Residency Training Overkill

[Angry Birds]

I disagree with the idea that a "Level 1" trauma center is great education for the ED doc. Those places are level 1 because they have a structure for dealing with the bad traumas, and it usually involves some sort of trauma team coming down and taking over.

A community ER program where the ED handles the trauma entirely is more valuable during residency than being designated to "the airway"

Also, we clamshelled a guy earlier in the year......and he made a full functional recovery. We don't do them a ton, but they do get done.

Disagree. I did my residency at a level one and think it was invaluable as far as trauma is concerned. There were so many traumas that we only called trauma service on severe cases and usually they would arrive later, meaning the senior ER resident would lead the trauma, at least initially but sometimes continue afterward or other times with the trauma resident. Often we would switch off and in any case there was plenty of trauma. Therefore it was not at all the case that we were just airway.

Also, you learn from being a part of a trauma team even if you are not leading it.

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[fahimaz7]

I disagree with the idea that a "Level 1" trauma center is great education for the ED doc. Those places are level 1 because they have a structure for dealing with the bad traumas, and it usually involves some sort of trauma team coming down and taking over.

A community ER program where the ED handles the trauma entirely is more valuable during residency than being designated to "the airway"

Also, we clamshelled a guy earlier in the year......and he made a full functional recovery. We don't do them a ton, but they do get done.

Did you clam shell a guy without a trauma surgeon or a CT surgeon ready to fix what you just did? We've been taught by both our trauma surgeons and our CT surgeons that while it's technically within our scope of practice in the right patient, it's a horrible idea to do such a thing at a site where you will be transferring the patient.

We do about 2 a year at our academic level 1 trauma center. And by "we" I mean the trauma team.

 

[FirstNobleTruth]

Did you clam shell a guy without a trauma surgeon or a CT surgeon ready to fix what you just did? We've been taught by both our trauma surgeons and our CT surgeons that while it's technically within our scope of practice in the right patient, it's a horrible idea to do such a thing at a site where you will be transferring the patient.

We do about 2 a year at our academic level 1 trauma center. And by "we" I mean the trauma team.

Ah yes, it's much better just to do nothing and let the patient stay dead...

Apologize for the sarcasm - it's not directed at you. Traumatic cardiac arrest is an area I'm intensely interested in and I have always found this argument a little strange. Similarly - if you don't have Ob/gyn or Pediatrics in house, would not even considering attempting a resuscitative hysterotomy (peri-mortem C-section) in a pregnant patient that meets criteria?

 

[deleted109597]

I would rather commit an act of commission than an act of omission.

 

[alphaholic06]

Agreed!

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[Arcan57]

Ah yes, it's much better just to do nothing and let the patient stay dead...

Apologize for the sarcasm - it's not directed at you. Traumatic cardiac arrest is an area I'm intensely interested in and I have always found this argument a little strange. Similarly - if you don't have Ob/gyn or Pediatrics in house, would not even considering attempting a resuscitative hysterotomy (peri-mortem C-section) in a pregnant patient that meets criteria?

Chances of at least one of the patients surviving a peri-mortem C-section performed in the ED for standard indications is significantly better than for a resuscitative thoracotomy. The morbidity to providers is also lower because you're not shoving your hands through broken ribs to perform the procedure. Additionally, most of us can resuscitate a neonate to the point of being stable for transfer to definitive care. So it's not really an apples to apples comparison. I legitimately don't know that I could get the copter to lift off from our level 1 center to pick the patient up and I damn sure couldn't get a surgeon to come in to take the patient to the OR at my hospital. If you can explain how I can obtain and maintain proficiency for a procedure I've done 0 times (including a 4 yr residency at a Level 1 trauma center) and then show that an EM doctor performing a resuscitative thoracotomy in the absence of any surgical backup has a positive influence on pt's outcome then I'm all in. Absent these requirements, the counter argument of not expending incredible amounts of resources for a futile procedure in a shop that's frequently single coverage seems convincing.

 

[deleted109597]

 

[FirstNobleTruth]

http://www.ncbi.nlm.nih.gov/pubmed/21131854

18% survival with thoracotomies being done on the side of the road and on the floor of pubs. Half of which were done by anesthesiologists.

Granted, I haven't had this situation yet (and I very well may never), but I find it hard to believe that at the community ER I work in, with no in-house Surgery, that if I did a thoracotomy on a penetrating chest trauma, relieved tamponade or stapled a hole in the heart, and achieved stable ROSC - that someone would then REFUSE to accept the patient in transfer?

I do admit the increased risk of needlesticks and other bloodborne exposures, so certainly not a benign procedure. I don't think it's really that resource-intensive - either they get ROSC, or they don't. I suppose it is a little quicker just to call it and then go see other patients (many of whom we all know do not have emergent medical conditions), but if it's indicated, I think it's tough not to try.

+1 for John Hinds.

Good discussion everybody

 

[fahimaz7]

Chances of at least one of the patients surviving a peri-mortem C-section performed in the ED for standard indications is significantly better than for a resuscitative thoracotomy. The morbidity to providers is also lower because you're not shoving your hands through broken ribs to perform the procedure. Additionally, most of us can resuscitate a neonate to the point of being stable for transfer to definitive care. So it's not really an apples to apples comparison. I legitimately don't know that I could get the copter to lift off from our level 1 center to pick the patient up and I damn sure couldn't get a surgeon to come in to take the patient to the OR at my hospital. If you can explain how I can obtain and maintain proficiency for a procedure I've done 0 times (including a 4 yr residency at a Level 1 trauma center) and then show that an EM doctor performing a resuscitative thoracotomy in the absence of any surgical backup has a positive influence on pt's outcome then I'm all in. Absent these requirements, the counter argument of not expending incredible amounts of resources for a futile procedure in a shop that's frequently single coverage seems convincing.

Couldn't have said it better.

 

[Fox800]

http://www.ncbi.nlm.nih.gov/pubmed/21131854

18% survival with thoracotomies being done on the side of the road and on the floor of pubs. Half of which were done by anesthesiologists.

Granted, I haven't had this situation yet (and I very well may never), but I find it hard to believe that at the community ER I work in, with no in-house Surgery, that if I did a thoracotomy on a penetrating chest trauma, relieved tamponade or stapled a hole in the heart, and achieved stable ROSC - that someone would then REFUSE to accept the patient in transfer?

I do admit the increased risk of needlesticks and other bloodborne exposures, so certainly not a benign procedure. I don't think it's really that resource-intensive - either they get ROSC, or they don't. I suppose it is a little quicker just to call it and then go see other patients (many of whom we all know do not have emergent medical conditions), but if it's indicated, I think it's tough not to try.

+1 for John Hinds.

Good discussion everybody

I imagine a large proportion of those victims received stab wounds vs. the higher proportion of GSWs in the US. Still very interesting, though.

 

[Janders]

I imagine a large proportion of those victims received stab wounds vs. the higher proportion of GSWs in the US. Still very interesting, though.

The cited study were all stab wounds.

Which is the only thing I'd be gung-ho to open in my community non-trauma ED. A stab in the box who literally dies in front of me in our resus bay... even without surgical backup it would be very tempting to open and attempt to ID a cardiac laceration and staple/sew. In this precise population there IS a decent chance of success.

Yes transport is an issue, but we've solved this in our ED by either sending a doc in the ALS unit with the patient (they'll drive ANYTHING if you ride with them!), assuming you have an extra doc, which we do during change of shift and other periods. We also have access to a critical care transport who would take an open chest if needed. Med control may allow ALS to take them as well, knowing its the patients only chance.

Of note, one of my partners did open a chest and repair a cardiac laceration and got ROSC and then rode with said patient to a trauma center just a few months ago. Patient ended up dying there from other sustained injuries... but I would still say he made the right call.

These trauma centers ARE quick rides from us, not 1 hour in the country each way.

 

[FroggerMD]

Disagree. I did my residency at a level one and think it was invaluable as far as trauma is concerned. There were so many traumas that we only called trauma service on severe cases and usually they would arrive later, meaning the senior ER resident would lead the trauma, at least initially but sometimes continue afterward or other times with the trauma resident. Often we would switch off and in any case there was plenty of trauma. Therefore it was not at all the case that we were just airway.

Also, you learn from being a part of a trauma team even if you are not leading it.

This was my experience training at a busy Level 1 trauma center as well. I think they key is to train at one that's a bit more dysfunctional than places like Shock Trauma - you want a place with tons of trauma and not enough surgeons. Great training.

 

[deleted547339]

This was my experience training at a busy Level 1 trauma center as well. I think they key is to train at one that's a bit more dysfunctional than places like Shock Trauma - you want a place with tons of trauma and not enough surgeons. Great training.

To be fair, our trauma department is plenty dysfunctional and seems to have surgeons falling over other surgeons.

 

[TheBlueBlazer]

#1 - The first few times you go into a chest, if there isn't a small, simple hole in the ventricle, you are going to have very little idea what the hell you are doing in there. I would argue that if this is not the situation you encounter, just stop.

#2 - people don't well appreciate the downstream effects of that patient who was dead who you just clamshelled and got back vital signs. Things are usually not rosy once that person leaves the department. If that kid has anoxic injury and ends up trached and PEGed with awful sacral wounds and living in a vent farm with minimal consciousness, do we consider that a good thing we just did? Or is that an even worse loss? I'm not always sure, but frequently being on the receiving end makes me think about it a WHOLE lot more than those with the "doesn't get worse than dead" mentality, and I seriously question what I would want if it was my family member who came in pulseless. Making someone die slower is definitely NOT a win. It prolongs the process for the family, causes a ton of pain, and utilizes a ton of unnecessary resources if done in the wrong patient. If someone truly fits the profile of someone that can be saved by a resuscitative thoracotomy, sure go for it, but pushing the indications is fraught with peril.

 

[njac]

Hold up.

Hinds was born in 1980? A millennial!?


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[HooliganSnail]

Did you clam shell a guy without a trauma surgeon or a CT surgeon ready to fix what you just did? We've been taught by both our trauma surgeons and our CT surgeons that while it's technically within our scope of practice in the right patient, it's a horrible idea to do such a thing at a site where you will be transferring the patient.

We do about 2 a year at our academic level 1 trauma center. And by "we" I mean the trauma team.

We have CT surgeons......we're Level 2. We just don't have them 24/7 in house.

He drove in very fast.

 

[HooliganSnail]

Disagree. I did my residency at a level one and think it was invaluable as far as trauma is concerned. There were so many traumas that we only called trauma service on severe cases and usually they would arrive later, meaning the senior ER resident would lead the trauma, at least initially but sometimes continue afterward or other times with the trauma resident. Often we would switch off and in any case there was plenty of trauma. Therefore it was not at all the case that we were just airway.

Also, you learn from being a part of a trauma team even if you are not leading it.

Yeah but you are basically describing the ideal situation I was referring too.

Most level 1 facilities have a trauma team that is expected to arrive immediately, and everything is paged out as trauma because you have to get your numbers to justify your designation. Most level 1 centers in my area just have the ED docs doing paperwork.

If your shop had the ER running many trauma's on their own, then it is the same as where I trained, and is the ideal place to be for ED residency as far as trauma is concerned.

So actually you don't disagree with me, you 100% agree with me. I suppose the real idea is that it doesn't matter if you are at Level 1 vs Level 2, what matters is what is the ED's role in any given trauma center.

 

[SilentCool]

Too soon.

Not quite!

 

[DeadCactus]

I don't think you can be overtrained for emergency medicine. I do think you can spend too long in indentured servitude and that the current model of medical education in the US is suboptimal. We focus too much on checking boxes and not enough on actual career-long professional development.

 

[deleted109597]

I'm overtrained at calling the lab and calling consults.
Everything else I could stand to get better at.

 

[LabMonster]

What matters is that an EDD (ER Doc) knows how to run a trauma, level one, level 4 - whatever. The skill is being a resuscitationist - Can you stabilize a patient so they can ascend to the next level of treatment? If you trained at a level 4 and did 20 resus during residency, great. If you did a residency at a level 1 and did 60+ great. The more you see, the better you are. This is the "Practice of Medicine" not the absolute cookbook of traumatic illness scout guide!

Talk to your surgeons if you're in rural locales. I have one surgeons who told be "Good story, penetrating trauma, if you open their chest I will always back you." He is the only one of 9-10 local surgeons who would back an ED thoracotomy. Backup is obviously clutch. Can you repair a ruptured aorta? I can't. I would love to, but we can't start something that can't be finished. I have a 30 minute transfer time to CT surgery. I do have 1 vaMacGyver the scular surgeon.

The level of your residency doesn't matter, but the experiences do.

E.G. 27 week precipitous delivery while I was covering a rural ED while in training. The Attending didn't want anything to do with it - I tubed, I did PALS and that kid lives.

Train beyond your usual. Embrace the abnormal. MacGyver the **** out of everything.

The ER doc is always scared of litigation. Don't be scared of training after your residency - you will anyway. We don't always see everything in the "book."

Paranoia, direct patient care, a good H&P are tools of a good EP. Level 4 or 1. If you suspect pathology, test reality -XR CT Labs whatever - image liberally.

Don't miss pelvis fractures (particularly in the old) and eff your superiors for prolonged stays with "normal" exams on altered patients requiring repeated exams.

 

[waterbottle10]

The issue w this is similar to medicine. You can't really be overtrained because your field covers so much.. But at the same time being a bit less trained prob won't be a huge deal either after residency. The only place that matters is resus I think.

I can totally see 'overtraining' reducing consulting other fields. If you aren't as good as others in reducing certain fractures, call ortho. If you can't interpret a weird rhtyhm on EKG call cards. If you can't intubate call anesthesiology. Call enough consults after residency and you will improve. Other doctors in the hospital are not going to call a EM consult.

It is important for other specialties to make sure all their residents are not less trained cause if you can't do xyz in your field there isn't some service after you to consult. Cards isn't going to like consult surgery if cards also can't interpret a weird ekg

 

[docdragon]

This is kinda the same argument regarding 3 year vs 4 year residency training sites. Is the 4th year overkill? Well, if you ask most of the people who graduate from an EM residency the answer is yes. If you ask the guys who did the 4th year, some say yes and some say no. It's all in the eye of the beholder.

Also, trauma is great and all, but it's not the end all be all. She is spot on to say that most sites don't get that much level 1 trauma and most of the time our role in it is somewhat limited. You won't find people doing clamshell's or REBOA in the community.

At the risk of flaming a straw man... If you find a site far enough from a Level 1 and close enough to some sort of potentially dangerous activity, you will find ED clamshells. In the community. Because the surgeon isn't there yet, and the highly active patient with penetrating trauma who just coded in front of you might live if you do it.
I will admit that I didn't believe this until I talked to docs (ABEM/ED trained) who had opened multiple chests, and then I started asking other semi-rural docs. A respectable sampling have done at least one. We had a recent blunt traumatic arrest via EMS with CPR, too long gone for a thora (plus... blunt...), no surgeon for 9 minutes. I might just start cutting if the guy had penetrating trauma & coded in front of me.

 

[namethatsmell]

Other doctors in the hospital are not going to call a EM consult.

Not to detract from the threat, but this is simply bogus.

I'm effectively consulted every time a doc sends their patient to me from their clinic. I gets calls from pcps and specialists all the time sending patients in with things like: "I don't know if something bad is going on with this pt" "This guy's heart rate is 150 and I don't know why" "The guy's in respiratory distress and needs to be managed" etc.

I also frequently get calls from docs upstairs: the icu hospitalist asks "my patient's norepi extravasated, can you help?" or the hospitalist asks "I got a patient up here going through heroin withdrawal, what do you guys do for that?" or the gyn asks "I got a lady with a BP of 190/70 but asymptomatic, what do I treat with?"

Don't get me wrong, I consult too. But it's most certainly a two-way street. And you know what? It's not a big deal.

 

[waterbottle10]

I meant official consulting not asking a few questions/curbsiding. Everyone does that, doctors or not. And when they get send tO ED its to escalate care. Do you write consult notes for those patients that come to the ED? Did you write a consult note for the infiltrated IV and Bill for the consult?

 

[Rendar5]

I meant official consulting not asking a few questions/curbsiding. Everyone does that, doctors or not. And when they get send tO ED its to escalate care. Do you write consult notes for those patients that come to the ED? Did you write a consult note for the infiltrated IV and Bill for the consult?

I do for codes on the floor and intubations on the floor

 

[namethatsmell]

I meant official consulting not asking a few questions/curbsiding. Everyone does that, doctors or not. And when they get send tO ED its to escalate care. Do you write consult notes for those patients that come to the ED? Did you write a consult note for the infiltrated IV and Bill for the consult?

Yeah, like Rednar if I do a procedure or am physically seeing a pt on the floor for something I'm leaving a note. If it's just a question on the phone, I don't.


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[vernhart]

Maybe 10 years ago...

At least in my experience, all the British, German, Austrian, Japanese, and South Africans I've worked with saw patients as med students.

As of this year many European med students (5 year MBChB or 6 year MBBS) spend at least 2 years doing "placements" and "electives" similar to US rotations. During both years med students see patients under supervision. While they have little to no responsibility for actual patient care, neither do most US med students nowadays.

But on the whole, yes, nearly all European registrars work less hours compared to US residents. In any event, some countries do have particularly brutal training schedules compared to the US. In South Africa at the moment EM registrars commonly work 60 to 80 hours per week including 16 to 24 hour shifts in the ER.

ok let me preface this by saying I'm just a first year, but I do know a few residents...and how exactly is that more brutal than a US EM residency (urban)?

 

[Venko]

Hey everyone,

Just curious what everyone else's perspective is on this? What I am basically asking is - do you think there is such a thing as being overly prepared (especially in our field)? I.e. my thought process for picking a residency destination was that I want a high volume (patients per resident), level 1 trauma center with enough (but not nonstop) trauma, that would make me more than capable when I left to do a solid job. This definitely factored into my final rank list as some programs that I felt had weaker training were lower, while those who arguably had extra intense (almost unnecessarily) training were also lower.

I spoke to a Kaiser ER doc recently and she said: "80-90% of you coming out will work at a place like this, where it is so rare that trauma is anything too bad, and you've seen way more than enough that you know what to do. The other 10-15% at big county scary academic centers will be giving their senior residents the lead and having their junior residents doing procedures. And as far as multi tasking, having gone through residency you will be more than fine doing it."

Thoughts?

From an ED patient perspective, the ED doc probably cannot be overtrained in either 3 or 4 year residency models.

From an individual physician perspective, I'm confident that no matter what anyone says or shares, some learners will want to put in enough but not too much energy. Will want to see enough but not too many patients in training. Especially in training it's easy to lose the joy and the perspective and feel that, "when will I ever need this" or "I already know that".

If you are trying to say it's got no value, it's because you're giving it no value.

If you want to find a way to continue to learn, you can do it. I have yet to see a resident so beyond their years that I couldn't teach them how to broaden their differential, get to the next step faster, be more efficient with movements and functions, be even more effective st explaining things to patients, be even more effective at communicating with the nurses and the inpatient units and outpatient docs.

If you WANT, you can find ways to IMPROVE yourself. But as throughout your entire life...it's a question of if you want to do it.


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[alpinism]

ok let me preface this by saying I'm just a first year, but I do know a few residents...and how exactly is that more brutal than a US EM residency (urban)?

US EM residents typically work 40-60 hours per week and do 8-12 hour shifts.

 

[littlejuan]

US EM residents typically work 40-60 hours per week and do 8-12 hour shifts.

How many patients are being seen per hour on those 24 hour shifts? What is the acuity level, etc.

 

[Apollyon]

US EM residents typically work 40-60 hours per week and do 8-12 hour shifts.

How many patients are being seen per hour on those 24 hour shifts? What is the acuity level, etc.

Where are you getting 24 hour shifts?

 

[littlejuan]

Where are you getting 24 hour shifts?

Sorry, I meant to quote alpinism who said South African "EM registrars commonly work 60 to 80 hours per week including 16 to 24 hour shifts in the ER."

 

[vernhart]

US EM residents typically work 40-60 hours per week and do 8-12 hour shifts.

really? I'm really surprised by that. My buddy's must be pretty atypical (he says he works 60-80, is in NYC)...I just assumed that that was the norm

 

[alpinism]

How many patients are being seen per hour on those 24 hour shifts? What is the acuity level, etc.

At Baragwanath we would normally see around 150 patients per day divided between 2 doctors.
On weekends and holidays however it was common to see twice that number.

On New Year's, South Africa's 2 Fates Unfold At Soweto Hospital

 

[Apollyon]

really? I'm really surprised by that. My buddy's must be pretty atypical (he says he works 60-80, is in NYC)...I just assumed that that was the norm

The EM RRC limits EM residents to 60 clinical hours per week, and 72 hours total (such as for journal club and conference). If he says he's doing 60-80, it's only one of three possible things: he's violating rules, he's making up time (so it will average out over 4 weeks), or he's exaggerating. I don't know the guy, but you do, so, draw your own conclusions.

 

[vernhart]

The EM RRC limits EM residents to 60 clinical hours per week, and 72 hours total (such as for journal club and conference). If he says he's doing 60-80, it's only one of three possible things: he's violating rules, he's making up time (so it will average out over 4 weeks), or he's exaggerating. I don't know the guy, but you do, so, draw your own conclusions.

I'd guess exaggerating then lol, he's a good guy but he's a complainer for sure (then again my other friend is in GS residency and claims they don't really follow the 80 hour limit, though 80 is what gets documented, so I guess I shouldn't make that assumption)

 

[Venko]

I'd guess exaggerating then lol, he's a good guy but he's a complainer for sure (then again my other friend is in GS residency and claims they don't really follow the 80 hour limit, though 80 is what gets documented, so I guess I shouldn't make that assumption)

It's possible that they are telling you hours that include their own studying, prep times etc. they could be including time spent doing research, quality improvement etc.

Also, the 60/72 rule only applies when in the emergency department, not for off service rotations.

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[Apollyon]

It's possible that they are telling you hours that include their own studying, prep times etc. they could be including time spent doing research, quality improvement etc.

Also, the 60/72 rule only applies when in the emergency department, not for off service rotations.
View attachment 218330



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Thanks for the kneecap, buddy!

(Just kidding, brother! It's all good!)

 

[littlejuan]

At Baragwanath we would normally see around 150 patients per day divided between 2 doctors.
On weekends and holidays however it was common to see twice than number.

On New Year's, South Africa's 2 Fates Unfold At Soweto Hospital

What was the acuity level of the patients? So about 3 patients an hour for 24 hours. No breaks? Sounds like a recipe for disaster

 

[Venko]

Thanks for the kneecap, buddy!

(Just kidding, brother! It's all good!)

Sorry, no harm intended




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[alpinism]

What was the acuity level of the patients? So about 3 patients an hour for 24 hours. No breaks? Sounds like a recipe for disaster

The acuity is incredible.

On the trauma side: Gunshot wounds, machete attacks, limb amputations, bowel eviscerations, crush syndrome, open fractures, etc...
On the medical side: Sepsis, meningitis, encephalitis, seizures, strokes, aneurysms, poisonings, overdoses, etc...

Its not uncommon to have 10+ intubations, chest tubes, and central lines in a single shift.

I lost a lot of respect for US EM physicians after working in South Africa.

 

[alpinism]

What was the acuity level of the patients? So about 3 patients an hour for 24 hours. No breaks? Sounds like a recipe for disaster

Here's a description of a typical EM shift:

BMJ Careers - Emergency and aeromedicine in Zululand

 

[WilcoWorld]

The acuity is incredible.

On the trauma side: Gunshot wounds, machete attacks, limb amputations, bowel eviscerations, crush syndrome, open fractures, etc...
On the medical side: Sepsis, meningitis, encephalitis, seizures, strokes, aneurysms, poisonings, overdoses, etc...

Its not uncommon to have 10+ intubations, chest tubes, and central lines in a single shift.

I lost a lot of respect for US EM physicians after working in South Africa.

Wow, doctors-in-training taking care of 3+ ED patients per hour at any acuity sounds concerning. At this level of acuity it sounds unsafe.

 

[Arcan57]

Wow, doctors-in-training taking care of 3+ ED patients per hour at any acuity sounds concerning. At this level of acuity it sounds unsafe.

I'm sure vastly different charting requirements, vastly different expectation of outcomes. Also, probably a vastly different role in patient management.

 

[Apollyon]

I lost a lot of respect for US EM physicians after working in South Africa.

Really? Did you every have any?

South Africa is a very poor, violent place. J'burg is at the epicenter. That's the busiest emergency department on the planet. LAC-USC is second. When there is no primary care, when there is poor infrastructure, and you are advised to not stop for red lights, then you're going to have interesting work in the ED.

But to say you "lost respect" sounds either misguided or just insulting.

Now, I don't know where you are in training, either by year or location. If you are South African, and you are there, have at it. But, if you go into an American ED and tell them that RSA is better, and they suck, they're going to show you the door.

 

[deleted109597]

Agreed. South Africa is where they did the first heart transplant, yet until recently there were hospitals there that didn't have power at night. Either your family bagged you all night, or you died.
Medical mayhem: Our reporter's 24-hour shift at a Joburg hospital

 

[filhodeinferno]

The acuity is incredible.

On the trauma side: Gunshot wounds, machete attacks, limb amputations, bowel eviscerations, crush syndrome, open fractures, etc...
On the medical side: Sepsis, meningitis, encephalitis, seizures, strokes, aneurysms, poisonings, overdoses, etc...

Its not uncommon to have 10+ intubations, chest tubes, and central lines in a single shift.

I lost a lot of respect for US EM physicians after working in South Africa.

Managing the very sick is the easy part of EM. The real hard part is finding the hidden sick or deciding what to do with the borderline sick.

 

[alpinism]

Really? Did you every have any?

South Africa is a very poor, violent place. J'burg is at the epicenter. That's the busiest emergency department on the planet. LAC-USC is second. When there is no primary care, when there is poor infrastructure, and you are advised to not stop for red lights, then you're going to have interesting work in the ED.

But to say you "lost respect" sounds either misguided or just insulting.

Now, I don't know where you are in training, either by year or location. If you are South African, and you are there, have at it. But, if you go into an American ED and tell them that RSA is better, and they suck, they're going to show you the door.

Don’t get me wrong I still very much respect US EM physicians.

However after working in both countries I personally don’t believe that our EM training is the best in the world.

 

[alpinism]

Managing the very sick is the easy part of EM. The real hard part is finding the hidden sick or deciding what to do with the borderline sick.

Sounds like a great description of primary care medicine.