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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, September 12, 2016

So you want to pursue Emergency Medicine?

Choosing your area of expertise in medicine often becomes a challenge for medical students. This is a crucial decision, as you will be spending 8-10 hours a day doing this job almost everyday for the rest of your life. 

This post is specifically targeted towards students who are thinking if they should consider EM as a career?
Emergency Medicine is a certainly distinctive specialty. It primarily involves the initial evaluation, resuscitation, and stabilisation of patients. EM was born in 1970, when the first EM residency program began in the US in 1970. EM in India is still developing and there is a long way to go. Currently, there are countless programs that are run by various organizations to fulfill the emergency healthcare demands of 1.2 billion people! However, the Medical Council of India recognizes only a few of these programs.  

At the outset, I would like to point out that there are pros and cons with every specialty. It just depends what do like doing the most. Here is what Emergency Medicine is like:
Unique features of EM as a specialty:
1. You get to see a wide spectrum of pathologies. Problems that you might come across as an Emergency Physician include drug overdoses, crash injuries, heart attacks, trauma, rape, abuse, and pregnancy complications. On the other hand there can be minor issues such a cold, sinusitis etc. EM always keeps you on your toes because you never know what you are going to see next. A child with fever or a homeless demented elderly man with sepsis. Patients from diverse socioeconomic, racial, and ethnic backgrounds will see YOU first with all medical and surgical conditions. So, planning how your shift is going to be is not an option! 
2. Triage: In the ED, the order in which patients are seen depends on the severity of their illness not on first come first serve basis. Life threats and sickest are treated first (Less acute conditions often wait for hours before seeing the doctor)
3. You see undifferentiated patients: Patients don’t come with a label of medical or surgical disease. It is you who is going to figure out what is wrong, whether it is DKA causing abdominal pain or Dengue fever or Acute Cholecystitis or it is a case of Acute Intermittent Porphyria!!
4. Procedures: This is your place to be if you are someone who likes to do procedures such as intubations, central lines, I & D, Chest tube insertion etc.
5. Do you like surprises?
Recognising who is sick and who needs intubation is a skill that comes with time but anticipation is the key. Thinking the worst possible outcome is the dictum in EM. Headache (SAH), Chest pain (ACS, Dissection), Back Pain (Epidural Abscess), Breathlessness (Pulmonary Embolism) and so on.. Get into the habit of expecting the unexpected.
6. Violent and difficult patients: Whatever happens in and around the hospital, it is the ED that faces the brunt whether it is due to overcrowding, violent patients, drug seekers, and criminals. Often they come to the ED and hurl abuses at you but you still need to stay professional and give the best possible care to them. For the same reason, policemen and other security personnel are always closely associated with the ED. This can make EM look intimidating and frustrating.
6. You make a difference everyday, every shift: It is privilege to be with patients during some of the most important times in their lives. Here is what an internist told me recently, “I was fed up adjusting the doses of Diabetic and Anti-HTN medications. EM sounds much more interesting”. He switched to EM after practicing Internal Medicine for 30 years!! 
7. Be the patient’s advocate: Frequently, you need to persuade the specialists about changing their decisions and deliver you ideas succinctly. This needs self- confidence and exceptional communication skills. Trust me, a wrong referral can turn over things over completely. 
8. Shift work: Emergency Medicine is practice in shifts of fluctuating lengths. They work a number of nights but the benefits of shift work include the ability truly to have time off when not on shift. You can easily plan shifts as per your choice. On the contrary, your circadian rhythm gets disrupted due to this. This becomes a major issue later in the career.
9. Are you open to Criticism?
Colleagues from other departments often question the clinical decisions and knowledge of Emergency Physicians without truly appreciating the situations that exist in the ED. It is easy for anyone to slam the Emergency Department. Be prepared to handle that. 
10. Burnout: All patients presenting to the ED may not need emergency care. Some seek their primary care in the Emergency Department because they did not get access to primary. ED's are frequently abused and used as in-patient wards which again can be very annoying. This may contribute to burnout. Scheduled vacations, fixed time for friends and family might alleviate burnout. 
11. You can’t follow up on your patients in EM: If you are willing to spend some extra time, this is possible. It can be done easily thru electronic medical records.
12. Financial pressures: In India, this is a significant concern. You cannot discharge any patient who needs emergency treatment but what if cost becomes a factor? Have clear existing protocols about this because as a physician you should not be discussing this with the patient. This can become a major source of stress for the physicians.


     Lakshay Chanana
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine


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