Emergency Medicine with Dr. Ed Walsh

Virtual Shadowing by MedSchool Coach brings you up close and personal with physicians from many different specialties. Walk through tough cases with each doctor and learn about their triumphs and the challenges that they face on a day-to-day basis. To view the video that this audio is from, and to take the quiz that is associated with each podcast, visit shadowing.medschoolcoach.com. Welcome to the Virtual Clinical Education Series. Our goal is to provide students with a shadowing, like clinical experience. It's obviously going to be very hard right now to do that because of the COVID-19 pandemic you're a person. Today we're joined by Dr. Ed Walsh, who is an emergency medicine specialist, Dan and I will spend about the first 15 minutes or so talking to Dr. Walsh about his journey into medicine and why he chose emergency medicine, and then we'll let him go through a few interesting cases. First of all, Dr. Walsh, I just want to say thanks for joining us today. I'm really excited to hear about emergency medicine. It's my pleasure to be here. Thanks for having me. Yeah. So, start with kind of a basic question. Why did you decide to go into medicine? Yeah, I had a very non-traditional background. I was a professional athlete right out of high school. I did go to college until I was about 29, and at that point I had made the decision to pursue medicine. I had a very interesting sort of academic background. It was pretty disinterested, but kind of an average student I was more interested in playing baseball than anything else, and that's what my focus was in high school, and my grades reflected that. And so, when my baseball career ended, I went into business and had a pretty successful career in the retail fashion industry. But then my mother got sick, and I remember traveling from New York down to Virginia Beach where I grew up to be with her while she was done with breast cancer surgery and her subsequent recovery, and I remember being struck by the physicians and doctors and nurses and techs who took care of her. And I literally drove home, packed my bags, moved down to Virginia Beach, to be with her. But also, at that point, I realized that I wanted to go pursue a career in medicine. So I enrolled in my local community college, and I started taking classes. I went to community college for two years, and then transferred to Virginia Commonwealth University in Richmond, Virginia, and got my degree, and then went to the University of Virginia School of Medicine, and did my residency there in emergency medicine. So a little bit of a slightly unusual background, but there it is. Right, wow, thanks for sharing that, Dr. Walsh. As someone who was more of a non-traditional applicant, do you feel like that was an advantage that you had going into the process where you weren't just going straight from high school and going to be a pre-med and trying to apply to medical school? You had done other things. Do you feel like that came up during your interview process, or in general when you were going to medical school? Absolutely. I can tell you that every male who interviewed me, all they wanted to talk about was baseball. So I would sit there, and I would sit and be ready to answer all these technical questions and be ready to recite the crem cycle, and we would talk about my early baseball, what it was like to live on Annabas in 1980s in Savannah, Georgia. The non-traditional background, I think, did help, but it's just in one way of doing it. I was always struck, and I admired my medical school classmates who were much younger than I was, but we're so together, so mature, and so dedicated, just because I knew when I was that age, I didn't have the maturity or the dedication or the commitment, so really pretty much anything except chasing baseballs around the ball parks. So I was always impressed by my colleagues who were much younger. I do think being older and non-traditional gives you a slightly different perspective, certainly, and that can be useful. That can certainly help a medical class. You learn not to get too high or too low. You tend to have a slightly more even keel. And I think that was helpful, it certainly brought some balance into the class. I think that can be an advantage in some ways, but I also think coming straight through and showing that kind of commitment, like a laser and having that sort of focus, is also an admirable quality. So I don't think one is better than the other. I think if I was going to advise, and when I advise my premedical students, I tell them, play up your strengths. If you're non-traditional, play up the why that's important and why that can be useful. If you're non-traditional, play up your academic background and the path that you take and how you have clearly set your sights on medicine. I think either way is completely viable. I just think it's important to, again, use the personal statement and your interview sessions to play up those particular strengths, especially as you can couch them under the guise of being a dedicated, kind, teachable team player who's going to be a great caregiver. I think that's super. Absolutely an answer. Moving forward a little bit, why did you decide to go into emergency medicine and did your background in sports being an older student, did that play any type of role there? It might have. It's hard to say. I certainly was in the ER a lot as an athlete, I broken bones and that kind of thing. I spent a fair amount of time there. I really, when I started medical school, wanted to be a pediatric oncologist. That was what I was really interested in. That's what I had done a little bit of research in. I had studied some of that, found cancer and working with children to be incredibly impactful during my shadowing experiences. When I got to medical school, I really wasn't sure in the first couple of years. I liked a lot of different things. I liked plastic surgery, I liked general surgery, I liked neurology, I liked biiatric neurology and these are very disparate fields and certainly they are not really related to emergency medicine. As I got into my third year and I realized as I started my rotations, I liked everything. I liked seeing kids, I liked seeing women, I liked seeing men, I liked the old young, I liked doing procedures, I liked being the first doctor to see the patient. I liked having a pretty broad array of skills in my armamentarium, I wasn't leisure focused on one part of the body. I can do it all to a certain extent. Now that's not to say that medicine doctors are experts, we're not experts in a lot of things. We are experts in some things. The whole jack of all trades, master of none, moniker for EM is I think misguided. We are experts. We're experts at managing emergencies and we're experts at airway management and toxicology and a myriad of other things which will hopefully discuss a little bit. I liked being able to see the length and breadth of the medical field. I liked procedures. I loved getting my hands in the people and doing things. Surgery was the loads you're confining for me. I always wanted to touch my nose or scratch something or do something, I just didn't feel comfortable in the OR and I didn't have the laser focus to focus on maybe a five centimeter square inch of the body for six hours and fix that. I admire the people who can do that. I think it's a wonderful skill. I didn't really have that. I'd say this is a former baseball player, I didn't really have the hands for it either. I didn't think I just had that natural gift that surgeons sometimes need. When I finished my third year, I was like, I like everything. When I delivered my first baby, I called my mom up on my OBGYN rotation and I said, I'm going to be an OBGYN. I'm like, everybody does. By the end of that month, I was like, I'm never going to be an OBGYN. But I'd like to learn babies and I'd like to see pregnant women and all the interesting pathology and embryology and whatnot. I began to do some soul searching and I had narrowed down between plastic surgery and emergency medicine and at the end of the day, I just wanted to do a little bit of it all. So that's why plastic surgery was the right move for me. I'm sorry, emergency medicine was the right move for me. Nice. I know a lot of students, including myself, when they're trying to gain clinical experience before medical school, they become EMTs. I found that personal to be very valuable in learning how to interact with patients and being there at the very first moment of patient-received support for the medical system. What are your opinions on medical students becoming EMTs or pre-meds becoming EMTs? And have you seen that it helps people? Have you seen that it's not really necessary and maybe there are other ways to get involved as a pre-med in terms of getting clinical experience besides just being an EMT? Yeah, that's a great question. Certainly, probably 90% of EM doctors have come up to the EMS sort of a training ground. I personally did not. I was not an EMT. I was working full-time, going to school full-time. I didn't have the opportunities. I shadowed a friend of mine who was an EM doc in Richmond and that's how I got most of my clinical experience. I was very lucky. And my best friend was a nephrologist at the University of Virginia, so I would travel and shadow her in clinic. So I had a couple of friends who were actually helping me get this great clinical experience. So I was not a firefighter or EMS person. I do think that is an extraordinarily good way to get training. Not only do you learn clinical medicine, you understand how the health system works, you also get great practical experience. You learn how to put patient on oxygen. You learn how to hook up a patient to an EKG monitor. You learn how to start IVs and IOs and all these other really incredible procedures and skills that are crucial to being a good bedside position. I will tell you that I did not come up to the EMS background, so I did not learn those skills. And my first day on the awards, I had no idea how to put oxygen on a patient or which tubing and where or how to light a Christmas tree or how to put pacer pads on a patient or how to start an IV. It's a dirty secret. I'm still probably the worst person in the department about starting IVs. I can do central lines, I can do a venous cut down, I can do a thoracotomy, but I can't have really bad IVs. I have the worst person on the depth chart for IVs. I think the EMS approach is a great way to go. It's not the only way. It's not necessary, but it is an absolutely, incredibly fruitful way to get hands-on clinical experience. The last question here before we go on to your slides. What has been the most difficult thing for you in regards to a career in medicine? Is there one thing that kind of sticks out? Well, I think there are certainly enormous challenges in healthcare right now. To me, I will start off by saying that I still love medicine and I still get and keep up to go to work every day and I can't believe people are coming to see me and they let me actually be a doctor. I still have that sort of pinched me kind of thing 20 years in. There are challenges in medicine, right? There are enormous wedges that drive a huge gap and a divide between the doctor and the patient. That space, in my opinion, is extremely sacred and we are allowed to step into that space with our patient's permission to try to provide care and relief suffering. There are enormous challenges, a raid that sort of again push us apart, whether it's the electronic medical record, whether it's big pharma, whether it's insurance and administrative hassles. and poorly conceived protocol-driven metrics in terms. They're, again, well-intentioned, but poorly conceived, that try to expedite care or treat patients like widgets. And that's just simply antithetical to the practice of medicines. This is a sacred profession. We've been doing it more or less the same way for almost 2,000 years. And we have got to get back to some grassroots where really the patient is in the crosshairs at all times. Right now, there's so much chaff in the way that sometimes it becomes very difficult to see exactly what it is we're trying to accomplish. You're not only in an individual encounter, but writ large as a medical profession. And I think those challenges will be part and parcel of the next generation or so. And that's where you guys come in. Hopefully you'll start to shake loose and figure it out how we can get back to getting closer and closer to our patients. So that's a challenge for me. That's one of the challenges that I struggle with. Okay. All right. I think we're ready to roll into your slides. All right. So you guys want me just to share my screen? Yeah. Yeah, that'd be great. All right. So I'm just going to roll through these fairly quickly. You guys will, you can of course, interrupt me if you have any questions or anything is unclear. So we're going to talk about the history of emergency medicine a little bit. This picture is a actually a left-sided thoracotomy, which occurs in patients who have penetrating injuries and have lost their vital signs. So this is life-saving procedure. I don't know how well you can see this. But there's a hole in the heart right here that's being ligated. And anyway, just an interesting picture in one of the more dire procedures that is done in our trauma-based in the United States and in emergency rooms throughout the country. Emergency departments, it may be surprising to a younger generation to know that any old days like back in the '50s, '60s and '70s, before the development of emergency medicine and specialty, emergency rooms were staffed by just random doctors with any myriad of training. It could be a neurologist, could be a surgeon, could be a cardiologist. It was whoever was working or moonlighting in the emergency room. And there was no specialty training, specifically for the types of patients that would present to the emergency department. So in 1968, the American College of Emergency Physicians was established to try to address this. The specialty was formed in 1979 and the ACGME granted emergency medicine independent specialty status in 1988, so not that old, really. So when I was training, the doctors who were training me were the first generation of emergency physicians, and it's very interesting to hear how things have changed and pivoted from their upbringing, their training to mine, to now, as I'm teaching the next generation, how things have changed and how they pivoted. It's actually a fairly interesting dynamic in such a short time frame. So the first resident graduated in 1969. The first residencies were established at the University of Cincinnati in 1970, and the first residency association was established in 1974. You can see how emergency medicine residencies have grown dramatically, almost exponentially. In 2000, when I was coming up, there were 971 PGI positions that's postgraduate year, so emergency medicine residents. Now, there are over 2,500 residency positions in the United States. When we talk about specialty selection, I think it was interesting to know what are some of the types of pathology that we see in the United States. And you can see a list of the top 10 causes of death in the United States. And if you look at this as an emergency room doctor, I look at this, and I see every day, I see patients with heart disease, cancer, strokes, COPD, accidents. I see upper respiratory tract infections. Right now, you could add COVID to that pneumonia and influenza slide. See that every day. I see diabetes every day. I see mental health every day. I see end-stage renal disease every day. And I see chronic liver disease and cirrhosis every day. So all of these patients funnel through American emergency rooms on a daily basis. It's a massive amount of healthcare that is being provided by emergency departments. Is there something you see most every day? Would you say? I see all of these pretty much every day. The most common chief complaint to the emergency room is abdominal pain. So undifferentiated abdominal pain is probably the number one reason people seek care in the United States. But I just worked to shift today. I saw probably 20 patients. I know I saw two cancer patients. I saw one acute stroke. I saw several patients with COPD. I saw two trauma alerts. So one car accident. One guy was beaten by some a salience. I saw a ton of COVID. As you can imagine, probably 50% of the patients I saw had diabetes. I saw three mental health patients. I saw one patient on chronic dialysis and two patients with renal disease. And I saw one patient with ascending colon angitis, which is a biliary and liver emergency. This patient is a very sick patient, septic from his infected gall bladder. So that's a day in the life of an emergency room. And I came home and my wife asked me how my shift was. And I was like, it's a normal day to day. That's a normal day. There wasn't anything unusual or a plan dish. It was pretty, pretty straightforward. And that's a typical day in the life. So I'm just going to go through the types of things you might see in the emergency room. Again, you'll see maybe somebody gets it by car. You'll see a 55-year-old guy playing basketball in the driveway with his son comes in chest pain and he's got a heart attack. Then you'll get called. They'll be a tone from the rescue squad that there is a 24-year-old male with a self-inflicted gunshot wound to the face. That's your picture on the right there. That was a shotgun blast. This is his jaw. That's his tongue. And this patient actually survived this injury and did quite well with some extensive cosmetic repair. Then you may go see a couple of kids or have an ankle sprain or a sore throat, catch a breath, and all of a sudden you get another tone. There's an ambulance coming in with a 60-year-old person CPR and progress. And then you'll go to your next room and it'll be a five-year-old with asthma. Maybe not so sick, but still wheezing, worried mom, worried dad. Kid looks like they're struggling. Then you'll see a 75-year-old patient with COPD. Then you'll see the societal ills that tend to funnel into the emergency room. The mental health issues and the substance abuse issues. So you may see a 45-year-old alcoholic whose mom may blood and is unstable. And then you'll see a relatively well-appearing three-week-old kid with a fever. But even though they're well-appearing, three-year-olds are sometimes hard to evaluate because they can't really give us a lot of clinical clues. So one of the analogies that is often described to emergency medicine is it's like walking through a minefield with clown shoes on because it's such an incredibly difficult day to plan for. There is no plan. Everything can change in a moment's notice. And this three-week-old with a fever who you think may be the healthiest one in your department, maybe the sickest, and you just don't know. And so when you have to have that vigilance, and you have to have that antenna up if every room, no matter how prosaic or mundane the complaint may seem, the emergency department doctor and their entire staff are constantly tasked with what is the leg threat today. So if that three-week-old comes in with a fever, it's what's going to kill them. Not to sound flip, but that's really how you approach your differential diagnosis from a top-down sort of perspective. So you're thinking immediately, "Okay, this gets septic." Do they have meningitis? And were they immunized? Are they suffering from pneumonia that's now gotten into their bloodstream? So you're always worried about the leg threat first. And then you see, again, as I said, all manner of patients. So now you have a 37-week pregnant female with vaginal bleeding who may be in pre-term labor and you may be delivering that baby in the hallway. That's always a good day in the ER when it goes well. When it goes bad, it's pretty awful. But fortunately, this does have a good, pretty well. Very interesting, Dr. Walsh, how you can see such a large variety of cases and patients in one single day in the emergency room. And it's actually a unique sort of way you approach the patient too, like you were mentioned, what's going to kill the patient first? Like, when I was on my emergency medicine rotation a few months ago, I had to kind of change the way I thought about it, rather than thinking of most likely differential diagnosis. It's what's the most deadly or the most dangerous diagnosis. And go that way and make sure that it's none of those things. So it's like playing the game backwards in a way. In a way it is, right? And I'm a baseball guy. So I always think of us in the emergency room as like, we're the catcher on the baseball team. We're the only ones facing the field. Everybody else is looking into the batter. We're the only ones on defense facing out. And we do have that different perspective. So that's a very important point that you bring up. And you do have to reorder your thinking. And we think differently than other clinicians. And so as often, there can be some professional dis sort of harmony there where the cardiologists may say, well, look, this is obviously not a stemmy. And my whole, a stemmy is a SC segment elevation, my cardio infarction to a heart attack essentially. And my whole first five, 10 minutes with that patient, is this patient having heart attack? Are they having heart attack? Are they having heart attack or is there aorta exploding? Are they having a huge pulmonary embolism? I'm thinking what is going to kill this patient? And how can I rule that in or rule it out? And how can I most appropriately apply the appropriate clinical decision making and medicines and therapeutics to this patient as quickly as I can? Meanwhile, my colleagues on the other side of the fence are saying, well, this is clearly not this or this. And I'm like, well, it could be. And I have to make sure that it isn't. So there is some sort of, there is a slightly philosophical perspective shift there sometimes. So again, just some interesting slides. You see, clearly sometimes the diagnosis is pretty straightforward like this one, sometimes job is not. And then continuing along with those more interesting cases, the ones that kind of grab the headlines. You'll see all these other things. These other prosaic sort of mundane kind of things. Like a 25 year old with an undifferentiated rash, a spousal of abuse. You'll see homeless patients who come in because they have nowhere to go. It's 10 degrees outside. They know that you are as open, it's warm. They can get a meal there. There may not be a shelter available. And so they'll come in. For no other reason than they either need TLC. They need just to talk to somebody. They may have mental issues. They may just want to get a cold and get a meal. And sometimes that's our role in those cases. And personally, I have colleagues who find that objectionable for me. I feel like anybody who comes to the emergency or I'm going to ask us for help. Yes. it, which is one of the really cool things about emergency medicine and one of the things that I didn't really become aware of until I started practicing in residency. There are several federal laws that mandate that, which I think are, again, well-intentioned, but there are downstream consequences, we won't belabor the point there. But one of the coolest things about my specialty is that anybody who comes to my hospital campus and asks for help gets it from my emergency department. Whether they can pay or not, whether they're from this country or not, no matter what. I think that gets overlooked sometimes, and it's one of the things that I think emergency medicines have an enormous amount of pride about, and I certainly share in that pride. But you'll also see patients with chronic migraines and back pain, the things that aren't exciting in the sense that they're going to be immediately life-threatening or life-altering, but these patients are miserable, they're very uncomfortable and providing relief is part of the job. Certainly, that's why we all go into medicine, right? We want to relieve suffering and be careful to sick. So another cool thing about emergency medicine is that you can practice almost anywhere in the world, and you can fashion your practice in so many different ways. You can work in a big city. You can work in an Indian Reservation in the middle of the Midwest. You can work in a community suburban hospital, which is where I currently practice. You can work at a teaching university, a big multi-center tertiary care center, have every service specialty known to man, work with some of the brightest and most brilliant clinicians in their fields, or you can work in a community hospital and practice out on your own, which is where I work. You can travel all over the world. Low countenance means you just show up and work for a short period of time and you travel. Maybe at 12-week contract, you can see parts of the world that you never thought you would see travel all over the country. There are enormous international opportunities. US residency trained EM doctors are incredibly sought after. You can work in Zealand, you can work in Africa. There's just so many different ways to get your emergency medicine career on track. There are, of course, their world opportunities, and interestingly, cruise medicine tends to be an emergency medicine friendly. They like emergency medicine doctors because of the length and breadth of our training and the fact that we can handle all comers. One of the things, again, that I really liked about emergency medicine was that you are able to make an immediate impact on patients' lives. Even if it's something as prosaic as a small maceration, your patients come in, they're obviously terrified. They're worried. They're worried about the cosmetic implications. They're worried about pain. You can fix them literally right then and there, again, a sprained ankle. It can also be an open, fibular fracture that you have to reduce at the bedside. You will see life-threatening injuries and illnesses that require immediate action on your part. We're literally seconds count, and that is enormously rewarding when you are able to apply your trade in such a way and such a patient. You have an undifferentiated patient population. You literally see the 99% or the 1% or so in everybody in between. There are two types of people in the world, either like the challenge of, I have no idea what's going to happen in the next 45 minutes, next 35 seconds, or you hate it. If you hate it, emergency medicine may not be the career for you. If you love it, if you like the idea that I could see anything today, I could literally have a mass casualty event. I could have gunshot wounds, I could have roll-over MVaches of car accident. I could have a sick and dying child, which is the worst case you can imagine, and everything in between. You can find that incredibly exciting, there are innumerable procedures to do. We do spinal taps, we do thoracotomies, which was our first slide. We do multiple intubations where we manage the airway, we treat strokes with TPA, and we get immediate results sometimes with that treatment, which is pretty exciting. We provide the safety net for American health care. Again, if anybody comes to our campus and asks for help, no matter what their insurance status is, we will help them best of our ability, which I think is incredibly exciting. Again, I'm a former athlete, I love the team approach, my nurses and techs. We are shoulder to shoulder, taking care of the patients. We are super tight, just the way a ball club would get, or a fraternity, or a sorority might get, once you struggle together and do this feeling, like you're out there fighting the good fight, so I love that team approach. We also tend to be very patient advocate, friendly. We are the ones calling up to insurance companies, demanding that they allow us to do these particular tests, maybe as an outpatient. For instance, if a patient has had back pain for months and months, and they're just getting stonewalled by their insurance companies, we will pick up the phone and say, "Look, we're in the emergency room. We're going to get an MRI today," because I believe that this patient needs it, and it needs to be happening right now, or stat, and so we'll be advocates for our patients. There are numerous academic opportunities, you've got a shift work set hours. For instance, today, my shift was from 6am to 2pm, and I knew that 2pm, I'm done, and I don't have to carry a pager. I'm free and clear. I can walk out of the emergency room, not say you don't leave some of yourself behind. You always do with difficult patient encounters, but it's nice to have a set start time and a set end time. That really helps with family planning and your work life balance, which is super important to young physicians. I think one of the things that I see young students do, pre-meds, and residents, they're so laser-focused on the job that sometimes they forget that work life balance is crucial, and physicians have a high rate of suicide, and it's unacceptably high. We have to do a better job as a medical society of nurturing our young physicians, and understanding that work life balance is actually a good thing. It's not a sign of weakness, the way it was taught to me when I was a resident. If you wanted to go home and take a shower, that's no longer the case. We understand that work life balance is absolutely crucial to healthy and productive physicians. Like most specialties, it continues to involve, we're establishing new parameters, new metrics, we're adding new sub-specialties and new fellowships, for instance, ultrasound and simulation are becoming new emergency methods and sub-specialties. There's some downsides. It's not all fun and games, and you deal with some difficult people. You deal with the mentally ill, you deal with intoxicated, violent patients. You deal with criminals. When they get shot up by the police, they bring them to the emergency. As you can imagine, those patients are not exactly thrilled to be there. Sometimes, the flip side of that insurance coin is trying to find followed care. For instance, somebody comes in and has congested part failure, and they need to see a cardiologist and a family doctor to get on an appropriate regimen, but they're uninsured. Well, nobody really wants to see those patients in the community, or they have a very difficult time securing an appropriate follow-up. What happens is, sometimes, those patients begin to use the emergency department as their primary care clinic. Not because of any fault on their own, it's just simply that's their only option. I am not a primary care doctor. I'm not skilled. That's not my training. I don't feel comfortable providing that type of care for patients, but they have no other place to go, so they come to me, and then it can be sometimes a difficult thing. It's not that I don't want to care for them. I don't enjoy it. It's just I don't have that skill set that's not really what I'm trained to do. I feel like the patient's getting short-tripped as well as they're really not getting the care that they need. One of the really hard parts about emergency medicine is we work in the fish bowl. We are constantly second-guests. We are making snap decisions with very little information, very little medical history. Sometimes it's downright misleading information. Patients are sometimes not completely honest with us if you should probably imagine. We have to make a decision in a call and a treatment pretty quickly. These patients are only in our grasp for maybe a few hours. Then the patients either get discharged to a specialist or they get admitted to the hospital where it further workouts, reveal other illnesses, or a completely different diagnosis. Then that dummy yard doc thought it was a heart attack, clearly this was a dissecting New York aneurysm. After they've been in the hospital for three days and had $10,000 workout, now we have no information, and then you are judged critically. Either that bothers you or it doesn't, and for me it does not bother me at all. I'm here in the first couple of hours, I'm going to do my best, I'm going to try to give as much information and treat these patients to the best of my ability. I'm going to send them, now once I've determined they need to be admitted, they can go to see some sort ofologist and let them take care of it and find the final diagnosis. I'm okay with not making the final diagnosis. Sometimes that can be hard. I like the Sherlock Holmes chase, trying to figure it out, but I don't like all the necessarily the legwork to run everything around. That's why I like to stay down in the emergency room and let the folks upstairs work it out. To receive one hour of credit for the shadowing experience, take a brief five-question quiz at shadowing.medschoolcoach.com. Pass the quiz and you'll receive a certificate of completion from med school coach. Now back to the show. All right, the lifestyle, the lifestyle at YAM is often referred to as a lifestyle specialty for the reasons that you do work well-defined shifts. You don't really take calls generally speaking, although depending on your group size and when have you, if somebody calls out sick, obviously you've got to get somebody there. You may have a call shift where you're just kind of around if somebody doesn't make it. You can also work as much or as little as you want, which is cool. It's pretty well-paying work in the middle of the bell curve of physicians, maybe a little bit towards the higher end in terms of salaries, but pretty close to the single standard deviation from the middle of the bell curve with regards to salaries. But you do work evenings and nights, you work weekends, and you work every holiday. I'm working Thanksgiving and Christmas this year, and that's time away from family. I missed a lot of ball games for my son. I missed a lot of family things that I couldn't go to. It's good and bad, so that's why two sides of the same coin, not everybody has a Lamborghini. There are a couple of different areas of specialty that you can go into in emergency medicine, and that may be a little bit unfamiliar to some people. Some of the biggest ones are pediatric emergency medicine, toxicology, which is super cool. All emergency medicine doctors are experts in pediatric emergency medicine and toxicology. Most of us, because of our long-standing relationship with EMS, we get a pretty good familiarity with the EMS systems and what have you. And then sports medicine. Sports medicine is another branch. of emergency medicine, you can do a sports medicine fellowship after completing your emergency medicine residency. But the reality is that I see all of these cases in my regular general exam practice. So unless you have a deep and abiding interest in that particular specialty, I would say go for it if it's really something that you specifically are interested in. You want to spend your life in a tertiary care center taking care of some specialty emergency medicine cases. For instance, if you were to do a pediatric emergency residency, you would almost certainly be working at a tertiary academic center because that's who has pediatric emergency rooms. My personal home institution has, it's a pretty big hospital. We have 500 beds. We have 70 beds. You are. We see about 80,000 patients a year. It's pretty high census. We see a lot of those are kids about, I think, 30% are children under the age of 21. So I didn't really need to do a fellowship to continue to see sick kids. But if you wanted to work in that environment and specialize in that, then pediatric emergency medicine would be a great choice. Same with toxicology, which I think most EM docs find super cool. It's just one of the fascinating offshoots of emergency medicine. I remember my toxicology rotations and my mentors in toxicology, extremely family. They were just incredibly brilliant people in the biochemistry and the social aspect of toxicology and the poison patient is just fascinating. But if you want to be a general emergency medicine doctor, you're going to see poison patients. You don't need to be a toxicologist. So it's been interesting dynamic there. So again, some areas and specific expertise, we are toxicology experts. We handle emergency medicine issues, pre-hospital stuff. We're all, most of us are online medical directors for local EMS crews. We help develop protocols and develop algorithms for treatment, pre-hospital. We're also disaster management specialists as well as wilderness medicine specialists. So I'll tell you a small anecdote, I'll try not to believe in the point, but if you guys remember back in the early 200s, there was a mass shooting at Virginia Tech. I was the third year resident at the University of Virginia, completing my residency. It was in April when it happened. And I remember getting a phone call from the small 8-bed emergency department near Montgomery County out near Blacksburg, Virginia where Virginia Tech is from a very calm, very cool, collected EM Doc saying, "I think I have 50 or 60 gunshot patients coming my way. I've got 8 beds. What can you take?" I said how it works with disaster medicine, these patients are farmed out to the local community hospitals. Now, at the University of Virginia, it was a big tertiary care center. So we were going to probably get an enormous amount of those patients on a normal day. Unfortunately, it was extremely wet, windy, and rainy, so none of the helicopters could fly. And these patients could not be transferred to the University of Virginia that day. But I remember being on the phone with that particular doctor and she was absolutely marvelous. That's the worst scenario every day when you get up to work, you think, "Okay, I don't want a blue-dying baby and I don't want a mass casualty event." If it happens, I want to be there, but I'd rather not have it because it's just an awful thing to deal with. And this particular EM train doc got everybody out of our hospital, got all the beds, a raid, downstairs, got all the beds set up in the hospital, and probably saved dozens of lives by her quick action. And I remember being on the phone with her, trying to help talk her through what the algorithms were. As a third year resident, my job was to supervise my own department. So I wasn't really having a tremendous amount of patient interaction, so I was able to go offline. And of course, we all knew it was one of those kind of one-of-a-lifetime experiences, just an awful day. Another thing, emergency medicine doctors, specializing as wilderness medicine, that the bare grills kind of thing, you're out on your own, a survival medicine, and what have you, but how to make a splint out of a spire web, and cool stuff like that, MacGyver-type things. And I find that stuff just fascinating, super cool. All right. Let's kind of switch gears here, and we'll talk a little bit about what you guys will do if you're EM hopeful and you're a second-year medical student. So it's always good to join the EM Interest Group affiliation. You'll get a lot of good advice about programs, about how to shadow your local institution. You'll get opportunities to observe. Sometimes you can get plugged into the summer research project with some of the EM faculty who might be doing some clinical trials or some research. But I would say that at this point, in your first and second years, I'd still keep your eyes and ears open. There are other changes you don't want to go in focused too much on one specialty. I think that's a mistake, and go ahead and just be open to other things. In your third year, you're going to see patients in the ER because you're going to be rotating on your general surgery, needs internal medicine, et cetera, and they'll often get admitted through the emergency room. So you will actually go down to the ER to see the patient on your office service or your other service and observe them. So in your third year, when you're down in the emergency room, make sure you take time and get to know some of the residents and become friendly with them and express your interest. And you'll help you navigate through the emergency room. We're all pretty welcoming. We want to help all of our students and residents when they're in the emergency room have a seamless and smooth encounter with their patients. But by spending a little bit extra time getting to know the third years, you can really help reach the skids a little bit. You may even get involved with an EM physician that you really like and can become a mentor for you. That's exactly what happened to me. I was in my third year on my PEDS rotation and I was seeing a pediatric hematology oncology patient and new diagnosis of leukemia. And the pediatric physician became one of my mentors, just a great guy and I sat and talked with him for a little bit and I just said, "Yeah, I'm really interested in the emergency medicine." And he sent me an email a couple days later and he said, "Man, just come and work with us any time. Just come drop in for a few hours. We'll teach you the ropes." And I wound up matching there largely because he was the assistant program director and he was, and I was super tight and it was just, I don't know whether that was the issue. I certainly wasn't because of my stellar academics, but I didn't know what it was. But those kind of relationships are really important in emergency medicine. Emergency medicine is a little different, we're pretty competitive, specialty, board scores and what have you, or important. But what's more important is, are you the type of person we want working in the ER at two o'clock when the ER is just going to help? And are you the type of guy? Are you the 2 a.m. that we want working alongside of us? That tends to be a little bit more important than maybe your step one score. Those are important. Don't get me wrong. So study hard for your USMLEs. But I think that the type of person you are, you're a good team player, can you work well under pressure? Can you keep going? You're not easily cowed. Those kind of things are the things we want in our EM residents. So when you're 30, you want to start looking at your fourth year rotations. And if your institution hasn't EM rotation, which I hope it does, not all do. Make sure you get one or two if you have to travel. This year, everything's up in the air. It's super hard. Condolences to all the students going through this year, I know how difficult it is. And your fourth year, you want to do at least your mandatory home institution rotation or get a rotation somewhere else. Try to get extramural rotations. I know this year, they wanted it limited because of COVID. That's an exception this year. Here, hopefully, they'll go back to things pretty quickly. And any time you can have an opportunity to get at another institution, you are essentially auditioning for a residency spot. So that's a long, month-long job interview, essentially. So you want to figure out a place that you might want to lay out that you think sounds interesting. Try to get an AI or emergency medicine rotation experience there. And just go there ready to work and just crush it. And that can be super helpful. It's also a great way for you to get letters of recommendation for people outside of your home institution. Great. What was that picture of? That is. Well, who's. Don't we have fourth year here? I don't know fourth year. It's Dan. Dan, what is that? What's that Dan? It looks like the tongue is really inflamed or the lips or something. I was thinking either Glossitis or, like, raditarian, Joedema or something like that. Yeah, it's Joedema. Yeah. This is a woman who's on ACE inhibitor, who she was on for a decade and all of a sudden just had this idiosyncratic reaction. So that is an emergency. That is one. Immersion doctor. We're pretty chill, generally, right? We're. Like, if there's not an arterial blood spreading out of her, like, "What's so bad?" Right? But this actually gets me. I just like in a picture makes me nervous. That is a terrible. That's a bad day of illness. You can. You see what's happening outside of her mouth. You know what's happening in her or a pharynx, right? She has no way to get air in and out. So this woman is about five to seven minutes from death if you don't get an airway in. How are you going to get an airway through that? You're not. You have to do a tracheotomy or a nasotracheal intubation if you get there early enough, and those are trache. You know, we don't do a lot of those. I've done maybe three in my entire 20-year career. And my hands shake when I do touch fingers a little bit. And my hands don't shake. That's a bad day of the illness. Good question though. The value problem. So. All right. So residency programs. Lots of residency programs. There's actually a slight dichotomy in the field. Should we continue to add residency programs? I'm a purely business standpoint. You don't want to bluff the market with emergency positions. You want to keep them a relatively prized commodity. But there are some money-making issues. And cynically, I think there's some other forces arrayed that are creating more and more residency programs. But right now, there are 269 programs. And as I mentioned, there are about 2,500 residency positions in the national match. Emergency medicine is interesting. There are two ways to become board certified. You can do a PGY 1 to 3-year. So a 3-year program or a 4-year program. Most of them are 3-year programs. The 4-year programs tend to be located at academic facilities. I went to the University of Virginia, a very high academic tertiary care center. It was a 3-year program. Personally, why take 4-years when you can do it in 3? I don't know. The fourth year gives you anything that. I don't feel like I missed anything by not going to fourth year. Sometimes if you want to do research or you're interested in perhaps a particular track, maybe you can pre-empt yourself for a fellowship, that kind of thing. Maybe the 4-year programs are worthwhile. I know many people who went to 4-year programs, they were very happy with their training. There's really no right answer there. It's really just what a personal preference, personal choice. There's no specific advantage to the extra year, though, for what it's worth. All right. There's a couple of combined programs, like EMPs, you do a 5-year program. EMP, I am also, is a 4 and 5-year program. And then you can also do internal medicine and critical care, which is a slightly longer track. We do a lot of critical care. in the restroom, but if you do the fellowship, then you're probably going to be working in an ICU somewhere, taking care of the sickest of the sick. So if I could just switch gears and talk about choosing a specialty, I think it's one of the hardest things that you'll encounter is you become an upper classmate in medical school. One of the best pieces of advice I got was when you're working on a rotation, you might want to gravitate towards the specialties where the people who are there, the residents and the attendants are like you, but they have the same worldview, they have the same sort of mindset. So for me, when I was in the emergency room, when I was trying to decide, and I was in the emergency room, I felt the men and women I worked with were me. They liked their free time, they were fun loving, they were easygoing, they had fun at work, they were bad asses academically, they knew their way around the body, they knew their way around procedures, they were super calm during the worst, gnarliest emergencies. But man, they knew how to play too, they would go out, they were ride bikes, they were doing extreme sports, surfing, all the things that I like to do. So that kind of was, and that's something that you need to start have to be a surfer to be an EM doc. But there are people who don't do that, there are bookish tech EM docs too. But I just felt like that was where I fit, I just felt at home in the emergency room. I like the chaos, I like the pace, I like to thrive in that environment. And I thought the docs who were residents were kind of like me, and we saw the world in the same way, a little bit cynical, smart allocate, but I found that the commitment to care and the commitment to being at the bedside and doing their best for patients and their families was absolutely 100% woven throughout the entire specialty. And I really like that. You'll go through this period where everybody will badmouth other specialties, EM guys who are just triage nurses, they're all just rolling nerds, that kind of stuff, surgeons don't care about anybody, they just want to cut and get them get out of there. That's all bogus, it's not true. And so I would ignore that. If you really want to get the insights to keep about a particular specialty, listen to the people that are doing it, and they'll kind of give you this straight though, they'll tell you. And if you come to me and work with me, you'll be like, "Hey man, what are you not like about a nurse mess?" And I'll tell you what is not great about it. To me, the scales are enormously balanced in a favorable position, but I'll tell you the straight tale about things that you may not like. And for instance, some people hate the fact that they don't know what's with their days, and they could never thrive in that environment. I have friends of mine who are doctors and other specialties, tell me that all the time. They're like, "I just can't know how you're going to go crazy, I kill myself." Where for me, I was like, "Man, I hate to show every day from 9 to 5, and be on call every 3rd night doing the same thing over there." That would drive me crazy. So emergency medicine is the perfect fit for me. But whatever specialty you choose, definitely commit to it if you can. Now, we all make bad mistakes, so if you get into it and you realize that you've made a bad choice, go ahead and punch out this, certainly. All right, you guys want to do some cases? Yeah, let's do one or two cases, so let's see what you got. All right. Okay. So these are all true cases. These are cases that I had. I'll walk soon pretty quickly. Now, should I be asking you guys quite normally, I would be pimping the students about this case. You guys, I don't think that is your problem. We can interject. Okay. Cool. All right. So you're just mining your business on a sleepy Sunday morning in your community ER. When you hear radio squawks with an ambulance, unruly to your facility, you're at level two trauma center. There's a 19 year old male who's been extricated from a low speed MBA. So what I will typically do is ask students what the next steps are and what have you, which you want to do. So I'm not going to really do that. I'm just going to go ahead and roll through the case if that's okay unless you guys feel like you can play that Q&A, okay? So EMS arrives with a 19 year old male on the back board. He's quite agitated. He's writhing on the gurney, the EMS crew and local police department are holding him down. He does not have a C color. Please. They try to put it on, but he kept taking it on. The initial report that you get from your EMS provider is that the patient was involved in a single car motor vehicle accident. Incidentally, this occurred in the same neighborhood that you that I actually live in and he was able to tell me where in the neighborhood this happened was a curve around near where the gate comes to let us let you in and out of the neighborhood. He hit a tree. There was minimal damage to the car, but the patient was found underneath the dashboard and he was extricated from the car without difficulty. There was no prolonged extrication. He was awake when the EMS folks got there. As I mentioned, he's quite agitated. There were some beer bottles. They had it at the scene. Guys, how many things do you want to say? Any ideas? I want to make sure that this patient is not going to die on you very soon. Exactly right. What's going to kill him? You're going to do a complete trauma evaluation. You get a stat horrible chest x-ray, a pelvic x-ray, but those of you unfamiliar with reading chest x-rays and pelvic x-rays, those are normal chest normal balls. Because he's so agitated and you think this patient might be either injured severely or have a significant head injury or a C-spine injury, you want to get control of this patient so you want to intubate him quickly so you should date him and intubate him. You put him in a C-collar to protect his cervical spine. You cut his clothes off. You look him overhead until you roll him on his side. You don't see any real signs of external trauma. There are no ominous findings. There's no deformities. There's no bruising. There's no bleeding or lacerations. This is initial vital signs. Our temperature of 98 is heart rate is 110 beats per minute. His respirations are 20 and his blood pressure is 110 over 60. So you placed two IVs and now you're ready for your secondary survey, including labs and images. So you turn around, you talk to your charge nurse about what the plan is and all of a sudden you turn around, you hear the monitor going off and his vital signs are changing right in front of you. So his heart rate has gone up to 147 beats per minute and his blood pressure is dropping to 90 over 45. Those are both markedly abnormal signs in a traumatic patient or in any patient quite frankly. So those are indicative of a patient who is becoming shocking. The term shock is misused a lot but for our purposes and what clinicians use shock to mean is that the patient is not getting adequate tissue perfusion. So you happen to look at his neckavans and they are bulging and as you listen to his heart which you can hear pretty well initially despite the noise in the trauma or cessitation bay. Now his heart is becoming harder to hear. So this is a classic presentation for an immediately life-threatening issue called a cardio tamponon where there's an injury to either the heart or the great vessels surrounding the heart. Now there's blood filling up the sac around the heart which if not arrested immediately will choke the heart off and cause a cessation of heart electrical activity. The heart will stop. So this is an ultrasound picture. So the big arrow shows this big stripe of dark fluid between the heart right here. This is the heart. This is the atrium and this is the pericardial sac right here. So this should be right here instead it's right there because this is all blood, it's full of blood. So now what? The CT text are calling you saying hey where's that trauma patient? We're ready for him and scanner. But his vital signs are continuing to decline and you are just putting away the ultrasound probe when his heart stops. So this is a blunt trauma arrest. The survival rate for blunt trauma arrest is essentially zero. So these patients are typically coded for a while but they are almost never resuscitated successfully. So we start CPR. We place a central venous catheter. Now what? Drugs, blood, you want to give up? Giving up is not flippant. That's a lot of times if patients lose their vital signs after a blunt traumatic arrest the trauma surgeon will say this is not a survivable case and we will cease resuscitated efforts. But this is a 19 year old kid who came in alive. So you're going to obviously not just raise the white flag here. You're going to try to do what you can to say this kiddo. As I mentioned, survival rates for blunt traumatic arrest are not good. Remember that first slide? That was a paracornomy. Anybody wants to crack his chest. That's not a bad idea. And actually we considered that a paracardiocentesis is where you actually place a spinal meal under the zyphoid process into the heart to drain that paracardiol fluid. That will buy the patient time to get up to the OR where you can repair the lesion and prevent the heart from being squeezed to death. So these were our options, we were going to do a thoracotomy or a paracardiocentesis. Fortunately, we got a pulse back. That was supposed to be a gift, but I don't think it came or I don't think it worked. I don't know why. Anyway. So we got a pulse back. So we didn't have to make that decision because I was going to put a needle into his chest and drain his paracardiol sac. That was what I thought was the next step to do because I thought he had tampon on. If I had done that, I would kill him. If we had cut him open down there, he would have done. So we would have done what we could have done, but he would have probably not survived. But we were lucky that we were able to buy enough time to get a pulse back with epinephrine and atropine and good CPR and good recessative efforts. So we bought him time to go to the operating room. So he goes to the OR where he gets a much more clean thoracotomy, a much more delicate procedure, where it was found that he had an atrial rupture. So the atrium, his right atrium actually ruptured. And what was happening was that he was going to bleed out from that paracardiol tampon nod, but there were a clot had formed and tampon nod in the tampon nod. So he was able to, being 19 and having all that reserve, continue to maintain his heart function for long enough to get to the OR and get that atrial rupture cross clamped and repaired. And you can see the two little caudal cells there after. But this is the way things go, unfortunately trauma patients are not always grateful for being saved. But anyway, even though a little bit of my soul died, at least he's allowed to make a series of further bad life choices. This happened in my neighborhood, I actually knew the parents of this night's year old man. And it was just hitting a grand slam in the bottom of the night, the game seven in the world series in terms of the luck involved with having a case like this. It was just an unbelievable save. And I can only take a small amount of the credit. The trauma surgery of folks took over the OR and saved his life. We just kept him alive long enough to get him to the people who could save his life. But it was just an amazing case. And I certainly did not expect that on a sleepy Sunday morning, as I mentioned. I always got to be ready. I always got to have those antenna out. So just at a curiosity, why did the aorta rupture, I don't know the case. - Oh, it was atatria. - It was atatria. - Even less likely, right? The aorta is out there hanging by the ligaments of arteriosum, and if you have significant deceleration that aorta can tear and rupture. Well, it's definitely sometimes, those people die on the scene 'cause you're bleeding out from your aorta, you're dead within a couple of minutes. So they almost always die, unless it clots immediately. Yeah, it's a mystery, right? This wasn't a super high force accident that we knew about, and of course, this patient lived, so we were asking him what happened, and he said, no, I just lost control of the car, he had a tree, minimal damage. He must have just hit the steering wheel just right, didn't have a seatbelt on, and just caught his atrium, and it just tore his atrium, just astonishing that he survived, you know? Pretty cool case. All right, I think I'm gonna skip to case three. I think that's a better case for the students, and a more classical one. All right, so 79-year-old male shows up at clinic with a chief complaint of nausea and vomiting times several hours. His wife tells you that he went to bed last night, he was fine, but we'll get this morning complaining of severe, intractable, nausea and vomiting. So, you remember, you always wanna do your ABCs, it's always airway reading circulation, disability and exposure, ease. That's a crucial component of ATLS and trauma resuscitation, but it's also just good general emergency medicine and good medicine in general. Patient doesn't have an airway, you can't go on to the next step, so you always check their airway first, then breathing, then circulation, then check for disability, like a neurologic deficit, and then check for exposure, get them exposed, and look at every square inch of their skin and body. So, ABCs, get used to it. A vital signs, heart rate is 52 beats per minute, he's breathing 20 times per minute, he has a febrile at 37, his blood pressure is 168 over 94. Okay, so this is a 79-year-old guy, he looked spooky, he doesn't feel well, you ask him the usual questions, apart from the nausea and vomiting, he says he feels okay, but he feels pretty rough because he's just so nauseated. So, he is actively vomiting when you see him, he's pale and he's diaphragmatic, sweaty. He has no other immediate complaints, he is a type 2 diabetic, his family history is not a contributory. He's an ex-smoker, he quit about 20 years ago, he takes metformin, which is a medicine for diabetes, he has no known drug allergies. All right, so you get an EKG. - Ooh, yes. - So, not good, right? So, the key here is to think about a acute coronary syndrome and a patient presenting with sort of vague symptoms, especially diabetic patients who present with nausea, and vomiting often that is their only angital equivalent because they simply cannot feel active chest pain. And this is relatively common presentation, and you will see it on every board exam, you will see it in your oral boards, you will get pimped on this mercilessly in third year and fourth year. Diabetics with nausea vomiting are heart attacks until proven otherwise. But there's something bad, they're septic, they're not just there with gastroenteritis, they have something bad. So, that's why this is such an instructive case, I think. So, this is a, obviously just a huge anterior stemming or elevation, so ST segments are, right, here were my analysis, elevation MI. And it's important to recognize this part of the inferior leads are showing reciprocal changes. So, what that means is that this patient is having actually such a bad heart attack that the other side of the heart is getting affected. It's physiologically more complex than that. I will leave it at that for the purpose of this lecture. But this is a massive heart attack, this guy's having. Okay, so what now, you have wisely decided to transfer this ill-appearant patient to your local ER after you've diagnosed him with a stemming. While reassessing the patient, and this is exactly how it happens in the real world, the patient goes, "I don't feel good." And boom, down he goes, slumps right over on the gurney, and this is his initial EKG, and you're like, "Now what do I do?" You guys have any bright ideas? Get another one. So, that's what you got now. That is a very disorganized rhythm. That is actually ventricular tachycardia, which is a shockable and non-life-sustaining rhythm. Wide complex, fast, that's a b-tach. When you see that, run and get your attending. So, it's heart rate is now 300 beats per minute. His respirations are 30. He still has a pulse. His blood pressure is 80 over 60. He is no longer a febrile. What is your next step at a shock? Yeah, I could free you to write electricity. So, this is one of the very few exceptions to the ABCB E-roll, right? Whenever you're pinned on the wards, whenever anybody asks you what's the first thing you do for a patient, it's always check the airway. Check the breathing with the ABCs. There are a couple exceptions. This is one. In this case, if I were to walk in and see this patient slumping over and see that on the monitor, I would say, everybody stop, everybody stop, everybody stop. Let's get electricity. I would say it so many times that the people who are working with me would think I was having a stroke or having a seizure. Because everybody wants to go start lines and get an airway going. And that's the long thing to do in this particular case. It's almost always the right thing to do to get an airway a stylist or at least verify that an airway is patent and then do breathing and then circulation and then disability, et cetera. In this case, you want to use electricity first. So you want to shock this patient. So good for you. So V-TAC patient is shocked with 200 joules into normal sinus rhythm. Amounts arrives takes patients to the cath lab where a large left anterior sending harder lesion was found and stented. So this was cardiogenic shock. You're a friend of cardiologists. Congratulations. You want a great save, but informs you that the patient unfortunately ruptured as a papillary muscle and is intubated in the ICU on a balloon column, federal accident. So cardiogenic shock is a common presenting issue in the emergency room often following an MOB. It can present with non-specific symptoms. So we wear a nausea and vomiting and things like arm pain and jaw pain, fainting. Even vague symptoms like fatigue, especially in elderly patients and women, especially diabetics as well, get EKGs, get them often and get serially EKGs. And that will be really helpful and save you and save your patients. So that's it. Any questions? - I have a quick question for you then. - Yes sir, lay it on it. - Now that you're an emergency medicine doctor and you've been practicing and you've gone through the ropes of all your training, right? And you've been doing it for a while now. Looking back, do you feel like you would have made any done anything different or made any changes in how you approached your entire medical career? - That is a great question. I want a good question. - I know that I would. Sometimes I think that would have been okay if I'd have gone to college out of high school. By be 10 years further along than I am now in terms of retirement and what have you. But I think those life experiences really shaped me and helped mold me and make me perhaps slightly more humble and able to empathize with patients a little better. Maybe you don't have the same education as a lot of us do in the medical field. I don't know if that's true or not, but I really don't think there's anything that I would have done differently. I think that my career has been just a joy and love, love, love, what I do. It's an amazing job. Patients come to us and they're terrified. Sometimes they're dying. Sometimes there's nothing wrong with them, but they're just scared. Sometimes they just need a hand to hold. And we get to, we're invited into this incredible slice of their life and it's an enormous privilege and an enormous joy to take care of sick patients. And I just love it. I can't really, I loved my medical school. I went to the University of Virginia in Charltsville which was beautiful. I got to train at UVA as well. Now I'm in a community practice. And I just, now I love it. It's a good question though. I can't think of anything. I'll stop my head. Not the greatest answer. But I have another question for you here. So you're talking quite a bit about tough patients and seeing death. You deal with that and not take that home with you and let that affect your life day to day. You don't, you do let it affect you. I think the day you stop letting it affect you is the day you need to hang up your steps as well. These are human beings and they affect you. It gets under your skin. You do learn quickly that you can't get too high or too low. Can, you just can. Provide the care that you can. Every patient can take a little piece of you and you have to protect that somewhat. So you have to have professional objectivity when you're seeing a dying baby and you're intubating them, knowing that this child isn't not willing to survive, but you're doing everything 'cause the mother's in there and family's in there and you're trying to want your hoping for some miracle. You can't do the job if you come apart of the seams. If you invest yourself in the emotion of the moment, you become part of the problem. And your job is to provide solutions. And the job takes over, the training takes over. And so you become focused like a laser beam and all the distractions go away. And I'm a pretty like fiery kind of high strung guy. It certainly was like that as a ball player. I was always willing to haul in and during the game to stand it up and jump it up and down. But I find myself in the emergency room because I was taught this by my mentors who are fantastic teachers that when the game speeds up, you slow down and you'll hear athletes talk about that, but it's true for the emergency room too, that when things are going really crazy and haywire, you have to slow everything down. And I will do this and I'll actually verbalize this. I will say it out loud to my team. We're having a crashing patient. I'll say, okay, this patient's right now he's got to be saccharctic, he's hypotensive, he's febriot, we think he's septic, but we have to think about talks, we have to think about trauma, we have to think about electrolyte abnormalities. Have we wet gases, let's get a gas, let's check his K. Did anybody get a blood sugar yet? Let's get a fully in him, let's get some fluids. Let's think about antibiotics. If we think that's the right move, but let's consider some other things. What are we not thinking about? And I will actually speak those words really loud in the trauma base. So my whole team is going through the process with me. And I think that focus keeps you from becoming affected by the comedy and the tragedy that's unfolding in front of you. And so by doing that, I think you can sort of compartmentalize a little bit. But if you ask me, have I ever taken a patient home with me? Of course we do. When you see a young kid wearing a sponge bob t-shirt, the same one your own son has, and this kid either, it may be something like a broken arm, but it could be a god awful head injury Shr. or chai. abuse or something awful. Those get to you. They hurt and they just soldier on. There's always another patient to see. But it's tough and it's a tough balance to find. Thank you so much Dr. Walsh. I was a lot of a lot of questions we asked so we really appreciate you answering them and taking the time to talk to us about emergency medicine. I had a great time. This was a lot of fun bells. I really appreciate it. I'm so excited for this project for you guys. I hope it's a success and if I can help find too many of this stuff or you have any questions for follow up or any of the EM hopefuls have questions for me. I'm always available. You may all happen to help anyway. I can. All right. Thank you so much. Appreciate it. It was my pleasure, gentlemen. Thank you very much tonight. We're great. Thank you. Thank you for listening to the virtual shadowing podcast powered by med school coach. Watch each physician present their cases along with fascinating images and visuals at shadowing.medschoolcoach.com. There you will also find a quiz that accompanies each specialty.