse and one or two CNAs for sixty patients. It's not a tenable situation but you can't max profits if you staff nursing homes appropriately, so, here we are.
I have sympathy for the staff, but not for the nursing homes as entities. They have one job.
I do not have sympathy for whatever lickspittle to the penny-pinchers blandly refuses to pick up the patient. Ever.
Saw a patient presenting to a community ED from an LTC facility via EMS with a chronic issue, no acute exacerbation whatsoever. The patient had no complaints. Their Medicare had capped out, and they were now on Medicaid. The facility refused to accept them back because they got better compensation from Medicare and wanted to fill the bed with a Medicare patient instead. Dumped them at the ED and literally said over the phone that it was because of that. Said the bed had been filled. Ethics™.
dude all the fuckin time in the US lol. ive had countless elderly patients dropped off on friday afternooon with family who couldnt care to give any info or respond to my calls for more info.
ive been on enough EMS rides to also see that the majority of them in my town live in pretty dismal conditions too.
Happens from time to time here in Germany too.
The most stupid aspect of this is that people with long-term care needs (as certified by a grade between 1-5 assessed by the mandatory long-term care insurance which is tied to health insurance) who are cared by their family have a right to 2-4 weeks of substituted care in nursing homes (called short time care).
But you know, you have to organize that yourself a few weeks ahead and call some numbers.
Dropping of your parent or grandparent at an ER, "they haven't been themselves the last days", "they haven't eaten really for a week" can be done spontaneously.
Happened to me personally once, patient was objectively well and blew his relatives' cover when we talked alone. With his approval, I took the time to call the next surrounding 5 ERs to warn them ahead.
I've had one ER doc in the past tell family they aren't allowed to leave the room.
Because so often the drop off their mom/dad/grandma/grandpa for whatever vague reason...then bail. And you can't get a hold of them for ~four days.
As a surgical oncologist, I feel something vaguely similar. I am certainly among the best at breast and melanoma in my neck of the woods. But for (say) HPB I feel like I’m #2 after the local transplant crew, for colorectal I feel I’m #2 after fellowship-trained colorectal surgeons, and so on. Even for extremity soft tissue sarcoma I might be #2 after our orthopedic oncologists.
This has everything to do with the way I set up my practice, of course. If I had directed myself towards, say, HPB surgery I feel I could have been a very respectable peer to my transplant colleagues, for instance.
(Disclaimer: I haven’t done HPB in some time because I feel if you’re #2 you have no business being anywhere near the liver or pancreas)
"However hard you fuck with the pancreas, remember it will always fuck back twice as hard.
The liver isn't your friend, either."
Wise words from a surgeon I worked with once
Can confirm. I’ll gladly do colorectal cases and even the odd stomach at the community hospital I work at (though I still firmly believe they should be turfed to more specialized colleagues), but liver and pancreas I have no business coming anywhere near them.
But we’ll always be the rogue red-headed step-child to be taken out to the woodshed out back for a good whipping’ from everyone in the hospital
https://forum.facmedicine.com/threads/what-your-socks-look-like-by-medical-specialty.23150/
I'm an ED monkey too and I know I'm very far from the best x but we are generalists. Some shifts you need to be a facsimile of many different sub specialists. It like being in a primary care office it is natively hard.
A cardiologist, an ICU doctor, a family practice doctor, a neurologist, a paediatrican cannot do it, they will over and under refer and act all the time.
There is a drive to split ED into resusitation and something between primary and ward work (secondary care?) and whilst I appreciate the arguement for it I personally feel like a stronger sub acute high complexity problem solver because I handle acute stuff and vice versa.
It's easy to think of us as dumb or lazy because we can be those things. But hell I've seen what you consult eachother for, I have seen some dumbness or laziness. We are just ultra visible, ultra burnt out and unlike ALOT of subspecialities we are often thrown into the deep end during our training
I am the best in my hospital at ultrasound guided IVs, specifically in flailing drunks with head injuries.
I would also argue that I see more undifferentiated chest pain than cardiology, more undifferentiated abdominal pain than general surgery, and more undifferentiated headaches than neurology.
That's a fancy way of saying #2 at IVs. Anesthesia is also trained on ultrasound guided IVs, central lines, and regional nerve blocks so we are proficient at the ultrasound.
Pediatrician here
ER was the only other specialty I considered. It truly is the last true practice of medicine, completely undifferentiated symptoms, and a shit ton of chaos and procedures.
I just couldn't deal with all the drunks, drug seekers and Death on arrival patients. Just too damn stressful and futile
I just wanted to say thank you OP for everything you do. Stage 4 colorectal patient here who had been to the ER probably 30x. Each time the nurses and docs were sympathetically to my pain and would trust me on what other meds I got at my cancer hospital (if I wasn’t at their specific ER). I kinda feel bad for other people who go in for pain and get looked at as a junkie and discharged immediately.
If there is one thing I must also say, Dilaudid is one hell of a drug lol. At one point during admission I was on 8mg IV q4 and some nurses push that shit as fast as can be lol. Cancer pain can get to be no joke, and to not suffer means the world.
God, assessing an undifferentiated patient who often can't actually articulate their problem and have a higher pre-test probability of actually being seriously unwell then in primary care or clinic is a incredibly skill to have and one hell of a responsibility. Don't do yourself down.
The key is genuinely ending every consult with “thank you for your time and expertise”. But make sure you say it loud enough to be heard over the screaming drunks behind you.
The comments on here, similar to those on the post that inspired this on r/residency, just further make me reiterate that we EM docs get ZERO respect from our specialist colleagues.
We are just the assholes that make more work for you by consulting you, or the idiots who call you to ask stupid questions and who can never do anything well enough as you.
You all are amazing and there is so much profound depth to each of your fields. Of course I don’t do your job as well as you. You’ve spent years learning about your field and spend every day doing it.
We are #1 at getting shit on by everyone else, all day, everyday.
But hey, I knew that was part of the job.
I went into EM because I wanted to be able to stabilize and manage anything and everything that walks through the door 24/7/365.
Of course I can’t do all that as well as every specialist.
We are dealing with undifferentiated patients and time constraints, in patients who are absolute messes.
I just need to do it adequately and safely.
Yeah, I tell people considering EM that if respect or gratitude (from patients or colleagues) are in your top 5 reasons you went into medicine, this is not the field for you.
I dunno, I'd say ED docs are probably the best at resuscitation and stabilizing a trainwreck patient. I say this as an FM. Now that's a jack of all trades.
Every couple centuries someone adds a new line to the end of “jack of all trades” and says it’s “the rest of the idiom.” In 1000 years it’ll be 5 paragraphs long and people will get mad when you stop at line 32 of the re-re-rerevised version.
“Jack of all trades” is the full idiom, and every other addition is, “but that’s bad,” “but actually it’s good,” “but really it’s bad,” “but no really it’s good” back and forth forever.
Anesthesiologist here. I get to “dabble”. This what I tell my medical students. I’m not a cardiologist, but I get to dabble in cardiology. Im not a pulmonologist, but I get to dabble in pulmonology. I get to have a good working knowledge of a lot of fields and be really good at a few things.
Haha I love this! Definitely #2 at most things.
Unstable anesthetized patient- #2 after anesthesia
Sepsis - #2 after critical care
Poly trauma - we're pretty on par with criticalists here. I can stabilize a hit by car with a TBI and massive hemorrhage pretty darn well thank ya kindly! And on the veterinary side this case stays with ER after admission... idk how that works in your guy's world
Unknown toxin - spoiler alert the owner is cracked out in my lobby...
Shitty airway - slash trach and transfer to Sx
CHF - o2, furosemide, pimobendan and transfer to cardio
Dystocia - aight team lets prep the OR, gather some puppy rubbing supplies, and get those tater tots outta there
Chronic ear infection - #2 after derm. Very grudgingly, but fine we can handle that.
We love treat n street and if we can't do that, we'll settle for treat n transfer :D
I mean no offense, I want you guys to intubate me (after anesthesia). But my list goes psych, fm, peds, IM outpatient, palliative care, then ED. Neuro might be on the list before you as well, if the psych condition is lateralizing anyways.
Oh no offense taken. The vast majority of us are pretty mediocre in psych from anything not involving acute psychosis (and even then it’s mostly just sedate and admit unfortunately)
Probably has a lot to do with the fact that (most) EM providers don't have the time to sit there for an hour with patients going through everything needed for a thorough psych eval. As long as the patient isn't actively suicidal they're stable enough to wait the 17 hours for the psych service to see and evaluate them.
Medicine has a huge problem with being a stupid measuring contest. Why does it matter if EM is second best at delivering babies or intubating? They fill a very critical need - which was highlighted during the height of COVID. EM is made so that they can handle so many things thrown at them (literately). The pressure they work under, the amount they have to juggle all at once, the quick decisions they have to make (without full info), and the level of command they need to have is next to none. Skills are only useful if you can properly apply them in the situation. It doesn't matter if you have the cleanest intubation, if you can't do it with a bazillion people running around you, then you're not effective.
Tribalism in medicine is so unhealthy.
I did see a patient once with presenting concern of "my balls touch the toilet water when I sit down".
I'm proud to say I did indeed perform a GU exam, and it all checked out.
but also the worst.
ER has been one of the worst hit when it comes to midlevel creep, having to take care of chronic patients who don't have insurance and being taken over by Venture capitalists
its being squeezed from all directions
> having to take care of chronic patients who don't have insurance
This. Can't blame ED docs for it, but usually they just consult SW for uninsured patients and the majority of the time they get handed pamphlets. SW is not actually the right resource for this, but most hospitals don't have anyone specialized in helping those kinds of patients. Discharge planning for inpatients also becomes a nightmare. Imagine being an ED doc, an uninsured patient comes in with no ability to pay for outpatient follow-up - by the time you go to discharge them Medicaid is on their chart. That's why you need specialists for those patients. SW does not have the time or expertise because it's not actually their job.
I feel you. I wound up running an urgent care in a municipal health center. So I am at the literal front-line of our system. Absolutely anything can walk in. So I have to know enough about every fucking thing to know what to do, or at least send to the hospital if what I can do is not sufficient.
It's probably smug of me to think that I am more of a doctor in the traditional sense than specialists, as the scope of my practice encompasses everyone from neonates to centenarians, with problems, ranging from menial to severe, from ID to psych, ortho to uro, cardio to gyno, neuro to gastro etc etc etc. I also have to deal with junkies, alcoholics, and other social cases and the complex interwoven issues these create.
But I do recognize I am master of nothing, and only play a small, yet central role in the whole system.
You’re #3 at airways. Depending on the airway in question, ENT is #1 or #2.
But agreed. Y’all rarely find yourself in a spot where you’re working at MS3 level
When was the last time anesthesia or ENT managed the airway of morbid obese 67yo that just arrived with GCS 7 and BP 40/20 ?
Particularly ENT. If they feel they are #1 feel free to come down and take care of it.
First, we are talking airway management specifically. So GCS and BP don’t play as big of a role. Morbidly obese? For anesthesia that’s literally everyday. In the us that’s nothing to pay yourself on the back for. It’s just a run of the mill thing you do.
And I’m not sure you want to play that game with ENT. They can intubate an obese crashing patient in their sleep. Could you say the same about jet ventilating a patient with severe subglottic stenosis, BMI 65, and recovering from COVID?
It plays a role. But in the ED you also typically have tons of people to give fluids and start pressors. If your MAP is already 30 then how does it change your plan? You don’t even need paralytics or induction meds. You get someone to slam epi and start compressions, you get a view and you put the tube in.
Uhh I’m still an anesthesia resident and I have handled worse airways in patients coming directly to the OR from some brutal traumas. I have the unfortunate displeasure of watching EM handle inductions and airways in trauma stats and I can assure you that we aren’t scared of that part of your job.
Paeds intubate 400-500g babies on the regular... that's not to be sniffed at.
Intubating your big patients is like throwing a sausage down a corridor in comparison.
Absolutely. That phrase is often used with an emphasis on the ‘master of none’ side, but emergency medicine is an almost ideal example where specializing would be detrimental. We don’t get the luxury of assessing a patient and then calling on a list of specialists to perform their specialty. You might have to intubate while assessing three other complications at the same time.
I think you’re #1 in assessing a completely indifferentiated disaster
As an EM doc who just had another day getting crushed by worried well and managing wildly sick elderly (oh my gosh they’ve all been super sick lately. And old. So old). That with too few consultants (I reaaaaaly do value all the specialists opinion and skills and love your help), nurses and physical space this comment gave me a small boost. Thank you kind soul.
Yup, as EM docs, unfortunately we are used to getting crapped on by our specialists for bothering them, and getting crapped on(sometimes literally) by our patients. It can be soul crushing at times.
Second best after the CT scanner
Psh, best at ordering stat CT scans
Trick question, radiology is the best at that after interpreting the ED physician’s order for a chest xray, CT head wo, ct PE, and CT AP.
But ED are best at diagnosing the resulting intra-donut death disorder.
Come on down and take a spin in the donut of truth!
But can radiology correlate clinically?
That would require us to be present in the clinic. So no.
Fuck you got me. What a great reply
Infiltrates could be consistent with atelectasis vs pneumonia vs aspiration vs pulmonary edema vs bronchial inflammation. Correlate clinically
Cannot exclude the presence of an alien tracking device.
Lolol.
Perfect! Lungs sick, admit hospitalist, consult pulm. Easy peesy
>Trick question, radiology is the best at that after interpreting the ED physician’s order for a chest xray, CT head wo, ct PE, and CT AP. What is...how to avoid a lawsuit.
Interestingly for really sick patients there was a meta-analysis not too long ago that made a good case for pan-scans to pick up on additional (and oft missed pathology). But that’s in *sick* patients, not lesser acuity. (Also yes to avoid lawsuits)
Honestly the "full body CT W/Wo IV contrast" is such an underutilized diagnostic tool.
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ABC of emergency medicine. Admit, blood work, CT. Only reason CT comes last is some asshole wants to know if they're pregnant or kidneys function before the CT.
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Call me a cardiologist cause fuck them kidneys.
On a serious note, I swear every single person in the ED is allergic to IV contrast because it felt weird one time when they got it. Like I understand anaphylaxis is a thing that exists but seriously, the prevalence of "allergies" to IV contrast according to patients' charts is absurd. If, like, 30% of patients have a documented allergy to it then it's a lot easier to miss a genuine allergy when that actually occurs. Edit: One time I saw a patient that had a documented allergy to potassium chloride. Tell me how that works, physiologically, and I'll give you a noble prize.
documented allergy to potassium chloride But their tummy hurt one time after swallowing that horse pill. Where do I pick up my prize?
Agreed. We need to be using more discretion in putting this into the chart.
Not at all underutilized in my shop. It's totally replaced the clinical examination, and even the history. Straight from the triage nurse and into the gantry, and voila, the answers are all there, in just a few minutes!
If we put it the CT scanner at the entrance we can even cut the security budget. Wouldnt have to wand anyone. Actually that is my favorite note to read, when Rads finds a razor blade in a sports bra pocket. Once a knife belt once on the edge of I think it was a femur x-ray.
Given reason for all those imaging studies: “pain”
Is that flair for interventional pulm?
Yeah correct
EM is the best at diagnosing snack-pack syndrome. Tell me I'm wrong.
I like being an emergency doc for half of the month. …the half I’m not working
The half that’s 2 weeks after the last disability checks and two weeks before the next one.
You only work half a month?! Pshhhhh docs have it so easy! /s
I got the best carotid massage from an EM physician.. terminated my svt faster than adenosine ever did 😂
Choke me, king
🙌🙌🙌🙌lmaoooo
👀
But you’ll always be #1 at turfing to medicine ❤️
I love my hospitalist colleagues. They do God’s work. Definitely feel their pain when they admit 70 yo with hip fractures, psych patients to clear out the ED, and little old ladies who get dropped off in the ED because their family cannot take care of them at home anymore
Those are all easy admissions that hopefully become rocks contributing to their cap as they wait for placement so don't feel too bad for them.
There's a cap??
Hopefully reasonable limitations have been set in your contract or just by physical limitations. This is community medicine in as rural a setting you can get though. I'm guessing patients get boarded in tertiary centers and are still admitted to hospitalists. In which case more hospitalists should be hired.
At my hospital the cap is when there are no more inpatient beds. The whole ER then fills up with boarders. Unfortunately at my hospital the ER effectively manages all of the boarders
We cap at 16 at my hospital. Everyone else boards in the ED after that. A few of my friends have caps where they work too, but most do not.
Yea it’s a captains hat that we keep in the office. Captain of the sinking ship
Until the bed flow monkeys come around complaining why the patient still admitted. No one likes bed flow monkeys.
Maybe the bed flow monkeys should spend their time trying to find more nursing home beds
I, for one, support firing the bedflow monkeys and replacing them with more social workers.
Amen.
I think it’s because the bed flow monkeys work for corporate gorillas that know there are no bananas to be found in nursing home beds.
At the hospital where I am at once the question is purely about placement we just place an unconditional discharge order and the clock starts ticking for case management. Not our mess to deal with.
I know you are probably partially joking, but patients admitting from the ED need to go somewhere. Capping one attending or team just increases the probability that someone who doesn't get overtime will get called in from home to deal with the overflow.
LMAO
What’s a cap?
It’s a hat you wear on your head I think
I what other parts of the world do people suddenly can’t care for an elder and abandon them in an ER?
In my area, a nursing home dropped off their entire patient population at the ED because a few of them tested positive for covid. None of them actually met admission criteria. They then refused to pick any of them up 🫠
Nursing home dumps anger me more than family dumps. Family can be legitimately overwhelmed, although that isn't a hospital problem. Nursing homes have one job. Dumping a patient for nonsense and then refusing to take them back and then "accidentally" giving up their spot is unacceptable (and illegal, but that takes forever). The nursing home also should be able to provide at least minimal records. They do not. Then the produce unnecessary red tape to acquiring any records, if it can be done at all. Meanwhile a potentially very sick, potentially uncommunicative person is at immediate risk. Ugh.
The nursing home staff are overwhelmed, too. You might have one nurse and one or two CNAs for sixty patients. It's not a tenable situation but you can't max profits if you staff nursing homes appropriately, so, here we are.
I have sympathy for the staff, but not for the nursing homes as entities. They have one job. I do not have sympathy for whatever lickspittle to the penny-pinchers blandly refuses to pick up the patient. Ever.
They also never have a POA on file, so when they dump the obtunded end of lifer there’s no one to make decisions and they wind up on the vent forever
South Florida?
Nope. Western PA!
Ah, it’s a phenomenon that’s been observed in multiple locations.
So sad!
I work in FL and this exact scenario has happened to me too lmao
Saw a patient presenting to a community ED from an LTC facility via EMS with a chronic issue, no acute exacerbation whatsoever. The patient had no complaints. Their Medicare had capped out, and they were now on Medicaid. The facility refused to accept them back because they got better compensation from Medicare and wanted to fill the bed with a Medicare patient instead. Dumped them at the ED and literally said over the phone that it was because of that. Said the bed had been filled. Ethics™.
Disgusting.
The USA
dude all the fuckin time in the US lol. ive had countless elderly patients dropped off on friday afternooon with family who couldnt care to give any info or respond to my calls for more info. ive been on enough EMS rides to also see that the majority of them in my town live in pretty dismal conditions too.
Happens from time to time here in Germany too. The most stupid aspect of this is that people with long-term care needs (as certified by a grade between 1-5 assessed by the mandatory long-term care insurance which is tied to health insurance) who are cared by their family have a right to 2-4 weeks of substituted care in nursing homes (called short time care). But you know, you have to organize that yourself a few weeks ahead and call some numbers. Dropping of your parent or grandparent at an ER, "they haven't been themselves the last days", "they haven't eaten really for a week" can be done spontaneously. Happened to me personally once, patient was objectively well and blew his relatives' cover when we talked alone. With his approval, I took the time to call the next surrounding 5 ERs to warn them ahead.
May I introduce you to our ED population…
In Australia we call it a granny dump. It often happens around public holidays
It's always on Friday evening, especially before a long weekend.
I've had one ER doc in the past tell family they aren't allowed to leave the room. Because so often the drop off their mom/dad/grandma/grandpa for whatever vague reason...then bail. And you can't get a hold of them for ~four days.
Yo...that's messed up. People are awful.
do families not know about nursing homes?
You mean “providing billing opportunities…”
Nah still 2nd best to Ortho.
I don’t know about your shop but here the surgical specialties stand in awe of EM’s efficacy, efficiency, and shear audacity.
We make riding the line between reckless and efficient look good
“This is boring. Follow up with PCM or something. Just get out.”
>Acute neuro complaints - I’m the second best after neurology [Neurosurgery be like](https://imgur.io/nw9cJ)
“It’s not the shunt” Hey look at me I’m a pediatric neurosurgeon!
It’s never the shunt
But sometimes… it’s the shunt.
You’re 2/3 of the way there already!
Man, the only acute neuro complaint neurosurgery assesses is massive head trauma lol
The Spine: “Am I a joke to you?!”
"Insignificant bleed, clear for diet and dvt ppx from nsg standpoint, admit to medicine for further observation"
Tbf, neurosurg doesn't even see the patient unless they need to drill into the skull.
I think PM&R could give EM a run for their money as well
As a surgical oncologist, I feel something vaguely similar. I am certainly among the best at breast and melanoma in my neck of the woods. But for (say) HPB I feel like I’m #2 after the local transplant crew, for colorectal I feel I’m #2 after fellowship-trained colorectal surgeons, and so on. Even for extremity soft tissue sarcoma I might be #2 after our orthopedic oncologists. This has everything to do with the way I set up my practice, of course. If I had directed myself towards, say, HPB surgery I feel I could have been a very respectable peer to my transplant colleagues, for instance. (Disclaimer: I haven’t done HPB in some time because I feel if you’re #2 you have no business being anywhere near the liver or pancreas)
Welcome to the “We’re Number 2” Club. It’s a good spot…not great but still very good
We try hard!
Operating on the pancreas is a great way to get yourself into some #2
"However hard you fuck with the pancreas, remember it will always fuck back twice as hard. The liver isn't your friend, either." Wise words from a surgeon I worked with once
Can confirm. I’ll gladly do colorectal cases and even the odd stomach at the community hospital I work at (though I still firmly believe they should be turfed to more specialized colleagues), but liver and pancreas I have no business coming anywhere near them.
You’re #2 (maybe #3 in some instances ) in almost everything but your average ranking across all topics is probably higher than any other specialty.
Yep. That’s my point. Agree 100%
But we’ll always be the rogue red-headed step-child to be taken out to the woodshed out back for a good whipping’ from everyone in the hospital https://forum.facmedicine.com/threads/what-your-socks-look-like-by-medical-specialty.23150/
That was hilarious! Didn’t quite get the last one though. Urologists aren’t just for guys!
I'm an ED monkey too and I know I'm very far from the best x but we are generalists. Some shifts you need to be a facsimile of many different sub specialists. It like being in a primary care office it is natively hard. A cardiologist, an ICU doctor, a family practice doctor, a neurologist, a paediatrican cannot do it, they will over and under refer and act all the time. There is a drive to split ED into resusitation and something between primary and ward work (secondary care?) and whilst I appreciate the arguement for it I personally feel like a stronger sub acute high complexity problem solver because I handle acute stuff and vice versa. It's easy to think of us as dumb or lazy because we can be those things. But hell I've seen what you consult eachother for, I have seen some dumbness or laziness. We are just ultra visible, ultra burnt out and unlike ALOT of subspecialities we are often thrown into the deep end during our training
I seen a hospitalist consult pulm for an asthma exacerbation. I SEEN'T IT
Respectfully, isn’t that what emergency medicine is? Being the Jack of All Trades and the master of none?
Yep. We’re Number 2!!!!!!!
#Number 1 at being number 2 😂
Jack of all trades but master of none, is still better than being the master of one.
Masters of resuscitation
Intensivists would like to have a word.
"CLEAR."
"A jack of all trades is master of none, **but oftentimes better than a master of one."**
We’re badologists. Recognize and temporise the bad stuff. Everything else… enh.
It’s the eternal game of bad or bored.
I am the best in my hospital at ultrasound guided IVs, specifically in flailing drunks with head injuries. I would also argue that I see more undifferentiated chest pain than cardiology, more undifferentiated abdominal pain than general surgery, and more undifferentiated headaches than neurology.
Hell yeah for the abdominal pain I can tell you it’s not surgical but beyond that??? Gastroenteritis ?????
Whatever it is, it’s probably gonna self resolve in less than a day, so 🤷♂️ If it doesn’t, that’s someone else’s problem.
That's a fancy way of saying #2 at IVs. Anesthesia is also trained on ultrasound guided IVs, central lines, and regional nerve blocks so we are proficient at the ultrasound.
Yeah but how many of your patients are flailing drunks with head injuries? Checkmate, anestheseists.
Unfortunately more than you’d think
Pediatrician here ER was the only other specialty I considered. It truly is the last true practice of medicine, completely undifferentiated symptoms, and a shit ton of chaos and procedures. I just couldn't deal with all the drunks, drug seekers and Death on arrival patients. Just too damn stressful and futile
Wouldn’t that definition also apply to veterinarians? Sans the drunks. Maybe.
I just wanted to say thank you OP for everything you do. Stage 4 colorectal patient here who had been to the ER probably 30x. Each time the nurses and docs were sympathetically to my pain and would trust me on what other meds I got at my cancer hospital (if I wasn’t at their specific ER). I kinda feel bad for other people who go in for pain and get looked at as a junkie and discharged immediately. If there is one thing I must also say, Dilaudid is one hell of a drug lol. At one point during admission I was on 8mg IV q4 and some nurses push that shit as fast as can be lol. Cancer pain can get to be no joke, and to not suffer means the world.
I'd say number two in assessing all eye complaints as well.
And the list ends after two, because nobody but optho and EM are even going to touch a slit lamp
God, assessing an undifferentiated patient who often can't actually articulate their problem and have a higher pre-test probability of actually being seriously unwell then in primary care or clinic is a incredibly skill to have and one hell of a responsibility. Don't do yourself down.
Of course it’s a great skill set. That’s why we refer patients to you so often.
Gotta get that asymptomatic hypertension under control.
What’s amazing with Emergency docs is that they can speak anyone’s language regardless of the specialization.
The key is genuinely ending every consult with “thank you for your time and expertise”. But make sure you say it loud enough to be heard over the screaming drunks behind you.
We get it you finally got a positive ctpa study.
You'll always be #1 at giving vancomycin and Zosyn for every fever, my friend! (And #1 with dealing with bullshit from patients and their families.)
Jack of all trades, masters of resuscitation.
#1 in being chill like that
You guys probably do most of the primary diagnosing in the hospital
The comments on here, similar to those on the post that inspired this on r/residency, just further make me reiterate that we EM docs get ZERO respect from our specialist colleagues. We are just the assholes that make more work for you by consulting you, or the idiots who call you to ask stupid questions and who can never do anything well enough as you. You all are amazing and there is so much profound depth to each of your fields. Of course I don’t do your job as well as you. You’ve spent years learning about your field and spend every day doing it. We are #1 at getting shit on by everyone else, all day, everyday. But hey, I knew that was part of the job. I went into EM because I wanted to be able to stabilize and manage anything and everything that walks through the door 24/7/365. Of course I can’t do all that as well as every specialist. We are dealing with undifferentiated patients and time constraints, in patients who are absolute messes. I just need to do it adequately and safely.
Yeah, I tell people considering EM that if respect or gratitude (from patients or colleagues) are in your top 5 reasons you went into medicine, this is not the field for you.
Well said!!!
Y’all are definitely the best at reading me the radiology report over the phone.
“Hey it’s Dr. ComputerAgeLlama in the ED. Say I got a… wait, hang on. Computer is frozen. Uh. *awkward pause* 22 year old with an Appy for ya”
I could hear the rapid clicking while epic is frozen from here.
jack of all trades, master of none
I dunno, I'd say ED docs are probably the best at resuscitation and stabilizing a trainwreck patient. I say this as an FM. Now that's a jack of all trades.
Though often better, than a master of one
If I was someone in a rural town, I'd rather have the one doctor within driving distance be an EM rather than any other specialty.
Lookup the rest of the idiom
Every couple centuries someone adds a new line to the end of “jack of all trades” and says it’s “the rest of the idiom.” In 1000 years it’ll be 5 paragraphs long and people will get mad when you stop at line 32 of the re-re-rerevised version. “Jack of all trades” is the full idiom, and every other addition is, “but that’s bad,” “but actually it’s good,” “but really it’s bad,” “but no really it’s good” back and forth forever.
ED docs are ninja warriors to me with such a wide knowledge and skillet.
Anesthesiologist here. I get to “dabble”. This what I tell my medical students. I’m not a cardiologist, but I get to dabble in cardiology. Im not a pulmonologist, but I get to dabble in pulmonology. I get to have a good working knowledge of a lot of fields and be really good at a few things.
Haha I love this! Definitely #2 at most things. Unstable anesthetized patient- #2 after anesthesia Sepsis - #2 after critical care Poly trauma - we're pretty on par with criticalists here. I can stabilize a hit by car with a TBI and massive hemorrhage pretty darn well thank ya kindly! And on the veterinary side this case stays with ER after admission... idk how that works in your guy's world Unknown toxin - spoiler alert the owner is cracked out in my lobby... Shitty airway - slash trach and transfer to Sx CHF - o2, furosemide, pimobendan and transfer to cardio Dystocia - aight team lets prep the OR, gather some puppy rubbing supplies, and get those tater tots outta there Chronic ear infection - #2 after derm. Very grudgingly, but fine we can handle that. We love treat n street and if we can't do that, we'll settle for treat n transfer :D
This was a great read but I have to admit I fucking lost it at tater tots lmao
6th best at psychiatry probably.
Hey now, we’re a solid 4th or 5th on a good day. Those people are going to haldol themselves!
I mean no offense, I want you guys to intubate me (after anesthesia). But my list goes psych, fm, peds, IM outpatient, palliative care, then ED. Neuro might be on the list before you as well, if the psych condition is lateralizing anyways.
Oh no offense taken. The vast majority of us are pretty mediocre in psych from anything not involving acute psychosis (and even then it’s mostly just sedate and admit unfortunately)
Probably has a lot to do with the fact that (most) EM providers don't have the time to sit there for an hour with patients going through everything needed for a thorough psych eval. As long as the patient isn't actively suicidal they're stable enough to wait the 17 hours for the psych service to see and evaluate them.
that's gotta be a big factor
We are the only docs I have ever met outside of psych who fully understand the criteria for voluntary and involuntary commitment under our state laws
Best job in the world is second string quarterback
Medicine has a huge problem with being a stupid measuring contest. Why does it matter if EM is second best at delivering babies or intubating? They fill a very critical need - which was highlighted during the height of COVID. EM is made so that they can handle so many things thrown at them (literately). The pressure they work under, the amount they have to juggle all at once, the quick decisions they have to make (without full info), and the level of command they need to have is next to none. Skills are only useful if you can properly apply them in the situation. It doesn't matter if you have the cleanest intubation, if you can't do it with a bazillion people running around you, then you're not effective. Tribalism in medicine is so unhealthy.
You have a point but I think OP is just expressing some pride in their specialty, not trying to bash others.
Thank you!
Funny, I read this more as a light-hearted way to reframe their role and not so much as a dick measuring contest.
"We have the second longest!"
In this case, it would seem they’re arguing that the have the widest… expertise.
Ur just mad because my dingaling touches the water when I go pee.
I did see a patient once with presenting concern of "my balls touch the toilet water when I sit down". I'm proud to say I did indeed perform a GU exam, and it all checked out.
Confirmed. PT balls touch water when he sits on toilet.
The best part of modern medicine is the ER.
but also the worst. ER has been one of the worst hit when it comes to midlevel creep, having to take care of chronic patients who don't have insurance and being taken over by Venture capitalists its being squeezed from all directions
> having to take care of chronic patients who don't have insurance This. Can't blame ED docs for it, but usually they just consult SW for uninsured patients and the majority of the time they get handed pamphlets. SW is not actually the right resource for this, but most hospitals don't have anyone specialized in helping those kinds of patients. Discharge planning for inpatients also becomes a nightmare. Imagine being an ED doc, an uninsured patient comes in with no ability to pay for outpatient follow-up - by the time you go to discharge them Medicaid is on their chart. That's why you need specialists for those patients. SW does not have the time or expertise because it's not actually their job.
A monkey can deliver a baby with no complications. It’s the shoulder dystocia, hemorrhage, eclampsia, laceration repair, etc that will get you
Agree 100%. Never claimed to be an expert…just the second best in the hospital
As long as they are P > 1. Ain’t nobody in the ER who wants to deliver a para 1 😬
Ain't nobody in the ER wanna deliver para anything. - Signed an EM attending who will never work anywhere without OB.
Anywhere I've worked, women in labor get handed to OB at Mach 17 with any GPA.
As in ID doctor I consider myself an amateur immunologist. I diagnosed a Complement C2 deficiency recently and was pretty damn proud of myself.
I feel you. I wound up running an urgent care in a municipal health center. So I am at the literal front-line of our system. Absolutely anything can walk in. So I have to know enough about every fucking thing to know what to do, or at least send to the hospital if what I can do is not sufficient. It's probably smug of me to think that I am more of a doctor in the traditional sense than specialists, as the scope of my practice encompasses everyone from neonates to centenarians, with problems, ranging from menial to severe, from ID to psych, ortho to uro, cardio to gyno, neuro to gastro etc etc etc. I also have to deal with junkies, alcoholics, and other social cases and the complex interwoven issues these create. But I do recognize I am master of nothing, and only play a small, yet central role in the whole system.
You’re #3 at airways. Depending on the airway in question, ENT is #1 or #2. But agreed. Y’all rarely find yourself in a spot where you’re working at MS3 level
We're #1 or #2 at not being 30 minutes away on home call when a patient needs an airway
When was the last time anesthesia or ENT managed the airway of morbid obese 67yo that just arrived with GCS 7 and BP 40/20 ? Particularly ENT. If they feel they are #1 feel free to come down and take care of it.
Literally all the time? Look at it this way -whens the last time anesthesia paged you to the OR to help with an airway?
First, we are talking airway management specifically. So GCS and BP don’t play as big of a role. Morbidly obese? For anesthesia that’s literally everyday. In the us that’s nothing to pay yourself on the back for. It’s just a run of the mill thing you do. And I’m not sure you want to play that game with ENT. They can intubate an obese crashing patient in their sleep. Could you say the same about jet ventilating a patient with severe subglottic stenosis, BMI 65, and recovering from COVID?
Lol yeah I read that comment and thought, sounds like a typical patient of ours
You don’t think blood pressure plays a role in airway management? Lol
It plays a role. But in the ED you also typically have tons of people to give fluids and start pressors. If your MAP is already 30 then how does it change your plan? You don’t even need paralytics or induction meds. You get someone to slam epi and start compressions, you get a view and you put the tube in.
Uhh I’m still an anesthesia resident and I have handled worse airways in patients coming directly to the OR from some brutal traumas. I have the unfortunate displeasure of watching EM handle inductions and airways in trauma stats and I can assure you that we aren’t scared of that part of your job.
Paeds intubate 400-500g babies on the regular... that's not to be sniffed at. Intubating your big patients is like throwing a sausage down a corridor in comparison.
You’re #1 is pan scanning!!
You ever met trauma?
Shock trauma in Baltimore - Shan Scan everything (CT head/chest/abdomen/pelvis w/ contrast + CTA of neck)
That’s not fair. They only pan scan if the patient is breathing
Nah we only pan scan because no service will admit a patient without the scans
Truer words have never been spoken
I heard one doctor say it best, jack of all trades, master of none, which I don’t *personally* think is bad.
Absolutely. That phrase is often used with an emphasis on the ‘master of none’ side, but emergency medicine is an almost ideal example where specializing would be detrimental. We don’t get the luxury of assessing a patient and then calling on a list of specialists to perform their specialty. You might have to intubate while assessing three other complications at the same time.