You just confirmed what my GP commented on after I went through the gallstone/colic/heart attack symptoms but no heart attack mess this past spring.
The paramedics treated it as if it were a heart attack, but I suppose they can’t take the chance.
Thank you for all of your info and your responses.
Do you get many addicts trying to get scripts for painkillers, etc? Do you deal with them sympathetically/throw then out/report them to the cops?
Right. It all goes back to what I was saying up thread. My primary concern is immediately life-threatening disease, followed by other badness, followed by stuff you could probably wait until the next day, followed by “what part of Emergency don’t you understand?”
We get patients seeking narcotics on a daily or hourly basis. I try to handle each one of them on a case by case basis. I give most people the benefit of the doubt unless I can find evidence of doctor shopping or that they’ve gotten a recent prescription. Ideally we would have individual treatment plans established for the patients who come in frequently, but it’s tough with so many physicians and midlevel providers in our group (more than 50).
Hey USCDIver, It’s been a while and a few Name changes since I last talked to ya and QtM 
Sorry for the TONS of questions, but since you asked, I figured I’d take advantage of this one
What was your fav. Subject in Med School? What was the most useful/practical for your field? Most Useless?
How’d you know you wanted to go into EM? Was it during rotations, or did you just know earlier?
Everyone loves to talk about “Burnout” in the EM- do you really see it, deal with it, or how do you manage to not worry about it? What do you see yourself doing in 10-20 years?
If you didn’t go EM, what would you have considered going into?
How’d you settle on a place to do your Residency?
Any advice for someone interested in going into EM?
Also, what’s the best advice you can give someone who’s about to start to tackle the USMLE and or 3rd and 4th years?
Thanks again, dude.
-R0osh
This scares me, a lot. I’m still detoxing from benzodiazepines and want nothing to do with them. But, because I’m detoxing, my anxiety is higher than usual, and, if I’m in the hospital, I’m gonna be scared anyways. I could conceivably panic in such a way as to not be able to think clearly.
Please tell me you’ve never done this without looking at the chart.
As for my question–have you worked with anybody who’s been let go due to malpractice?
And, as it was said on Grey’s Anatomy, is it true that every doctor eventually kills somebody? (As in, their mistake cost the patient his life)
How do you feel about people who come in with “false alarms?” For example, I went into urgent care after falling hard on a flight of metal stairs (landed with my kneecap right on the edge of the step–ouch). I didn’t know whether it was serious, but thought it was better to get it checked out than to end up messing it up further if it was broken or something. It wasn’t broken, just badly bruised and the joint was all filled up with blood. The doctor who saw me was very condescending, making it seem like she thought I was a hypochondriac or just seeking attention. Is that a typical reaction, or is that unusual?
I used to work for a malpractice insurer, and designed tons of risk management newsletters and educational materials. Do you find that kind of stuff useful or does it make you feel like you’re being told how to do your job by a bunch of insurance idjits?
Have you ever had any on-the-job scares like needle sticks or anything that made you worry you could pick up something nasty from one of your patients?
ToeJam? Nice one… Let’s see… I’ll tackle this one line by line.
From the didactic years, I enjoyed Pharm best. It was the first time everything seemed to come together. Pathology was most useful for me given the breadth of disease processes I’m faced with. Useless… hmm… probably one of the combo biopsychosocial classes.
I considered EM near the end of my third year and confirmed the decision after rotating through the Orlando ER at the beginning of fourth year.
Burnout seems to be a bigger issue among doctors practicing in the ER who did not go to an EM residency. I manage it because this is my chosen career and I know when my shift is over I get to go home. I’ll be doing the same thing in 10-20 years, but that’s probably about as long as I want to practice full time.
I strongly considered Pediatrics and General Surgery.
Scramble. I don’t recommend it.
If your school does not have a required EM rotation, or if it is going to be late in the year, go shadow in the ER. It’s important to have an idea of what you’re getting into before you make the leap and this is especially true in the ER because it is so radically different from all other areas of practice.
I found the old adage about USLME to be very true: You need to study 2 months for Step 1, 2 Weeks for Step 2 and bring a #2 Pencil for Step 3.
My pleasure.
:eek:
We’ve got people now who are skipping class and trying to dedicate 10 hours a week min. to studying for the USMLE 1 right NOW… I feel so overwhelmed by it- as I’m just trying to survive the onslaught of Pathology right now. But wow. 2 months? O_o
Also- one last longshot sort of a question: How important do you think having research experience?
Because I REALLY hate research- and know that’s a shortfall that’s going to be on my record- do you have any thoughts on that, or was that one of those “hey, I got in, and now I’m waaaay past that sorta stuff”
Well presumably I’m not going to go blindly ordering stuff without evaluating the patient, which includes “looking at the chart”. Not that I’m going to go into every detail of your medical history though. That isn’t usually something I need. But suffice to say, if I think you’re bleeding out or about to die from something and are freaking out about getting a needle stick or a CAT scan, I’m going to give you a sedative regardless of your detox status. That can be dealt with later. Now if you’re freaking out and won’t let me sew up your little finger, that’s a different story. Priorities, man priorities.
I know of a few doctors who have been sued, but I’m sure there are more who don’t make that public knowledge, but as far as I know no one I’ve ever worked with has been fired specifically because of a lawsuit.
I wouldn’t put it in exactly those terms, but I’m sure a missed diagnosis has led to death in everyone’s career at some point.
A lot of what we see I would consider false alarm (eg 99% of the people with cold symptoms) and that can be frustrating to deal with. But if the patient feels like they have an emergency, it’s hard to just dismiss them out of hand. Certainly if I thought I had shattered my patella, I’d want an xray pronto.
I’ve done some online risk-reduction coursework which was required by a previous employer, but in general, I think the things that are most commonly missed are fairly well known and those medicolegal pitfalls can be avoided by a conscientious physician. Everyone has a bad day or one in which they’re so busy they overlook a single piece of data that might change something. The other more esoteric stuff is hard to plan for.
Thankfully the only needle sticks I’ve had so far have been clean needles (ie before they went into the patient). I’m pretty cautious about that kind of thing and I’m good at getting out of the way before the bodily fluids start to fly.
That’s going a little overboard. If I were studying now for an exam in June I would forget most of the important stuff. I dedicated 4 total weeks to studying for Step 1 and I did really well. My daily schedule was awake at 10am, study by the pool until noon. Quick lunch and then to the library from 1p-dinner. Back to the library until about 1am and then to bed. I’m a bit of a night owl and I didn’t have any family so that schedule worked well for me. I definitely wouldn’t skip class to study for Step 1 at this point.
Inasmuch as getting into an EM residency, research is not weighted very heavily. Other residencies vary on what they consider important. There is a good book by Iserson called ‘Getting into a Residency’. I guarantee someone who is graduating next spring can lend you their copy. The best part is that Iserson is an Emergency physician, so there’s lots of good info in there.
Thanks, dude!
One last Question then i SWEAR I’ll stop:
How often do you use your Stethoscope in a day/ dealing with the average patient and what for usually?
I use the stethoscope on just about every patient. Nothing too fancy, listening to heart, lungs, belly,etc. Occasionally I’ll use it to listen for stridor or bruits or as a makeshift reflex hammer.
Have you ever read this thread: Things I Learned From My Patients? (Warning: It has over 2800 replies and will take DAYS to get through, but dammit it’s worth it!)
Here’s a question I wondered from my own experience, as far as ER docs missing what seems to have been a clear diagnosis in retrospect.
Patient (me) was 19 yrs old female, sudden sharp lower abdominal pain lasting two days and radiating up towards the ribcage. Only noted on the right side.
My dad took me to the ER on Mom’s recommendation (former ICU nurse) as we were all afraid it might be appendicitis.
The ER doc (young, probably 26-30), after palpating ruled out appendicitis. I had no fever and the area wasn’t vomit-worthy painful when he poked, but still pretty damn painful. He told me to go home and check with my PCP in the morning.
Still in pain, I saw my PCP first thing the next day she palpated, pushed hard up near my ribs, and when I noted surprisingly that the pain was worse there she said “classic ruptured ovarian cyst, take some Aleve and we’ll do a US to see if there is any damage.”
Ultrasound later in the week showed another 1cm cyst on that ovary.
I’m mostly just shocked the ER never once mentioned ovaries to me at all, as it seems this was a typical presentation. He just shrugged and said it wasn’t appendicitis, and he didn’t know what else it was.
So my question is, is it likely that ER docs tend to rule out possible traumas and leave the rest of the diagnosis for the patient’s general practitioners? It wouldn’t have seemed so odd if he’d said something like “I ruled out appendix, but it could be this this or that which are all non-life threatening, so I’d recommend checking with your PCP.” But his answer was more like “Not appendix, no idea what it is but please go home.”
The way it went down it almost seemed like he had no knowledge female specific complaints, as if they didn’t even enter his diagnostic list.
I’m curious about how your profession has effected your view of the world. I often hear that Cops become remarkably different people after being on the force for a while - something to the effect of not trusting people.
Is there something similar with regard to ER doctors?
Can you place yourself in your pre-college ‘you’ and compare it with your current ‘you’ and tell us what is different in terms of how you view death, life, other people, etc?
I’m curious if the reality of people’s lives being saved or ending has effected you on an existential level.
Even I can answer this one- of course! If an ER doctor had to be an expert in all fields and thoroughly work up every patient that came in, the ER waits wouldn’t be several hours, but several days. Some fields, including dermatology and gynecology, and extremely complex and much better left to the patient’s own specialist. The ER doc will probably keep you from dying, and then you go now.
Ovarian cysts are very common and rarely life-threatening, although they can be very painful.
This is sort of specific, but anyway: I have an elderly relative who is fragile and had a bad bout of C. diff. recently that almost killed her. Her GI doc says no prophylactic antibiotics - she can have antibiotics only if there is something more life-threatening than the C. diff. She also has CHF and sometimes ends up in the ER with breathing problems. (Much less since we got her on nighttime oxygen, but still occasionally.) What’s the best way to keep the ER from giving her prophylactic antibiotics for pneumonia? She can’t be relied upon to refuse them herself, and relatives can’t always get there in time. We don’t necessarily know which ER they will take her to, either - there are a few local hospitals.
Outside of work, do you often internally diagnosis people you see (looks like that person has xxx)?
I always struggled in my healthcare law class about hospital employment. You don’t work at the hospital, you’re a contractor? Do you split payment, or is that all formulated? Why work at 4 ERs and not just 1?
I have a few posts in that thread.
I can’t speak for that particular physician’s diagnostic abilities, but Alice the Goon is on the right track. An ovarian cyst is not going to kill you in most circumstance. But I would hesitate to say that right upper abdominal pain is considered ‘classic’ for ruptured cyst. And in my experience ovarian cysts can mimic many other potentially life threatening diseases processes like appendicitis, ovarian torsion, tubo-ovarian abscess, pelvic inflammatory disease, diverticulitis, etc.
I can’t really comment on your family member specifically, but I doubt she is being prescribed *prophylactic *antibiotics by an ER physician. If a patient has a pneumonia or a urine infection for instance, I would likely likely prescribe a course of antibiotics, despite their history of C. diff infection.
Not very often. I do notice when people have nice looking veins.
ER doctors are a little bit unusual in that regard. There are few specialties that practice primarily in a hospital setting, but are not necessarily hospital employees. Anesthesiologists tend to be another. There are multiple ways ER docs are employed. Some are indeed hospital employees. This is a little bit rare though. Some physicians are independent contractors who are contracted by the hospital. Most commonly though, a group of ER docs will form a corporation and it is the corporation who holds the contract with the hospital to provide staffing for the ER. In my particular case, the ‘hospital’ is a multi-facility system so we are contracted to staff all of their ERs. We send a bill to the patient for the physician charge separately from the bill the hospital sends for the facility, nursing, medications, equipment, etc. Our billing, coding, revenue stream etc is handled completely independent from the hospital itself.
I haven’t really consciously noticed any change. I’ve always had a healthy amount of skepticism like any other Doper. I am probably more cynical than I was prior to going into the ER business, but it happened so smoothly it’s hard to really tell.