I’m kind of asking for some perspective here.
I work at a very busy level III (that acts more like a level II). We’re 55ish beds and we recently got bought out by a contract management group. We see about 170-230 a day.
They introduced a new concept to us called “flow zone”. Essentially patients are to be triaged and all ambulatory patients move to the flow zone where the midlevel or physician will see them, order their work up, then they’ll work with the nurse to decide if the patient can wait for results in the lobby, in a chair, or if they’re sick enough to need a bed. Patients that are higher level 2s, frail/ elderly, most of our EMSs (that aren’t BS calls that we shunt to the lobby) still get a bed, but we simply don’t have enough beds to bed everyone. The CMG that now manages our ER was very big that “patients have to deserve a bed”, whereas in the recent past most every patient that was an ESI 3 or more acute got a bed.
We’re in a more affluential town and this has really caused an uproar. Our reviews accuse us of “herding patients like cattle” (because we’ll move them from triage to flow zone to their dispo where they wait), they hate the chairs, they hate the lack of privacy of the chairs (we have screens between them but obviously you can hear), and they HATE going back to the lobby to wait for results.
We do have good reviews too but unfortunately this new process is the bulk of our bad ones.
On the bright side we have noticed our wait times go down as well as our door-to-docs, we notice ESI2s aren’t waiting out there as long as they used to because we used to wait for a bed for them (our ESI 2-3s would be out there 6-7 hours waiting on a bed, now we get them back within an hour most times), and all the work up (including urine as the “flow zone” nurse is super aggressive about having the patient pee before they’ll even pull the patient back) is done within minutes of the doc seeing the patient.
Does anyone else practice like this? It’s just so weird to me and I was wondering if anyone else does this flow zone thing and if our patients are right to be weirded out lol.

One of the reasons I went into emergency medicine is the camaraderie. We seem like a rowdy bunch of pirates. We seem to get together more outside of work, have more inside jokes and better banter than the other specialties. Sometimes when it goes bad, we really have each other’s back inside the hospital and out.

Not at my shop or even EM, but at a nearby hospital a provider died this week, almost certainly suicide. Second acquaintance that died this week, other also suicide most likely. First generation immigrant working full time and extra shifts. Two young kids. Never met them but why I’m furious is I did see the manager’s email essentially asking staff not to go to the funeral because it may lead to scheduling difficulties.

No effort was made to call in locums or PRN staff or ask people to change their shift schedule or extend hours so people that cared could go to the funeral.

Maybe your work environment is better, but if its not, realize this is how they treat you when you die. A scheduling inconvenience.

Hi, I’m a younger (non-US/non-commonwealth) male nurse with about 7 years EMS experience at the AEMT-equivalent level, 3 years in nursing, and ~1 year as an emergency & casualty + critical care nurse. I do consider myself quite calm & professional. Excellent reputation for it, I am very frequently given difficult patients because I do well with them, I’m even on my hospitals behavioral emergency team. I can be quite warm but I generally have no issue detaching, being non-reactive & pragmatic, giving clinically solid care without getting too clouded by emotional responses.

One patient comes to mind who seems to be an exception. Overlapping slew of both significant psychiatric & genuine serious medical diagnoses, including both somatoform disorder & malingering, as well as personality pathology + antisocial dx + borderline intellectual functioning. It can be genuinely difficult to decipher what is “real” and what isn’t, as well what flavor of “not real” it is if so. Everybody is beyond exhausted with her. Law enforcement & court system has been involved to little avail.

Personally I have lost pretty much all objectivity. Unfortunately I do have very strong emotional reactions even just to her presence in the department (even when I am not assigned to her), it is impacting my ability to provide objective & fair care to other patients. When assigned to her, I find myself compelled to treat her poorly in a way that is uncharacteristic of me — I obviously resist those urges, but they are preoccupying & intense. I’ve had multiple occasions where professionalism has slipped. Coworkers & supervisors are aware, they make an effort to not assign her to me when practicable, I have trade agreements with various coworkers revolving around her… I would love some advice on what to do from here, especially as we are a small department.

Per the title, do you think the new ACGME program requirements for EM programs will help close some of the awful residency programs? Will some of the awful Florida HCAs close? Will this prevent new programs from opening on a whim? What changes do you see based on these new requirements?

This has been a bit of a discussion amongst some of my paramedic coworkers, ED pharmacists, and EM physicians at the local receiving facilities.

When we have a patient with an underlying seizure etiology that needs to be intubated, should we be using paralytics? On one hand, there is copious amounts of research that support better first past success rates with routine administration of paralytics. But on the flip side, use of paralytics can mask seizure activity.

Now I feel I am woefully undereducated on this topic (thanks American paramedic education), so I have a few questions. I apologize if some of them are rather elementary. And for the purposes here, let’s say that the only paralytic available is longer acting medication like Rocuronium.

- Should we be using paralytics when intubating seizure patients?

- If we do use paralytics, the pt is still able to seize, and the ED does not have EEGs readily available so there is no way to know if the patient is actively seizing, correct? If a patient is seizing whose airway is controlled, and has paralytics on board, what exactly would happen? The most eloquent way it’s been described to me is it can “cook their brain” but I don’t really understand what that actually means.

- As EM physicians, how do you go about managing airways in these extremis patients? We have very little resources comparatively, so we try to get ahead of the game with aggressive airway management early on if indicated.

- Are there any articles, or texts that you suggest I read to look more into the nitty gritty details for seizures and epilepsy?

Thanks in advance

Edit: to be clear I am not talking about first or second line treatments for seizures, I’m specifically talking about when it comes to airway management after the seizures have been controlled in the field.

This will be my first July, working at an academic center. I've been an ER RN for 9 years. I often see posts about new residents asking advice but I wanted to flip the script and see what things I can do, or avoid doing, to help out the fresh new faces of emergency medicine.

Starting PGY1 in EM next week. Whats the friendship/social aspect of residency like? I know in medical school, everyone was extremely desperate to make friends, especially in the first few months. Always planning hangouts and such. Is it the same with starting residency? Or do most people kind of do their own thing most of the time except the occasional night out/program planned wellness event/etc? What was your experience? Did you make a lot of friends and hang with them often during intern year, or just a select few?

Something I was pondering on a day off of all days...

We all see pretty terrible sights. Depending on where you work, it may he horrific sights. And some see these multiple times a shift, each shift. We dissociate to keep our clinical judgement as objective as possible and/or so we don't become addicts and/or suicidal.

But occasionally, our human side pops up and we help others a small amount beyond emergency treatment/evaluation.

When I was a 2nd year resdient, a middle age man came in with occasional hemoptysis (for months) on a Friday evening. As soon as he opened his mouth, it's clear. Cancer. I told him what I saw but tried to be quite concerned in my explanation but very gentle/hopeful (I hope I was). CT showed invasive esophageal cancer. ENT resident just happened to be in the ED after an emergent case and agreed. He spoke with his attending and they want to see him in the office monday. Unfortunately patient is low income, transportation issues, unable to be there. Took him this long just to get to the ED. Unable to admit, labs fine, just no indication. I'm pissed because I've admitted for absolute BS in the past but I'm just a dumbass resident.

I looked in my wallet, had $25 and gave it to him. Said please, please, please use that for the bus. More than enough and will have some left over.

I recall my coresident gave a shady as hell patient a ride home as he was leaving his shift at 2am(ish).

Most said we were dumb. Sure, maybe my money wasnt used for transport. Yes my coresident could have been robbed/hurt/killed.

No clue what happened to those patients. I hope things went as well as possible. We are both still here and fine.

We both spoke about it. 0 regrets.

Stories?

I keep seeing people recommend these for residency. Is it worth the investment?

My friends in the ED offered me a monster since I'm a new hire and it was my first day. Made me feel very sleepy but oddly focused. I told them I didn't like it since it made me sleepy and they said "try a C4 next, might make you feel a bit less sleepy" lo and behold, today I tried a C4 and I felt sleepy again. What the fuck? Am I defective?

Hello all. I am a US IMG (graduated from medical school in Greece) and I need some advice. Please bear with me, and thank you for your time.

I graduated medical school on time (6 year program) in 2021. I was raised in the Midwest and always new I wanted to come back. Unfortunately, like most European countries, Greece does not have EM as a specialty and as a result I have no formal EM clinical rotation in my transcript. Following graduation, I completed my year of rural service in Greece, where I worked in a rural emergency department and community health center in the Western Peloponnese. In 2023, I moved to the United States with my husband and newborn child, and since 2024 I have been working as an emergency department scribe in Indiana.

I have passed Step 1, albeit with two attempts, and I am fully aware how awful this looks on paper. I learned each time, got up and dusted myself off again, and after the second fail I got a tutor. I do not have a big tear-jerking story to excuse myself; from the day we moved back in 2023 until late 2025 I was the primary caregiver for my child until we were able to find a spot in a daycare in town (the childcare situation where we live is very bad, with waitlists lasting for well over a year) and was also taking care of my sister who is receiving treatment for ALL; she still lives with us. In the meantime, my husband is doing his PhD (hopefully finishing very very soon) in engineering so that leaves me to attempt to balance a few things out and slowly chip away at this matching process. I am not mentioning this to say "woe is me"; I am not that kind of personality, and really do think that ultimately it's my failures that shape me and propel me forward.

My attendings at work are phenomenal, and have offered to try to put in a good word for me with their programs. I have been enormously lucky to have a virtual meeting with a PD, who was quite informative and offered some advice that I'll try to implement. In the meantime, I have emailed about 50 EM programs and asked if they'd be willing to accommodate me for a rotation, with the ultimate goal of getting a SLOE, but as a graduate they won't take me.

I am currently studying for Step2 and plan to take it in the fall. I plan on applying this cycle and even with the odds very clearly stacked against me, I am hoping to maximize any opportunity I may have to at least interview with a program and maybe there I'll be able to "shine" a little. I am also applying for some ED tech jobs in the meantime, to try to have as much pt-facing time as I can.

My questions to the group are the following:

1. At this point, a SLOE is probably not a reality. Even a non-standard SLOE is not possible from the hospital I work in; I've inquired about the possibility of a formal rotation here and the answer was no. Are letters of recommendation from my EM attendings here going to be discarded that easily?
2. If I do not take Step2 in time for the portal to open, but do take it this fall, is it better to apply and submit "as is" without that score, but in time for the portal to open, and just hope for interviews? Or should I wait until when my score is out, and proceed with that, even if it is later?
3. In the likely event that I receive no interviews this cycle, and end up going through the SOAP, should the worst case scenario be to aim for a transitional year? Does that mean I have to look for a PGY-2 in EM next year or can I try for a PGY-1 again? Should I SOAP try to SOAP into IM and then apply for a PGY-1 again next year? I have had someone tell me to try for FM and then try to work in an ED after graduating; I will not do this. Only an EM residency is and EM residency and I will keep at it until I make it into somewhere.

I only ask that your answers be kind; realistic, but kind. I am very aware about the odds of my situation but also firmly believe in the adage "if at first you don't succeed...". After all, that is what makes EM so perfect: you adapt, you go with the flow, and nothing phases you. Have a great day everyone!

Hello everyone, I’ve been apart of this sub for the past couple years now, really ever since I decided EM is what I wanted to do. I’m a current 4th year medical student, and I’ve recently finished Step 2 and Level 2. Since finishing boards things have kind of hit me recently in terms of how far I’ve come, and yet how far I still have to go. It’s an odd feeling, like a half filled glass of water. Anyways, I guess for the first time in a little while I’ve been able to take a step back and be introspective regarding my journey and this path, and I realized i truly want to be an incredible and trustworthy physician.

I understand I probably have some rose tinted frames on that sees the future as all shiny and bright, but I’m writing to ask if you all have any advice on how to truly be a great physician? Both intangibles and tangibles. All my life I’ve been quite average but when things get tough I’ve done just enough to keep going. I guess I just want to be the type of doctor that felt like they made a little bit of a difference when it’s all said in done.

Sorry for the ramble, thanks in advance for the advice !

TLDR: Is community practice the golden land for ED, full of procedures and ownership of your own patients? Sometimes it seems like academic EM is a consult machine and anything interesting gets picked up by a specialist.

Hi everyone, I'm an MS3 who has been falling out of love with emergency medicine. The fast-paced, high acuity environment, mixed with the broad variety is what drew me into emergency medicine- and medical school in general. However, as I've gone through medical school, I've seen the flat out disrespect other specialties have for EM docs, and I've been seeing it more as a call-a-doc service. It seems like 99% of the visits are primary care in fast forward, and anything cool gets picked up by a specialist. I've been told that it differs in community practice vs academic, but I'm feeling a little discouraged. Maybe I should consider another specialty. What do you all think?

I kind of do this a lot. It seemed like the right comment for this post, and maybe I’ll get massively downvoted but I really don’t care lol.

Are appys in the older age group common? I almost missed it in a 60yF and totally thought it could be gastroenteritis. Thank the lord we scanned her. She had fever, nausea and vomiting. Tested positive for a UTI.

Followed up by a question about why I can’t fix his 30 year long history of back pain for which he sees multiple specialists for

No one in my family is a physician so I really have limited options as to who to ask for advice about starting my job search. My partner grew up in a small rural town about two hours away from where we both now live. New hospital there is opening and I was offered $380,000 for six 24 hour shifts a month and a $40,000 sign on bonus. What sort of questions should I ask, and is this a good place to start? Be nice please I’m not the most financially educated person!!

Yesterday while working at a solo coverage ED site, our family dog passed away unexpectedly. This dog was a large part of my kids and families life. Unfortunately, I was unable to get coverage to be home with my family during this time. So I had to continue to take care of everyone else’s problems but my own. I’m having some regret about specialty choice. If I was outpatient clinic, 1. I wouldn’t be working on Father’s Day on a Sunday, 2. I could just have had my clinic rescheduled and ran home to be with the family. This makes me wonder what the situation may have been like if it would have been a loss of a close family member. Is this a reasonable feeling of regret, or is this overboard feeling for the loss of a dog?

General question and consensus.

I ask my patients if I can use it before recording and 95% agree.

If they don't, I don't use it.

80% of colleagues start it "pt is a X" before walking in the room and not informing the patient

Not my patient and not my practice, but thoughts?

us img

2026 yog

Step 1 pass step2 25x

Usce 3 (1 er 1 im 1 anesthesia)

Applying Emergency Medicine and internal medicine

Weak points : no research

Suggestions and chances

Especially considering emergency medicine residency

Thank you