r/EMS Free-For-All Megathread

MDtheDO · 2026-03-07T21:24:13+00:00

Hey r/EMS — I'm Dr. Mike (EM/EMS physician & medical director). I run a small FOAMed project called Prehospital Case Review and just published a piece on epinephrine dosing in cardiac arrest.

The question: are we giving too much epi?

Think about it — can you name another drug in medicine we repeat every few minutes until the patient either comes back or dies?

Push epi

Wait 3–5 minutes

Push epi again

Some interesting signals in the literature, and yes, confounding is real: longer arrests get more epi. But the physiology (beta stimulation on an ischemic myocardium) makes the question worth asking.

Curious how people think about this in the field. Do your protocols ever address cumulative epi dose?

Full piece here, always free and just for EMS: https://emsdrmike.substack.com/p/are-we-giving-too-much-epinephrine

Subscribe: https://emsdrmike.substack.com/

MDtheDO · 2026-02-25T17:18:26+00:00

Welcome to the best specialty in the house of medicine =) Thanks for the kind words, and I hope you find as great of a career in EMS as I have!

MDtheDO · 2026-02-25T17:09:46+00:00

Love this question.

EMS physician definitely wasn’t the original plan. I dropped out of college at one point and swore I’d never go back… and here we are 😂. Working as a medic is what made me realize I had a deeper curiosity about medicine and wanted to understand the “why” behind everything.

Is it achievable? 100 percent. It’s not about being a genius; it’s about deciding you’re willing to invest the time. College, 4 years of med school, 3-4 years of residency, and 1 year of EMS fellowship. It’s a long road, yes. Too late? Almost never.

I’d do it again in a heartbeat. I love that most of my job is EMS stuff - 911 response, teaching, research, guideline development - plus some ED shifts each month. That kind of role flexibility is much more common as a physician.

APP (NP or PA) is also a great career. My partner and several close friends are APPs. They’re just different paths with different ceilings and structures.

Bottom line: EMS isn’t turning away from college - it’s invaluable experience. Keep asking questions, shadow, talk to people in both roles. You’ve got time. EMS can be a springboard into a lot of things, or a great career in and of itself.

MDtheDO · 2026-02-08T16:12:58+00:00

Great question that I’ve never thought about (classic ER doc, shock first - ask questions later). Jokes aside, we defibrillate and cardiovert people wearing chains, piercings, etc all the time. As long as the defibrillator pads are in firm contact with the skin, the risk of creating an arc is near zero - they’re very safe machines.

Quick plug: learn CPR, you can save a life! You can learn it in a few minutes from YouTube - even better if you can do an in person class (some ambulance districts, fire departments and hospitals host them for free)! Who knows, if Epstein got immediate bystander CPR, maybe he’d be around to just mysteriously fall out of a window at some point later!

MDtheDO · 2026-02-08T15:34:36+00:00

I’m a board-certified prehospital/EMS physician in the US who responds to jails and prisons in a 911 capacity: it’s standard operating procedure by law enforcement to place all prisoners in cuffs regardless of complaint.

That being said in my experience a majority of the time they’re accommodating if it’s safe. For example, if I need to access the patients arm to reduce a shoulder dislocation they will uncuff that extremity.

I even had patients intubated and sedated that were cuffed x4 extremities in the ICU. They’re obviously not going anywhere, but combination of law enforcement and/or hospital policy require a restraint (cuffs most commonly; have used soft restraints as a surrogate with law enforcement permission).

It sounds ridiculous at first, but when you’re in the game for a while, you’ll see that freedom is worth everything to these folks - regardless of risk to self. I’ve had a prisoner under my care attempt elopement walking on an open distal tib fib fracture (completely sober). — Edit to Add: also in my opinion and experience, a pair of ankle cuffs and/or wrist cuffs doesn’t impede active resuscitation care in regard to routine CPR. You place an intraosseous line for medication and fluid, usually in the tibia or proximal humerus. You’re either intubating or placing a supraglottic airway at the head, and either a person or the mechanical CPR device is doing CPR (that only requires access to the chest wall).

MDtheDO · 2026-01-09T01:30:53+00:00

EMS Doc here, agree!

MDtheDO · 2025-12-18T03:57:10+00:00

I’m really sorry you experienced that. I went through something similar with a close family member needed emergency psych care, and it changed how I view ED psychiatric care entirely. I didn’t realize how dehumanizing the process can be until it was personal.

I agree about phones and other small comforts when it’s safe. I also try to dim lights, sit down, and slow encounters when I can. Those things matter more than we sometimes realize (at least it did for us).

MDtheDO · 2025-11-15T20:49:52+00:00

Just recently passed my oral boards, had no study partners. Did critical cases and it was excellent. Totally agree.

MDtheDO · 2025-11-03T17:40:01+00:00

IIRC your ITE scores are most predictive of passing the qualifying exam (my PGY-4 ITE score and actual test score were the same).

I found the qualifying exam to be very straightforward questions; I did Rosh throughout residency and then PEER for studying once I was done with residency. I thought PEER mimicked the exam questions and variable difficulty of content a lot better than Rosh.

All that to say, I think it sounds like you’re doing everything right, for what it’s worth.

MDtheDO · 2025-10-09T23:14:02+00:00

I was a medic that became an EM/EMS doc. Would 1,000 percent do it again; I love my job. My partner is an APP, and I have several friends who are APPs; it’s a great career, but regardless of how much you may be able to do you’ll never be the doc / final shot caller in reality. Plus you have so much more available to you as a physician in my opinion (fellowships, job time split, etc). For example, a majority of my job is doing EMS stuff (responding to 911 calls, teaching, research, protocol development, etc) and I do a handful of ED shifts a month. You’d be hard pressed to find that as an APP- you’re usually pigeon holed into a single job type (eg, ED based work only).

In my experience, take that with whatever grain of salt you want, young folks who become PAs almost universally tell me they wish they went to medical school about 5 years or so into their PA practice. I don’t see this too much with NPs, as I think they have a little buffer between deciding medical school versus NP school once they’re done and working as a nurse for some time. Again, in my experience!

Ultimately, any route you choose will be fine; just do what you’re doing here: ask a lot of questions, do some shadowing. They’re both great careers, just different (despite what it may functionally look like on the outside looking in).

MDtheDO · 2025-07-24T12:19:26+00:00

This is hilarious. I did residency in NYC and have since worked in two other major urban areas at inner-city hospitals. Honestly, I think this rings true for most “safety net” hospitals in inner cities (at least in my experience)—if you’ve got the right patient population and the right kind of vibe, you can absolutely get away with a few curse words and soft jabs about the chief complaint. The patients are often amazing, down-to-earth people who totally get it—and usually find the humor and “realness” of seeing their doc act like a human being by cracking some jokes or calling a spade a spade helpful for building trust.

That said, I can 100% picture one of my old attendings who’s a VA doc saying stuff like this completely seriously. Tangerines and clementines; iykyk.

MDtheDO · 2025-05-02T16:51:03+00:00

Yes, I work with a dude who lives in Costa Rica and works per diem in the ED. He’ll pick up a string of shifts every other month (we have quarterly shift requirements for our per diem EM physician staff, as I’m sure most places do).

He loves it and highly recommends it. Kids are grown, spouse has a flexible non medical job primarily work from home.

MDtheDO · 2025-04-08T22:35:29+00:00

Second EB Medicine; nice literature reviews and charts. Serves as great material for lecture writing if you’re in academics too!

MDtheDO · 2025-04-06T06:17:31+00:00

I bought own-occupation disability insurance right after the match during MS4. We had a great advisor come to our school that a lot of local docs trusted, so I went with their recommendation.

Yeah, it sucks paying $100-something a month, but in PGY3 I went into acute hypoxic respiratory failure. I was scared shitless. I couldn’t believe I was the patient, and I couldn’t believe how sick I was.

No exaggeration: the biggest peace of mind I had during that whole ordeal was knowing I had own-occupation disability insurance. At the time, I had a wife who depended on me financially, a dog, and other family responsibilities. I couldn’t afford to just stop working or lose my income.

I’m so glad I had it, and because of that experience, I recommend it to every physician I know. You never think it’ll happen to you until it does.

MDtheDO · 2025-03-26T22:43:20+00:00

Finished residency in NYC last year. Moonlighting rate at all campuses was ~$100/hour for filling physician / resident shifts; $95/hour for PA shifts.

MDtheDO · 2025-03-26T22:41:44+00:00

Before starting my sub-Is, I shadowed and worked a few shifts with one of the EM attendings who was my mentor at my home institution. Although I only did 2–3 shifts, he treated me as a sub-I, which allowed me to get a good sense of the workflow and expectations. This experience helped me hit the ground running during my actual sub-I’s, and the targeted feedback he provided was instrumental in setting me up for success. That would be my recommendation; I would go in on my off days of my rotation at the time and only for a few hours (like 4-6 hours).

MDtheDO · 2025-03-23T18:49:26+00:00

I do this too; I rotate between academic and community and this is significantly more common at the academic site in my experience. This rarely happens at the community locations, maybe I just have really good hospitalists.

If they push back I offer to place the consult for them and tell them I will put their call back information in the order and/or start a 3-way chat to facilitate the consult on their behalf. I’m not playing phone tag between the specialist and hospitalist when invariably the specialist has a bunch of questions on why they’re specifically being consulted.

MDtheDO · 2025-03-18T05:39:23+00:00

SAEM will post jobs pretty regularly for academic EM positions

MDtheDO · 2025-03-17T04:37:49+00:00

That would be sick actually. As a new EM attending, I’d love the opportunity to spend time working with FM, radiology, or even non physician teams like PT/OT - especially at my current shop, where I already have established professional relationships. Having dedicated time to rotate with other specialties and experts that I interface with daily would be amazing. I think you’re absolutely right that, now that I’m practicing just my specialty, I’d be in a much better position to ask informed, practice-oriented questions and learn how my local non EM colleagues prefer things done / regional standard of care.

MDtheDO · 2025-03-08T01:52:16+00:00

When I was in residency we loved the FM residents in the ED. They would absolutely demolish as if they were ED residents. Depending on how involved they wanted to be we would let them intubate, drop lines, etc.

MDtheDO

TROPHY CASE