IM vs EM?

[Consult]

What are some ways an individual can decide between IM and EM. I'm still a preclerk (start clerkship next year), but I wanted to know have a better idea so I can plan rotations/electives accordingly.

 

IM is so vast but I think I would be most interested in ICU or GIM possibly cardio.

 

In EM I know you can subspecialize (in the FRCPC) so I could still do ICU through that.

 

Any thoughts would be appreciated!

[Lactic Folly]

- Shift work

- Focus on initial triage/stabilization versus longer term work up and management

[NLengr]

IM: Spend 3 hours debating a sodium value.

EM: Look at abnormal sodium value, call medicine.

 

As a side note, surgical specialty: What's a sodium value?

[A-Stark]

IM: Spend 3 hours debating a sodium value.

EM: Look at abnormal sodium value, call medicine.

 

I can assure you that we never have time to spend 3 hours on a single patient let alone a single lab value...

 

As a side note, surgical specialty: What's a sodium value?

 

Something that's low when you over-irrigate during a TURP.

[spontaneouscombustion]

Internal medicine residency will be more team-based, with more focus on inpatient care, and lots of consults. Your patients will generally be old, sick, and complicated. You'll generally be overseeing their care while in the hospital, unless you can get general surgery to take them. You can sub specialize later and do rheum or endo if you realize you just wanna work in an office.

 

Emergency medicine residency is not team-based. The practice is essentially family medicine, but with higher acuity. Most of your patients will not be sick. Some will be very sick. Your job will be to deal with the pressing issues, identify if there is a need to seen by someone else (i.e. are they safe to go home), and then hand them over.

[ploughboy]

Emergency medicine residency is not team-based. The practice is essentially family medicine, but with higher acuity.

 

I guess that depends on what you mean by "team based". In the ED I work much more closely with the nurses and allied health than I ever do on the floors (with the exception of the unit). I'd be screwed without them, in fact. Contrast that to the medicine ward, where the team comes in, rounds, writes a bunch of orders and then disappears; leaving the nursing staff to spend their day grumbling and complaining, and for entertainment sending the occasional passive-aggressive page to the on-call junior resident.

 

If you work in a family practice where people regularly come in with gunshot wounds, airway obstructions and in cardiogenic shock, then I suppose your other analogy holds.

 

Just my perspective.

[A-Stark]

Contrast that to the medicine ward, where the team comes in, rounds, writes a bunch of orders and then disappears; leaving the nursing staff to spend their day grumbling and complaining, and for entertainment sending the occasional passive-aggressive page to the on-call junior resident.

 

I don't know where you did CTU, but whenever I'm on CTU/MTU I'm on the ward all day long. Where else would I be?

 

Emerg is simply the more acute side of family medicine, and as ever it's hard to be a generalist. You're making decisions based on a lot less information, on a much broader array of problems, and with much greater time pressure than is ideal. People in IM don't spend a lot of time delving into minutiae on a regular basis, but sometimes an extra 5-10 minutes can be helpful.

[rogerroger]

I gotta say there are some major fundamental misunderstandings about what EM, IM and FM are as specialities in this thread. These specialties in various ways are at differing ends of the spectrum. However, all of them are team based. I highly suspect those making such comments have spent very little time in the ER...

 

EM in a nutshell is the speciality of acute medicine. EM is about putting out the fires and dealing with the worst of the worst. The nightmare situations. Everything it does is geared towards finding things that will kill you in the next 24hrs. It is not uncommon to receive patients who are basically dead, or soon to be dead in the next few min to hours unless you do something immediately. Once these things are found the major focus becomes keeping you alive for the issue can be definitely fixed, be this the OR or PCI etc.

 

EM docs resuscitate, start lines, intubate, consciously sedate, reduce bones, do LPs, and lot of EM docs are qualified with US. EM does all these things regularly, sometimes all during one shift. Furthermore, in EM you need to read CT scans and plain film XR with confidence. EM docs are readily able to do a thoracotomy or start a surgical airway or place a chest tube, do a pericardiocentesis, or paracentesis at all times. Few specialties demand an expert level of proficiency in all these tasks.

 

Sure, patients are not doctors so they often come in with minor issues that are not life threatening. But still, EM is geared towards making sure even these "minor issues" are not life or limb threatening. When identified as truly non-threatening we fix the minor issues if it is quick to do so or redirect the care of the patient to the family MD if long term care is needed. Chronic care, significant counselling as expected at the FM or IM specialist level, continuity of care etc, all of that is less emphasized in EM.

 

All of the above are defining characteristics of EM which are unique to this speciality.

 

On the issue of team work... The Emerg only functions because of a team. There can be dozens upon dozens of very sick patients in the ED. The ED doc must work very closely with the RNs, probably more so than in IM and FM. Multiple patients are always unstable. The RN is your eyes are ears. I have asked for OT/PT and SW several times a month. We have security guys which can be very key in the ED. They literally saved my butt a few times. We have the desk clerk which coordinates the whole circus. If any of these people are missing you will know it in a hurry and the quality of care would plummet. The ED is by definition a team. Thinking anything else is just misguided fantasy.

[A-Stark]

Internal medicine residency will be more team-based, with more focus on inpatient care, and lots of consults. Your patients will generally be old, sick, and complicated. You'll generally be overseeing their care while in the hospital, unless you can get general surgery to take them. You can sub specialize later and do rheum or endo if you realize you just wanna work in an office.

 

Just to be clear, surgery will NEVER accept a patient in transfer who doesn't have an immediate or anticipated surgical issue. I don't know why you'd think they would.

 

Generally speaking IM is not an especially easy specialty to define, as it differs a lot depending on the centre and the subspecialty. It is more certainly oriented toward acute medicine as well, but with attention toward definitive diagnosis and management rather than simply arriving at a disposition. It is largely about the systematic organizing and addressing of patient "issues" or "problems" and arriving at a comprehensive care plan. And it also entails running codes, starting arterial and central lines (from a triple lumen to a cordis to a dialysis cath), obtaining and evaluating gases, doing LPs, paracentesis, pericardiocentesis (not that it happens much), thoracocentesis, marrows, among other things.

 

The "team" is often comprised of other housestaff and students, and RNs and other allied health throughout the hospital. You can spend almost as much time in emerg seeing consults (and, yes, complaining about inadequate workup from ERPs) as you do on the ward.

 

Anyway, it's a very different career from emerg, of course, and (thankfully) lacks shift work, though there will be more hours worked overall.

[The Journey Man]

EM in a nutshell is the speciality of acute medicine. EM is about putting out the fires and dealing with the worst of the worst. The nightmare situations. Everything it does is geared towards finding things that will kill you in the next 24hrs. It is not uncommon to receive patients who are basically dead, or soon to be dead in the next few min to hours unless you do something immediately. Once these things are found the major focus becomes keeping you alive for the issue can be definitely fixed, be this the OR or PCI etc.

 

EM docs resuscitate, start lines, intubate, consciously sedate, reduce bones, do LPs, and lot of EM docs are qualified with US. EM does all these things regularly, sometimes all during one shift. Furthermore, in EM you need to read CT scans and plain film XR with confidence. EM docs are readily able to do a thoracotomy or start a surgical airway or place a chest tube, do a pericardiocentesis, or paracentesis at all times. Few specialties demand an expert level of proficiency in all these tasks.

 

Sure, patients are not doctors so they often come in with minor issues that are not life threatening. But still, EM is geared towards making sure even these "minor issues" are not life or limb threatening. When identified as truly non-threatening we fix the minor issues if it is quick to do so or redirect the care of the patient to the family MD if long term care is needed. Chronic care, significant counselling as expected at the FM or IM specialist level, continuity of care etc, all of that is less emphasized in EM.

 

All of the above are defining characteristics of EM which are unique to this speciality.

 

On the issue of team work... The Emerg only functions because of a team. There can be dozens upon dozens of very sick patients in the ED. The ED doc must work very closely with the RNs, probably more so than in IM and FM. Multiple patients are always unstable. The RN is your eyes are ears. I have asked for OT/PT and SW several times a month. We have security guys which can be very key in the ED. They literally saved my butt a few times. We have the desk clerk which coordinates the whole circus. If any of these people are missing you will know it in a hurry and the quality of care would plummet. The ED is by definition a team. Thinking anything else is just misguided fantasy.

 

Im not sure which ED you work in, but the day to day is not near as hardcore as you're making it sound.

 

In my experience in Academic Centres, there are certainly issues above you describe, but quite a lot of is acute family medicine. On my shifts, there may be one sick patient and the rest are either discharged or told to follow up in urgent clinics (urgent neuro, urgent ob/gyn, urgent medicine etc..)

 

Very often when there is a sick patient, ICU/CCU or General Medicine is consulted quite quickly and they are responsible for management from that point on. The ER is very rarely responsible for life or death management in Academic Centres at least, but certainly initial stabilization.

 

Regarding CT scans, I highly disagree. Sure the ER docs can look at it, but there is a Radiology resident reading urgent CT scans and calling the ER doc with her/his interpretation. In no way shape or form is a management decision being made based off an ER doc's interpretation of a CT head for example.

 

I agree with becoming good at X-rays. They are quite good at it and taught me a lot about interpretation. The Radiology resident will not go through them at night unless there is a specific concern from the ED so the ER doc has to be good with X-rays on there own.

 

Agree about U/S. They are trained with bedside and its becoming standard I think.

 

I disagree with being "expert" as surgical airways. Many R5s have never even seen one, may staff have never done one. Thats why they practice on cadavers just in case. Pericardiocentesis is almost certainly done by a Cardiology resident/fellow. Usually urgent thoracocentesis is not required. ER is almost never expert at any of these.

 

ER can be a very satisfying field I'm sure, but the above makes it sound much different than I have experienced it in multiple centres in Canada and including the US.

 

I dealt with more crashing, sick patients in one month of Internal Medicine CTU than all my electives/selectives in ER. I certainly did more procedures however in ER. Perhaps in the community, ER may be very different as well. Just an alternative perspective.

[NLengr]

Im not sure which ED you work in, but the day to day is not near as hardcore as you're making it sound.

 

In my experience in Academic Centres, there are certainly issues above you describe, but quite a lot of is acute family medicine. On my shifts, there may be one sick patient and the rest are either discharged or told to follow up in urgent clinics (urgent neuro, urgent ob/gyn, urgent medicine etc..)

 

Very often when there is a sick patient, ICU/CCU or General Medicine is consulted quite quickly and they are responsible for management from that point on. The ER is very rarely responsible for life or death management in Academic Centres at least, but certainly initial stabilization.

 

Regarding CT scans, I highly disagree. Sure the ER docs can look at it, but there is a Radiology resident reading urgent CT scans and calling the ER doc with her/his interpretation. In no way shape or form is a management decision being made based off an ER doc's interpretation of a CT head for example.

 

I agree with becoming good at X-rays. They are quite good at it and taught me a lot about interpretation. The Radiology resident will not go through them at night unless there is a specific concern from the ED so the ER doc has to be good with X-rays on there own.

 

Agree about U/S. They are trained with bedside and its becoming standard I think.

 

I disagree with being "expert" as surgical airways. Many R5s have never even seen one, may staff have never done one. Thats why they practice on cadavers just in case. Pericardiocentesis is almost certainly done by a Cardiology resident/fellow. Usually urgent thoracocentesis is not required. ER is almost never expert at any of these.

 

ER can be a very satisfying field I'm sure, but the above makes it sound much different than I have experienced it in multiple centres in Canada and including the US.

 

I dealt with more crashing, sick patients in one month of Internal Medicine CTU than all my electives/selectives in ER. I certainly did more procedures however in ER. Perhaps in the community, ER may be very different as well. Just an alternative perspective.

 

I generally agree with this as well.

 

When it comes to imaging, the rads resident is supplying the CT/US interpretation from which management is based.

 

When it comes to procedures, ER is rarely the expert at any of them. But they do have the skills to get the job done on many different procedures as needed in an emergency. Which is impressive in its own way.

 

ER are experts in the undifferentiated patient and also initial stabilization.

[Maxime]

I agree with the journey man as well. Pericardiocentesis, in every single center I've seen, is ALWAYS done by cardiology (very rarely by cardiac surgery), as it should be. I can't imagine emerge doing this... Paracentesis is also extremely rare in emerge, have only seen it done a handful of times. LPs more often. Emerge docs often want to be super efficient, and diminish ER waiting times. Doing paracentesis/any technique slows you down, so patients accumulate in emerge. The next guy definitely does not want to see the waiting room full of consults... So, he doesn't do the technique, sees the patient in 5 minutes, and fills a consultation before seeing the next patient... This is how emerge works in the real world.

 

Emerge is rarely very acute medicine. If you're looking for acute/critical medicine, look at ICU.

[leviathan]

I agree with the journey man as well. Pericardiocentesis, in every single center I've seen, is ALWAYS done by cardiology (very rarely by cardiac surgery), as it should be. I can't imagine emerge doing this... Paracentesis is also extremely rare in emerge, have only seen it done a handful of times. LPs more often. Emerge docs often want to be super efficient, and diminish ER waiting times. Doing paracentesis/any technique slows you down, so patients accumulate in emerge. The next guy definitely does not want to see the waiting room full of consults... So, he doesn't do the technique, sees the patient in 5 minutes, and fills a consultation before seeing the next patient... This is how emerge works in the real world.

 

Emerge is rarely very acute medicine. If you're looking for acute/critical medicine, look at ICU.

 

Paracentesis in the emerg is not rare at all. That said it's usually done after a consult to internal medicine or GI as I can't imagine many situations where it needs to be done emergently before you have time to consult. I guess in some cases a patient with frequent reaccumulation of ascites might drop in to get a therapeutic tap, but even then they might have a direct to GI/IM consult to get it done and then get discharged.

 

I agree with the rest of what you said. The sick patients are usually referred to and managed by either by IM or ICU very quickly. The surgery team is always down and waiting for major traumas to come in, so thoracotomies, chest tubes and other procedures are done by them.

 

It's not that the emerg docs can't do these things, but as you said I think they are more focused on moving patients through the dept. That said, they are obviously expected to be proficient and responsible to do them when the unexpected occurs, which does happen from time to time. For example if an arrest comes in, all bets are off and they're going to be expected to do everything including pericardiocentesis if they felt it was indicated.

[rogerroger]

Pericardiocentesis is very rare in the ED. I agree. It would only be done in the extreme case of obstructive shock with a basically dead patient. But it is a procedure that is trained within a 5 year EM program. Many things are rare, but competency is expected. Another example is a thoracotomy. But it is still a procedure that is taught, examined, and ultimately done in the ED. Paracentesis rare in the ED? I gotta disagree. It is done all the time both therapeutically and diagnostically.

 

Is the emerg rarely acute medicine? In a large urban department a normal shift can have a handful of of patients in septic shock, an acute intracranial bleed, maybe an anaphylactic patient or an acute unstable toxic ingestion or two... After all, who gets those acute ICU patients alive, intubated and on their way to being stabilized prior to going down to the ICU? It's the emerg. But even more importantly, the focus in EM is finding the acute patient within a mass of undifferentiated patients. This focus is where everything within EM is geared. It is all about the hunt for the acute patient. When found, keep them alive for the service which deals with their particular issue can solve the problem.

 

I completely agree that ICU is also acute medicine. Going back to the original question on this thread. If one is interested in doing ICU for a living you can subspecialize into critical care through FRCP EM. Then you one could be involved in both initial stabilization and longer term management of the critically ill patient.

[NLengr]

After all, who gets those acute ICU patients alive, intubated and on their way to being stabilized prior to going down to the ICU? It's the emerg.

 

During my 4 months of ICU at my center, I would say it's about a 50:50 split of ER:ICU doing the intubating on crashing patients.

 

Some ER docs would have the guy basically ready to roll right into the unit before they call, others would call right away and ICU would take over.

[Satsuma]

To the OP. There are fundamental differences between EM and IM. Doing several electives in each will do more to help you decide then many of the misguided opinions that seem prevalent in this thread. You can look at patient care as a continuum, and you need to decide which part of it you prefer to be on...the initial stabilization part or the subacute part or the long term part.

 

A glimpse at my last shift (which is no way is unusual):

 

1. Anticoagulated pt with severe H/A and left sided deficits. Presumed INR to be high expecting ICH. Vit K given on way to CT and high BP managed. Large intraventricular bleed on CT (yes, I saw the bleed myself), INR in interim comes back 5.9, octaplex given and neurosurgery consulted.

 

2. Pt with inferior STEMI - cath lab mobilized (it takes 20-30 min at night for the staff to come in), ASA, Plavix, heparin given, and pain controlled. Prepared to manage patient further if needed waiting for PCI since ectopic beats developing, but luckily pt up to PCI before anything worse happened.

 

3. Unstable patient with wide-complex tachycardia and a HR of 220. Cardioverted and stabilized.

 

4. Pt with HTN non compliant with meds, comes in with slurred speech and left sided deficits. But alert and otherwise stable. Off to CT for ? ischemic vs hemorrhagic stroke. Return from CT with ALOA, no longer protecting airway. CT shows - large intraventricular bleed (again - this is not hard to see myself on the the scan). Obese pt with a beard and anterior larynx. Direct laryngoscopy 1 try - grade 4 view, repositioned grade 3 view. Successfully intubated with video laryngoscope. Initial orders to manage high BP and neurosurgery consulted to take pt to ICU. Write further orders for BP management and establish and art line since ICU resident does not know how. All patients in the emerg remain the responsibility of the emerg doc even if another service is consulted, fyi.

 

5. Tachypneic and tachycardic pt with SOB and a ginormous swollen leg (that her chiropractor has been treating for the last 3 weeks - clearly unsuccessfully). PMHx - lymphoma in remission. CXR- moderate bilateral pleural effusions (again, read the images myself - yay, good for me). Thoracentesis done with US guidance (US is not "becoming standard" but is standard in Canada) relieving patients symptoms of SOB, normalizing VS and sent off for labs that will help the internist figure out further the cause of the effusions.

 

6. Elderly gentleman febrile, septic and delirious. Treated as per early goal directed therapy and source of infection found.

 

7. Pedestrian hit by car and high on drugs....usual trauma management.

 

These were my first 7 patients. And then of course, I saw some more minor patients after those fires were put out- non cardiac CP, intoxicated pt, epistaxis - packed etc.

 

I suppose none of the interventions I carried out above were "life saving". And of course represent the more "Acute side of family medicine".

 

Thoracotomy - yep is rare. But when a pt needs it done in the ER it is expected the emerg doc knows how to do it. It has been done in my centre by emerg twice in the last month. In one instance it was life saving.

 

Pericardiocentesis - it's ridiculous to think that cardiology is always going the be there fast enough to help your unstable patient in cardiogenic shock. You bet, the emerg doc is going to do it, if there is not enough time to have it done under more controlled conditions. In most cases, thankfully for the pt, there is enough time to have it done under US guidance by cardiology.

 

Paracentesis - done often enough in the ER, especially if you can do it, relieve the pts symptoms and send them home. If they are coming in, and it's busy and the pt is stable, then yeah, the admitting service can do it in order to keep the flow of the department going.

 

As I said, this just happens to be my last shift. Are there busier days? Yes. Are the slower days - yes. It's emerg and is therefore not predictable. But don't let anyone tell you life and death decisions are not made in the ER or that it's glorified family medicine.

[Consult]

Thank you all for your replies. I apologize if I started some sort of inter-discipline flame war, that was not my intent, I just really wanted to get people who are in the field views on each.

 

Thanks again

[Lactic Folly]

Thank you all for your replies. I apologize if I started some sort of inter-discipline flame war, that was not my intent, I just really wanted to get people who are in the field views on each.

Heh, this thread seems to have taken on a life of its own - not your fault

I think it just goes to show the value of soliciting multiple viewpoints and obtaining firsthand experience in a range of settings so that you have a better idea of the possibilities after graduation, not just what happens in one hospital in one city where you happen to train. There's certainly much variation in local practices, and spending time in various settings has been beneficial in broadening my perspectives and influencing my thoughts on career.

[rmorelan]

Thank you all for your replies. I apologize if I started some sort of inter-discipline flame war, that was not my intent, I just really wanted to get people who are in the field views on each.

 

Thanks again

 

the debate is healthy No worries at all.

[rogerroger]

Well said Satsuma, I can relate to your shift description. Those saying EM is not acute care centred should have seen my last shift...

 

To the OP. There are some fundamental differences between EM and IM. These differences are broad and range from patient management foci to intra-specialty culture. That is one of the reasons why you can get a pretty good debate going on here. Unfortunately, because of this there can also be the occasional misunderstanding about the roles of our two respective specialties.

 

Regarding the differences between EM and IM, the spectrum described by Satsuma really sums it all up: initial stabilization/identification of the critical patient - subacute stabilization - long term management - chronic care

 

EM is at the far end of that spectrum. There is a lot of great info in this thread. But at the end of the day you gotta just get out there and get some exposure to the ER, ICU and CTU and I'm sure you will quickly recognize the differences and see the wide spectrum in practice.

 

To the OP. There are fundamental differences between EM and IM. Doing several electives in each will do more to help you decide then many of the misguided opinions that seem prevalent in this thread. You can look at patient care as a continuum, and you need to decide which part of it you prefer to be on...the initial stabilization part or the subacute part or the long term part.

 

A glimpse at my last shift (which is no way is unusual):

 

1. Anticoagulated pt with severe H/A and left sided deficits. Presumed INR to be high expecting ICH. Vit K given on way to CT and high BP managed. Large intraventricular bleed on CT (yes, I saw the bleed myself), INR in interim comes back 5.9, octaplex given and neurosurgery consulted.

 

2. Pt with inferior STEMI - cath lab mobilized (it takes 20-30 min at night for the staff to come in), ASA, Plavix, heparin given, and pain controlled. Prepared to manage patient further if needed waiting for PCI since ectopic beats developing, but luckily pt up to PCI before anything worse happened.

 

3. Unstable patient with wide-complex tachycardia and a HR of 220. Cardioverted and stabilized.

 

4. Pt with HTN non compliant with meds, comes in with slurred speech and left sided deficits. But alert and otherwise stable. Off to CT for ? ischemic vs hemorrhagic stroke. Return from CT with ALOA, no longer protecting airway. CT shows - large intraventricular bleed (again - this is not hard to see myself on the the scan). Obese pt with a beard and anterior larynx. Direct laryngoscopy 1 try - grade 4 view, repositioned grade 3 view. Successfully intubated with video laryngoscope. Initial orders to manage high BP and neurosurgery consulted to take pt to ICU. Write further orders for BP management and establish and art line since ICU resident does not know how. All patients in the emerg remain the responsibility of the emerg doc even if another service is consulted, fyi.

 

5. Tachypneic and tachycardic pt with SOB and a ginormous swollen leg (that her chiropractor has been treating for the last 3 weeks - clearly unsuccessfully). PMHx - lymphoma in remission. CXR- moderate bilateral pleural effusions (again, read the images myself - yay, good for me). Thoracentesis done with US guidance (US is not "becoming standard" but is standard in Canada) relieving patients symptoms of SOB, normalizing VS and sent off for labs that will help the internist figure out further the cause of the effusions.

 

6. Elderly gentleman febrile, septic and delirious. Treated as per early goal directed therapy and source of infection found.

 

7. Pedestrian hit by car and high on drugs....usual trauma management.

 

These were my first 7 patients. And then of course, I saw some more minor patients after those fires were put out- non cardiac CP, intoxicated pt, epistaxis - packed etc.

 

I suppose none of the interventions I carried out above were "life saving". And of course represent the more "Acute side of family medicine".

 

Thoracotomy - yep is rare. But when a pt needs it done in the ER it is expected the emerg doc knows how to do it. It has been done in my centre by emerg twice in the last month. In one instance it was life saving.

 

Pericardiocentesis - it's ridiculous to think that cardiology is always going the be there fast enough to help your unstable patient in cardiogenic shock. You bet, the emerg doc is going to do it, if there is not enough time to have it done under more controlled conditions. In most cases, thankfully for the pt, there is enough time to have it done under US guidance by cardiology.

 

Paracentesis - done often enough in the ER, especially if you can do it, relieve the pts symptoms and send them home. If they are coming in, and it's busy and the pt is stable, then yeah, the admitting service can do it in order to keep the flow of the department going.

 

As I said, this just happens to be my last shift. Are there busier days? Yes. Are the slower days - yes. It's emerg and is therefore not predictable. But don't let anyone tell you life and death decisions are not made in the ER or that it's glorified family medicine.

[Consult]

Thanks everyone again for their replies.

 

I have shadowed a bit in both specialties, and there are aspects I like and dislike about both. I guess when I get to clerkship I will have a much better idea though.

 

Can someone comment on Emerg docs as Trauma Team Leaders (TTL)? My understanding is that alot of TTL's are ER docs.

 

Thanks again

[rogerroger]

Thanks everyone again for their replies.

 

I have shadowed a bit in both specialties, and there are aspects I like and dislike about both. I guess when I get to clerkship I will have a much better idea though.

 

Can someone comment on Emerg docs as Trauma Team Leaders (TTL)? My understanding is that alot of TTL's are ER docs.

 

Thanks again

 

 

The number of EM Docs who are TTLs will vary depending on location. However, most sites have a handful of EM Docs as TTLs. It is not uncommon for EM docs to subspecialize in trauma. In these cases they often have normal ER shifts and then take a few TTL call every month.

 

On a related note, it is not uncommon for EM trained docs to be ATLS instructors. During residency you will also spend a fair amount of time as part of the trauma team. TTL or not, initial trauma stabilization is a fundamental aspect of EM.

[Satsuma]

There will always be things you like and don't like about a specialty. The trick is finding one where the bread and butter is what you like, and the things you don't like don't really bother you a whole lot. Even with clerkship it's still sometimes difficult. You make the best decision you can, and people still end up changing in residency. If you are still in preclerkship and you have time to do longitudinal electives in each area, then you will have had a longer exposure, and hopefully, make the right choice. Talk to people and ask them what they like and don't like (ie don't ask them if they like or not - because what they don't like might not be an issue for you - so ask more specifically what they like and what they don't and see how it might apply to you)

 

At my centre, in terms of TTL, there are ER docs, Gen surg, and Anesthesia who fill that role. If you are interested in trauma, try to gain exposure to it, to see if you really like it. I can take or leave trauma, although I thought it would be pretty cool as a med student - but I had limited exposure. The initial part can be ok, but after that too much baby sitting and my attention is lost. I don't hate it, but don't love it. If you do emerg, you will know more than ATLS in the end, if that's an interest.

 

Now, you can still be involved in trauma even if you are not TTL. TTL simply coordinates the initial care - once the patient goes to the OR/is admitted, they no longer follow. (unless they happen to be the admitting doc, which if you are emerg will never be you - I see this as a pro, but not everyone would). So intubated trauma pts go to the ICU - as the ICU doc you would be taking care of these patients even though you are not TTL. Ortho is going to fix the broken femur, gen surg the liver lac, plastics the orbital floor fracture, neurosurg the ICH etc. And the anesthesiologist is going to be there to make sure the pt is safe during those surgeries! Radiology is going to do and interpret imaging. Physiatry is going to be around if the pt needs rehab etc. Trauma is really a team effort for the most part. So you don't have to be a TTL or even involved in the initial hour to be involved in trauma care. So you still have alot of choice of specialty if your interest is trauma. Even psych can be consulted for trauma pts if say the pt jumped off a bridge or drove their car intentionally into an oncoming transport truck! My point is simply, you don't have to limit yourself to TTL to be involved in trauma.

 

Thanks everyone again for their replies.

 

I have shadowed a bit in both specialties, and there are aspects I like and dislike about both. I guess when I get to clerkship I will have a much better idea though.

 

Can someone comment on Emerg docs as Trauma Team Leaders (TTL)? My understanding is that alot of TTL's are ER docs.

 

Thanks again

[ploughboy]

I don't know where you did CTU, but whenever I'm on CTU/MTU I'm on the ward all day long. Where else would I be?

 

Likewise, I don't know were you did CTU but during my terrible months of CTU at two different academic centres in the centre of the world, we would round in the morning across several geographically separated wards, then disappear for teaching, and then spend our afternoons either doing consults in the ER or sitting in the team room (physically far away from the wards where most of our patents were bedded) preparing discharge summaries, having family meetings ("so this is the fifth time this year that grandma has been admitted to the hospital with weakness and dizziness nyd -- have you ever talked with her about maybe going to a nursing home?"), chasing down tests and dealing with all the other mindless scut that goes with inpatient medicine.

 

Occasionally the juniors would get paged to let them know that Mrs. Snickerdoodle's potassium was 3.6 or other similar pressing issues. ("Thank you. MD aware.")

 

Having done all of my CTU when I was very junior, I honestly believed this was the natural state of MD-RN interactions, and I kind of hated my life...until I spent a bunch of time in the ER and ICU and started loving the people I worked with.

 

If your inpatient medicine experience has been different then that's great and I'm kind of jealous, actually.

[ploughboy]

 

Can someone comment on Emerg docs as Trauma Team Leaders (TTL)? My understanding is that alot of TTL's are ER docs.

 

 

Depends on the local culture where you work. The TTLs will be a mix of general surgeons, trauma surgeons, ER docs with maybe an anaesthesiologist or two thrown in for good measure. Like somebody else said, trauma sounds really exciting until you've done it for a while. The first half hour or 45 minutes are cool, but after that not so much..