Couple of questions about Emergency Medicine

[Aurelius]

I'm interested in EM because on paper it seems like a great fit for me, but I wasn't able to shadow it before the coronavirus situation. I was wondering if any EM docs, residents or students who have worked in an ER at a community hospital in an major city could answer my questions:

1. I've read that a large number of cases don't need emergency care and should have gone to their family doctor. Plus there isn't a lot of variety and most of the cases are chest pain/abdominal pain/chronic back pain. Is there truth to this? How much acuity and variety do you get to see?

2. How often do you get to treat patients (go beyond stabilizing the patient)? I read that interesting case are quickly taken over by medicine/surgery. I understand the role of EM is to stabilize patient but I'd like to still treat people and not always rely on consults. 

Thanks for your help!

[Arztin]

1- It depends where you work. Areas where there aren't enough family docs will more often have this problem. To name a few, people do show up for prescription refills, chronic things for which the ED isn't the place, for severe undertreated hypertension, and really benign stuff sometimes like a wart on their foot. Yes people do show up with chronic pain, including chronic back pain. Yes there are healthy 20 year old adults who go to the ED when they have a common cold.

Variety-wise I totally disagree. There isn't a place where you will see presentations as varied as in the ED. You never know what will happen during the shift. There isn't a place where you can see a paeds status epilepticus, then a STEMI, then a shoulder dislocation, then a major trauma, then a septic patient, then a diverticulitis, then a schizophrenic patient, all that in one single shift. 

On the fast track side, in one shift you can see a big hand laceration for which do a ultrasound guided nerve block, a retinal detachment, a corneal foreign body, a fishing hook stuck, and a patient who had a shoulder patient who was actually having a STEMI all in one shift. 

Acuity-wise, it depends on the days and where you work. If you work in a low volume center, you will see less high-acuity patients. But in a high volume center, if you are covering the high-acuity area and resusc, you will pretty much always see at least one very sick patient during your shift.

2- It depends where you work. In many large academic hospitals, with all the consultants and the residents available, emerg will often ask the initial labs and consult right away. When you are outside these hospitals, consultants typically only see patients during the day, unless if they need an immediate intervention. From 4 pm to the 8 AM next day, you are actively managing patients. It's up to you if you want to ask for urine lytes if you want to figure out why your patient is in hyponatremia and why they have metabolic alkalosis before consulting the admitting service (although emerg physicians typically don't do this).

Obviously, emerg is the place to stabilize and to initiate the treatment - It is not a hospital ward for patients to stay. Eventually if a patient needs to go to the OR, then surgery will need to take over anyways. If a patient needs to be admitted by a medical service, then that will happen. For example, finding brain mets on a guy who seized in the ED means this patient will need to see a consultant regardless. However, a patient who comes with an asthma exacerbation that doesn't need to be admitted ? Emerg will treat it and let the patient go. A shoulder or a wrist got dislocated? They will reduce it and have the patient seen shortly by ortho on an outpatient basis. A patient comes with hypertention undiagnosed but not in hypertensive crisis? The emerg will start a PO medication and have them seen by their family doctor after. (although this should have been managed by their family doctor)

As you can see it all depends. I would suggest you to go shadow when it's possible.

Hope it helps.

[MountainAmoeba]

It depends on the academic center. The handoff point in patient care is culturally defined and differs for each center. Many large centers do significantly more than just the initial work up. Some barely even do an initial work up. 

[magneto]

On 4/27/2020 at 6:32 PM, Aurelius said:

I'm interested in EM because on paper it seems like a great fit for me, but I wasn't able to shadow it before the coronavirus situation. I was wondering if any EM docs, residents or students who have worked in an ER at a community hospital in an major city could answer my questions:

1. I've read that a large number of cases don't need emergency care and should have gone to their family doctor. Plus there isn't a lot of variety and most of the cases are chest pain/abdominal pain/chronic back pain. Is there truth to this? How much acuity and variety do you get to see?

2. How often do you get to treat patients (go beyond stabilizing the patient)? I read that interesting case are quickly taken over by medicine/surgery. I understand the role of EM is to stabilize patient but I'd like to still treat people and not always rely on consults. 

Thanks for your help!

1. There is a lot of acuity in emergency medicine. You see very sick patients upfront and your task is to stabilize them. It does not matter whether it is trauma, septic shock, stroke - emergency medicine physician should be able to do the basic initial steps for resuscitation until definitive care can be arranged. There are lots of patients with chest pain, abdominal pain, chronic back pain etc. But I like helping them. No where in medicine it says that only the very sick and dying need help. Sometimes all the patients are looking for is reassurance and I am happy to provide that.

2. I treat patients every day. Medicine/surgery are busy and have tons of consults to see in tertiary care center. If I get a traumatic intracranial bleed patient, I am managing them until neuro ICU and neurosurgery have time to come and do the consult. I am doing the resuscitation. I am doing the intubation. I am doing the ventilation settings. I am managing the intracranial hypertension and herniation. Ofcourse, I need my neurosurgery and neuro ICU colleagues because I only do shift work and once I have stabilized the patient, my surgery/medicine colleagues will provide definitive care as indicate.

Hope this helps. Happy to answer any other questions about emergency medicine.

[gogogo]

1 hour ago, magneto said:

1. There is a lot of acuity in emergency medicine. You see very sick patients upfront and your task is to stabilize them. It does not matter whether it is trauma, septic shock, stroke - emergency medicine physician should be able to do the basic initial steps for resuscitation until definitive care can be arranged. There are lots of patients with chest pain, abdominal pain, chronic back pain etc. But I like helping them. No where in medicine it says that only the very sick and dying need help. Sometimes all the patients are looking for is reassurance and I am happy to provide that.

2. I treat patients every day. Medicine/surgery are busy and have tons of consults to see in tertiary care center. If I get a traumatic intracranial bleed patient, I am managing them until neuro ICU and neurosurgery have time to come and do the consult. I am doing the resuscitation. I am doing the intubation. I am doing the ventilation settings. I am managing the intracranial hypertension and herniation. Ofcourse, I need my neurosurgery and neuro ICU colleagues because I only do shift work and once I have stabilized the patient, my surgery/medicine colleagues will provide definitive care as indicate.

Hope this helps. Happy to answer any other questions about emergency medicine.

This is really exciting. Is the kind of management, where you do a lot of the stabilization and help before consulting, taking place in in larger communities (e.g., GTA) or is this more common in small towns? I wonder if in larger, busier centres, it's a quick initial check-up before admitting the patient.

[magneto]

4 hours ago, gogogo said:

This is really exciting. Is the kind of management, where you do a lot of the stabilization and help before consulting, taking place in in larger communities (e.g., GTA) or is this more common in small towns? I wonder if in larger, busier centres, it's a quick initial check-up before admitting the patient.

It totally depends on the ED physician.

In smaller towns, there is not much help available. So you really need to do most of the things.

In larger centers, there is help available but not always immediately available. So you still need to know your stuff.

Except for really bad trauma, usually the ED physician will do all the initial check-up, investigations, resuscitation, stabilizing the patient and then consult a specialist as needed. However, some centers are different where trauma team is called for most traumas so they are there to help out. Also some centers, stroke team is also available right away. But at the end of the day, ED is home turf of emergency medicine physicians. If you need help, you can ask for help. If you don't want too many people there, politely ask them to step back until they are needed.

[rogerroger]

I’m an emerg doc working in an academic centre. Here are my answers. 
 

1. You do see a certain proportion of patients that have non-emergent chief complaints. On some days this makes up the majority of the patients I see. Most patients fall into the grey zone. They may or may not have an emergency and I need to sort that out. That process is the most time consuming part of my job. 

 In the  group of patients that obviously do not have an emergency they can be broken down into one of two categories. 1) The patient is not aware that their concern is not emergent and is concerned. 2) The patient is aware that they do not have an acute issue but for some reason cannot access a GP. 

As emergency physicians we are the safety net of the healthcare system. When things go south out in the community for whatever reason, medical complication, access issue, resource issue, social-economic issue, we are the folks that are the “last line of defence“. That’s as much part of our role as resuscitating the acutely ill. 

This said, I see a huge amount of verity. It is one of the joys of the job. Just last night I resuscitated a polytrauma, with sig facial injuries (difficult intubation), I managed patients such as; ACEI angioedema, a STEMI, a few NSTEMIs, a cholecystitis, cellulitis, a serotonin syndrome, a few elderly falls needing stitches, a few homeless people looking for social help, a sick septic and suspected COVID patient, cellulitis, pacemaker malfunction, urinary tract infection, a end stage cancer patient needing palliation, renal collic... That’s just what I recall from last night off the top of my head... 

2. It depends. My job is to make sure a patient lives to get definitive treatment, or to initiate definitive treatment and while doing so disposition them to some place where recovery can occur safely. This may mean stabilizing and consulting. This may mean diagnosing and treating. Part of this job is also managing a department that has multiple very acute and rapidly evolving patients. So all these factors play a role.

At times it is about stabilizing +/- diagnosing the patient for they can get to an OR or ICU (such as the trauma patient above). Other times it’s about ruling out other potential badness, diagnosing, getting the patient set up with a treatment plan and arranging follow up outside the hospital (such as the renal collic patient above). When you decide to consult in house will depend on a few factors. Outside of the clinical factors unique to the patient,  two big considerations are the availability of other services, and your overall department situation. If you are in some rural place you may have no choice but to manage into the subacute phases because of resource realities. If your department has multiple critical ill patients and limited emergency expertise, you may also consult earlier once initial management is started due to those resource realities.

As an aside, one part of the job that is often not considered early on by trainees is the managerial aspect. The emergency department is very unique in the managerial challenges it presents. Personally I find that part of the job one of the most enjoyable aspects. 

Edited May 21, 2020 by rogerroger

[Redpill]

On 5/20/2020 at 11:10 PM, rogerroger said:

As an aside, one part of the job that is often not considered early on by trainees is the managerial aspect. The emergency department is very unique in the managerial challenges it presents. Personally I find that part of the job one of the most enjoyable aspects. 

Would you be able to expand more on the managerial challenges of the emergency department?