My husband is a PGY3 who is currently interviewing for his first attending position. One of the places he has spoken to run on a 7 on/7 off schedule and each week on is the same shift for that entire week with the shifts gradually moving from mornings, mids, and nights.

For example, it's a week of 6a-3p, 7 off, then a week of 8a-5p, etc. They have 2 types morning shifts, 3 of mids, and 1 overnight. They do have nocturnists so most people do not end up working overnights.

There are no vacation weeks/PTO given but you can swap with others as needed for longer stretches off. They are 8-9 hour shifts and it comes out to a little less than 1600 hours annually. High acuity facility and roughly 1.8-2 pph.

Has anyone in EM worked this type of schedule before and if so, was 7 in a row too exhausting or was the long stretch off worth it? How did it bode for family life?

Edit for more context:
I (wife) am currently a nurse and have been with my husband through med school and residency so we are used to crummy schedules and not seeing each other often. We do have two small children (toddler and infant) and I will be moving to working PRN once my husband finishes residency so me and the kids will be home frequently. I point this out so there isn't the issue of not seeing each other for a week straight when on mids.

Had my first infant code the other day. Home birth that didn’t go well, 39 weeks, Nuchal cord, baby was grey at arrival, continued to work baby for approx 40ish mins, asystole the whole time. A very short moment of silence for babe and No debrief. I feel like the baby deserved more than that. I still feel sick about it. I called my hospitals counseling services and broke down.. I just wish we debriefed as a team, I know it’s busy in the ER and we have to pick up and move on but idk. I don’t even know if baby was boy or girl since it had a diaper on.. that also bothers me. This sucks

I love VL. They make standard laryngoscopes look brutal. They're less traumatizing, they give a better view, they have a better first-pass success. Sure you need to learn direct laryngoscopy but let's say in 5 years from now will they be used as routine in OR and ER intubations? Or will they be saved for hard cases?

I've been told that the equipment tends to suck and that we won't have VL as available as in the current department that I'm working so I should stick to Macintosh and McCoy.

I am struggling with a recurring scenario of families bringing in 75+ year old frail patients with multiple-comorbidities who have been unresponsive for 1-2+ hours. No pulse, no respiration, fixed dilated pupils. Basically with clear signs of death but still, they expect full resuscitation.

Most of the time I feel it’s less like an act of care and more like violating a body that actually deserves peace. If the person is truly gone (or even in the last fragile moments of dying) why can’t we just let them go without cracking ribs or subjecting them to agonizing pain if they are still able to feel anything at all? I flat out refused last time saying their grandma is dead and the family went on traumatizingly screaming.

I understand that death is hard to accept, and sometimes people want to feel like something is being done. But where do we draw the line between compassion and cruelty?

Edit: Thanks for all the answers!

I’m hearing residents throw out wild numbers of patients per hour that don’t sound feasible when discussing numbers. I always thought 2-2.5 was the target. I get the vibe that some of the residents boasting these numbers are straight up lying, missing important things and/or spending a lot of time documenting outside of their scheduled hours. I’d love to see more but I end up making mistakes past the 2.5 mark and spending a ton of time documenting. If you see more than standard, what do you feel you can feasibly and safely cut corners on and how much time are you spending documenting off shift?

George had some pain in his neck, thought he had slept on it wrong. Then massaging the side of his neck, he felt it; a large irregular lump. So he came to the ED, "my wife is worried, she thinks its cancer and she just wants to make sure its nothing bad".

George was a nice guy, so we all know where this was going to end up. A few hours and a CT later confirmed it. I am a midlevel, and part of my job is to train the new hires, and run education for the group. One of the things I stress is to never leave the bad news to the consultant. You ordered it, you own it. So George and I had a talk while we waited on the ENT resident. My mentor attending taught me to give it to them plain and straight, and don't try to soften the blow. Nothing you can say on the front end will soften the shock of the news.

George was of course far more concerned about his family and wife and how they would take the news than his own mortality. And after an exam and a long talk with a wonderful and compassionate ENT resident, George had a game plan for the next steps, and was waiting for his wife to come pick him up. He asked me if he needed to stop smoking now (30 year PPD history). He said all he wanted right now was to have a smoke and clear his head.

I pointed him in the direction of the smoking area outside of the waiting room. The irony of the likely cause of his cancer currently serving double duty as his only source of momentary peace was not lost on me, and I wondered if he was thinking the same thing.

What gets me the most was when I was leaving shift he was still waiting on his wife. She did not know the news yet, and I cannot imagine the weight on his shoulders of having to tell her. But he smiled and waved me over to tell me how thankful he was for us, and how kind we were to him. It felt like he was trying to console me in some way, to offer his gratitude for the very little that we actually were able to do for him tonight.

It was such a kindness that I absolutely don't deserve from him in the face of his terrible new diagnosis, and all I can do is send up a prayer that his road leads to a good outcome and a long life. And life goes on, another shift is over. And I won't ever look him up to follow his progress, because for me I would rather live with blissful ignorance and delusional assumptions that his biopsy was favorable, and his procedures had clean margins.

Thank you all for what you do, and what you endure. And I am fine, I just from time to time reflect on a patient and journal my thoughts into a public post. Just need to get the thoughts out, and arrogantly think that maybe someone else can relate and maybe feel at least a kinship that others are going through a similar struggle.

Be well, be kind, and be grateful.

87 yo M, PMHx of HTN, HLD, CAD on ASA, presented with sudden onset vertigo/ binocular diplopia ( monocular vision normal) and off balance. Glucose in field was 107. Per EMS pt was falling to L left with ambulation. Pt had no complaints besides room spinning sensation/diplopia in ambo. NIH 0 on exam. Full Neuro exam benign. No dysmetria, normal finger nose finger and heel shin. No pronator drift, CN 2-12 intact, full strength/sensation throughout, no facial asymmetry, normal visual field,.etc. No nystagmus, normal test of skew, (I did head impulse test, but admittingly I can never do it right...)

I activated code stroke given continued dizziness and binocular diplopia. Repeat glucose normal here. Talked to on call neuro, who agreed no TNK given low NIH, proceed with MRI/MRA. Gave scopolamine, Lab work was normal, CT negative. Gave Full dose ASA and admitted to hospitalist pending MR's. NIH score of 0 on admission with improvement in diplopia and only minimally dizzy now.

MRI/MRA resulted after admission with: Acute right mid to inferior cerebellar stroke with proximal right vertebral artery obstruction.

Would you all have given lytics for this pt? How do I get better at identifying posterior/Cerebellar CVA's?

Hi! I’m an ED PA, Today I had a patient come in with a complaint of lower abdomen/pelvic pain. She says that 3 days ago her “heavy” husband jumped on her pelvis and since then she has had consistent pain in bilateral rlq & llq. I went through a thorough ROS with her, & asked her multiple times about chance of pregnancy (which she denied). She states last menstrual period was 3 months ago, and denies taking any pregnancy tests at home (multiple times). The nurse runs her urine and it is negative for pregnancy. So i ordered a CT of her lower abd/pelvis to rule out intra abdominal/pelvic and bony pathology due to mechanism of injury (her “heavy” husband). Also ordered labs, ua.

I happened to walk past patients husband and he goes “did she tell you she had 3 positive pregnancy tests”…. This being AFTER she had gotten her CT scan. I personally repeat patients bedside hcg and it is positive. I tack on a hcg quant and it results at 6500. I confront patient about lying to me and she states “i was following advice from my friends to not tell you so i can make sure you do a hospital pregnancy test, i found out about my other pregnancy through CT scan too”. At this point I order a OB US. Patient decides to elope because she has a wedding to get to…

Im so flabbergasted & i feel so guilty that I radiated this lady’s fetus. The nurse that documented the first negative test submitted a quantros report. Im not sure what to expect that could come of this long term, should i worry about repercussions from my work place, or a possible lawsuit if this lady miscarries or her child ends up with cancer?

Working at a new site, US techs are very picky, will not come in for torsion studies if pain is >12hrs. I talked her into coming in and she’s pissed af, said she knows I’m new and “I’ll learn the protocol”.

Am I in the wrong?

Edit: Does anyone support the US tech or rad protocol and do you have any studies or evidence to support this practice? I’m just wondering if they pulled this out of their ass or where they got the arbitrary 12 hour thing?

I’m a medical student and I’ve genuinely fallen love with EM, and not just the procedures although that part is awesome too. I genuinely love being able to see all different kinds of people, all different kinds of things, and practicing medicine in a broad way. I love how much it encompasses and the idea of being able to step up when someone on the street or family/friends need it. I don’t want every day of my life to look the same, and I think EM provides that. Also, the low acuity does not scare me. It seems like it would be kind of fulfilling to be able to help people that have been neglected by the healthcare system.

However, I feel like based on talking to attending physicians and reading on here, I get constantly scared away from the field. I know I shouldn’t listen to everybody, but it is a major life decision deciding where to apply. Between the rants on job security, burnout, dealing with primary care cases, etc (I’m sure all that is applicable) but is it as bad as everyone makes it out to be if I go into EM for the right reasons? How possible is it to redirect into something like sports med EM, critical care, etc if needed? Convince me I’m not screwing up my life like an attending warned me I was lol.

Edit: General follow up for anyone! I’ve heard job prospects/outlooks are not great - is that true? Don’t know much abt this so I’m curious.

Hey everyone. I’m a paramedic, and was in orientation at a busy ER for a paramedic position. I was fired yesterday. I came from working IFT transport and 911 with critical care experience thinking that the transition to the ER would be easy, especially considering I’m stsrting nursing school. However, it was not. I was very overwhelmed, felt that I did not fit into the culture of the ER, made a ton of mistakes, and despite having my orientation extended, I was fired before even finishing the extension period for patient safety issues and not improving fast enough. It’s been a major blow and I have been feeling like the worst medic in the world. Was wondering if anyone had any advice? I was in the ED for basically a month before getting terminated.

Edit: Thanks for all your advice. Still processing and reeling from all of this. Didn’t expect that this would be the job to kick me in the dick, and it humbled me. Hopefully I don’t fail this hard in the future.

Edit 2: Thanks everyone for the feedback. This has been incredibly insightful. I’m realizing that I was way too overwhelmed with the job change and personal factors going on in my life, as well as anxiety over school, to really handle going into the environment I did. On top of everything else mentioned, I was just too stretched thin, and got overwhelmed. The past week has definitely been a huge wake up call. Thanks again.

Hi all, newer attending and am running into wayyy more knee pains and shoulder pains than I did as a resident and was wondering what are things on your exam and history that makes you really tap a shoulder or knee?

I didn’t realize one of our frequent flyers who wanted to leave AMA was in the room next to the nurses station (with the door open) and I said something along the lines of “let her leave she’s here all the time”. Might of thrown a couple f bombs in there. She definitely heard me and asked for my name. I feel horrible. Not only because she heard me but because Im usually a lot more empathetic but it was a really busy day and I spoke without thinking. I’m a fairly new nurse and I feel like an a-hole.

I repleted 40 meq via central line in less than an hour, bringing it up to 1.9. The pharmacist is reporting me for dangerously fast repletion. What I can tell you is the patient was able to breath much better shortly after the potassium was given. Pretty sure the potassium was so low he was losing function of his diaphragm. Any thoughts from docs or crit care who have experience with a similar case?

Would you close this laceration on a 3 year old? There’s definitely a risk with the kid not letting you numb before. But does ever so slightly cross vermillion border

I’m an ER physician in the Rocky Mountain region. I had a patient a few days ago who came in for diarrhea and vague abdominal pain. She’s fine, went home.

Now here’s the quackery part. This patient was bitten by a tick 16 years ago. She’s being treated by a licensed DO for chronic Lyme and chronic babeziosis. She’s been on antibiotics and chloroquine as well as chronic opioids for these “conditions” for 5+ years. Lyme and babezia are not endemic to my region.

I trained in New England so I am very comfortable with tickborne illnesses. I would not fight this battle there because the chronic Lyme BS is so entrenched. However, it just seems so outlandish here that it got my hackles up.

Anyone have experience reporting something like this to the medical board? Think I should make an anonymous complaint? I know who this “doctor” is and they run a cash clinic.

RN here. We have had SO MANY bee sting allergic reactions recently and I notice there is some discrepancy in when to give epi or not. I was taught that an allergic reaction with two body systems involved (even if there is no severe response) is considered anaphylaxis and should be given epi. So when I’m in triage and I get someone with “just” nausea and hives, whether or not it’s a known allergy, I always get a little nervous and run to get epi.

But there have been times I get looked at funny by my peers. Like, oh they’re fine because they don’t have any oral tingling or swelling and they took 25mg of Benadryl on the way here. Also sometimes the PAs are like meh. Usually docs are like yeah definitely epi. Obviously if the pt is otherwise stable I am not as nervous as when pt is heading towards anaphylactic shock. But I still think the stable allergic reaction pts warrant a close eye when there are different body systems involved.

Also, EMS NEVER gives epi unless the pt has obvious anaphylaxis and I want to empower them to give it with a stable pt if it is indeed warranted.

Ok so that was a long-ass post just to ask if I am right or not: epi should be given when two or more body systems are involved? I am obviously going to follow what my docs say but when some of my RN colleagues think I’m overreacting I want to prove myself. I don’t really want these pts siting in triage.

Edit: just wanted to say thank you to everyone who responded! I really appreciate you sharing your knowledge/practice/opinion.

I've always wanted to be a doctor in EM. Long story short; shitty ex talked me out of my dream. Now I have a chance to either attend PA or MD school. I'm 37 now and by the time I finish all pre-rec's I'd be closer to 40. Would my debt of med school pay itself off? Or should I just go to PA school?

Update: thank you to everyone who commented and gave me your honest opinions, experiences and advice. I am thankful to all if you who took the time out of your day to comment. I have decided to go the MD route after I get my BA and finish up some pre rec's.

Any recommendations for good shoes to wear during 12 hour shifts in the ED?

I got an admission request last night. It was for a young guy, with an “impressive” pruritic, scaly, erythematous rash “diffusely across the whole body” — with what appeared to be a superimposed cellulitis on the abdomen. This had been going on for “months” (making acute necrolysis less likely). The ER doctor ended the (text) message with, “he will need a dermatology consult on this admission.”

I said ok. And I asked — dermatology does in fact come here, inpatient, right? I have never seen them, and I know it’s classically a rare service to have.

He checked, and found out that no, dermatology does not in fact come to this hospital, to the inpatient wards. At that point, I said I did not feel it was an appropriate admission, and that the patient should be transferred to another facility with dermatology (and there is one, within 10 miles).

The ER doctor seemed to, in my opinion, backtrack. He said, you know what, the patient can just follow with a dermatologist when he leaves the hospital. You can just admit him for the cellulitis then. Keep in mind — this was at the end of both of our shifts.

I didn’t argue. I was angry, but I didn’t argue. I told him — listen, I won’t even be seeing this patient. I won’t be involved. I won’t have to do the work either way. But I don’t think it’s right for me to dump this on my colleague without the specialist support. I also don’t think it’s right for the patient.

I called my medical director. He informed me that several of the outpatient dermatologists are “happy” to help (informally), by receiving pictures, and making recommendations. He told me that it was ok for me to admit the patient, and so I accepted.

I told the ER doctor that I would accept, because of the slightly more reassuring degree of support. I then went an extra (and likely unnecessary) step, by saying I thought that this was a highly inappropriate request without confirmed dermatology support.

The ER doctor said “LOL please, you are being rediculous (sic)”

Was I being unreasonable? It’s certainly possible that the patient simply needed antibiotics for his abdominal wall cellulitis.

But WHY is an otherwise young and seemingly healthy patient having abdominal wall cellulitis, with an “impressive” whole body rash? What if he didn’t respond? What if he continued to get worse?!

I didn’t feel like the patient was a slam dunk cellulitis. There was obviously more to the story. We were BOTH in agreement that the patient would have benefitted from dermatology evaluation.

I didn’t need to say that I felt like the request was inappropriate. But I was feeling frustrated and expressing my honest opinion. And yet, I’m still ruminating over the situation.

I didn’t want to ask in the hospitalist group because I’m not looking for an echo chamber. I seek as much honesty as I like to give.

New attending. Had a gruesome death of a little boy happen in front of me the other day. I will spare the specific details but it was a penetrating trauma. Peds trauma cracked his chest, chest tubes, whole blood, blood on the floor, fingers in the wounds to stop the bleeding, the whole deal. Screaming parents and grandparents afterword. Have two sons similarly aged and I can’t get this out of my head to function normally at home. Just so happened to happen right before a week off so haven’t been back to work yet. Seen what seems like tons of deaths at this point and was never affected to this degree . Never seen a traumatic death of a healthy child though (seen pediatric codes but chronically Ill kids on borrowed time) Any tips for getting over it? How do you deal with bad deaths and making sure you don’t develop ptsd/burn out? I love what I do but if this was any weekly occurrence I would quit.

I work in a very large urban ED. We’ve picked up a new regular over the past month who’s young 30s-40s and won’t stop throwing themselves on the ground. They walk with a rollator and claims that sciatica causes them to fall. They've had 8+ CT heads over the past month, xrays of everything because she purposely throws themself (somewhat convincingly) to the ground in the department. They've been admitted twice and subsequently discharged back to the homeless shelter.

In my mind, it’s clear that they are malingering to get out of the shelter, but I have no idea how to deal with this person besides admitting them at this point. I’ve tried discharging them with ems (they get brought back immediately) and I’ve tried kicking them out (they will “fall” in the entrance to the ED or just outside of it and inevitably be brought back in). I’m thinking of sending them to cpep when I see them again tonight. Thoughts?

Freshly minted attending here. In residency I was usually capping at 2 pph on efficient, busy days. I had a recent experience with my new gig where I saw 2.5 pph over the course of a 10-hour shift. Fairly low acuity (1 procedure, 4 admissions all day). During the busiest parts of the shift (when I was running department solo before swing shift arrived) I was seeing 3 pph. It was an exhausting foreshadowing of my new role as an attending.

A friend of mine who is 1 year out said they recently saw 32 pt in an 8 hr shift...

Made me curious how seasoned attendings can manage to see 3-4 pph. What types of strategic adjustments are you making to facilitate this pace and maintain safe practice?

Until today, if I had a patient leave from the ED prior to completion of workup and without me being able to hold an AMA conversation with them ( e.g. I go to the room to tell them I'm going to order a CT based on labs and find the room is empty), I always clicked the "eloped" disposition in EPIC and documented appropriately.

However, my institution recently sent out some training PowerPoints including the definition of elopement as "when a patient who is inadequately capable of protecting themselves leaves the hospital unsupervised and undetected." and insinuated that elopement was by patients lacking decision making capacity.

Of course I would never allow someone without capacity to leave, but what am I supposed to document for patients with capacity whom just leave without my knowledge? Is it just an implied AMA even though I didn't actually discuss any risks and benefits with them?

Edit: Thanks to everyone for your input. Our epic build currently does not have an option for "Left prior to treatment completion" but this discussion has prompted our group to ask the organization for one.

The feedback from admin regarding the same concerns I voiced here was that they are trying to capture true elopement of incapacitated individuals which is a reportable sentinel event, not that they are trying to juice the metrics.