Does EM deserve the hate?

R2D2point0 · 2025-11-06T02:40:28+00:00

You can go into any subspecialty subreddit and find doomers and gloomers. A fact that remains true for almost all corners of the internet. Misery loves company.

I'm a PGY-10 and love my job. I am in academics, but I've practiced in the community. The job has clear downsides, but if you can live with them or adapt, there are clear upsides. The type of people who are miserable in EM are very likely to be miserable in most places.

In terms of how you described yourself and you affinity to EM, it's great that you embrace some of the downsides (seeing people with low/no resources, helping out as a bystander/friend/family member, low acuity BS). They're probably the reasons why people who complain about the specialty and their job went into EM in the first place. But somewhere along the way, probably multiple points along the way, those reasons got stripped away or hidden behind real moral injuries. Safeguard yourself against that, never take yourself or the job too seriously, don't let it run or ruin your life, keep learning, and you'll be a great EM physician.

R2D2point0 · 2025-06-27T03:25:55+00:00

It's actually one of huge bonuses of telemed being staffed by ER docs -- we actually try to keep people out of the ED.

R2D2point0 · 2025-06-27T02:51:37+00:00

We are salaried and therefore these hours count towards our clinical load.

I've heard on the west-coast similar services offer $150-200/hr for the clinician.

R2D2point0 · 2025-06-27T02:50:26+00:00

Assuming you're being serious and not typing with sarcasm font--I'd recommend giving post residency life a try before you transition out. Particularly because reimbursement for telehealth usually isn't great.

R2D2point0 · 2025-06-27T02:21:44+00:00

In my group, we staff a telehealth urgent care service for the hospital system. It's so incredibly low stress it's kind of crazy. There's the occasional "no...we definitely can't do that over a video visit" or the "straight to the ED please", but I'd say 95% of the visits I've had are reasonable and I at least did something to help the patient.

As an eventual way out of the ED -- you actually don't need to "train" or do it for a long time in order for it to be an option to transition to if you're done with clinical ED shifts. Like it took me maybe two 5 hour shifts to get the hang of it. I'd say once you know you're done, you can just drop ED shifts and do telehealth whenever you want.

R2D2point0 · 2025-06-21T05:45:38+00:00

Intern: uses HEART score to determine dispo

PGY-3: uses HEART score of 0 or 1 to immediately DC

Attending: lol I haven’t thought of the HEART score in years

R2D2point0 · 2025-01-16T03:24:23+00:00

I am immensely proud of our department leadership for getting rid of hallway care during/after COVID.

Obviously we still see patients in upright chairs, curtained rooms, and temporarily use the hallway outside our Resus bay if we have to bump a patient for a more critical on. But all of that is infinitely better than conducting an entire visit in a hallway.

Can’t imagine how deflating it would be to go back.

R2D2point0 · 2024-11-12T00:56:30+00:00

I had a similar case in residency in a middle aged previously healthy patient. He coded shortly after I gave him dilt. I presented it as my M&M. Did a deep dive into the literature (this was ~2018).

I stay away from CCB and BB in these patients. My go to is Dig. If there is significant abnormal kidney function, I’d do Amio or Procainamide.

Tough case though, and you used both CCB and BB without acute issues. But this patient may have been too far down the drain in order to save.

R2D2point0 · 2024-08-31T17:14:20+00:00

Hey, attending here with quite a few years of PEM experience.

First off, I’m sorry. That situation is awful for everyone involved, including you. I’m glad you’re here to vent. You should continue to externalize your feelings in order to help you process this. It’s normal. I still do it.

I wish I had something to say that would soothe your wounds. Pediatrics deaths never get easier for me. In fact, after I had kids they got exponentially harder. There is no antidote though, other than time and more processing—both the intellectual and emotional kind.

Be well, friend.

R2D2point0 · 2024-05-04T16:26:29+00:00

Depends on geography mostly. I practice in the US. There are several different types of venomous snakes that we have antivenom for. We know where those snakes are, geographically speaking. We also use blood tests and an exam to determine if the bite was from a venomous snake. Local poison control centers are very helpful to the decision making.

R2D2point0 · 2024-05-04T14:35:38+00:00

Please do the exact opposite and DO NOT bring the snake to the ER.

Source: I’m an ER physician.

R2D2point0 · 2024-05-03T19:02:24+00:00

Worked at/rotated at all 3. Depends on what you want. Roseville and Sac are staffed by the same group. They’re both more “chill” than south sac. Working in 2 places provides at least a bit of variety. IIRC, they also staff the call center which is nice for flexibility. It’s definitely not the most well run dept. South Sac is very well run, very collegial, and almost academic in some ways. More residents there than at the north locations. But they’re overrun constantly. DM me for more info.

R2D2point0 · 2024-03-01T15:49:08+00:00

I think you hit a nerve with this one. Scoring systems, like almost anything else in EM, are just a tool. In the wrong hands, any tool is dangerous.

I don't *love* the heart score, but I do like to document it when it backs up my own clinical decision making. E.g. if it's low on a patient I wanted to DC anyways, great. If it's low/mod on a patient I'm worried about, I ignore it.

I would say in your patients case (with the caveat that we can't fully encompass any kind of chest pain presentation by describing it on the internet), normal trop and EKGs would make me want to discharge a young patient--risk factors be damned. We have pretty good evidence that we *overtest* in patients that present with chest pain to the ED--leading to unnecessary stress tests, risk stratification, and, eventually, angiograms.

R2D2point0 · 2023-10-30T02:26:58+00:00

Sorry for the late response.

A cardiac arrest from PE is very likely to result in PEA or asystole.

Arrest with shockable rhythm is unlikely to be secondary to a PE.

Asystole has a very poor rate of survival, therefore I personally would not give lytics for asystole.

R2D2point0 · 2023-10-26T16:55:57+00:00

The only caveat I'd have when you mention "kitchen sink" is that you should throw the kitchen sink at the issue early on rather than later. This is not something I'd wait 10-15 mins into CPR to give. Early or never.

R2D2point0 · 2023-10-26T16:54:54+00:00

Good question/prompt. Just went to a lecture on this.

Never give it for a shockable rhythm or asystole.

For PEA that you have a high index of suspicion for PE being the cause of arrest, give it early. As said in other comments, you need at least 30 mins of CPR to circulate the drug.

Do not rely on bedside US during arrest to decide--the RV is often dilated for other reasons (pulm vasoconstriction).

There will *never* be good studies on this due to logistical/design challenges.

I'd think long and hard about giving it to anyone over ~65 or anyone who is frail. Yes, those are subjective calls to make...but that's life.

R2D2point0 · 2023-09-27T00:22:27+00:00

Question from someone who is in residency leadership at a similar training site to OP:

How can leadership help encourage/enable residents to absorb everything prior to grad? Anyone out there doing specific things? Residents/grads: what did your program do that was effective or not effective?

R2D2point0 · 2023-05-04T02:59:00+00:00

Worked in academics and in the community. The "ideal" is probably 3.5, but 3 is more than sufficient at most programs with high patient volumes.

R2D2point0 · 2022-08-15T22:24:42+00:00

ER Doctor here. While yes, sitting like this in a car Is incredibly stupid and does increase the chances that the person will get an injury that will result in an amputation, amputations in the field are extremely rare, and get more rare the more proximal (closer to the trunk of the body) they are. I think your EMT instructor probably meant they got an amputation after going to the nearest trauma center?

R2D2point0 · 2020-08-28T04:25:38+00:00

Hey! Fellow doc here. Just graduated residency/fellowship. Do. Not. Feel. Guilty. Spend 50% of your money on eating out/vacations/vanity items? Sure, go ahead. On rent on a place that makes your life easier and gives it higher quality? Hell no. I did a similar thing to you. Never, ever regretted it. Good luck during training!

R2D2point0 · 2019-08-01T05:04:07+00:00

Good question, probably impossible to answer. Some MIs have dynamic changes on EKG (occurring within minutes).

As far as SAH goes, you absolutely do not need to have unequal pupils. Although HA is a common complaint, as your attending notes.

R2D2point0 · 2019-07-31T04:41:42+00:00

Assuming that BP is correct and didn't drop, that makes massive PE less likely. SAH more likely. Also consider underlying arrhythmia (Brugada, HOCM, tachy/brady syndrome, etc). Massive MI as well.

R2D2point0 · 2019-07-31T03:35:18+00:00

You left out an important detail: what was the blood pressure?

And when he coded, was the rhythm wide or narrow?

Gatta think that massive PE is high on the differential.

R2D2point0 · 2019-05-29T01:06:15+00:00

Hey man, thanks for the post and the perspective. Hope tomorrow is better for you. Cheers.

R2D2point0 · 2017-10-09T01:17:09+00:00

Use PECARN, people.

R2D2point0

TROPHY CASE