Pursue EM even if you don't love trauma?

[surely]

Edit: In case anybody finds this thread in the future, wanted to report back that my nervousness with critical patients was indeed temporary (and now I'm seriously leaning toward EM with an emphasis on CC). The advice I got here was solid and I appreciate everyone taking the time to help me along.

MS3 on an EM rotation. Really enjoying certain aspects of it. Thing is... Some of my classmates who know they want to do EM are downright enthralled by trauma, and I'm definitely not. Critical care stresses me out. Not horribly so, but enough that I'm here asking about it, I guess. I can't tell whether I'm feeling this way temporarily because I need to get used to it or because I simply don't know what I'm doing yet, or whether it's a complete dealbreaker that should steer me away from EM.

Did you always/do you still love trauma? Is the nervousness a normal thing that goes away with experience? Can someone be a relatively happy and fulfilled EM doc if they feel a bit overwhelmed in time-critical situations, or am I setting myself up for PTSD? (Even if it never becomes my favorite part of my job, not all EM docs go on to work in level-1 trauma centers, right?)

Any advice would be appreciated. Making my way through third year with an open mind and seeking input. Feel free to tell me "only adrenaline junkies need apply" and I'll cross EM off my list of potential careers, but I'm hoping it's not that simple.

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[RustedFox]

Always found trauma to be "meh". Moreso even now.

 

[Tiger26]

Trauma is such an unbelievably small part of the job. You need to know how to be proficient at dealing with the drunks, drug addicts, the chronic pain population, the worried and weak 80+ crowd, the parents of the febrile and concussed, and the my elbow is numb every leap year crowd

 

[zyx189]

spoken to a few docs who don't like trauma that much, its very protocol driven and mundane after doing it again and again from what i hear ... plus surgery is having a more active role in this than in the past
if you end up working at a community non-trauma center after residency, you are not likely to see much at all (apart from running a code)

disclaimer: med student

 

[EMDOC17]

Trauma is really a small part of the ED. Sure trauma seems really intimidating at first but it really is not. Do they need a tube? Yes tube them; if no move on. Do they need a chest tube? yes throw it in. If no move on. Do they have a fracture or dislocation that compromises circulation? If yes reduce it (or if they are hypotensive) give them blood or fluids. If no or you have addressed them than move on to admit or transfer depending on your ED. The more worrisome problem is you are not comfortable with critical care. Trauma doesn't scare me. It is the crashing medical patient. If you go into EM you will find this patient. Not every day but frequently. The patient that needs immediate IV access and your best nurse can't get a single IV and you are the one to get access. That really doesn't even really scare me nor does the patient that comes in cardiac arrest. What actually scares me is the 80+ year old weak and dizzy.

 

[Psai]

Trauma is kinda boring tbh

 

[surely]

Trauma is such an unbelievably small part of the job. You need to know how to be proficient at dealing with the drunks, drug addicts, the chronic pain population, the worried and weak 80+ crowd, the parents of the febrile and concussed, and the my elbow is numb every leap year crowd.

That's exactly what I was hoping to hear, thank you! That population sounds great. My big interests are in mental health and substance abuse, so I already know that I want to work with that group. (I'm leaning towards psychiatry, but I want to make sure I'm not missing out on a great fit that would allow me to be more... medical.)

Trauma is really a small part of the ED. ... The more worrisome problem is you are not comfortable with critical care. Trauma doesn't scare me. It is the crashing medical patient.

Is this just developmentally-appropriate MS3 inexperience that lots of folks transiently deal with, or is a high comfort level with critical care at baseline (so to speak) a prerequisite for considering EM?

 

[alpinism]

Regardless of whether you like trauma or not, if critical care stresses you out EM might not be the best choice.

No one expects you to be comfortable with critical care as a med student but at the same time it should still be interesting and exciting.

 

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[racerwad]

That's exactly what I was hoping to hear, thank you! That population sounds great. My big interests are in mental health and substance abuse, so I already know that I want to work with that group. (I'm leaning towards psychiatry, but I want to make sure I'm not missing out on a great fit that would allow me to be more... medical.)



Is this just developmentally-appropriate MS3 inexperience that lots of folks transiently deal with, or is a high comfort level with critical care at baseline (so to speak) a prerequisite for considering EM?

I don't know that a high comfort level in critical care is a pre-req, but as @alpinism mentioned, you should be interested in it. These acutely ill patients are what we are here for (both literally and existentially). It is true that the overwhelming majority of our job are the worried well, the people who can't figure out how to achieve timely follow-up, drug seekers and drunks, etc. However, these folks do not need EM trained physicians. Traumas are very protocol driven and, in the end, these patients need surgeons. However, as you mentioned, not all EM docs work in Level 1 centers and those are the very docs that need to be comfortable doing invasive or high risk procedures to stabilize and then transfer to said Level 1 center.

Just based on your few posts here, EM does not sound like the right choice for you. The vast majority of our patients are meh, but we are here to make the high risk, high acuity decisions. Only you can decide if that is what you want to do.

 

[racerwad]

MS3 on an EM rotation. Really enjoying certain aspects of it. Thing is... Some of my classmates who know they want to do EM are downright enthralled by trauma, and I'm definitely not. Critical care stresses me out. Not horribly so, but enough that I'm here asking about it, I guess. I can't tell whether I'm feeling this way temporarily because I need to get used to it or because I simply don't know what I'm doing yet, or whether it's a complete dealbreaker that should steer me away from EM.

Did you always/do you still love trauma? Is the nervousness a normal thing that goes away with experience? Can someone be a relatively happy and fulfilled EM doc if they feel a bit overwhelmed in time-critical situations, or am I setting myself up for PTSD? (Even if it never becomes my favorite part of my job, not all EM docs go on to work in level-1 trauma centers, right?)

Any advice would be appreciated. Making my way through third year with an open mind and seeking input. Feel free to tell me "only adrenaline junkies need apply" and I'll cross EM off my list of potential careers, but I'm hoping it's not that simple.

Also, to directly answer the questions in your OP, I do still enjoy really sick traumas and I love the nervousness/anticipation prior to any sick patient coming in. I love that challenge (even though I still am pretty green) and I love making time-critical decisions.

 

[Old_Mil]

MS3 on an EM rotation. Really enjoying certain aspects of it. Thing is... Some of my classmates who know they want to do EM are downright enthralled by trauma, and I'm definitely not. Critical care stresses me out. Not horribly so, but enough that I'm here asking about it, I guess. I can't tell whether I'm feeling this way temporarily because I need to get used to it or because I simply don't know what I'm doing yet, or whether it's a complete dealbreaker that should steer me away from EM.

Did you always/do you still love trauma? Is the nervousness a normal thing that goes away with experience? Can someone be a relatively happy and fulfilled EM doc if they feel a bit overwhelmed in time-critical situations, or am I setting myself up for PTSD? (Even if it never becomes my favorite part of my job, not all EM docs go on to work in level-1 trauma centers, right?)

Any advice would be appreciated. Making my way through third year with an open mind and seeking input. Feel free to tell me "only adrenaline junkies need apply" and I'll cross EM off my list of potential careers, but I'm hoping it's not that simple.

I never much cared for trauma. A lot of social pathology, high malpractice risk, etc. There are many post residency options where you don't see much trauma. However one of the paradoxes of community EM practice is that the less trauma a given department sees, the less prepared to deal with it when it shows up.

A guy who lays down his Harley in a tshirt and a brain bucket is going to be the same presentation whether it is at the door of Detroit receiving or your tiny critical access ed where it's you and a nurse at 2am after the bars close with the helicopter an hour away.

Your best bet if you don't want to do trauma post residency is to find a slower level three or four hospital in the shadow of a level 1 or 2 trauma center so ems and scene flights just pass you by.

But remember, people do crazy things. Had an eighteen month old vs pickup brought in by pov a couple of years back.

 

[KinesiologyNerd]

My big interests are in mental health and substance abuse, so I already know that I want to work with that group. (I'm leaning towards psychiatry, but I want to make sure I'm not missing out on a great fit that would allow me to be more... medical.)

Bear in mind you're not going to be providing psychiatric care in the ED. You medically clear them and let psych/rescue/social work/whatever do the rest.

 

[InternistDO]

MS3 on an EM rotation. Really enjoying certain aspects of it. Thing is... Some of my classmates who know they want to do EM are downright enthralled by trauma, and I'm definitely not. Critical care stresses me out. Not horribly so, but enough that I'm here asking about it, I guess. I can't tell whether I'm feeling this way temporarily because I need to get used to it or because I simply don't know what I'm doing yet, or whether it's a complete dealbreaker that should steer me away from EM.

Did you always/do you still love trauma? Is the nervousness a normal thing that goes away with experience? Can someone be a relatively happy and fulfilled EM doc if they feel a bit overwhelmed in time-critical situations, or am I setting myself up for PTSD? (Even if it never becomes my favorite part of my job, not all EM docs go on to work in level-1 trauma centers, right?)

Any advice would be appreciated. Making my way through third year with an open mind and seeking input. Feel free to tell me "only adrenaline junkies need apply" and I'll cross EM off my list of potential careers, but I'm hoping it's not that simple.

I don't think anyone experiencing a crashing patient for the first time feels terribly comfortable, but if you don't think you'll enjoy that kind of thing (specifically with crashing medical patients) then what attracts you to EM? If you take out the acute patients and the traumas it starts to look like working in a clinic.

I saw you were interested in substance abuse and mental health. While I'm just a med student, when I used to work in the ambulance we would transport (and then transfer from) plenty of psych and drug related patients. In my experience they mostly were referred to psychiatrists for any sort of treatment. The pysch patients that were managed aggressively in the ED tended to be very combative and violent, and therefore were treated with sedatives and anti-psychotics, not any sort of long term care.

I guess what I'm saying is that in the ED, while you see and deal with a lot of drug and psych related issues, you don't really treat those conditions, just the nasty side effects (combativeness, psychosis, DTs, opiate overdoses, that kind of thing).

 

[surely]

I don't think anyone experiencing a crashing patient for the first time feels terribly comfortable, but if you don't think you'll enjoy that kind of thing (specifically with crashing medical patients) then what attracts you to EM? If you take out the acute patients and the traumas it starts to look like working in a clinic.

Since you asked, things I like about EM: Broad knowledge base required to dispo patients (I like learning!), procedures, interesting stories, short residency, shift work, job portability, lack of rounding. Outpatient Family Med certainly hits some of those boxes, but comes along with a lot of management of chronic diseases and emphasis on preventative care. Obviously patients with chronic disease get seen in the ED, but it's not the same. Either way, while I do sort of enjoy preventative care and chronic care, I just don't find it quite as interesting as working up an undifferentiated patient.

Anyway, appreciate everyone's input. Sounds like I should see how my feelings on critical care evolve during this clerkship and others as the year goes on and let that guide my decision. Thanks for everyone who chimed in with a reality check - it was super nice of you to take the time to help advise me!

 

[Zebra Hunter]

In my single 10 hr shift yesterday at our busy community hospital I had 2 massive, unstable, upper GI bleeders I tubed, transfused, and got to endoscopy immediately. Had a V-fib arrest that presented as an on going seizure in triage that I shocked 3 times before conversion, then intubated, and got an EKG showing an obvious proximal LAD occlusion all while talking to the cardiologist after I had activated the cath lab. Had a refractory hypoglycemic I gave glucagon to, 6 amps of D50, started a D10 drip, taught an intern how to throw in a central line on her, and saved her from getting intubated, as well. Had a dying, hospice patient whose family I convinced to let him go. Another woman that literally skewered her epiglottis with a chicken bone. Heck, I even found time to see a couple sicklers, several crotchety old women, a few more "I'm not leaving until we figure out why I hurt", and some babies w/ rashes. Yesterday was F***ING AWESOME. If that kind of stuff doesn't get you pumped, you might need to consider another field.

(sorry, just kinda wanted to brag about the fun I had yesterday)

 

[EMDOC17]

That's exactly what I was hoping to hear, thank you! That population sounds great. My big interests are in mental health and substance abuse, so I already know that I want to work with that group. (I'm leaning towards psychiatry, but I want to make sure I'm not missing out on a great fit that would allow me to be more... medical.)



Is this just developmentally-appropriate MS3 inexperience that lots of folks transiently deal with, or is a high comfort level with critical care at baseline (so to speak) a prerequisite for considering EM?

Well you are an MS3 so everything should scare you. I think its a natural progression. I think when I did my EM rotation as a early/mid MS4 (not so much MS3) I thought critical care was awesome but really didn't have to do anything so I was mostly watching but thought it was cool. As an intern I was scared ****tless that the critical patient was coming to me. Gradually I gained experience and now as a 3rd year resident if I hear a really sick patient coming in I tap the charge nurse to try and put it in my room. I would rather see that patient rather than yet another ankle or abdominal pain. I still have backup if I can't get the tube, CVC, or am stuck. I bet that when I'm an attending on my own I will again get somewhat nervous for the really sick patient because no one is standing over my shoulder. I will get past that probably pretty quickly. You are really early so keep getting into the room of sick patients. If it is something you can see doing then go for it. If it still scares you pick something else. Plenty of specialties that don't see really sick patients.

 

[Tenk]

While trauma is almost 99% boring and 1% TV style action, I agree with the above in that you really should be excited about critical patients. I mean it's in the freaking name of the specialty: emergency! If you are not, you are less inclined to be aggressive at times you need to be and people may die because of it.

 

[engineeredout]

Always thought (pre ms3) that trauma was the ultimate excitement in medicine. I'm sure all of us who grew up in the 90s watching George clooney thought the same way. I had some pretty sweet trauma rotations as a med student and still get a little excited by a good alert. I knew I had no desire to be a surgeon but was happy doing the EM side of trauma.

It wasn't until I was an intern and really started working in the ED and the ICU that I realized the medical resuscitation is far more exciting and fun. Septic or cardiogenic shock, arrhythmias, cardiac arrest and post cardiac arrest care, lines, intubations, pacemakers, pressors, vent management, that's where the fun is.