Even more ER questions

Humane hours?
Q: Are the hours of a pediatric surgeon any better (or more humane) than those of a trauma surgeon? Thanks, Amy

A: Yes, especially if you, as a trauma surgeon, work in an area plagued by violence. People who shoot, stab, beat up, etc. other people are more likely to do so at night -- it's as if they sleep under a rock during the day, and only come out at night. Hence, people who treat trauma are often busier at night. Also, nighttime is when people get drunk in bars, go driving afterwards, or just beat up Billie Bob 'cause he looked at Big Joe's "woman" the wrong way, etc. In contrast, most (but not all) pediatric surgeries are scheduled in advance.

Can drugs produce superhuman strength?
Q: I just heard about a man who crashed through the reinforced cockpit door on an airliner. The newscaster said the man may have been on drugs. Other than testosterone or anabolic steroids (which take time to increase strength), are there any drugs that substantially boost strength, especially rapidly? Many thanks, Jerry

A: Yes. It is well-known that some drugs can rapidly improve strength and/or endurance, but this increment is usually mild. However, as an ER doc who saw countless people on all kinds of drugs, I've witnessed some amazing reactions. The first time I saw this, I was stunned beyond belief. An ER frequent flyer (a patient who frequently comes to the ER) came in by ambulance, as usual, with a drug overdose, as usual. We knew this character would go wild as he woke up, so we put leather restraints on him, and used handcuffs to attach the restraints to the metal bed frame. These restraints were thick, and made of several layers of leather. I doubted that a Russian weightlifter or grizzly bear could break them. As the patient awoke, he flexed his arms and snapped the restraints as if they were made of cardboard. The ER staff was horrified, and we retreated to call in the security guards, who were pummeled. We called in the police, and initially I thought that Mr. High-on-Drugs would beat them, too. However, the cops called in reinforcements, and the melee continued, with the police eventually gaining the upper hand by clubbing Mr. Crazy with their nightsticks. This allowed them to handcuff him, after which he was thrown into a police car for some rapid rehabilitation. An hour or so later, the police returned to tell us that we wouldn't have to worry about Mr. Crazy any more. Given that he once showed up so frequently, and after that Fight Night he never showed up again, I think he was removed from the gene pool. Can't say I was sorry to see him go.

A: Do you think I want high school football teams taking that stuff just so they can make mincemeat out of their opponents? No way. Given the appeal of superhuman strength, it's a sure bet that if people learned of this drug, they would take it. In the course of being an ER doc, I learned some things that aren't common knowledge, but I refuse to divulge them because some things are better kept secret.

Q: Haven't you considered the positive aspects of using that drug, whatever it is? For example, if it were available to the passengers on the aircraft hijacked on 9-11, they could have beaten the shit out of those terrorists. Jerry

A: Perhaps. But it's even more likely that the terrorists could have used that drug to their advantage, and they may have succeeded in commandeering Flight 93 into the White House, or whatever their target was.

Also, you're overlooking how impractical your suggestion is. Do you really think that airline executives would stock their planes with this drug, so it could be dispensed during hijackings? Every airline executive I've heard speak since 9-11 has impressed me with his stupidity and utter absence of common sense. No wonder the terrorists had an easy time taking over those flights. The airline execs resist implementing common sense measures, so they'd never adopt "emergency drug dispensing" as a way to counteract a hijacking.

Education? Salary?
Q: Hi, I am in the tenth grade and I wonder what kind of schooling you have to go through to be an emergency room doctor? Also, what is a typical salary? Thank you, Jennifer

A: Those answers (and a hundred more!) are on my web site. Did you see all the Q&A pages? In any case, to answer your questions .....

Schooling? 4 years college, 4 years medical school, and 3 years of slavery -- um, excuse me, ER residency.

Salary? Usually 140K - 200K. Might sound like a lot now -- just wait until you get out, and you see business people (e.g., Bill Gates) making more in 2 minutes than you'll make in two years. You'll be saving lives, and he's selling buggy software. (I'm in an "anti-Microsoft" mood right now because my computer crashed about a dozen times today and I spent 90% of my day talking to tech support. Wasn't Windows XP touted as being more stable?)

Training? Hours?
Is pay proportionate to educational level? (I've been waiting for this question for years!)
Q: Hi, I was wondering if you could answer some of my questions. What type of schooling do you need in order to become an ER physician? If you don't mind me asking a personal question: how much do you make when you first start out and how much does it go up as you have more schooling? What type of hours do you start with? Do they change when you eventually become a doctor? I know I asked a lot of questions but I would appreciate if you could answer as many as possible. THANK YOU! I am eager to hear from you. SlickChick

A: > What type of schooling do you need in order to become an ER physician?

4 years of college, 4 years medical school, and usually 3 years of ER residency.

> How much do you make when you first start out and how much does it go up as you have more schooling?

ER docs typically make $140,000 to $200,000. Here are a few notable things about that income:

1. It doesn't rise much with more experience, nor does it usually rise if you receive additional education.

2. There is virtually no connection between physician income and performance. In my experience, many of the best physicians I've seen (of ANY specialty, not just emergency medicine) had incomes toward the lower end of the range and some of the most quackish docs had the highest incomes. This generalization isn't always true, but I've seen many examples of cases that substantiate it.

3. In most specialties, physician income is leveling off, or falling in some cases. Consider this: even if their income just remains the same, it is still effectively a pay cut because it doesn't keep up with inflation. In the years that I've been a physician, there has been a demonstrable decrease in real (adjusted for inflation) physician income, and experts predict this trend will continue in the future. Therefore, if money means anything to you, I'd advise you to not go into medicine. Why? 1) If you're smart enough (and hard-working enough) to be a doctor, you could make far more money in business. 2) Collectively, the public harbors some animosity toward physicians making $150,000 per year and that animosity and resentment influences the behavior of their elected representatives, who reduce physician reimbursements. In contrast, you can be a businessman making ten times as much, and suffer no public wrath and incur no yearly pay cut from Washington. As I've said before, becoming a doctor is such a noxious and demanding process that the Supreme Court would prohibit it if mass murderers were subjected to the same experiences. Enduring such a demanding preparatory period will only fuel your resentment when you listen to people bitching about how much money doctors make, and watching politicians codify such a sentiment into yearly pay cuts for doctors. Some sports stars and singers make more money in a minute than a doctor makes in a year, yet people usually adore the stars and resent the doctors. Makes sense? Not to me. I think the public antipathy toward docs making a good income stems from a public realization of the fact that the public is ultimately responsible (through taxes, insurance premiums, or via direct payments) for paying doctors. However, most people don't realize that the astronomical incomes of sports stars, recording artists, the Hollywood elite, and assorted other celebrities are ALSO paid by the public through higher ticket prices, higher costs of goods they produce or endorse, etc. Consequently, a movie actor might make over twenty million dollars in a year, be addicted to drugs and alcohol, have sex with prostitutes and little boys, and flaunt his latest bout in rehab as if it were some badge of honor -- an actor could do all that, and still be put on a pedestal by the public, and ushered onto talk shows where he'd be treated like royalty. On the other hand, a person who gave up the best years of his life to become a doctor and who works days, nights, weekends, and holidays to take care of people -- that doc must live with the realization that the public values him so little that not only does he not even make 1% of what many celebrities make, his income is cut year after year.

> What type of hours do you start with and then do they change when you eventually do become a doctor?

During my training (medical school and residency), while on-call (which was as frequent as every third night for me, but some docs are on-call every other night) I'd work nonstop shifts lasting 36 to 38 hours. The easy days would consist of 12 hours in the hospital and 6 hours studying thereafter -- oh, and that was usually 7 days per week, including major holidays like Christmas. On a rare "day off," I'd still often study 16 hours. The schedule is now somewhat more humane, especially in some states like New York, whose legislators realized that torturing interns and residents with inhuman schedules was not in the best interests of patients.

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You know that writer's block you get when you sit down to write the essay portion of your personal profile for online dating? And you know the difficulty you have trying to think of a catchy headline? Well, MyProfileWriter allows you to create a profile essay and headline without typing, just by clicking!

Is an ER career worth the nightmare and total banishment of my social life for the next two years?
Q: I'm a sophomore in high school and I've wanted to be an ER doctor for 2 years now. My family doctor recently informed me that to be prepared for premed I will have to take Biology, Advanced Biology, Chemistry, Advanced Chemistry, and Psychology at a high school level. Last year, I got gypped out of Biology and will now have to double up on science classes the next two years. Basically what I'm asking you is it worth the nightmare and total banishment of my social life to prepare myself for college? Sincerely and thanks for your help, Megan

A: The short answer: no.

The long answer . . . . There are enough drawbacks to the specialty of emergency medicine that everyone should think long and hard about whether that is a worthwhile goal. In my web site and books, I discussed the multifaceted brutality of life as an ER doctor. Perhaps that wasn't a wise business decision, because as an author I want to sell books, and readers generally prefer books that put a positive spin on their subjects. However, I think it'd be unethical and unconscionable for me to gloss over those drawbacks because my primary goal is to help people, not make money. I would certainly make more money by writing books that paint a rosy picture of what it's like to be an ER doc, but in the process I would be contributing to the ruination of many lives.

Every so often, I receive a frenetic e-mail message from an ER doc who is concerned that I am hurting the profession of emergency medicine by dissuading people from entering it. I disagree. First, from a practical standpoint, there is no shortage of people clamoring to enter that field. Given that people often possess a "it won't happen to me" mindset that enables them to think that the drawbacks of emergency medicine will not befall them, there is absolutely no chance that I will some day be an old man gasping for breath and there won't be an ER doc to treat me. Second, my goal is to help the profession of ER, and the practitioners of it. Firstly, by openly discussing its problems. Whether it is problems in a marriage or problems in a profession, they cannot be solved unless they are identified and dealt with. The ostrich approach — ignoring problems and hoping they'll just go away — is ludicrously ineffective. By putting these problems in the spotlight, I hope to help solve them. Secondly, I can help future practitioners of emergency medicine by pointing out these drawbacks because some of them can be avoided if ER docs know what is coming, and take steps to avoid them. It's like walking through a minefield. You can't get around the fact that there are mines present, but you don't have to step on them — if you have the right tools, such as a minesweeper or a map of where the mines are. Think of me as that map.

If you've read much of my web site, you probably noticed several questions submitted by Amy. I realized a long time ago that Amy could not be deterred, so I gave up trying to discourage her from going into ER, and instead decided to help her succeed in every way I can. For as long as she retains the desire to practice emergency medicine, I'll be there, by her side, helping her. I am convinced that Amy can make it on her own, but this isn't a question of whether or not she can do it, it's a question of helping make her journey not just successful, but also more tolerable.

Incidentally, not all ER docs object to my realistic depiction of emergency medicine. Here is an excerpt from the "Reader Comments" section of my True Emergency Room Stories page:

After an ER doctor ordered a second copy of my book from Amazon.com's Marketplace, I e-mailed him to ask if this was a new order, or perhaps a snafu from Amazon repeating the first order. He responded:

"Yes, it's a new order. Having been a residency-trained, board-certified ER doc for 22 years (one of the first), I wanted to keep the first one for myself, and loan out the second to various people, including one of my fighter pilots who is going to attend med school and wants to be an ER doc despite my dire warnings. Great book!!! Your writing sounds exactly like many of the "sermons" I've been giving for years. Your use of the exact same language was uncanny. I've experienced almost everything you've written about in the book in my 26 years of ER work. Thanks for putting it in writing so I can tell people to read it if they want to know what my life is like. Thanks again for the awesome book."

CDR William Voelker, MD, MC (FS/VFC-13) USNR, FAAEM
Medical Director, Emergency Department, Enloe Medical Center, Chico, California

Would you pay to have an ER doc live next door? He might save your life one day

Q: Perhaps I'm an ostrich for thinking this, but I've always thought the best way to deal with a problem is to ignore it. After all, don't most things that people worry about never materialize? With that little insight into my personality, here is what I want you to do for me: just tell me the positive aspects of being an ER doctor. That is my career aspiration. Thanks, Kathy

A: Before I enumerate the positive aspects of emergency medicine, let me clarify why I don't gloss over the drawbacks of that field. In third grade, we studied the various occupations: doctor, nurse, lawyer, businessman, butcher, banker, candlestick maker, you name it. The one notable recollection that I have of this career expo is these careers were whitewashed; we heard the pros, but never the cons. Perhaps that is to be expected in elementary school, but things never got much more realistic as I progressed in my education. You might think that a medical school dean would realize that choosing the right specialty was sufficiently important to warrant a day or two to learning more about them. I suppose that deans think we receive enough exposure in our third- and fourth-year rotations (in which we work in the hospitals in various specialties). There are four problems with that:

· Medical students must commit to a specialty (during “The Match”) before completing their rotations.

· By and large, medical students are exposed only to practicing physicians who are full-time or part-time faculty affiliated with medical schools. These docs tend to have more of a rah-rah attitude, and the burned-out docs who don't practice in ivory towers never have a chance to speak with the medical students. Here's an example: all of the family practitioners (FP's) that I met during medical school spoke glowingly of it, with the exception of one at an HMO who moaned about the hectic pace: four patients per hour, every hour, or else. In contrast to the generally positive spin voiced by faculty FP's, family practitioners not affiliated with medical schools often express contrasting sentiments. I cannot think of one who said, “This is a great profession, and I recommend it.” Instead, I hear them warning people to choose another specialty.

· Even if an academic doc had something negative to say about his specialty, he is usually too busy to say it. When I was an attending doctor in a teaching hospital, I had a lot of contact with medical students and residents. However, the pace was such that we never had time for a leisurely discussion of the pros and cons of emergency medicine. Instead, it was rush to see one patient, then rush to see the next. What little time I had for talking was devoted to instructing them, and helping them take care of patients in the ER.

I don't think we're doing the younger generation a favor by failing to apprise them of both the plusses and minuses of various career choices. Why shouldn't people considering a career be given both sides of the story, and leave them to decide if that is the career for them? Furthermore, to some extent it is possible to either avoid or mitigate those problems if the person is forewarned of them, especially if experienced docs forthrightly discuss those potential gotchas. Consequently, I am not an advocate of the head in the sand approach to problems; that leads to one generation passing its problems onto the next generation.

While I agree with you that people worry about many things that never materialize, that is usually true about life in general, but usually not true about emergency medicine. For example, how can an ER doc avoid the problem of working crazy hours? Emergency rooms are open 24 hours a day, 365 days per year, and some doc is always there. Or how can an ER doc avoid being inundated with more patients than he can optimally treat at one time? There is no way to control the influx of patients into an ER. If you think it is stressful to care for one critically ill or injured patient, just try treating several at once in addition to the other patients who come to the ER for a variety of reasons. (Want to read an example of what may await you in your ER career? Read this.)

· Every day is an exciting unknown. If you specialize in internal medicine, you could scan your appointment book every evening and know whom you will see the next day. Perhaps you like that predictability, and perhaps it would bore you to tears. In the ER, your next patient might be a man with a knife in his gut, or a movie star with a kidney stone. I've seen both, and innumerable other cases.

· There is no need to invest your money into buying equipment (other than a doctor's smock, scrubs, and a stethoscope); the hospital provides the equipment and the facility, provides the support staff, and deals with the zillion and one regulatory hassles imposed by the government.

· You are freely mobile. If you want to move, it is simple: get in your car and go. Finding a job is generally easy. There isn't any need to spend years building your practice in a new area. You can walk into your new job next Tuesday and see more patients than you would ever hope for! The value of this mobility should not be overlooked. Some docs who have their own offices devote years into getting established, and that time is sometimes wasted. Here is a real-life example. One of my friends told me about a pediatrician in Petoskey, a beautiful town on the shores of Lake Michigan in the northwestern part of Michigan's Lower Peninsula. The pediatrician loved the area, but found that he was not fitting in very well because the residents of that area weren't very accepting of outsiders. He said he felt so much like a pariah that he felt compelled to move, even though he hated to uproot his family and start all over again. You might very well face a similar problem in the ER. I worked in some places where the ER nurses and staff were like beloved sisters to me, and other emergency rooms where many of the nurses despised me because I was too intense and they did not want a doc telling them that “good enough” isn't good enough. However, if you must move, it is easier to do this as an ER doc than it is to move in any other specialty.

· The constant exposure to so many diseases and abnormal people makes you appreciate health and normalcy even more.

· You get to know the local police. If you are a speeder, as I once was, that can save you a lot of money in traffic tickets and higher insurance premiums!

· It is highly rewarding to save lives, and make a real difference. This is a concise sentence, but don't overlook it. While I was usually too busy to relish the times when I saved a life, every so often I would think how wonderful it was to know that I did. The pleasure was usually inversely proportional to the patient's age. If I saved the life of someone aged 70, I felt good; if the patient was 45, I felt great; if the patient was 8 years old, I felt utterly fantastic. This was highly rewarding even if the patients or their family members said nothing, but it was even better if they acknowledged it. A simple “thank you” can be priceless, but I've had patients who went far beyond that. Eventually, I will tell some of these stories, a few of which are in the “truth is stranger than fiction” category. Television writers, eat your heart out!

· You will be what one of my doctor friends calls “a real doctor.” She is somewhat scornful of physicians who are “more technicians than doctors and don't save lives.” No other specialty will give you the opportunity to save more lives. Think of another life-and-death specialty, such as cardiology. Compared to a cardiologist, you will save far more people. More often than not, cardiologists just tune up people saved by ER doctors. I'm not trying to minimize the value of what cardiologists do, but it's a fact that ER docs run far more codes and take care of more patients with acute MI's (myocardial infarctions or “heart attacks”), not to mention treating countless other patients with potentially fatal conditions, such as asthma, coma, and trauma.

· You will be a valuable part of the community. Except for people who are perpetually averse to work (in the ER, I met several non-handicapped adults who had never worked a single day), everyone has a role to play in society, but not all jobs are equally important or valued. If a telemarketer did not show up for work some day, that would hardly be a tragedy. But if an ER doc didn't show up and his position wasn't filled by someone else, that could be a disaster. As an ER doc, you will matter.

· It is fun to meet new people every day. Besides meeting several thousand patients per year, you will meet many of their family members, too. You will also meet countless nurses (emergency rooms often have a rapid turnover rate), paramedics, police officers, and reporters.

Whenever possible, I enjoyed either making or buying presents for patients. I made handcrafted “Get Well” cards and personalized coffee mugs, bread and other baked goods, and bought them pizza—when the ER was slow, it was fun to throw an impromptu party! I gave children stuffed animals and scratch-n-sniff stickers, and I dispensed expensive antibiotics from my personal stash when patients could not afford them. I also gave some books (usually not ones I'd written) and other gifts. In any case, the fact that you will meet so many people means that you will have an opportunity to put a smile on many faces! J

· You will have the opportunity to be a star and outshine your colleagues. I think there is more variation in skill between the best and the worst ER doctors than there is between the best and the worst in most other specialties. I hate to criticize my peers, but a distressing number of them seem to think that emergency medicine is a synonym for superficial medicine. There are times when ER docs must cut corners because the ER is inundated with patients, but I've heard some hard-headed docs insist they should do that even when the ER isn't busy. One doc insisted this was necessary to keep his edge; if that is true, he did not have much of an edge to begin with.

· The knowledge you possess is more valuable than that possessed by many other doctors. Put me into almost any imaginable situation—from a man who collapsed from a heart attack in a store, to a child turning blue, to an accident victim—and I can do more for a wider range of problems than a doc in any other specialty. Or would you prefer a dermatologist? If they are smart, your neighbors will love you . . . what a gift it is to have someone living next door who might some day save your life or the life of your child. Sure, everyone can dial 911, but by the time the ambulance arrives, it may be too late. Here is an interesting thought. People who live near an ER doc are in effect obtaining a free service; that is, very rapid access to a life-saving doc whenever the doc is home. While I loved my neighbors and never thought of charging them, consider this following scenario. An ER physician is considering a move. He could move virtually anywhere, and like everyone else he considers the merits of moving to Place A versus Places B or C. Why not broaden the calculus? Instead of just considering the usual variables (schools, taxes, climate, entertainment, etc.), what if people in various neighborhoods offered incentives to lure the doc there? Perhaps their spouse has a bad heart, or their child has seizures, asthma, or severe allergies. Having an ER doc seconds away might make the difference between life and death. Isn't that valuable? Of course it is; it is almost as good as paying an ER doc to be on-call for some potential emergency. People in a neighborhood usually don't know that an ER doctor is considering a move there, but what if they did? They might offer him an incentive to move there instead of somewhere else. Perhaps they would offer to purchase the lot his home was built on, if he stayed a minimum length of time—a decade, perhaps. Amortized over several years and several families, the cost could be very reasonable and the benefits priceless. This could be a win-win situation for everyone involved. If there is enough interest in this concept, I will serve as a matchmaker between interested ER docs and homeowner's associations or groups of neighbors who want an ER doc living nearby.

Review of
TRUE Emergency Room Stories
by Kevin Pezzi, M.D.
Book info Ordering info

Now available as a free e-book download

What really goes on in emergency rooms? If you're a fan of the television show ER, you might think that you know. Not so, asserts Kevin Pezzi, M.D., an ER doctor and author of True Emergency Room Stories. Pezzi says the show ER only scratches the surface; the truth is far more interesting — and bizarre. So bizarre, in fact, that the cases could shock even an experienced ER physician. "I'm now a firm believer in the saying that truth is stranger than fiction," he says. "I don't think that anyone could dream up such unusual stories."

Pezzi's book is packed with nothing but unusual stories. There are no "the patient's in v-tach, shock 'em with 200 J and give 'em 100 mg of lidocaine, stat" type of cases. While such cases are a mainstay of the show ER, Dr. Pezzi believes that they quickly become repetitious. Instead, he presents an amazing collection of true stories. The book begins with a story of how he may have saved Michael Jackson's life by averting an assassination attempt by a person who claimed to be a Cosmopolitan cover model, and ends with an interesting tale of how he was propositioned on a beach by a relative of a recent ER patient. In between, he recounts stories of unusual murders and other crimes, truly odd reasons for dialing 911, unfathomable reasons for visiting the ER, and people with an extraordinary affinity for their pets. Then there's a shocking end to a pregnancy, a twisted tale of revenge that would be a spellbinding plot for a movie, and the story of a man who attempted to remove his liver at home.

In this book, you'll accompany Dr. Pezzi as he meets the world's unluckiest man and woman, deals with people who have strange requests, and attends to a bride whose genetic disorder wasn't discovered until her wedding night. There is also the story of the man who didn't know that he had been shot in the head, and the case of the pit bull who picked on the wrong person.

True Emergency Room Stories has something for everyone. Besides the strange cases, readers will be captivated by dozens of incredible, tragic, humorous, steamy, heartwarming, thought-provoking, and poignant tales.

Recipe for putting fire into the veins of a person: have him work in the ER
Q: You're opinionated, you always have something provocative to say, and you write with an unparalleled intensity. Were you always this way? Michelle

A: No. When I graduated from high school, my only firm conviction was that anyone who bought a snowmobile other than a Ski-doo was nuts. I've since softened my position on that, but I've cultivated a number of other opinions after being exposed to the cauldron of medicine, and especially emergency medicine. If you throw someone into a fire, he'll either come out tempered or burned or both. I've been exposed to situations at work that are far more intense than most people ever experience. I know this because I've had almost two dozen jobs in addition to being a doctor, and I don't know of any job that is comparably intense. I suppose that other emergency workers, such as police officers and firemen, also have intense jobs, but their intensity is more sporadic and interspersed with long periods of waiting for something to happen (e.g., waiting for the fire bell) or doing relatively low-key things (e.g., handing out traffic tickets). In contrast, a doc in a busy emergency room can spend almost every minute in his career on an adrenaline high. It's been scientifically proven that intense events are far more likely to stick in your mind and form indelible impressions. This is why there isn't much of a market for shoe salesmen or dermatologists to write their memoirs; they probably can't recall anything worth writing about. ER docs have the opposite problem. Over time, this frequent exposure to stress molds docs and their opinions. If you think about some of the most colorful characters in history, they're usually the ones who've been under the gun. (Have you ever noticed the American penchant for wartime Presidents?) People have an affinity to vicariously experience intense events if they can't live them in real life, and so it's usually more interesting to read what someone has to say if he has TNT in his veins rather than Valium.

Too old for med school?
Q: My name is Casey and I was more than happy to come across your web site since I had been looking for one just like it. Anyhow, in the past two years I have thought about becoming an ER physician. My situation is as follows: I'm 24 and currently a junior at a regional state university in western Texas. My major is in kinesiology and probably will graduate in May of 2004. My grades are decent at 3.4. My question to you is: will a medical school admissions committee take into consideration that I will be 26 when I graduate with my bachelor's? What I mean is will my age reflect negatively on me getting into a medical school? Thank you, Casey

A: 26 is still young. Bottom line? Don't worry about it. I've never heard of a medical school worrying about the age of any applicant under the age of 30.

Years of medical school?
Q: Hey Dr. Pezzi, I read True Emergency Room Stories and loved it. I agree with everything you said about lazy welfare-dependents . . . what a waste of life. I'm 17 and a junior in high school, and I AM going to be an ER doc -- it's just what I want to do. How many years of med school are we talking about here? I have no problem with school. I took your advice and read all of Harry Lorayne's memory books, so I do excellent on exams. Just wondering how many years of med school an ER doctor requires, not counting residency. Good luck with the trash you get in the ER. Sincerely, Ian

A: Thank you for your comments.

I admire the fact that you are taking positive steps, like reading The Memory Book. Too many people SAY they want to be a doctor but aren't willing to do the preparatory work. You are, so you have a tremendous advantage over them.

Medical school is almost always 4 years. A few universities combine undergraduate education and medical school into one 6-year program. The duration of medical school does not vary depending on your eventual specialty.

Good luck and continued success in school.

Who does the dirty work?
Q: What happens to people who die in the ER? Who is responsible for removing tubes, cleaning up, etc? Thanks, Diana

A: Removing tubes? The ER tech or nurse (IF it's not a coroner's case, in which there will be an autopsy for legal reasons -- then the tubes are left in place.) Cleaning up? The housekeeping staff.

A: You're welcome, Diana. That was an easy question -- you should see some of the questions I receive! The last person told me he had a crush on his
doctor, and he wanted to know if it was ethical if she were to date him. I had a hunch about the correct answer, but I wanted to be sure, so I researched this and found the AMA's position on the matter, then forwarded it to him.

Do I have any words of wisdom regarding use and misuse of the ER?
Q: Kevin, I ran across your web site while doing some research for an article which I may or may not write for Odyssey, a magazine for 10 - 16 year-old kids with an interest in science. An upcoming issue will be devoted to the topic of Emergency Rooms. I am having trouble making myself work on this project as I spent a lot of time in ERs in my working life as a general surgeon and don't care to dwell on the experience in what is otherwise a nice retirement. Since I have written for Odyssey before and admire the job the editor does, I feel compelled to contribute something if for no other reason than to prevent this issue of the magazine from resembling some of the present TV shows. I think the remarks you make in your interview regarding blatant misuse of ERs are right-on. They remind me of the time when I was called to an ER at 3 a.m. to see a women who was perfectly healthy as far as I could determine. When I asked her why she was there she said that she had just gotten her Medicaid card and wanted to see if it worked. I was not a happy camper. The purpose of this diatribe is to ask if you have words of wisdom for kids, which I could pass along via this article, regarding use and misuse of the ER. Could I use some of the points you make in your interview, with proper acknowledgement, of course? Thanks for developing such a refreshing web site. Linda Bickerstaff, M.D.

A: Thank you for the compliment on my web site.

Hmmm, good question. In my experience (and your experience, too!), many people have an exceedingly low threshold for determining what constitutes an emergency. On the other hand, a few folks don't call 911 until 12 hours after someone stopped breathing (I saw such a case one day when I rode around with some paramedics during my residency). I suppose the trick is to dissuade the "low threshold" people without further repelling the "high threshold" folks. My first thought was to ask, "Does the prospective patient have a medical problem for which immediate treatment is needed?" However, this demands that a judgment be made, and I've learned that my opinion on what is a legitimate medical problem is far more restrictive than the opinions held by some people -- such as the guy who brought his ex-fiancée to the ER just after she dumped him because he thought I could convince her that she should still marry him (our tax dollars, hard at work!). Hence, perhaps it's best to give more concrete guidance, such as, "Is the person short of breath? Having chest pain? A change in heart rate or rhythm? A loss of consciousness?" Etc.

I wish I could be of more help, but I'm stumped!

Response from Dr. Bickerstaff: Kevin, thanks for your reply. I appreciate your willingness to let me use some of the points your make in your interview. I will use them judiciously! I appreciate your help.

ER changes in the past two decades?
Q: Would you please outline the changes you have seen in ERs over the past 20 years? Thanks, Gunnard

A: I'm not old enough to give you a 20-year perspective, but in the years I've been a doctor (since 1986), I think the biggest change in ER is the dramatic increase in volume. These increases dwarf the population increase, so the only explanation is that people lower the threshold every year for what constitutes an emergency -- or at least they do in the wacky ol' United States. Considering some of the cases I've seen in the ER (loose vaginas, diminution of penis size, belly button lint, farting, seeking romantic advice, etc.), I wonder how much lower the threshold can go.

Q: What things have hospitals done in the past to solve the problems in the ER?

A: I hate to be pessimistic, but after attending hundreds of meetings and seeing almost nothing change, I've come to the conclusion that meetings are held by people who love to hear themselves talk but don't care if anything constructive ever results.

Kudos
Writing a novel; wants help making it more realistic
Q: Dr. Pezzi,

If you can stand to hear it one more time: "This is an awesome web site!"

I am working on a second novel and am having some difficulty with the "realism" of a brief ER scene. I would greatly appreciate the advice of an expert, such as yourself.

After a drug overdose, a man is running a dangerously high fever. He is not breathing. There is no pulse. (#1) Where would the stretcher fly to? A trauma room? Or some other room? ... The man flatlines. (#2) If the doctor calls for epinephrine and/or atropine (which would he?), who actually administers the drug intercardially? Him or a nurse? (#3) What would the dialogue sound like in said situation? (#4) How many people would be present in the room, and who are they? (#5) How long would the doctor wait before using the paddles? ... Of course, the man is brought back from the edge of death. Cut to the man in the CCU in critical but stable condition. (#6) Who would examine him after such an ordeal? The ER doctor? A nurse? A specialist? THANKS SO MUCH FOR YOUR HELP. :) I look forward to hearing from you.

A: Thank you for the compliment on my web site. I haven't had time to add much to it lately because I've been busy working on a new book.

> (#1) Where would the stretcher fly to? A trauma room? Or some other room?

Most codes are run in the trauma room (that's true of every ER I've worked in).

> (#2) If the doctor calls for epinephrine and/or atropine (which would he?) . . .

Both could help.

> . . . who actually administers the drug intercardially? Him or a nurse?

First, intracardiac injection is antiquated. Second, it's usually an RN who administers the drugs. The role of the MD is primarily to:
-- Assess the patient, before and during the code.
-- Based on the exam and any available history (e.g., from family members), try to determine a likely reason for the code. For example, if the patient has renal failure, an abnormal blood potassium level may be present and needs to be addressed. If it isn't, the efficacy of the other drugs used (epi, atropine, etc.) will be reduced.
-- Perform certain procedures (e.g., intubation, central line placement) that are not within the province of nurses.
-- Monitor the effectiveness of the resuscitation efforts.
-- Monitor the cardiac monitor for changes in cardiac rhythm.
-- Keep an eye on any spectators in the room. For example, if the patient's wife is in the room and looks as if she's about to faint, unless someone catches this, there will be one more patient in the ER. In the time I've spent in the ER, I've prevented dozens of bystanders from nosediving to the floor, and one beautiful candystriper (volunteer) who, when she fell, knocked me to the ground. (I had bloody gloves on at the time, so when I darted behind her, I tried to catch her between my elbows.)
-- Think of the other patients in the ER. If there is one ER doc (as if often the case), that doc cannot afford to spend an hour trying to save someone who has almost no chance of living if spending that hour will detract from the care of patients who are critically ill or injured, yet salvable. In other words, the doc must look at the "big picture" in the ER and not fritter away time on a hopeless (or semi-hopeless) case. Or, if there are multiple codes running at the same time (I've run up to three simultaneously, with just one nurse), the doc must decide how to best apportion his time. There aren't any set rules for this because every situation is unique.

(#3) What would the dialogue sound like in said situation?

Not much. Often just "epi 1 mg IV" or "atropine 1 mg IV."

(#4) How many people would be present in the room, and who are they?

This varies from hospital to hospital. I've worked in small ERs in which the entire ER team was one doc and one nurse, and large teaching hospitals in which I'd see so many people in the room I'd wonder, "Who the heck ARE all these people?" Often they'd be gawkers from other departments of the hospital. The core team would be the ER doc, a few nurses, a respiratory tech, a lab tech, an ER clerk, a patient representative, the head nurse of the hospital, some residents and medical students, etc. With so many people present, I'd often need to order all non-essential personnel out of the room.

> (#5) How long would the doctor wait before using the paddles?

That depends on the cardiac rhythm and several other factors.

> (#6) Who would examine him after such an ordeal?

In this country, usually a personal injury attorney digging for dirt. OK, I'll be serious . . . usually the CCU nurse and doc. Again, that varies with the hospital. I've worked in some small hospitals that had no dedicated CCU doc, so I'd often leave the ER to check on the patient. Also, I'd sometimes start my day by checking patients in the CCU to see who might code during my ER shift -- because if they coded, I'd be the one coding them. A stitch in time saves nine . . . that proverb is applicable to medicine, too. Whenever I'd take steps to ward off a possible code, that code never occurred.

Licensure required? Job description?
Q: What type of licensing do you need to become an ER doctor? Also, what is the job description?

A: To work as an ER doctor you need a full, unrestricted medical license. That requires 4 years of college (usually), 4 years of medical school, and typically 3 years of ER residency.

Job description? A physician who attends to the medical, surgical, psychological, and social needs of patients presenting to an emergency department.

What licensure is required for doctors?
Q: Hello. My name is Natalie and I'm considering going into the field of medicine. I was just wondering a few of the following things:

- What Schooling is required?
- What degrees do you need?
- Any certificates?
- What registration qualifies you?
- What licensure is required?

Thanks a lot. ~Natalie~

A: I answered most of those questions on my web site. To answer the other one: "What licensure is required?"

To independently practice medicine, a doctor needs a full, unrestricted medical license. (Medical interns and residents have "limited licenses" that allow them to practice under the supervision of a fully licensed doctor.) Medical licenses are issued by the states after an applicant has completed medical school, undergone postgraduate training (residency), passed the qualifying examinations, and paid the fee (which is currently over $500 every three years in Michigan).

Many comments on my web site, and topics therein
Q: 3.8 hours . . . that's how much time I just spent reading through the many pages of your website. ;-) That said, I'm sure that's a mere fraction of the time you've invested in writing all the words I just read, so thanks a bunch for putting it all together.

Anyhow, I can't say that I'm writing a report for school, nor am I a 14-year-old girl planning on changing the world by becoming a doctor, but here are just a few things I thought of (among many others that I can't recall at the moment) while perusing your website:

A: (I'll intersperse excerpts from his long e-mail in my response.)

> I sometimes wonder how much students in high schools and colleges really know about the nature of practicing medicine today and the potential of the profession in the next couple decades, assuming things progress as they are.

For as long as I've been a doctor, things have become worse every year: more regulation (even to an absurd and insulting degree, such as the regulation of Hemoccult testing), higher insurance premiums, more patients, and less pay. I'd be more optimistic if there was some light at the end of the tunnel — some glimmer of hope that this trend would reverse course, but there's no indication of that.

> In any event, I can't help but feel that if it weren't for shows like ER and Scrubs and whatever else is out there these days, applications to medical school would be decreasing even more than they have been.

I agree.

> Incidentally, I've been to a lot of places in the U.S. in my life, and the four "fattest" states I've witnessed are Michigan, Ohio, Indiana, and Wisconsin. Any ideas on why this quadrant of Great Lakes states is so rotund?

Some scientists suspect the obesity epidemic may be linked to adenovirus infections (Ad-36 and, I think, Ad-37). There may be something to that, but I heard one person quip that it's funny how that infection only infects people who overeat and don't exercise. When I was a resident I was fat for all the predictable reasons: too much food, and not enough exercise. No adenovirus infection that I know of . . . .

> That said, even if many more women are now capable of supporting themselves financially, it would seem to me that the desire to be loved and to ultimately have children and raise a family would still be strong enough to encourage women to watch their appearances in order to attract suitable mates. The biological and social urges to reproduce are still as strong as ever in women as far as I can tell, and I wonder why this isn't enough to convince women that they should stay in better shape?

There's been a relaxation of competitive pressure. People compete for spouses, and when the competition is weak, there's little need to lift a finger. Given that there are so many obese women in Michigan, most men must either choose between putting up with someone who is fatter than they'd like, or being alone. If there was a sudden influx of slim women into this state, the native women who don't feel a need to keep in shape would either need to lose weight, or THEY would be alone.

> Anyhow, just wanted to see precisely what you meant when you mentioned "sunk costs" in life. Do you mean to say that they should not be considered when making future decisions about life, career, etc., or that they inevitably will be considered?

I meant that they should not influence one's decisions regarding the future. If a person spends over a decade becoming a doctor and hates that profession, the fact that he invested so much into that career should not dissuade him from walking away from medicine. A doc may not have that luxury if he has a family to support --- which, now that I think of it, is probably the only reason why most doctors don't quit practicing medicine. I've heard so many say that they hated it, but they had a wife, two kids, a mortgage, and student loans.

Teacher thinking of having a leech suck his blood to entertain his students
Q: Hello doctor. I am an advanced high school biology teacher. I have read a lot about medicinal leeches and how they can be used to drain inflamed areas after surgery, and how their saliva contains anticoagulant and other fun stuff to prevent infection and keep the blood flowing.

I would like to do a shocking demonstration for my students in which I allow a leech to bite into my arm, drink blood for a bit, and then remove it by stroking it with alcohol. I know that this will probably cause continued oozing for about a day. But I am sort of a crazy high school biology teacher. Do you think that this is too crazy of an idea? Carlos

A: Yes. I'd love to be able to answer your question, but there are too many bloodthirsty lawyers -- leeches themselves -- in this country to make it feasible for me to give you the green light to incur a possible risk when there is no medical benefit. It'd be one thing if I knew your complete medical history AND was your personal physician, but even then I'd be reluctant given there is no medical indication. Instead, why don't you regale your students with just a lecture on this subject?

What is harder: OR surgery or working in the ER?
Q: Is it more difficult to be an ER doc, or to do surgery in the OR? Eagerly awaiting your reply, Christine

A: Surgeons would likely claim that it's more challenging being a surgeon than an ER doc. Rather than give you my (biased) perspective, I'll give you an answer from someone who is both a surgeon and an ER doc:

"Working in the ER is far more challenging than doing surgery in the OR. The OR is a very controlled environment, and you don't waste any time dealing with recalcitrant patients -- as so often happens in the ER. Also, in the OR you have ONE PATIENT. In the ER, you often have dozens of patients, and it is not uncommon to have many who need your attention RIGHT NOW. Just when you think things can't get any worse or more chaotic, ambulances will often show up with multiple victims of an automobile accident. Now that's stress. In comparison, OR surgery is a walk in the park."

How can a medical school applicant stand out from the crowd?
Q: (Long e-mail, the crux of which follows:) In essence, I guess what I am asking is where do I go from here? How do I stand out more? My dad has several cousins who are doctors, including my family physician, who I don't know very well. I have thought about shadowing them, but in reality what good is that? Danny

A: I agree. It's too blasé. Amongst medical school applicants, shadowing a doc is almost as common as breathing, so if you do it, you won't differentiate yourself from the hundreds or thousands of other applicants who are similarly vying for attention. If you want to stand out, you have to really stand out. You can do that with exceptional grades or MCAT scores, but admittedly they can be as hard to get as a date with the mesmerizingly beautiful Shannon from the first The Bachelor miniseries. If you have good but not great grades, you still can stand out from the crowd by doing something exceptional. For example, as I discussed elsewhere on my web site, you could make the Admissions Committee take note of you by designing and building some medical device that does not currently exist. Sound impossible? It's not. It only seems daunting because of the myriad steps involved. For example, I once made a programmable robot that mowed my lawn by itself. Making each one of the parts was not difficult -- it's just that there were a heck of a lot of parts! Fortunately, making some medical devices is considerably easier than making a robot that traverses variable terrain and conditions, so you needn't forsake the best years of your life to make such a device. If you'd like to see a few of the medical gizmos I've made, they're pictured on my page of medical inventions.

If there is enough interest in this, perhaps I'll offer a workshop in which I teach the fundamentals of building electronic devices, from circuit design, layout, and prototyping to actual production of functional units. I'm already mentoring a 15-year-old girl who aspires to become a doctor who wanted a way to stand out from the crowd. She will.

Is getting an MD degree a route to romance?
Q: I wish I could tell you that I have altruistic reasons for wanting to become a doctor, but the anonymity of the Internet gives me the freedom to tell you my real reason: I think I'll have a much easier time getting gorgeous women to date me. I know that TV shows and movies probably overdo the romance bit, but isn't there some truth to the fact that having an MD after your name will turn you into a babe magnet?

A: To some degree, yes. In retrospect, I've dated women who probably wouldn't have dated me had I continued my career in lawn mowing. Funny thing is, I've met some people who mow lawns who make more than doctors . . . and they only work six months of the year. Now who's smarter? OK, I'm digressing.

Yes, I've dated some stunningly beautiful women, but it's an unsettling experience (at least for me) to not know why someone wants to date you. Is it me? Or my house? Or my paycheck? Or my gizmo collection? (OK, it's not my gizmo collection!) I wish it were feasible to follow the advice of my mother, who suggested not divulging my occupation. Unfortunately, that isn't practical in this country. In the United States, when people meet, the first or second question they usually ask is, "What do you do for a living?" I've been told that it's different in other countries, such as Russia, in which the focus is on learning details of the other's family, not occupation (perhaps because the pay is so abysmal there!). Keeping your house a secret is similarly difficult, especially if you wish to, ahem, avail yourself of the romantic opportunities afforded by the ol' MD degree. However, I solved the latter problem by selling my 3500-square foot mini-mansions and moving into a very modest home. If I ever get married, I'll move "back" if that's what my wife wants, but for now I'd rather not spend my time taking care of such a large home.

In regard to your statement "I know that TV shows and movies probably overdo the romance bit . . . ." In my experience, Hollywood may overemphasize the frequency of romance involving doctors, but the actresses portraying those women are, strangely enough, often less attractive than the women doctors date in real life. If you've ever seen my picture, you know that my appearance isn't commensurate with that of some of the women I've dated.

Do female drug reps usually flirt with the docs?
Are docs faithful husbands/boyfriends?
Q: Hi. My boyfriend is a cardiac surgery fellow at Stanford and I'm wondering about the drug reps. The other day he told me they had this very "Hollywood" drug rep visit the OR and that all the docs were talking with her. Do female drug reps usually flirt with the docs? And do docs (generally speaking) make faithful husbands/boyfriends? Thanks, Nancy

A: Did you read the section on my web site where I discussed drug reps (specifically, beautiful drug reps) and how they use their pulchritude to entice
doctors?

> Do female drug reps usually flirt with the docs?

Yes.

> And do docs (generally speaking) make faithful husbands/boyfriends?

No. I think the incidence of infidelity is much higher in the medical profession, if for no other reason than doctors have so many more opportunities than other people. I'm not into that stuff (having a healthy fear of contracting some sexually transmitted disease, or getting someone pregnant that I don't want to marry) BUT if I were into sleeping around, I could have slept with hundreds (perhaps thousands) of women. Not all drug reps, obviously. Patients, relatives of patients, nurses, other hospital personnel, the FedEx lady (that story will be in my next ER book), people who knew I'm a doc, people who read my books — I've had many opportunities. And I'm not always very affable! If I were, the list would likely be even longer. Believe me, I'm not bragging because it wasn't ME they were after — it's the notion of "bagging a doctor." I can't understand the attraction, but I've seen too many examples of women gloating over their "catch" to make me think that there isn't anything to this "bagging a doctor" thing. Obviously, some women who date docs have substantive reasons for doing that, but other women just relish the conquest. The bottom line is that docs have an easy time finding sexual partners — even the ones who you might think wouldn't be inclined to sleep around. The sister of one of my friends is married to a doc who is not the epitome of a stud (actually, milquetoast is more like it), but even he slept around a lot (and ended up with herpes, not surprisingly). Have you heard of rock groupies? Well, there are medical groupies, too. Lots of 'em.

Q: Thanks for the response, Kevin! While doing social work in the hospital atmosphere that is what I've noticed — but it's nice to have my thoughts reaffirmed. However, my boyfriend says it's usually the uneducated women who have the dream of being with a doctor.

Unfortunately, I didn't see your section on drug reps. Would have made interesting reading. You know, I don't think that docs are necessarily great catches due to the fact that there are so many of them (nothing special).

I've heard that docs should get new wives every 10 years because after 10 years their 'old wives' are tired of the lifestyle/bitter. Especially the ones who stick with their husbands through residency/fellowships and moving around everywhere (the docs with high-demand type fields and are academically motivated) and no time with husband.

I guess I should keep my options open. :-) Thanks, Nancy

PS: Have you visited Stanford Hospital? It's strange, but in the cardiac surgery department the chair hires all foreign medical school graduates for the fellowships (including my boyfriend who went to Oxford).

A: The next time I find that section on beautiful drug reps I'll forward it to you (finding something in my web site can be difficult — even for me! — because it is so extensive).

> However, my boyfriend says it's usually the uneducated women who have the dream of being with a doctor.

To some extent I agree with him, but a couple of women with 150 IQs were interested in me. One turned out to be . . . well, let me euphemize her
shortcomings, and just say that she needed a psychiatrist, not a husband.

> I've heard that docs should get new wives every 10 years because after 10 years their 'old wives' are tired of the lifestyle/bitter.

That's one reason I wonder why some women value doctors so much — the lifestyle can be arduous.

> I guess that I should keep my options open. :-)

Hey, I'm still single! :-) Ever think of moving to Michigan?

> Have you visited Stanford Hospital?

Nope, never been there, but I read (& reviewed for my web site) a book by a female neurosurgeon at Stanford (Walking Out On the Boys). Quite an
eye-opener. By the way, it also discussed how rabid some docs can be about sex. What's that saying about how power corrupts?

Does cold prevent erection?
Q: I was raped last winter. The prosecutor believes me, but my boyfriend doesn't — he doesn't think a man can get an erection when it is as cold outside as it was when I was raped. Will you please set my boyfriend straight? Thanks, Kim

A: I wonder where your boyfriend got the idea that exposure to cold precludes erection? Granted, cold isn't conducive to sexual activity, but it certainly doesn't prevent it. In True Emergency Room Stories I told the story of a patient I'd seen who was sexually active with a man in a parking lot while it was way below zero. No doubt they would have preferred a warmer environment, but the woman's husband was inside.

A: It would likely help, but not by much. Even Mother Theresa wouldn't be accepted into medical school unless she had relatively high grades and MCAT scores.

Q: I think I should have been more specific. Would going on a medical missionary trip, or any medical trip to a foreign country for that matter, help my chances of getting accepted into medical school? Amy

A: Going on such a trip would manifest your dedication and industriousness, so it'd be a plus. The question is, how much of a plus? For the answer to that, consider the following extreme. Imagine someone who spent his entire life doing medical missionary work. If that person applied to medical school, would he be accepted? Yes, if he had good grades and MCAT scores. Now imagine that this person spent his life obsessing over Tina Panas (a.k.a., Tina Fabulous) from the "who gets to marry into the Firestone fortune" The Bachelor mini-series. Would he be accepted into medical school? Yes, if he had good grades and MCAT scores. See a pattern developing here? I don't mean to imply that extracurricular activities are unimportant, because they would likely increase a person's chances of medical school acceptance — but not by much, and certainly far less than stellar grades and MCAT scores. Other than grades and MCAT scores, some factors increase the probability of acceptance, but these factors are not under your control. Examples? Are you a woman? A minority? Do you have a rich or powerful parent or relative?

On one hand, I'd like to tell you not to worry about getting into medical school, because I know you, and I know you have what it takes to get in and become a good doctor. On the other hand, people who are destined for successful medical careers often doubt whether or not they have "the right stuff," and it is these doubts that propel them to ever-greater achievements. On my first day in medical school, if some little genie tapped me on my shoulder and whispered in my ear that I was guaranteed to graduate from medical school, would I have worked as hard as I did? No way. As a result, I would not have done as well as I did, and I would not have graduated in the top 1% of my class. I would not have had my ER residency program so eager to get me that they worked out an under the table agreement (such things are supposedly prohibited, but they happen anyway). In fact, I may not have become an ER doctor at all, because competition for the limited number of ER residency positions is fierce.

What I'm trying to say is this: a bit of anxiety is good. It impels people to try harder, and thus achieve greater success.

If you want a beautiful garage that is easy to keep organized, see the GarageScapes web site: www.GarageScapes.com.