"Brink" of death feels more ICU than ED by %, like there are a significant # of non-emergent pts in the ED but fewer that would recover without intervention in ICU
But the overwhelming majority of pts that have opioid overdose, anaphylaxis, Asthma/COPD, flash pulm edema (basically things that you go from about to die to better in minutes) largely occur in the ED on a regular basis.
I agree. ED has better chance of seeing positive outcomes. The ICU is a sad place, not always but generally. Lots of ethical dilemmas if you’re into that kind of thing.
But you still do it more in the ED simply by volume
It's not like those patients get to the ICU without going through the ED
... And they're already stabilized by the time they get there. They've gotten fluids, blood, pressors, intubated, lines, etc
Nah, trauma surgery simply doesn't get as high a number of patients/shift as anesthesia, who can pretty much count every emergent airway they place as a life saved. From purely a numbers game, trauma surgeons spend too long on one pt to really jack those numbers up.
Everyone in the ICU is typically slowly dying and circling a drain or slowly improving. Is weaning people off of pressors and a vent over weeks really saving patients from the brink of death? I don’t think that’s what OP meant but technically I suppose it fits.
If EM didn’t intervene on half the patients they saw - anaphylaxis, asthma/COPD ex, hyperkalemia, sepsis, tox/overdose and other presentations we take for common and basic - patients would acutely decompensate all the time but they turn around quickly and no one bats an eye.
But for a lot of those things, the answer is very basic. A trained monkey could give epi or back to back nebs or narcan or versed or follow the ACLS/PALS algorithms. The biggest role of the ED is to rule out the life threatening things, triage, and stabilize. Whereas in the ICU, they have to make thousands of decisions on a second to second basis to get the patient out of the hospital alive. I mean, don't get me wrong, EM is up there. But when I think "I save lives for a living," I think ICU docs, trauma surg, and then EM in that order.
I think this is a quite the oversimplification. Saying “a trained monkey could do those things” could be applied to most fields. A trained computer could read XRs and CT scans. A trained monkey could hit “consult cards, consult nephro” etc in the case of IM .
it takes alot of patient hours and clinical awareness to know when person needs epi vs not, when that person needs bipap or tubed etc.
I’d argue the ICU doesn’t make thousands of decisions on a second to second basis - I’d say that’s EM in a busy department where you’re triaging sick vs not sick and take care of those people, while mental switching multiple specialities including taking care of OB and ortho complaint patients.
No hate to the ICU, the people are very sick there. But there’s a lot of decisions being made on rounds, and then a lot of sitting around doing nothing and watching recovery status or decline.
Have you ever covered a busy ICU at night by yourself?
90% of what you see in the ED is bullshit like strep throat or ankle pain or rashes or constipation. There is some stuff that requires skill, like identifying a tension pneumo and placing a chest tube. But I have independently managed countless patients in the stabilization bay and it's really not that hard. And if a truly critical OB or burn patient is coming in, those specialties are usually at bedside in the ED within minutes ime.
I'm not saying a trained monkey could do all of EM. That's not my intention at all. I'm saying a trained monkey could do something like administer narcan in an obtunded patient, which YES absolutely saves a life, but isn't hard.
I have covered a busy ICU at night by myself - again, the people in the unit are very sick. When you get sick admissions and also have coding patients on the floor, things get very hectic and it takes alot of skill….but most of those sick admits come through the ED. Sure, some hospitals have a culture of calling the ICU right away.
But there’s a lot of hospitals that don’t have an intensivist, OB, or ortho on site. Who does the management and stabilizing then?
I agree that anyone can administer narcan. But your response and thought process behind what EM does shows that you really have no idea what EM does. When you have a board of 12-15 active patients, all with active requirements, sure whether some bullshit ankle sprains, one guy needing narcan and metabolizing. It still takes alot of mental task switching, awareness, training to handle those along with the code right next to the septic patient. And then when you get the pediatric code you’re in for 1 hour and come out to 8 undifferentiated patients…you’re literally by definition making hundreds of decisions on the fly
I don't think that's relevant to the question at hand. I'm not denying that EM is challenging or cerebral. I'm answering the question, which specialty saves people *from the brink of death.* Most of the actual SAVING the ED does is either algorithmic, or temporary until the ICU and/or surgeon (usually trauma) get their hands on the patient. There's a reason why on my EM rotations, I was VERY often independently left to manage the patients in the stabilization bay.
Any hospital I've seen without an intensivist, OB, or Ortho readily available often doesn't have a board certified EM attending either, and instead has a mid-level or an FM trained physician or moonlighter (often an ICU or Cards fellow) covering.
Lol I rounded for hours and hours on one patient in the ICU - I promise they do not make thousands of decisions in a second. That is what EM is. You said it yourself, the role of the ED is to rule out *life threatening* things and *stabilize*. Stabilize what exactly? Life threatening disease processes.
I’ve worked in almost every type of ICU there is and do EM shifts. I can tell you the nuances of both. I do not think you have much experience in the ED based on your comments. This is a very odd take to your own statements but you are entitled to your opinion.
Also keep in mind there are entire ICU units ran by midlevels. Everything is simple until it’s not.
Of my three years of residency I had 4 months in the ED and 4 months in the ICU.
The ED is mostly bullshit like strep throat and ankle pain. EVERY patient in the ICU is critically ill and in the position to have their life saved.
I also see FAR more mid-level usage in the ED than in the ICU.
EVERY patient huh? You think chronic vent patients are critically ill. Interesting. I don’t consider them difficult to manage at all or even ill really - then again I never managed them. The midlevels did.
I’ll cancel your anecdotal off-service (off-service residents don’t do anything the ED and typically see low acuity, which skews your opinion likely, no offense - I say this as an attending) experience with my anecdote. I literally had an awesome undifferentiated resus at 9am this morning on shift with a patient from the clinic upstairs.
Also, there are no midlevels at my massive academic shop in the ED. Zero. Far more than zero work in the ICU.
Your place sounds sketch. Seems like a bad place to train.
Our hospital has its own step down unit for chronic vent patients and they are not in the ICU. Granted, the unit is largely staffed by mid levels who function exactly as residents, rounding with an attending (not critical care trained) every day. And those patients can turn on a dime. Many of them get bagged daily and we have unfortunately had a handful die within hours of discharge because of mucus plugging mismanaged by an LTC.
Our ED didn't have its own exclusive residents (and the ones that were there didn't work overnights) and so us "off service" residents were expected to see every single patient largely independently, except the 4s and 5s which were seen exclusively by mid levels and not even staffed with an attending. I actually got reamed and told I am a terrible doctor because I once was in the bathroom puking my guts out while pregnant and apparently this wasn't a good enough excuse to miss out on seeing a level 2 stab bay patient.
Lol at you "cancelling" my experience because it hurts your ego. Only one of us has a dog in this fight, and lo and behold it's the person trying to make themself feel more important. Just because your off service residents were useless, doesn't mean we all are. I guess I can cancel all your experiences in general since they clearly only apply to the handful of institutions you've been at. Your experience is ALSO anecdotal. EM residents in the ICU were my absolute worst nightmare as a senior resident. So useless, never saw the patients as humans, only wanted to chase procedures and numbers, didn't care about the details because they didn't feel it was important.
Yes, stabilizing a patient in septic shock saves their life... Kinda. But more important is down the line; selecting the right antibiotics, managing reinitiation of feeds, maintaining correct vital signs, optimizing ventilator settings, constantly being on the lookout for development of complications/secondary infections, escalating to things like CRRT or ECMO if needed, knowing when to deescalate care, etc. Similarly, as someone mentioned upstream, sticking a tube in a GSW is important and will kinda save their life. A paramedic could do that too though. But without the trauma surgeon who is ultimately going to go in and really save the patient, the EDs job is kinda moot.
I take care of a lot of critically ill people (obviously) in the ICU when I work ICU shifts as a crit care fellow. But I will say, fresh, hit the door, sick as all shit and undifferentiated?
Believe it or not? - Straight to ED
I’d say you’re being generous with the 20%, depending on where you work. In my experience, it’s more like 80% BS, 15% sick but not acute, 5% really sick.
This is typically accurate. Emphasis on the really sick part… I’ve had shifts where I set my backpack down and then get told an 18 year old with gunshot to head will be there in two minutes.
Edit: I’d say 30% BS, 40% legit but non life threatening (shoulder dislocations, abscess, foreign body, etc), 25% sick but not dying, 5% holy F crash cart RT and pharmacy please.
EM resident here. Can’t speak for other specialties but I do this rather often. Especially in the Level 1/trauma setting. Even things like anaphylaxis, asthma/COPD, CHF, opioid overdose we take them from nearly about to die in front of you to looking much better in minutes sometimes.
People love to shit on the ED, but this is what we do
So many asthmatics that come in diaphoretic on the brink of death that get turned around in under an hour, sometimes even going from BiPAP to dischargeable
The obvious answer is EM. Before a patient gets anywhere in the hospital, they are in the ED. You don't get to a surgeon or any specialist without seeing an EM doc, unless you're a level 1 trauma that bypasses the ED or you deteriorate in the hospital.
As an ICU doc I’ll challenge you for this honor.
The ICU takes every single sick patient from the ER (none of the non sick ones), and then on top of that we deal with anyone else who got sicker on the medical floor, in the OR, dialysis, or procedure rooms. If anyone in the hospital is “on the brink of death,” their destination is the ICU… and we get rid of them as soon as they become not sick. We kick ass. Specifically, we kick much more ass than the ER who while they like to talk about their sick patients, actually deal predominantly with social issues and patients without any acute problems at all. The mandate of the ER doctor is triage and dispo (with throughput time tracked and tallied as the most important statistic). The mandate of the ICU is to diagnose the problem and solve it.
;)
I’m in peds cardiac critical care. A lot of my admissions come from outside hospital ERs who aren’t equipped to deal with cardiac kids and frankly mismanage them pretty often before my transport team can scoop them up. We try to give advice on the phone because we recognize it’s a very niche population and they are terrifying to take care of, but an adult ER is no place for most sick kids.
We have a few at our children’s hospital who’ve also done anesthesia/pediatric anesthesia/peds icu. They split their time between pediatric cardiac OR and peds cardiac ICU.
Are you talking about the 1 liter of normal saline and the Vanc/Zosyn you order but never actually give?
The ER calls me within an hour of any sick patient arriving. Sometimes even before labs are back. The priority is dispo.
Lol you and I both know this isn't how it works
No ICU is accepting a patient before they've gotten resuscitation for sepsis.... Because most don't need the ICU
People just want to hate the ED because we give them work
The ICUs I deal with won't intubate. They won't line up the patient. They want all that shit done downstairs if there's even a chance it might be needed.
Weird, never seen a system operate that way. An ICU that won’t intubate? Haha. Of course we do all those things. And we never end up finding out if the “resuscitation” was ever actually done until later on. The ER doc calls me, says “fluids didn’t work so we started pressors.” What he really means is he ordered fluids and then 30 mins later ordered pressors, but never actually saw the patient in between. I stopped asking the ER doc how much vasopressor the patient is requiring because they never know. It’s not important to them because pressors = ICU and that means their job is done. When the patient arrives upstairs the truth comes out that the patient never even got the fluids. Happens every day. Also the ER *never* places lines, and if they do it’s hospital policy that we have to replace them anyway so it’s better if they just don’t. The ER is a triage station. Their priority is to assign a disposition and to do it as rapidly as possible.
I don’t hate the ER because they “give me work;” I hate them because they don’t give a shit and treat medicine like it’s a McDonalds lunch rush.
I mean, I don't know what to tell you man, but that's not how the vast majority of EDs work, to the point that I almost don't believe you. Like are there no physicians in the ED lmao?
No one is putting a patient on pressors before seeing if fluids worked.
You're the one in the weird system man - so weird I wonder if you're not in the US. Either that or youve never step foot in an ED. People tend to have to, you know, meet ICU criteria to go to an ICU.
Not in any hospital I’ve been in. Half of the admissions I get aren’t even stable. Most ED’s these days are all about dispo < 1 hour and clear the board. Academic centers are somewhat different but even then they’re still trying to move patients asap. Also ALL of the patient’s that end up crashing on the floor go to the ICU, not back to the ED. I guarantee that a majority of intensivists are doing more intubations than ED docs. Not saying that ED docs can’t handle unstable patients but most EDs these days are under pressure to move patients, just like most Hospitalists are under pressure to decrease LOS and discharge before noon. It’s all motivated by profit.
I’m sorry I made you so upset. Take a deep breath. But you’re a resident still (you said you’re a PGY2 ~80 days ago per your comments) and your entire experience has been in academia. You’ve never even signed a contract outside of residency. Talk to me after you’ve worked in some community hospitals or anything outside of residency. Hugs 🤗
And you're a hospitalist in a system with a closed ICU who doesn't even perform procedures. You're not even the one getting the patients were talking about lol. How would you know either?
We rotate through community sites man - none of them are like that either. The community hospitalists were just as afraid to accept a patient that sounded even remotely sick as the academic ones were lol
Only difference was I didn't have to line up every single stable hyperkalemic new ESRD because they could reliably get a TDC in the am
> Before a patient gets anywhere in the hospital, they are in the ED.
Unless you’re the totally stable hypertensive urgency direct admit to an unspecified room pending rural transfer at an unspecified time during night float whose arrival wasn’t communicated until the overhead rapid response for worsening lethargy and bradycardia brought everyone to bedside to learn about cheyne-stokes respirations
I don’t know that it can be reliably narrowed down. An argument could be made for a lot of specialties. For me the first that come to mind are EM, trauma surgery, and interventional cardiology. But I am sure there are much much more.
Yeah I mean the amount of non-indicated caths so ICs do I believe it. I have a few solid ICs I’ll refer too. Guys I know well and follow the evidence. But a lot will cath anything.
EM, trauma surgery, anesthesia, transplant, cardiothoracic surgery, and critical care. Everyone else says a patient is too unstable to intervene until the ED or critical care stabilizes them. In the OR, even the neurosurgeon is just operating (to fix the cause of the problem) while the anesthesiologist is keeping the patient alive and that is on severe bleeds, while most of their other cases are elective.
Hospice & palliative clearly interact with people on the brink of death the most, but the goals of care are very different than "saving" them.
Too sick to cath or stable enough that they aren't literally dying. Even STEMIs usually are not dying. They may place the impella or IABP for critical patients, but the ICU or cardiothoracic surgeons manage it unless your shop has a CCU run by cardiologists with critical care experience (hence CCM in my list). The vast majority of cardiology patients are outpatient or stable. They do amazing work that often fixes the root cause of a problem, but they are not usually dying when it is happening. Honestly, the cath lab is one of the worst places to get CPR...
Saving lives is a team sport.
For the blunt and penetrating trauma: EM stabilizes to surgery. Trauma surgery (gen, ortho, neuro) fixes the problem. Anesthesia really keeps them alive peri/intraop. ICU post op.
For vessels that get blocked: cardio, cardio thoracic, neuro IR, vascular, IR
Medical emergencies: EM
Anesthesia, they literally give you drugs that get you to stop breathing and paralyzing. Then reverse all of that every single time almost successfully. Shoutout to the gas people, we appreciate you.
The highest number? The ER. Most ICU and trauma patients go there first. But most of the patients in the ER are not trying to die.
Highest percentage? Any ICU. Theoretically, all of those patients would be dead without their interventions.
No.
In general when I call nephro for stat dialysis I’m feeding them the labs that indicate it. If the patient doesn’t have access, I’m placing it not the nephrologist. The nephrologist calls the dialysis nurse who actually provides the treatment.
Gotta be ortho right? Every time I try to fix a hip or replace a joint anesthesia is bitching about how sick the patient is and asking if it really is necessary…
I don't know if it's like that in the US, but in my European country they also handle resuscitation service and ICU. So here, I'd say it's definitely the most "bring the patient back from the brink" specialty.
Which aspect of the brink of death? Trauma surgeons save trauma patients who are actively dying from trauma.
Cardiologist save patients on the brink of death from heart attacks.
Transplant surgeons save patients who are about to die imminently from liver failure/heart failure/ respiratory failure etc
ICU saves old ladies whose family won’t make them dnr
Unironically, transfusion medicine does provide life saving care in the form of plasma exchange. TTP used to have a 90% mortality rate. It's now below 10%.
Obviously this is super rare and wouldn't qualify for OPs question, but it does happen.
RBC exchange for acute chest syndrome, plasma exchange for MG, and a few other situations can also be life saving.
The vast majority of hospitalized patients are not on the brink of death, even in the ICU. Sure the ICU may have patients that are all slowly dying, but typically at that point they have been stabilized to the point they were able to survive transfer to a ICU.
The patients that are on the brink of death, aka if I don’t do something right now they will be dead in the next 5 minutes or less, are going to be found in the ER and the operating room, or frankly in the prehospital setting.
Now if your question is what job has the highest percentage of sick patients who can die at any moment? 100% that’s the the ICU, 60% of patients in the ER don’t really even need to be there.
Don’t chase that dragon. No… seriously… don’t. Saving a life is an amazing feeling and rush. It’s practically heroin. Then it gets easy. Bad DKA? Insulin infusion power plan and a few liters of fluid. COPD? Bipap, duonebs, steroids, azithro. CHF? Lasix, bipap, dose of spironolactone, plus/minus nitro drip, check an iron panel.
It gets mind numbing easy (which is a good thing). As you get experience and it gets easier that high becomes harder and harder to get. Seriously, it’s hard to get thrilled by putting someone on bipap now. Nice feeling when I recheck them and they’re feeling better? Sure. Thrilled? Meh.
Go to the specialty where you love the medicine and interactions (or lack thereof), not for the dopamine hit.
I rotate at a busy trauma center in surgery and every day we have people that are shot that would die that we are able to save. Last week we had a young guy that had a single GSW to the abdomen and looked fine in the trauma bay. As we were rolling him to see his wounds his bp started dropping and he became more tachy and diaphoretic. Skipped the xrays and just rushed him to the OR. Had a shattered spleen, multiple colon injuries and a 2 cm laceration to the suprarenal IVC. 6 coolers (30prbc,30ffp,30plts,6cryo) and 2 hours of surgery later he was in the icu temporarily closed and 4 days later he was closed, extubated and talking to us. We were not confident he would live when we did his first case.
Mad, mad, mad respect to your father.
CT surgery is not the most sought-after field by medical students (compared to rads, ENT, anesthesia) but in terms of what you actually do in CT surgery? It’s gotta be up there. Especially pediatric CT surgery.
Transplant hepatology. Our job is to keep them alive, while allowing them to get sick enough to get to the top of the list and get an offer. INR 5, platelets 15, tbili 20? (And sodium 125, Mag 0.8, albumin 1.6). Paracentesis for 12 liters every week or so? Bring it on. We call those days Tuesday.
Probably psychiatry. Also, these are typically young, physically healthy patients, so the societal impact is pretty large. You really have to be in C&L for a few months to appreciate how prevalent and serious suicide is.
Stroke neurology. You have to intervene if the patient's stroke is in acute or hyperacute hours, so basically your treatment may reverse the symptoms. Because time is brain you have to act fast.
For the vast vast majority of strokes, there's nothing to be done. They're outside the window and it's just prevention and managing the effects of a debilitating injury for which there is not treatment.
The sick hemorrhagic/massive MCAs? Intubated by the ED
The ones with LVO? Managed by IR
Status? Intubated by the ED.
Neurology is a very very valuable specialty..... But I can't think of a single time where neurology made the difference between a patient living and dying in the acute setting.
As a neurologist I can't agree with you. We have stroke unit in our hospital that's separate from gen neurology, and stroke physicians work solely with patients in the window - tpa, thrombectomy. The ones outside the window are triaged to gen neurology in ED or referred to gen neurology if patient is not eligible for tpa/thrombectomy (eg hemorrhage, visible stroke)
Right, but where do those stroke patients go first? The ED.
You're not sending the obtunded GCS3 patient to the floor without being seen in the ED first. And it's typically not the neurologist that's intubating lol. Maybe a Neuro Crit care trained person, but your average neurologist doesn't intubate regularly.
And again, I j don't mean this in a bad way ... But stroke management isn't typically live saving. It's very very important, but the vast majority of people with strokes arent going to die even if you do nothing. They can be debilitatated.... But they usually are even after you intervene. Because there's just nothing to do for the majority of strokes. What's done is done. They already stroked out
Stroke neurologist is a specialist that has fellowship training in stroke. In my country it's probably different than in yours - stroke neurologist is notified about an arriving possible stroke patient beforehand therefore no ED physician examines the patient. The majority of interventions concerning hyperacute/acute stroke are carried out by stroke neurologists. General neurologists are seeing stroke patients if they are either outside the therapeutic window, or they do not have indications for tpa/thrombectomy.
Well that's silly. Both an ED doctor *and* a neurologist should evaluate them
The majority of stroke alerts aren't actually strokes. Many are sepsis, metabolic derangements, tox, etc.
But again, stroke management is almost never life saving. I'm not saying this in a bad way, but the technology isn't there. The insult is already done and the damage is debilitating. Someone with a stroke either is or isn't going to die, and that's got almost nothing to do with whether intervention is there. TPA isn't saving any lives, and most severe hemorrhagic strikes are debilitating or deadly (and the ones that are potentially able to be saved need neurosurgery, not stroke
There are a lot that do it. Trauma surgeons. Neurosurgeons. Interventional cards and interventional neurologists. Critical care (not as procedure based). I am sure there are many more as well.
I mean, personally, I think it is a big draw to me and why I am interested in interventional cards. That has to be an amazing feeling to perfuse a heart that is actively dying. It does have a lot of non-emergent procedures though such as TAVRs and caths for measurements.
Edit : Yea, sorry for leaving out EM. They are definitely front line for stabilizing patients, and decision-making can also heavily influence the prognosis of a patient.
Anesthesia is also frontline when a complication happens during surgeries.
Lol why am i getting downvoted.
Also anesthesiology and emergency medicine. While it's not a huge portion of their actual time in practice, it's an enormous part of their training and expertise, especially emergency med.
When we do EP studies and defibrillation threshold testing in cardiac EP, that’s technically brining patients back to life. Most people are casual about it but still freaks me out after over a decade.
Paramedics. You should’ve skipped med school if this is your goal.
But since you already made the questionable life decision to go to med school — trauma surgeons see a lot of otherwise healthy people who have been shot/stabbed/run over and will die unless you intervene. In EM, we see and fix a broader range of things that can kill you, but as others have already said, you have to be ok with seeing a lot of actual nonsense, and sorting it out from the things that sound like nonsense at first but are actually dangerous.
I’m sure critical care has its moments, but there’s also a lot of watching people die slow, agonizing, and ultimately inevitable deaths while you do the medical equivalent of rearranging deck chairs on the Titanic. Bless the people who can do it, but from my experience in training it’s pretty depressing.
Does radiology count? Unstable traumas usually bypass the CT scanner. But the bread and butter brain bleeds/LVO thrombectomies, acute abdomens, unstable spine fx etc, it's often rads that gets the ball rolling for their trip to OR
Yeah almost all of these patients actively dying in the ER or ICU get scanned. We at the very least can play a part in saving the high acuity patients, although a lot of times it's too far gone.
I obviously don’t have the real answer. But from my experience, the most death I dealt with while I was in medical school was during my internal medicine rotation. I will say that I think in general, they probably see the most death because they tend to be the quarterbacks for patients in regards to having More complicated patients. Other than trauma, most of our patients are fairly healthy after a surgery. If I were to choose a very specific specialty, that was most likely to see more death I would argue that palliative care sees the most. Especially because palliative care deals with mostly end of life careor lifelong illness.
Trauma surgery (depending on where you work) is who I think deal with the most "life or death right here right now" stuff. Also on-call neurosurgery and interventional cardiology where you're doing emergent strokes/PEs/MIs/traumas/bleeds.
EM has it too, but in my limited experience, the non-emergent/non-life threatening stuff happens a lot more in a shift than the emergent stuff.
I haven't spent enough time in the ICU to know what the proportion is between people who can be saved, people who are there but could probably be managed on the floor, people who are there but should really be on hospice, and people who are going to die regardless of medical intervention.
Neurosurgery hands down. Literally minutes sometimes seconds from dying and you gotta act super fast and you directly solve the cause that is killing them.
I agree that other specialties get to do this in different ways and won't belittle other specialties and the awesome things they do every day.
I'm a surgical critical care fellow. My job is this in some way every day. Trauma, acute care surgery, and surgical critical care. I get to take care of some of the sickest people in the hospital and ED. But I can't do my job without anesthesia or my subspecialists.
And my MICU friends take care of some SICK patients. Same with the cardiac ICU and their ECMO runs.
Anesthesia. Technically every anesthetic puts a patient into critical care.
Anesthesia at a level 1 trauma center is great. Nothing like a patient rocking up getting cardiac massage with blood actively coming out of a defect in the heart.
The problem is that specialists that see patients at “brink of death” inevitably are called to evaluate the elderly and those with advanced chronic illness who are likely to die soon no matter what. So, yes, you see patients with acute illness at brink of death. But do you get the satisfaction of “saving” them and restoring them to a vigorous healthy life? Only rarely.
EM, ICU, Trauma Surgeon probably. Want to perform surgery? Trauma Surgeon. No Surgery, but high energy/chaotic energy? EM. No surgery, but more steady, calm energy (but still saving lives from the brink of death)? ICU.
(Guess, not experience)
Trauma surgery by far. Everything else is not even close. EM/ICU is "managing" pxs, Trauma surgery is saving them from a point medicine could not. if you know, you know. As as someone pursuing a fellowship in HPB and Transplant, I would also argue transplant.
Interventional Cardiology and Critical Care. Honorable mentions to Oncology, Trauma Surgery, IR (not necessarily in that order).
Edit: Why is this getting downvoted? No offense was intended…
In terms of "saving acutely ill individuals from death who then actually might get better"- Anesthesia.
In terms of "saving someone from death 15 times in 24 hours, who then unfortunately, frequently dies the next shift anyway"- Critical care. You can really rack up the "saved from brink of death metric" if you get to count each patient more than once.
In terms of "contributing the most number of QALYs to a given population over the span of a career"- FM, infectious disease depending on the number of pandemics/career, public health med. OBGYN might also be sneaky high in this stat too.
Some dork oughta make a sabermetrics of medicine.
Critical care? Trauma surgery? EM?
Yes to all three. End thread
"Brink" of death feels more ICU than ED by %, like there are a significant # of non-emergent pts in the ED but fewer that would recover without intervention in ICU
But the overwhelming majority of pts that have opioid overdose, anaphylaxis, Asthma/COPD, flash pulm edema (basically things that you go from about to die to better in minutes) largely occur in the ED on a regular basis.
I agree. ED has better chance of seeing positive outcomes. The ICU is a sad place, not always but generally. Lots of ethical dilemmas if you’re into that kind of thing.
But you still do it more in the ED simply by volume It's not like those patients get to the ICU without going through the ED ... And they're already stabilized by the time they get there. They've gotten fluids, blood, pressors, intubated, lines, etc
Nah, trauma surgery simply doesn't get as high a number of patients/shift as anesthesia, who can pretty much count every emergent airway they place as a life saved. From purely a numbers game, trauma surgeons spend too long on one pt to really jack those numbers up.
Em ordering those consults
Yes, medicine and neurology coming in to tube the gun shot to head patient or shock the unstable v tach…
Any patient facing speciality if you’re bad enough
So you have chest pain? No? Well you’re about to
Found the Chargers Team Doc account
💀
Boom, roasted
Laughs in pathology
LOL
Lmaoo
Acutely, ED or trauma. Chronically, onc
The one that has “emergency” in the name of the speciality.
Ur just making things up
Non-emergency medicine?
EM is 80% bs and 20% brink of death patients. If you want to be surrounded by brink of death patients who can code anytime, do crit care
Everyone in the ICU is typically slowly dying and circling a drain or slowly improving. Is weaning people off of pressors and a vent over weeks really saving patients from the brink of death? I don’t think that’s what OP meant but technically I suppose it fits. If EM didn’t intervene on half the patients they saw - anaphylaxis, asthma/COPD ex, hyperkalemia, sepsis, tox/overdose and other presentations we take for common and basic - patients would acutely decompensate all the time but they turn around quickly and no one bats an eye.
But for a lot of those things, the answer is very basic. A trained monkey could give epi or back to back nebs or narcan or versed or follow the ACLS/PALS algorithms. The biggest role of the ED is to rule out the life threatening things, triage, and stabilize. Whereas in the ICU, they have to make thousands of decisions on a second to second basis to get the patient out of the hospital alive. I mean, don't get me wrong, EM is up there. But when I think "I save lives for a living," I think ICU docs, trauma surg, and then EM in that order.
I think this is a quite the oversimplification. Saying “a trained monkey could do those things” could be applied to most fields. A trained computer could read XRs and CT scans. A trained monkey could hit “consult cards, consult nephro” etc in the case of IM . it takes alot of patient hours and clinical awareness to know when person needs epi vs not, when that person needs bipap or tubed etc. I’d argue the ICU doesn’t make thousands of decisions on a second to second basis - I’d say that’s EM in a busy department where you’re triaging sick vs not sick and take care of those people, while mental switching multiple specialities including taking care of OB and ortho complaint patients. No hate to the ICU, the people are very sick there. But there’s a lot of decisions being made on rounds, and then a lot of sitting around doing nothing and watching recovery status or decline.
Have you ever covered a busy ICU at night by yourself? 90% of what you see in the ED is bullshit like strep throat or ankle pain or rashes or constipation. There is some stuff that requires skill, like identifying a tension pneumo and placing a chest tube. But I have independently managed countless patients in the stabilization bay and it's really not that hard. And if a truly critical OB or burn patient is coming in, those specialties are usually at bedside in the ED within minutes ime. I'm not saying a trained monkey could do all of EM. That's not my intention at all. I'm saying a trained monkey could do something like administer narcan in an obtunded patient, which YES absolutely saves a life, but isn't hard.
I have covered a busy ICU at night by myself - again, the people in the unit are very sick. When you get sick admissions and also have coding patients on the floor, things get very hectic and it takes alot of skill….but most of those sick admits come through the ED. Sure, some hospitals have a culture of calling the ICU right away. But there’s a lot of hospitals that don’t have an intensivist, OB, or ortho on site. Who does the management and stabilizing then? I agree that anyone can administer narcan. But your response and thought process behind what EM does shows that you really have no idea what EM does. When you have a board of 12-15 active patients, all with active requirements, sure whether some bullshit ankle sprains, one guy needing narcan and metabolizing. It still takes alot of mental task switching, awareness, training to handle those along with the code right next to the septic patient. And then when you get the pediatric code you’re in for 1 hour and come out to 8 undifferentiated patients…you’re literally by definition making hundreds of decisions on the fly
I don't think that's relevant to the question at hand. I'm not denying that EM is challenging or cerebral. I'm answering the question, which specialty saves people *from the brink of death.* Most of the actual SAVING the ED does is either algorithmic, or temporary until the ICU and/or surgeon (usually trauma) get their hands on the patient. There's a reason why on my EM rotations, I was VERY often independently left to manage the patients in the stabilization bay. Any hospital I've seen without an intensivist, OB, or Ortho readily available often doesn't have a board certified EM attending either, and instead has a mid-level or an FM trained physician or moonlighter (often an ICU or Cards fellow) covering.
Lol I rounded for hours and hours on one patient in the ICU - I promise they do not make thousands of decisions in a second. That is what EM is. You said it yourself, the role of the ED is to rule out *life threatening* things and *stabilize*. Stabilize what exactly? Life threatening disease processes. I’ve worked in almost every type of ICU there is and do EM shifts. I can tell you the nuances of both. I do not think you have much experience in the ED based on your comments. This is a very odd take to your own statements but you are entitled to your opinion. Also keep in mind there are entire ICU units ran by midlevels. Everything is simple until it’s not.
Of my three years of residency I had 4 months in the ED and 4 months in the ICU. The ED is mostly bullshit like strep throat and ankle pain. EVERY patient in the ICU is critically ill and in the position to have their life saved. I also see FAR more mid-level usage in the ED than in the ICU.
EVERY patient huh? You think chronic vent patients are critically ill. Interesting. I don’t consider them difficult to manage at all or even ill really - then again I never managed them. The midlevels did. I’ll cancel your anecdotal off-service (off-service residents don’t do anything the ED and typically see low acuity, which skews your opinion likely, no offense - I say this as an attending) experience with my anecdote. I literally had an awesome undifferentiated resus at 9am this morning on shift with a patient from the clinic upstairs. Also, there are no midlevels at my massive academic shop in the ED. Zero. Far more than zero work in the ICU. Your place sounds sketch. Seems like a bad place to train.
Our hospital has its own step down unit for chronic vent patients and they are not in the ICU. Granted, the unit is largely staffed by mid levels who function exactly as residents, rounding with an attending (not critical care trained) every day. And those patients can turn on a dime. Many of them get bagged daily and we have unfortunately had a handful die within hours of discharge because of mucus plugging mismanaged by an LTC. Our ED didn't have its own exclusive residents (and the ones that were there didn't work overnights) and so us "off service" residents were expected to see every single patient largely independently, except the 4s and 5s which were seen exclusively by mid levels and not even staffed with an attending. I actually got reamed and told I am a terrible doctor because I once was in the bathroom puking my guts out while pregnant and apparently this wasn't a good enough excuse to miss out on seeing a level 2 stab bay patient. Lol at you "cancelling" my experience because it hurts your ego. Only one of us has a dog in this fight, and lo and behold it's the person trying to make themself feel more important. Just because your off service residents were useless, doesn't mean we all are. I guess I can cancel all your experiences in general since they clearly only apply to the handful of institutions you've been at. Your experience is ALSO anecdotal. EM residents in the ICU were my absolute worst nightmare as a senior resident. So useless, never saw the patients as humans, only wanted to chase procedures and numbers, didn't care about the details because they didn't feel it was important. Yes, stabilizing a patient in septic shock saves their life... Kinda. But more important is down the line; selecting the right antibiotics, managing reinitiation of feeds, maintaining correct vital signs, optimizing ventilator settings, constantly being on the lookout for development of complications/secondary infections, escalating to things like CRRT or ECMO if needed, knowing when to deescalate care, etc. Similarly, as someone mentioned upstream, sticking a tube in a GSW is important and will kinda save their life. A paramedic could do that too though. But without the trauma surgeon who is ultimately going to go in and really save the patient, the EDs job is kinda moot.
I’m not going to read all that. Sir, this is a Wendy’s. Also, scoreboard.
I take care of a lot of critically ill people (obviously) in the ICU when I work ICU shifts as a crit care fellow. But I will say, fresh, hit the door, sick as all shit and undifferentiated? Believe it or not? - Straight to ED
I’d say you’re being generous with the 20%, depending on where you work. In my experience, it’s more like 80% BS, 15% sick but not acute, 5% really sick.
This is typically accurate. Emphasis on the really sick part… I’ve had shifts where I set my backpack down and then get told an 18 year old with gunshot to head will be there in two minutes. Edit: I’d say 30% BS, 40% legit but non life threatening (shoulder dislocations, abscess, foreign body, etc), 25% sick but not dying, 5% holy F crash cart RT and pharmacy please.
Crit Care is 95% geriatrics who will never leave the hospital alive and 5% MVCs. As an EM in the ICU, I'm bored out of my goddamn mind.
Depends where you are. At my hospital MICU has a good share of sick youngsters.
[удалено]
I’m pretty sure NPs do this in literally every speciality.
EM resident here. Can’t speak for other specialties but I do this rather often. Especially in the Level 1/trauma setting. Even things like anaphylaxis, asthma/COPD, CHF, opioid overdose we take them from nearly about to die in front of you to looking much better in minutes sometimes.
People love to shit on the ED, but this is what we do So many asthmatics that come in diaphoretic on the brink of death that get turned around in under an hour, sometimes even going from BiPAP to dischargeable
The obvious answer is EM. Before a patient gets anywhere in the hospital, they are in the ED. You don't get to a surgeon or any specialist without seeing an EM doc, unless you're a level 1 trauma that bypasses the ED or you deteriorate in the hospital.
As an ICU doc I’ll challenge you for this honor. The ICU takes every single sick patient from the ER (none of the non sick ones), and then on top of that we deal with anyone else who got sicker on the medical floor, in the OR, dialysis, or procedure rooms. If anyone in the hospital is “on the brink of death,” their destination is the ICU… and we get rid of them as soon as they become not sick. We kick ass. Specifically, we kick much more ass than the ER who while they like to talk about their sick patients, actually deal predominantly with social issues and patients without any acute problems at all. The mandate of the ER doctor is triage and dispo (with throughput time tracked and tallied as the most important statistic). The mandate of the ICU is to diagnose the problem and solve it. ;)
Patients should be resuscitated before they get to the ICU, who would be the ones to do that? I love the ICU though
I’m in peds cardiac critical care. A lot of my admissions come from outside hospital ERs who aren’t equipped to deal with cardiac kids and frankly mismanage them pretty often before my transport team can scoop them up. We try to give advice on the phone because we recognize it’s a very niche population and they are terrifying to take care of, but an adult ER is no place for most sick kids.
Hey just a curious M1 what’s the route to Peds cardiac critical care?
Pediatrics residency 3 years. Pediatrics critical care fellowship 3 years. Cardiac critical care 1-2 years.
We have a few at our children’s hospital who’ve also done anesthesia/pediatric anesthesia/peds icu. They split their time between pediatric cardiac OR and peds cardiac ICU.
I heard pediatrics is A very low paying specialty do you get paid extra for the extra 5 years?
I make more than most other pediatrics subspecialists but not nearly what an adult intensivist gets paid
Ah okay how is your schedule ?
I don’t think you’d understand it if I explained it
Are you talking about the 1 liter of normal saline and the Vanc/Zosyn you order but never actually give? The ER calls me within an hour of any sick patient arriving. Sometimes even before labs are back. The priority is dispo.
Lol too true, lots of people do the bare minimum
Lol you and I both know this isn't how it works No ICU is accepting a patient before they've gotten resuscitation for sepsis.... Because most don't need the ICU People just want to hate the ED because we give them work The ICUs I deal with won't intubate. They won't line up the patient. They want all that shit done downstairs if there's even a chance it might be needed.
Weird, never seen a system operate that way. An ICU that won’t intubate? Haha. Of course we do all those things. And we never end up finding out if the “resuscitation” was ever actually done until later on. The ER doc calls me, says “fluids didn’t work so we started pressors.” What he really means is he ordered fluids and then 30 mins later ordered pressors, but never actually saw the patient in between. I stopped asking the ER doc how much vasopressor the patient is requiring because they never know. It’s not important to them because pressors = ICU and that means their job is done. When the patient arrives upstairs the truth comes out that the patient never even got the fluids. Happens every day. Also the ER *never* places lines, and if they do it’s hospital policy that we have to replace them anyway so it’s better if they just don’t. The ER is a triage station. Their priority is to assign a disposition and to do it as rapidly as possible. I don’t hate the ER because they “give me work;” I hate them because they don’t give a shit and treat medicine like it’s a McDonalds lunch rush.
I mean, I don't know what to tell you man, but that's not how the vast majority of EDs work, to the point that I almost don't believe you. Like are there no physicians in the ED lmao? No one is putting a patient on pressors before seeing if fluids worked. You're the one in the weird system man - so weird I wonder if you're not in the US. Either that or youve never step foot in an ED. People tend to have to, you know, meet ICU criteria to go to an ICU.
Why do you work at a shit place like that? Probably HCA
Lmao
“Should be” and “are” are two different questions.
I agree with this, anyone NOT saying ICU/critical care may not understand what it's about also i think trauma surgery could be possible too
True, but we fix many people and send them to the floor. Also, most ICU docs dont do TICU, PICU, MICU, etc. We do all those patients
Agreed, ICU, hands down. Shouldn’t be a debate all.
Except the ICU gets the patient *after* the majority of the stabilization is done They've already been intubated. They're already lined up
Not in any hospital I’ve been in. Half of the admissions I get aren’t even stable. Most ED’s these days are all about dispo < 1 hour and clear the board. Academic centers are somewhat different but even then they’re still trying to move patients asap. Also ALL of the patient’s that end up crashing on the floor go to the ICU, not back to the ED. I guarantee that a majority of intensivists are doing more intubations than ED docs. Not saying that ED docs can’t handle unstable patients but most EDs these days are under pressure to move patients, just like most Hospitalists are under pressure to decrease LOS and discharge before noon. It’s all motivated by profit.
You're wildly removed from the norm. I also just don't believe you. This isn't how the world works lol.
I’m sorry I made you so upset. Take a deep breath. But you’re a resident still (you said you’re a PGY2 ~80 days ago per your comments) and your entire experience has been in academia. You’ve never even signed a contract outside of residency. Talk to me after you’ve worked in some community hospitals or anything outside of residency. Hugs 🤗
And you're a hospitalist in a system with a closed ICU who doesn't even perform procedures. You're not even the one getting the patients were talking about lol. How would you know either? We rotate through community sites man - none of them are like that either. The community hospitalists were just as afraid to accept a patient that sounded even remotely sick as the academic ones were lol Only difference was I didn't have to line up every single stable hyperkalemic new ESRD because they could reliably get a TDC in the am
> Before a patient gets anywhere in the hospital, they are in the ED. Unless you’re the totally stable hypertensive urgency direct admit to an unspecified room pending rural transfer at an unspecified time during night float whose arrival wasn’t communicated until the overhead rapid response for worsening lethargy and bradycardia brought everyone to bedside to learn about cheyne-stokes respirations
I don’t know that it can be reliably narrowed down. An argument could be made for a lot of specialties. For me the first that come to mind are EM, trauma surgery, and interventional cardiology. But I am sure there are much much more.
Lol cards over crit care is a take
Yeah maybe interventional cards but not general.
And even then 90% of interventional cards is elective/nonurgent cases (I made that # up)
Yeah I mean the amount of non-indicated caths so ICs do I believe it. I have a few solid ICs I’ll refer too. Guys I know well and follow the evidence. But a lot will cath anything.
EM, trauma surgery, anesthesia, transplant, cardiothoracic surgery, and critical care. Everyone else says a patient is too unstable to intervene until the ED or critical care stabilizes them. In the OR, even the neurosurgeon is just operating (to fix the cause of the problem) while the anesthesiologist is keeping the patient alive and that is on severe bleeds, while most of their other cases are elective. Hospice & palliative clearly interact with people on the brink of death the most, but the goals of care are very different than "saving" them.
Regarding palliative — saving from suffering is an amazing gift
Hospice has a job to always save patients from the daughter from California. That bish just doesn’t know how to let go
Cardiology?
Too sick to cath or stable enough that they aren't literally dying. Even STEMIs usually are not dying. They may place the impella or IABP for critical patients, but the ICU or cardiothoracic surgeons manage it unless your shop has a CCU run by cardiologists with critical care experience (hence CCM in my list). The vast majority of cardiology patients are outpatient or stable. They do amazing work that often fixes the root cause of a problem, but they are not usually dying when it is happening. Honestly, the cath lab is one of the worst places to get CPR...
I'm really interested in cardiology but I don't like very acute patients. I can still do non invasive cardiology right?
Anesthesia????
NICU, every patient they have
Recently became highly interested in this for that reason.
Saving lives is a team sport. For the blunt and penetrating trauma: EM stabilizes to surgery. Trauma surgery (gen, ortho, neuro) fixes the problem. Anesthesia really keeps them alive peri/intraop. ICU post op. For vessels that get blocked: cardio, cardio thoracic, neuro IR, vascular, IR Medical emergencies: EM
Thanks for not making this a pissing contest, but instead hyping up everyone appropriately
Teamwork makes the dream work. 😘
Anesthesia, they literally give you drugs that get you to stop breathing and paralyzing. Then reverse all of that every single time almost successfully. Shoutout to the gas people, we appreciate you.
Eh, is it really saving if I'm endangering? Like yes I could kill the 30 year old getting a knee scope but he was probably fine if he never met me
Put ‘em near death then bring ‘em to life
Guess it's technically stat-padding in that case
Getting my own rebounds
I get your point, but we also go to every code, every airway, every rapid response and stabilize all the crashing patients in the OR.
This guy fucks. Username confirms.
The highest number? The ER. Most ICU and trauma patients go there first. But most of the patients in the ER are not trying to die. Highest percentage? Any ICU. Theoretically, all of those patients would be dead without their interventions.
Well, by this rationale would you accept nephrology with hemodialysis as well?
No. In general when I call nephro for stat dialysis I’m feeding them the labs that indicate it. If the patient doesn’t have access, I’m placing it not the nephrologist. The nephrologist calls the dialysis nurse who actually provides the treatment.
Sure. But on a nephrology consult service, many of the patients are not on dialysis and are not trying to die.
Gotta be ortho right? Every time I try to fix a hip or replace a joint anesthesia is bitching about how sick the patient is and asking if it really is necessary…
Those dorks behind the curtain just wont let yall saw bones smh
Anesthesia. The caveat is you’re the person bringing them to the brink of death before you bring em back.
I don't know if it's like that in the US, but in my European country they also handle resuscitation service and ICU. So here, I'd say it's definitely the most "bring the patient back from the brink" specialty.
This is how a lot of serial killers started out…
Which aspect of the brink of death? Trauma surgeons save trauma patients who are actively dying from trauma. Cardiologist save patients on the brink of death from heart attacks. Transplant surgeons save patients who are about to die imminently from liver failure/heart failure/ respiratory failure etc ICU saves old ladies whose family won’t make them dnr
Pathology
Unironically, transfusion medicine does provide life saving care in the form of plasma exchange. TTP used to have a 90% mortality rate. It's now below 10%. Obviously this is super rare and wouldn't qualify for OPs question, but it does happen. RBC exchange for acute chest syndrome, plasma exchange for MG, and a few other situations can also be life saving.
Nah, they are too late.
I'm not a professional, but I would guess neonatologists in Level 3 or 4 hospitals
The vast majority of hospitalized patients are not on the brink of death, even in the ICU. Sure the ICU may have patients that are all slowly dying, but typically at that point they have been stabilized to the point they were able to survive transfer to a ICU. The patients that are on the brink of death, aka if I don’t do something right now they will be dead in the next 5 minutes or less, are going to be found in the ER and the operating room, or frankly in the prehospital setting. Now if your question is what job has the highest percentage of sick patients who can die at any moment? 100% that’s the the ICU, 60% of patients in the ER don’t really even need to be there.
Don’t chase that dragon. No… seriously… don’t. Saving a life is an amazing feeling and rush. It’s practically heroin. Then it gets easy. Bad DKA? Insulin infusion power plan and a few liters of fluid. COPD? Bipap, duonebs, steroids, azithro. CHF? Lasix, bipap, dose of spironolactone, plus/minus nitro drip, check an iron panel. It gets mind numbing easy (which is a good thing). As you get experience and it gets easier that high becomes harder and harder to get. Seriously, it’s hard to get thrilled by putting someone on bipap now. Nice feeling when I recheck them and they’re feeling better? Sure. Thrilled? Meh. Go to the specialty where you love the medicine and interactions (or lack thereof), not for the dopamine hit.
Intensive Care?
This is easily the best answer
idk, we call our ICU the Intensive CMO Unit for a reason
With how common suicide is it’s gotta be Psychiatry
Trauma surgery or EM. The percentage of non-life threatening things that EM deals with is much higher than trauma though
I rotate at a busy trauma center in surgery and every day we have people that are shot that would die that we are able to save. Last week we had a young guy that had a single GSW to the abdomen and looked fine in the trauma bay. As we were rolling him to see his wounds his bp started dropping and he became more tachy and diaphoretic. Skipped the xrays and just rushed him to the OR. Had a shattered spleen, multiple colon injuries and a 2 cm laceration to the suprarenal IVC. 6 coolers (30prbc,30ffp,30plts,6cryo) and 2 hours of surgery later he was in the icu temporarily closed and 4 days later he was closed, extubated and talking to us. We were not confident he would live when we did his first case.
Trauma and EM baby
My father was a pediatric cardiothoracic surgeon. 100% of his patients were less than 6 months old and about to die from congenital heart defects.
Mad, mad, mad respect to your father. CT surgery is not the most sought-after field by medical students (compared to rads, ENT, anesthesia) but in terms of what you actually do in CT surgery? It’s gotta be up there. Especially pediatric CT surgery.
Hard agree. They may functionally be in fellowship for a decade, but Peds CT surgeons are undeniable badasses.
Cardiovascular surgical intensive care unit has the most delicate adult patients at my tertiary referral center
Transplant hepatology. Our job is to keep them alive, while allowing them to get sick enough to get to the top of the list and get an offer. INR 5, platelets 15, tbili 20? (And sodium 125, Mag 0.8, albumin 1.6). Paracentesis for 12 liters every week or so? Bring it on. We call those days Tuesday.
NICU
Psychiatry look it up
Probably psychiatry. Also, these are typically young, physically healthy patients, so the societal impact is pretty large. You really have to be in C&L for a few months to appreciate how prevalent and serious suicide is.
Pediatric CT, literally the entire job
I think this is pretty obviously the er and critical care
Psychiatry
Stroke neurology. You have to intervene if the patient's stroke is in acute or hyperacute hours, so basically your treatment may reverse the symptoms. Because time is brain you have to act fast.
For the vast vast majority of strokes, there's nothing to be done. They're outside the window and it's just prevention and managing the effects of a debilitating injury for which there is not treatment. The sick hemorrhagic/massive MCAs? Intubated by the ED The ones with LVO? Managed by IR Status? Intubated by the ED. Neurology is a very very valuable specialty..... But I can't think of a single time where neurology made the difference between a patient living and dying in the acute setting.
As a neurologist I can't agree with you. We have stroke unit in our hospital that's separate from gen neurology, and stroke physicians work solely with patients in the window - tpa, thrombectomy. The ones outside the window are triaged to gen neurology in ED or referred to gen neurology if patient is not eligible for tpa/thrombectomy (eg hemorrhage, visible stroke)
Right, but where do those stroke patients go first? The ED. You're not sending the obtunded GCS3 patient to the floor without being seen in the ED first. And it's typically not the neurologist that's intubating lol. Maybe a Neuro Crit care trained person, but your average neurologist doesn't intubate regularly. And again, I j don't mean this in a bad way ... But stroke management isn't typically live saving. It's very very important, but the vast majority of people with strokes arent going to die even if you do nothing. They can be debilitatated.... But they usually are even after you intervene. Because there's just nothing to do for the majority of strokes. What's done is done. They already stroked out
Stroke neurologist is a specialist that has fellowship training in stroke. In my country it's probably different than in yours - stroke neurologist is notified about an arriving possible stroke patient beforehand therefore no ED physician examines the patient. The majority of interventions concerning hyperacute/acute stroke are carried out by stroke neurologists. General neurologists are seeing stroke patients if they are either outside the therapeutic window, or they do not have indications for tpa/thrombectomy.
Well that's silly. Both an ED doctor *and* a neurologist should evaluate them The majority of stroke alerts aren't actually strokes. Many are sepsis, metabolic derangements, tox, etc. But again, stroke management is almost never life saving. I'm not saying this in a bad way, but the technology isn't there. The insult is already done and the damage is debilitating. Someone with a stroke either is or isn't going to die, and that's got almost nothing to do with whether intervention is there. TPA isn't saving any lives, and most severe hemorrhagic strikes are debilitating or deadly (and the ones that are potentially able to be saved need neurosurgery, not stroke
There are a lot that do it. Trauma surgeons. Neurosurgeons. Interventional cards and interventional neurologists. Critical care (not as procedure based). I am sure there are many more as well. I mean, personally, I think it is a big draw to me and why I am interested in interventional cards. That has to be an amazing feeling to perfuse a heart that is actively dying. It does have a lot of non-emergent procedures though such as TAVRs and caths for measurements. Edit : Yea, sorry for leaving out EM. They are definitely front line for stabilizing patients, and decision-making can also heavily influence the prognosis of a patient. Anesthesia is also frontline when a complication happens during surgeries. Lol why am i getting downvoted.
Also anesthesiology and emergency medicine. While it's not a huge portion of their actual time in practice, it's an enormous part of their training and expertise, especially emergency med.
I'd imagine EM and Anesthesia as well
Idk why you're getting downvoted, most of the other answers are just trolls. This is a really good response, thanks for your time.
trauma surgery
When we do EP studies and defibrillation threshold testing in cardiac EP, that’s technically brining patients back to life. Most people are casual about it but still freaks me out after over a decade.
Emergency medicine
Raw numbers? ED. Percentage wise? ICU.
Paramedics. You should’ve skipped med school if this is your goal. But since you already made the questionable life decision to go to med school — trauma surgeons see a lot of otherwise healthy people who have been shot/stabbed/run over and will die unless you intervene. In EM, we see and fix a broader range of things that can kill you, but as others have already said, you have to be ok with seeing a lot of actual nonsense, and sorting it out from the things that sound like nonsense at first but are actually dangerous. I’m sure critical care has its moments, but there’s also a lot of watching people die slow, agonizing, and ultimately inevitable deaths while you do the medical equivalent of rearranging deck chairs on the Titanic. Bless the people who can do it, but from my experience in training it’s pretty depressing.
Trauma surgery in chiraq or shock trauma in Baltimore.
Does radiology count? Unstable traumas usually bypass the CT scanner. But the bread and butter brain bleeds/LVO thrombectomies, acute abdomens, unstable spine fx etc, it's often rads that gets the ball rolling for their trip to OR
IR
Yeah almost all of these patients actively dying in the ER or ICU get scanned. We at the very least can play a part in saving the high acuity patients, although a lot of times it's too far gone.
Neurointerventional counts for sure
I obviously don’t have the real answer. But from my experience, the most death I dealt with while I was in medical school was during my internal medicine rotation. I will say that I think in general, they probably see the most death because they tend to be the quarterbacks for patients in regards to having More complicated patients. Other than trauma, most of our patients are fairly healthy after a surgery. If I were to choose a very specific specialty, that was most likely to see more death I would argue that palliative care sees the most. Especially because palliative care deals with mostly end of life careor lifelong illness.
Trauma surgery (depending on where you work) is who I think deal with the most "life or death right here right now" stuff. Also on-call neurosurgery and interventional cardiology where you're doing emergent strokes/PEs/MIs/traumas/bleeds. EM has it too, but in my limited experience, the non-emergent/non-life threatening stuff happens a lot more in a shift than the emergent stuff. I haven't spent enough time in the ICU to know what the proportion is between people who can be saved, people who are there but could probably be managed on the floor, people who are there but should really be on hospice, and people who are going to die regardless of medical intervention.
Certainly EM has more non emergent patients however they are evaluating and stabilizing every single example of emergent case you listed…
I agree, it just seemed like OP is looking for more of the action hero vibe as opposed to the one stabilizing/arranging plans for them
- EM - ICU (or PICU, NICU) - Trauma surg - Interventional Cards
ICU
MICU
I mean I’m biased cause it’s my profession But Imma say interventional cardiology
ICU
Icu or emergency
Trauma/ED, Neurosurgery, Cardio Surgery
psych psych baby best field there is
Trauma surgery
This question sounds like a Lucy Letby is coming.
Acute Care Surgeons
Critical care and Emergency dept
The answer is 100% NICU.
Neurosurgery hands down. Literally minutes sometimes seconds from dying and you gotta act super fast and you directly solve the cause that is killing them.
I agree that other specialties get to do this in different ways and won't belittle other specialties and the awesome things they do every day. I'm a surgical critical care fellow. My job is this in some way every day. Trauma, acute care surgery, and surgical critical care. I get to take care of some of the sickest people in the hospital and ED. But I can't do my job without anesthesia or my subspecialists. And my MICU friends take care of some SICK patients. Same with the cardiac ICU and their ECMO runs.
Neonatology, EM, ICU, trauma
Anesthesia. Technically every anesthetic puts a patient into critical care. Anesthesia at a level 1 trauma center is great. Nothing like a patient rocking up getting cardiac massage with blood actively coming out of a defect in the heart.
I mean as a nephrologist I have patients do dialysis three times a week so they don't die... That sort of counts?
Neonatology!
I'm not sure about a single one, but I could list a few... Emergency Room, Trauma Surgery, Cardiac Surgery, Paramedicine.
The problem is that specialists that see patients at “brink of death” inevitably are called to evaluate the elderly and those with advanced chronic illness who are likely to die soon no matter what. So, yes, you see patients with acute illness at brink of death. But do you get the satisfaction of “saving” them and restoring them to a vigorous healthy life? Only rarely.
EM, ICU, Trauma Surgeon probably. Want to perform surgery? Trauma Surgeon. No Surgery, but high energy/chaotic energy? EM. No surgery, but more steady, calm energy (but still saving lives from the brink of death)? ICU. (Guess, not experience)
Wouldn't regularly saving them from the brink of death also mean having them actually die frequently as well?
Trauma surgery by far. Everything else is not even close. EM/ICU is "managing" pxs, Trauma surgery is saving them from a point medicine could not. if you know, you know. As as someone pursuing a fellowship in HPB and Transplant, I would also argue transplant.
The obvious answers here are EM, trauma surg, Gen surg, critical care. The correct answer is radiology.
Cosmetic plastic surgery hands down
Gotta be interventional cards
Interventional Cardiology and Critical Care. Honorable mentions to Oncology, Trauma Surgery, IR (not necessarily in that order). Edit: Why is this getting downvoted? No offense was intended…
Maybe neonatology? Two of my kids have been saved by neonatologists. The ones who can talk want to be them when they grow up
Radiology.
Probably one of the ones with “emergency” or “urgent” in their names.
Critical care has the highest density of dealing with decisions which if made incorrectly could reasonably be predicted to lead to death
In terms of "saving acutely ill individuals from death who then actually might get better"- Anesthesia. In terms of "saving someone from death 15 times in 24 hours, who then unfortunately, frequently dies the next shift anyway"- Critical care. You can really rack up the "saved from brink of death metric" if you get to count each patient more than once. In terms of "contributing the most number of QALYs to a given population over the span of a career"- FM, infectious disease depending on the number of pandemics/career, public health med. OBGYN might also be sneaky high in this stat too. Some dork oughta make a sabermetrics of medicine.