Hey all this is a throwaway and primarily just ranting. I'm a PGY 9 in the US. Loved EM and went to a really good 3 year program which affirmed my choice of speciality. Initially worked at a large academic center which was fun but chaotic and a bit stressful, eventually moved to a SDG staffing rural and suburban ERs and free standing sites.

I'm partner in my group now also have transitioned to noctornist for the pay differential, scheduling preference and at our sites you usually get to take a nap at night at least for an hour or two.

Over the last 3 or so years I've started to feel increasingly disillusioned at our job. I feel like 80% of what I see is absolute bullshit that could be handled by a PCP or urgent care. Volumes seem to just be increasing too. It sounds bad but there are so many unnecessary visits to my sites in the middle of the night for URIs, sprained ankles that happened days ago, chronic abd pain, etc. I struggle to find empathy for these patients when I could be sleeping. I'd gladly half my salary if I could half the patient volumes.

As for the 20% of patients that actually need an ER doc they seem sicker, less compliant and less medically literate compared to when I started. It's also become significantly harder to transfer people from my rural and free standing sites due to bed shortages. Also things that used to excite me like procedures, codes, trauma, etc now just seem like a burden and cause more stress than anything.

I find myself wanting to move on from EM to something with more control and regularity in schedule however with our shitty post graduate medical training system it's almost impossible to go back and do something else. Part of me just wants to just staff a local chill urgent care or find a non clinical gig and give up on EM altogether.

Anyone else ever felt similar so early on in their career?

Hey everyone, just checking to see if anyone would be interested in running/alternating some Okuda cases today (Sunday)/Monday/Tuesday? Wife has been helping me so far but she's not EM and I've annoyed her with enough cases already. If you have your boards Wednesday too and want to cram some cases, if you are taking them later and want to start getting prepared early or just want to dabble with a couple cases, leave a comment here or shoot me a message!

Also if anyone has advice from having taken the boards recently, feel free to drop it below!

Any other shops experiencing an uptick in pts that need US IVs???

Been an attending for almost a decade, so not my first go around with this diagnosis, but I practice in Texas, so, you know…

Last night 33 year old F comes in with lower abdominal pain and vaginal bleeding. Do a bedside US and she’s got free fluid from her lower abdomen up to Morrison’s pouch. She didn’t know, but pregnancy test comes back positive. Great, I’ve got a diagnosis and a dispo in less than 30 mins. Luckily she’s stable.

Immediately call OB and I say I’ve got a patient with a ruptured ectopic. I need you down here now.

“Is she stable?” Yes she is “Ok can you get a beta then?” ….. that’s not going to change anything “Yeah but I would like to know the level” Uhhhh ok are you going to come see her? “Yeah I’ll come down”

So dumb. Whatever gets her upstairs though, I guess. Order the beta, it’s 2800. Call him back.

Hey HCG is 2800. Have you seen her yet? “No not yet is she still stable?” Yes but you still need to see her stat “Can you get an official US?” I already did one, she’s got blood everywhere “No I mean an official pelvic US” Dude she’s in a lot of pain, I’d really rather not put her through that. “Well it’s not a slam dunk ruptured ectopic she could have a bleeding hemorrhagic cyst or something”

At this point I’m already angry. Just do the best thing for the patient. You know damn well she needs the OR, and at this point you’re just delaying the inevitable. Luckily this lady is a fucking trooper, and she’s ok with getting the US.

US shows….. wait for it…. A FUCKING RUPTURED ECTOPIC in the R adnexa. I call him back again before the radiologist reads it and tell him. He looks at the imaging (because he doesn’t believe me), and is like oh shit yeah that’s real. I’ll be right down. Dude you haven’t even seen the patient yet!? Unreal. So he comes down, sees her and preps the OR, she’s upstairs and gets surgery within 30 mins. She’s doing well post op, and will ultimately be fine and walk out of the hospital, but holy shit. This job is exhausting enough as is, but with these consultants who don’t want to work makes it so much worse.

I just needed someone to vent to. Thank y’all for listening. Can’t wait for another adventure today

When you were partying

I studied push dose iv haldol...

When you were having premarital sex

I mastered The Scromiter

While you wasted your days at the gym in pursuit of vanity

I cultivated relevant treatment alternatives to non diagnostic belly pain work ups

And now that the world is on fire and the barbarians are at the gate you have the audacity to come to me for help?

Have a resident friend who implied it's an SVT while it was atrial flutter in front of a very senior physician and they're beating themselves up hard about it and very embarrassed saying it's unforgiveable

Im currently working in a one doctor per shift urgent clinic in a rural zone. Nearest secondary care hospital is 2 hrs away by land and nearest tertiary care is 4-5 hours by land or 40 min (plus prep time) by air evac.

Sure we can solve simple lacs, tummy aches and whatnot, but what about CVAs, AMI, or any surgical issue? Sometimes I feel if patient is stable and has their own car it’s best to not even lose time and just send them to secondary care and then figure out from there.

Or if needed, stabilize but have ambulance on standby.

Feels kinda stressful, even though there is nothing I can personally do about it, to know people can have bad outcomes or even die because there are no resources nearby. A few weeks ago a pt died from sepsis because they came here first, we stabilized and sent them to secondary and she didn’t get the treatment she needed in time. I felt like shit. How do you guys deal with that?

Hello everyone

I'm applying for ER next year As you know, one of main requirements for ER is the SLOE letter, how I can get one? Do i have to do an externship or just observation Is there any hospital or program could give it to IMG ?

I'm research fellow at Mayo clinic now, can I do observerships and get non SLOE letters and apply?

Plus a normal EKG. Time to go home sir!

Hey all, like the title says, I’m a non-US IMG, YOG 2023. I recently finished internship in my home country and started working as a house officer (resident but not in a training program) and honestly no specialty has felt more of a fit to me than EM. I love the plethora of pathology you get to see, having to quickly rule out diagnoses and stabilize patients as quickly as possible, being able to do procedures, it just covers so much, both adult and pediatric EM. I’m studying right now in order to write both Step 1 & 2 next year, but haven’t made any decisions on where or what observerships I want to do, as I’ve been trying to get as much information on the pathway I need to take to get to EM. My medical school didn’t focus at all on post grad specialization, neither did we have rotations in EM. So, my questions are;

1. Is an SLOE make or break to match?

2. Can I possibly match into EM with Steps, observerships, great LoRs (and possibly connections) but no SLOE?

3. If option 2 isn’t possible, can I get an SLOE or something similar from my HOD, who’s affiliated with my university? Or is there anything that will substitute?

4. Given that I also enjoy Paeds EM just as much as adult EM, would it be more feasible for me to try matching in Paeds, then do a fellowship in Paeds EM?

Any advice will be greatly appreciated!

Currently it’s 0100, and here in the ED we have received 19 ems units in the last 2 hours with various complaints from shortness of breath, chest pain, and family violence. Day shift had less than twenty patients all day. This is just the beginning. Happy holidays yall!

Hello! I can’t post this to r/nursepractitioner due to my account age, so I will post this here. I am in my undergrad and currently a nursing major. I am very unhappy lately and realizing I have been depressed as I do not want to be a nurse any longer. I have been working as an ED tech/CNA for a while, and before that a PCT/CNA on an ortho unit and I have realized that I would much rather be a provider.

I am wondering if those of you who are NPs would you do it again if you could? If no, why?

Also- what speciality are you and are you under and attending physician? Thank you!

Edit: I have all good intent in asking my questions, and I do not have a background on a lot of the difference between what a midlevel provider can do vs. an MD/DO. I am not sure why this post attracted so much nastiness. I especially don’t think it’s necessary to message me hateful things.

I’m an ER PA and on my shift last night I had a patient with a 5cm laceration into subcutaneous tissue on his face. It extended inferiorily and obliquely from the top of the left naso-labial fold down to just lateral of the left oral commisure. The patient was a musician in a well-known band and obviously cared about the scar that would be left in the aftermath of primary closure. After cleaning, irrigating, and exploring, I ended up putting in 14 6-0 prolene sutures but I asked several of my docs on staff and they all had different opinions about what type of closure I should use - sutures vs. steri-strips. We don’t have derm or plastics on staff and the patient didn’t want to AMA and go someplace locally that have those specialities on staff. He asked me just to take care of it but I gave him the option of AMAing. My question is, what would you have done and why? I’ve seen several papers that suggest that steri-strips may leave slightly less of a scar but there’s a ton of contradictory information out there. Thoughts?

Im a critical care tech in the ED and was in my first code blue today. We did cpr for about 1 hour after calling TOD twice because we kept getting a pulse back but he ultimately passed away. I guess i’m looking for some advice on anyone’s first time doing cpr and dealing with the emotions of it afterwards because im having a bit of a hard time. Very emotional but an amazing learning experience. Any advice?

I’m trying to get more information about this pathway as I understand application window is open.

1. Does anyone know what the cut off for the self assessment for ST3 DRE-EM score is?

2. Are there specific centres that offer this program and is there a specific number of slots available?

Nights. Worked in high paced community shop for first few. Switched to academic life this past year due to being closer to family.

Love working with residents / camaraderie of a large academic shop. The academic center/admin is very supportive. Took a (relative to community) pay cut so I can work in the place where family is and to work with residents.

Fast forward and I now find myself losing some of my skills and being bored since most of the job is accepting / seeing transfers / pre-packaged transfers (different experience than in my academic residency). I definitely miss being able to see all the patients as the first doctor and do miss some of the simple peds cases. However, I do not miss the struggles of transferring, struggles of community consultants being less than helpful, and other community related struggles. I've also been thinking about transitioning to a more traditional "day" schedule. The nights have taken a toll over the past 4 years and I find myself more and more irritable when I need to switch to nights to go to work.

here are the options I'm considering (in no specific order):

A. Full time locums (pros: ability to choose schedule, pay bump / cons: time away from home, uncertainties of community shops, no residents to teach, often single coverage)

B. Full time community through the academic center (community sites of academic powerhouse) but no ability to work with residents (pros: pay increase, transfers are easier to mothership / cons: less schedule flexibility, some nights, no residents)

C. Part time academics + Part time locums/community (pros: increased variety in community, retain skills + see pediatric patients, residents / cons: may not lead to huge increase in pay, travel/time away from home)

D: Full time nights at academic center (current work life) (pros: schedule, being home / cons: nights, boring sometimes)

E. ????

I'm thinking part time academics (to get the ability to work with residents and live in town with family) and part time locums (ability to choose schedule and maybe work in my previous community shop) or saying no to residents and going back to full time community/locums. A large part of me feels like after spending 10 years of effort in school, our pay in academia is not matching our effort (~14 shifts per month).

Has anyone been in this dilemma? Would love to hear from the hive.

Tl;dr I work nights at an academic center after switching from nights in the community. Trying to find the best balance of pay and schedule.

Also please check out our EM Attending page: r/EMDocs (must send a message confirming PGyear and current work setting (academic, community, etc) and favorite EM drug)

Vituity docs, I guess everyone saw the executive email yesterday admitting that they subsidize partner bonuses through charging outrageous health insurance premiums.

“Decreasing the cost to each partner would ultimately lower our bonus” - Maureen Bell MD

2025 insurance costs for a vituity doc Single: $684-878 monthly Couple: $1344-1678 monthly Kids: $2261-2842 monthly

Well-researched update on Rural Emergency Hospitals from the Bipartisan Policy Center: https://bipartisanpolicy.org/download/?file=/wp-content/uploads/2024/10/Final_BPC_Rural_Emergency_Hospital_2024.pdf

Intro:

In response to increasing rural hospital closures, Congress established the Rural Emergency Hospital (REH) model. The model launched on January 1, 2023, to provide struggling facilities a novel care delivery option in the Medicare program when their full closure would cause significant hardship to their community.

Although some hospitals have successfully implemented the model, many others are not pursuing it despite financial pressures that could force them to eliminate services or close altogether. This report highlights the key factors preventing facilities from converting to an REH. Challenges include constraints around the types of services that the hospitals can offer in the REH setting, the lack of clarity and flexibility around eligibility and operational rules, and inadequate administrative support offerings appropriately aligned with other small rural hospitals.

Since the REH model’s launch, 32 rural hospitals in 14 states have converted. Under the model, a rural facility can offer emergency department, observation, and outpatient care, as well as skilled nursing facility services in a distinct unit. The REH receives enhanced Medicare reimbursement for outpatient care compared with other rural hospitals and an additional monthly fixed payment to support these services. For rural hospitals, this REH payment structure provides an effective pathway to sustaining necessary emergency and outpatient services, while also enabling them to pivot away from offering often higher-cost inpatient hospital care that the community may no longer need.

BPC’s extensive research found that the REH model has provided a viable option for financially struggling hospitals. Conversion has allowed them to avoid closing and to maintain emergency and outpatient care—a significant benefit to communities with few other or no treatment options. The relatively rapid growth of the REH model has helped reduce the national rate of rural hospital closures from an average of 14 closures per year before the COVID-19 pandemic to three closures so far in 2024.

For context, I’m a PA practicing in emergency medicine for the last two years, the majority of them being at a standalone ED in the city. 69F comes in with non-radiating substernal pleuritic chest discomfort and shortness of breath for the last day. PMH htn, smoking, doesn’t go to the doctor much. Not a very convincing story, but did the work up anyway given her risk factors. EKG with ST elevations in leads II, III, aVF and recip changes in lead I and precordial leads. Diagnosed it as inferior MI. Initially hypertensive 178/97 but became normotensive after some morphine. Didn’t give nitro due to concern for right sided MI. Gave heparin bolus, aspirin, ticagrelor, oxygen, at the direction of interventional cardiologist. Transferred to nearest cath lab, she had total occlusion of RCA, got DES placed.

I called the medics who brought her and asked if they did an EKG for her. They told me they did a three lead (which was not presented to us with the patient). I had the medic review it and he’s like “oh shit. There’s an elevation in lead 3”

Overall had a decent outcome but my index of suspicion for MI was super low. I even said to her “so you want to make sure you’re not having a heart attack?” I ended up eating those words.

Felt good to actually practice some medicine. My attending was very supportive in his guidance as well, so I’m thankful for that.

tl;dr: last night elderly female presented with chest discomfort and unimpressive story. Had right sided MI and went to cath lab. First time I managed a patient like that.

Does anyone know any good resources to practice for the CCFP-EM structured orals? I'd appreciate any tips from anyone that has taken it in recent years.

I was looking for a site/resource that would regularly post challenging EKGs with the interpretation and commentary, or some platform experienced professionals use to share their cases for me to keep my interpretation skills sharp. Where I work right now I've been seeing fewer abnormal EKGs than I usually would, and after a while in this situation I can already tell I'm not as accurate or quick at reading them as I was

Posted this case in r/medicine: https://expertwitness.substack.com/p/dissection-after-psych-visit-20-off

tl;dr

Pt seen for alcohol detox.

While sobering up overnight reports leg pain.

Cleared and discharged in morning.

Bounces back a week later with necrotic leg from clots that come from a focal distal aorta dissection.

Hello, emergency doctors! I am a mod over on r/diverticulitis, not a doctor myself. I’m posting over here because so many folks post on our sub saying they were diagnosed with diverticulitis in the ED and sent home to recover with absolutely no diet advice, or worse, they have been told to increase their fiber intake, with no timeline for that fiber increase given.

This causes so, so much pain. Yes, long term, fiber is good - AFTER the patient’s colon fully heals. WHILE the patient has an infected colon, it’s like sandpaper on a sunburn.

We have found that we experience way less pain when we go to a clear liquid diet for a couple days, then full liquids for a day or so, then once the pain is mostly gone, low fiber foods until we are completely better. Then slowly introducing fiber and getting up to a high level as tolerated.

Here is our community wiki with the best diet advice we have been able to gather:

https://www.reddit.com/r/Diverticulitis/s/6rZgNcTsNL

The people sending these patients home with no idea what to eat are probably OTHER doctors, not you wonderful folks, but just in case, maybe take a look! And see if what prints out from your hospital’s EMR on discharge handouts is likely to help the patient or cause them pain.

Thanks for all you do!!!

I just finished 1 month internship in EM ( if you are wondering am a nursing student 2nd year) .... It's lot more hectic 🙂 some time it's quite but most of the if you know you know... I worked 2 weekends( Sunday on night shifts) ... And Next morning I mark it as a nightmare.... That time I thought of never go in ER route.....

Thinking of that.... Just wondering when you guys thought about quitting... ?

NOTE:- I was in a hurry soo i mispelled and miscommunicate the last post .. soo if anyone of you read that post ... sorry. :(

Man it sucks. Fy1 equivalent dr. Patient reports to the emergency department as a possible syncope. Exhibits short and long term memory loss and bradycardia. Referred px to neuro and admitted to cardiology ward. Patient was seen by cardiologist the following day. Codes 2 days after admission and autopsy reveals a thoracic dissection.

This is hard for me to conceptually understand and hard for me to find answers for.

Let’s say the average EM doc works 16 shifts a month, 10hr shifts, on average 2.3 pph. Assuming averages, average acuity with average admission.

1. How much rough collections does the average emergency medicine doc bill with a calendar year?

2. How much of those collections actually pay out roughly? Assuming there’s going to be a rate of no-pay and delayed payment from some insurance companies.

Knowing this information, I could effectively negotiate with a corporate employer, that I know has deep pockets, for an outrageous hourly rate. If they agree awesome but if not I have independent democratic groups that I can throw a much more reasonable number at.

This is the shit they need to teach in residency. I don’t need another lecture on hyperkalemia.

I have 2mil/4mil in New Jersey. Is this enough?