Specialties

[ChrisPAinED]

What is one thing you love about your specialty and one thing is hate about your specialty. Also when you reply please leave your specialty. Also is you would like I would love to hear the rarest diagnosis you discovered. Maybe the bread and butter of your specialty. 

 

I will start. My specialty is Emergency Medicine. My favorite thing is the rewarding feeling of discharging people that came in with 10/10 pain and be leaving with 0/10. What I hate is emergency medicine can take a toll on you if you don't focus on your mental health alot. The rarest diagnosis I have diagnosed with my physicians help was AFM also called acute flaccid myelitis. The bread and butter of EM is really a mix of treating things like MI's, PE's, strokes, minor trauma's, infections, chronic conditions with exacerbation, and just unspecified lab abnormalities and some cases that you just don't think you are going to be able to diagnose in the ED.

[LT_Oneal_PAC]

Moved to general discussion as the public health section seemed inaccurate.

 

EM. I love it because we are managers of chaos. We deal with so many emergencies that almost nothing feels like an emergency. It was the opposite of my anesthesia training where almost nothing ever goes wrong with good planning, but anytime something deviates from the plan they act like the whole world is coming to an end.
 

Patient slow to wake up and room turnover slow, oh god what if the surgeon is mad? You can’t do that block unless you know how to put in a chest tube. Don’t hold the blade that way, you’ll kill someone because you won’t intubate as well as me. Sux is the devil. Roc is the devil. Atracurium is the devil. 

EM:

looks like bill’s BP is going back into cardio genie shock. Grab that push dose epi would ya? Thanks. Hey, we going for drinks and trivia after the shift? Cool. Hey, Betadine splash his femoral, I’m going to throw in a crash dirty central line. Who is going to be on my team for trivia?

 

Rarest thing? I won’t mention since it would ruin my anonymity, possibly.
 

Maybe rare for the ED is I diagnosed MS with optic neuritis. Maybe temporal arteritis? I’ve done a couple detumescent procedures for priapism. Lots of people act like that is rare. I’ve also detorsed 2 different testicles. Saw a surprising amount of guillian barre in residency 

[ChrisPAinED]

13 hours ago, LT_Oneal_PAC said:

Moved to general discussion as the public health section seemed inaccurate.

 

EM. I love it because we are managers of chaos. We deal with so many emergencies that almost nothing feels like an emergency. It was the opposite of my anesthesia training where almost nothing ever goes wrong with good planning, but anytime something deviates from the plan they act like the whole world is coming to an end.
 

Patient slow to wake up and room turnover slow, oh god what if the surgeon is mad? You can’t do that block unless you know how to put in a chest tube. Don’t hold the blade that way, you’ll kill someone because you won’t intubate as well as me. Sux is the devil. Roc is the devil. Atracurium is the devil. 

EM:

looks like bill’s BP is going back into cardio genie shock. Grab that push dose epi would ya? Thanks. Hey, we going for drinks and trivia after the shift? Cool. Hey, Betadine splash his femoral, I’m going to throw in a crash dirty central line. Who is going to be on my team for trivia?

 

Rarest thing? I won’t mention since it would ruin my anonymity, possibly.
 

Maybe rare for the ED is I diagnosed MS with optic neuritis. Maybe temporal arteritis? I’ve done a couple detumescent procedures for priapism. Lots of people act like that is rare. I’ve also detorsed 2 different testicles. Saw a surprising amount of guillian barre in residency 

What is something you dislike or hate in EM?

[LT_Oneal_PAC]

1 hour ago, ChrisPAinED said:

What is something you dislike or hate in EM?

Catching primary care run over or people using the ED as primary care because their insurance doesn’t have a copay for the ED. Normally not a big deal, but I work 72 hour shifts. Coming in at midnight for your cough of 2 weeks isn’t cool.

[sas5814]

8 minutes ago, LT_Oneal_PAC said:

Catching primary care run over or people using the ED as primary care because their insurance doesn’t have a copay for the ED. Normally not a big deal, but I work 72 hour shifts. Coming in at midnight for your cough of 2 weeks isn’t cool.

Drunks. I worked a small ER in a college town. 2 or 3 times a week a bunch of drunks would drag in another drunk that couldn't wake up. A few times I paralyzed them, tubed them, and put them on a chopper to Dallas. Explain that bill to mommy and daddy Timmy.

[ChrisPAinED]

21 minutes ago, LT_Oneal_PAC said:

Catching primary care run over or people using the ED as primary care because their insurance doesn’t have a copay for the ED. Normally not a big deal, but I work 72 hour shifts. Coming in at midnight for your cough of 2 weeks isn’t cool.

I definitely agree that is a con. 

[ChrisPAinED]

14 minutes ago, sas5814 said:

Drunks. I worked a small ER in a college town. 2 or 3 times a week a bunch of drunks would drag in another drunk that couldn't wake up. A few times I paralyzed them, tubed them, and put them on a chopper to Dallas. Explain that bill to mommy and daddy Timmy.

Yeah that's definitely a con of EM! 

[ChrisPAinED]

Another thing that bothers me is when past medical history is over exaggerated. I know mother's can be scared and unintentionally over exaggerate but we do need a accurate history for proper eval. I once had a patient that on the HPI section on the chart said suspected vagal syncope. Saw his own blood and had a syncope. BP was low when passed out but went up as he woke up. No major bleeding but in the history given to triage nurse was teen pmx of past MI, "some blood disease", and a kidney tumor. I was talking to the teen and he told me he got diagnosed with pericardial catch syndrome not a heart attack, had dehydration with a electrolyte ab not a blood disease, and when he was younger had a kidney stone not tumor. And I was relieved and confused about that pmx in the chart that was given then triage nurse said she got the history from mother than I knew what happened. 

[kettle]

Rural EM- I like the teamwork aspect the most. Long shifts with long periods off is nice but I'm not married nor do I have children so a re coup day after is no big deal. I echo LT_Oneal, the 2am urgent care stuff can get frustrating. One place I work at has me cover walk in clinic for 4 hours on Sat morning along with the ER, big reason why they don't get people wanting to work there. On holiday weekends when we don't have the walk in urgent care my nights are swamped with runny noses and coughs, so I like getting my butt kicked for four hours with less minor stuff in the middle of the night since they come in for clinic.

Had a dilutional hyponatremic patient w/o neuro deficit as well as sepsis, not responding well to pressors, gave hydrocortisone, worked well, drew a cortisol level, send out. Find out patient had addisons a few days later

[mgriffiths]

Ortho:

Love - hand's on and half the time my patients are asleep which can be a nice break from patient interaction 

Con - the worst is that OR staff can be incompetent throwing a wrench and completely screwing an OR day, making what should have been a 6-8 hour day 10-12, or worse.  Obviously beyond that, surgery is surgery and anything can happen.  During a surgery for a hip fracture a large amount of foul smelling, white, cloudy fluid drained out from the capsule as it was opened.  Major "OH CRAP!" moment. We cultured the fluid and sent for stat testing while we waited with patient open on the table.  Initial lab work came back concerning for infection so we just closed him up and he was transferred to tertiary center.  Don't know all the details since he was transferred, but I do know further testing revealed recurrence of leukemia. That gem made what should have been a relatively short OR day into 13 hours I believe.

Rarest - Charcot-Marie-Tooth (CMT) disease - 12yo girl who had been passed around from provider to provider and essentially ignored and told she was faking.

Bread and Butter - pretty obvious...we're carpenters so pretty much anything bone and joint related.  We don't treat back issues, but we tend to work it up A LOT because primary care refuses to and back surgeons in our area won't accept a referral without an MRI (my understanding is this is pretty standard).

[ventana]

PCP and Geri (no kids)

PLUS

relationship building, being there in hard times as a resource, helping through hard life decisions, holding hand of a loved one when discussion of end of life care, fully explaining what the heck happened and put them in the hospital (AMI, AKI, CHF or infection or CA), being a privileged part of the peoples inner circle, helping someone newly sober from their drug of choice, helping someone recovering from any chemical abuse slip up, being a part of peoples families.

The most enjoyable part is simply the human body mind and medicine.  Getting tired or board, just go learn something new.  wow

 

CONS

Insurance companies and their stupid prior Auth's. this month - one ordering a CT for new onset right hydrocele, US done about 2 weeks prior, and checked off that it was done 2 weeks prior and that made the Dx.  Had to go all the way to a pier to pier to get the ABD pelvis CT approved..... stupid waste of my time - the insurance company just paid for the scrotal US and I put it on the form....  

Patients that seem to be just a bit crazy that have no health literacy, have pathology but come in and complaint about every little thing.  You want to blow them off, but that little voice in the back of your head says you gotta not miss something

mean patients doing mean things to office staff cause I asked for a urine, or would not refill their controlled for a contract violation - man they suck the life right out of you

Call - really what is the point beside critical values from the lab.  We no longer need to be on call for every bump, hang nail and insane med refill.  No you can not get your viagra refilled on a Sat afternoon phone call

lack of respect and compensation - respect just got a lot better in a new hospital system that values people, employees and PA.  Pay - - I will go over 3500 rvu this year and likely 4000 next year but still making about "average" pay while the doc's doing the exact same job, with same revenue get twice as much...

 

 

 

list for cons seems longer, but the plus's are worth far more.....

 

[ChrisPAinED]

59 minutes ago, ventana said:

PCP and Geri (no kids)

PLUS

relationship building, being there in hard times as a resource, helping through hard life decisions, holding hand of a loved one when discussion of end of life care, fully explaining what the heck happened and put them in the hospital (AMI, AKI, CHF or infection or CA), being a privileged part of the peoples inner circle, helping someone newly sober from their drug of choice, helping someone recovering from any chemical abuse slip up, being a part of peoples families.

The most enjoyable part is simply the human body mind and medicine.  Getting tired or board, just go learn something new.  wow

 

CONS

Insurance companies and their stupid prior Auth's. this month - one ordering a CT for new onset right hydrocele, US done about 2 weeks prior, and checked off that it was done 2 weeks prior and that made the Dx.  Had to go all the way to a pier to pier to get the ABD pelvis CT approved..... stupid waste of my time - the insurance company just paid for the scrotal US and I put it on the form....  

Patients that seem to be just a bit crazy that have no health literacy, have pathology but come in and complaint about every little thing.  You want to blow them off, but that little voice in the back of your head says you gotta not miss something

mean patients doing mean things to office staff cause I asked for a urine, or would not refill their controlled for a contract violation - man they suck the life right out of you

Call - really what is the point beside critical values from the lab.  We no longer need to be on call for every bump, hang nail and insane med refill.  No you can not get your viagra refilled on a Sat afternoon phone call

lack of respect and compensation - respect just got a lot better in a new hospital system that values people, employees and PA.  Pay - - I will go over 3500 rvu this year and likely 4000 next year but still making about "average" pay while the doc's doing the exact same job, with same revenue get twice as much...

 

 

 

list for cons seems longer, but the plus's are worth far more.....

 

The pros definitely sound super rewarding. 

One thing I love about EMS is no prior authorization order the stuff get it done send bill and that's it. 

I am glad you don't sound burned out. 

[greenmood]

Hospital Medicine.

 

I love the range. Hate getting patients dumped on me that should be under a subspecialist's care. I can handle an awful LOT of stuff, but sometimes a cards patient just needs a cardiologist (even if they also happen to have diabetes... oh the horror).

 

Bread and butter: CHF, COPD, sepsis, alcohol, frailty. Rarest thing ever? That is really hard. Probably Castleman disease. Started on rituximab and developed tumor lysis syndrome and acquired hemophilia. That was a very wild ride.

[ChrisPAinED]

33 minutes ago, greenmood said:

Hospital Medicine.

 

I love the range. Hate getting patients dumped on me that should be under a subspecialist's care. I can handle an awful LOT of stuff, but sometimes a cards patient just needs a cardiologist (even if they also happen to have diabetes... oh the horror).

 

Bread and butter: CHF, COPD, sepsis, alcohol, frailty. Rarest thing ever? That is really hard. Probably Castleman disease. Started on rituximab and developed tumor lysis syndrome and acquired hemophilia. That was a very wild ride.

Thanks for sharing

if I didn't go into ED I would probably have done internal medicine or critical care

[polarbebe]

On 4/8/2022 at 1:30 PM, ChrisPAinED said:

What is something you dislike or hate in EM?

Understaffed ED.  Patients sitting for 2+ hours, feeling entitled and taking it out on you and every staff member.
 

Press-Ganey.  Patient satisfaction score based on wait time and time to dispo (really that is staffing, which you don’t control), wanting opiates (limited to 6 tabs when indicated) and demanding abx for probable viral syndromes (explaining why it’s not indicated).    
 

Receiving monthly emails that compare your average patients seen per shift compared to the entire team.  
 

Seeing primary care in the ED (pregnancy test, STD test, asymptomatic HTN, etc).  
 

Patients seeking a euphoria.  Intoxicated patients are way easier to handle, metabolize to freedom (generally sleeping and not yelling).  Patients seeking opiates are much more challenging.  
 

Eating lunch at 9PM at the end of my 12 hour day shift that started at 7AM.  
 

The constant “move the meat” mentality and dispo as soon as possible, which can mean an incomplete work up and initial management.  
 

The burnout.  
 

Some of the reasons I left the ED.

 

What do I enjoy about critical care?  When the patient is no longer medically interesting (stabilized and life is saved), they go to the floor or rarely discharged.   Don’t worry about social/dispo issues; only worry about practicing medicine.  Yeah we get EtOH withdrawal but those are interesting at times (Valium, phenobarb, precedex gtt, intubation then propofol gtt).  
 

Seen some really rare and interesting pathology like HLH, catastrophic anti phospholipid syndrome, TTP, anti-NMDA encephalitis from a teratoma, SJS, massive hemoptysis from Goodpasture, hypertriglyceridemia requiring plasmapharesis, hungry bone syndrome, anticholinergic toxicity causing coma requiring physostigmine (just to name a few)…. On top of the usual septic shock, respiratory failures, multi organ failures, ICH, severe symptomatic hyponatremia, DKA, post-op that I see every day.   
 

Requires a very wide range of medical knowledge, critical thinking, ability to handle stress and technical skills. 

 

 

 

 

Edited April 14, 2022 by polarbebe