The Next Two Minutes: Emergency Medicine with Tyler

Show Notes

In Episode 7 of No Referral Required, Mandy, Courtney, and Lara are joined by Dr. Tyler, an emergency medicine physician with more than 25 years in practice, to talk about the one specialty that takes whoever walks through the door. Dr. Tyler lays out the mental framework behind every encounter in the emergency department — what could kill this patient in the next two minutes, two hours, two days, two months — and why that approach looks so different from the primary care doctor who already knows you well enough to ask whether you played tennis this weekend. He also takes on the biggest misconception about his field: the crowding isn't people treating the ED as an urgent care, it's the sheer volume of genuinely sick patients, compounded in Tennessee by rural hospital closures that leave people driving hours to reach specialty care.

The conversation turns to The Pitt and ER — Dr. Tyler trained alongside several of the show's writers and vouches for the realism, chaos and all, though the county hospital with a budget for a retinal scanner still makes him laugh. From there it goes to the harder material: the moral injury behind the highest burnout rate of any specialty, the colleagues he lost after they were physically assaulted at work, why the Tuesday after a three-day weekend is rougher than the Fourth of July, and what a geriatric ED certification means for an aging population. He makes the case that AI will never intubate a patient but has made him more receptive when a patient's family floats a long-shot diagnosis, and he leaves both residents and patients with one piece of advice each — know when to get help, and find yourself a primary care doctor (then stay off the scooters).

Transcript

Courtney [00:00:07] Hey, everybody, and welcome to episode number seven of No Referral Required. Hello. Lucky number seven. Lucky number seven.

Mandy [00:00:15] Our guest does not agree with that.

Courtney [00:00:16] Yeah, we’ll let you determine. But yeah, Mandy, why don’t you introduce our guest today? We have Tyler. Thanks for coming, Tyler.

Tyler [00:00:25] It’s my pleasure.

Mandy [00:00:25] Yeah, so Tyler is an emergency medicine physician. So just a little background for myself, Tyler, because this is about me, obviously. My introduction into medicine was as a scribe in the ER in the Harris Methodist system in Fort Worth. And I loved emergency medicine, not enough, obviously, to go into it. But it was such a great exposure to every type of medicine. And because that was my really first deep dive, I have such a special place for it in my heart. So I’m so excited that we’re going to get to talk to you today. I didn’t realize, so emergency medicine became as young as a specialty.

Tyler [00:01:03] Yeah, it’s still, I’m not even sure it’s quite 50 years old as a specialty yet.

Mandy [00:01:07] Yeah, 79 is what it said when I, you know, looked online, which is a pretty big party. Yeah, you should have a big party.

Tyler [00:01:14] Cincinnati probably will. They were their first residency, so.

Mandy [00:01:17] That’s amazing, because, you know, just to put in perspective, GYN is like the late 1800s, which, you know, it’s fair, because women have been having babies, well, you know, forever. So, you know, we have our, a long history, but 70s is fairly young, and it looked like a massive increase in popularity over time as a specialty, probably for a lot of reasons, which we’ll get into. Shift work, not taking things home, and high adrenaline, which I think becomes fodder for a lot of television, which we’ll also get into. Courtney’s so excited. So why don’t you just start by telling us about yourself, why you chose emergency medicine, how’d you get into it, what keeps you there?

Tyler [00:01:59] So I went into med school thinking I wanted to be a pediatric surgeon. Ironically, because one of the shows we made talked about ER, the actress who played the pediatric surgeon on that show was just, you know, such an awesome character. And I knew I Always wanted to be a doctor since I was like seven. And I have no physicians who are in my family, but was just decided that’s where I was going to be. And AP Bio was my favorite high school class and loved that. Went through college and went straight to med school. And then the summer between first and second year of med school, I spent it down in the emergency department. essentially it’s just like a research, you know, just doing projects for all the physicians that didn’t have anybody to do the projects and just fell in love with it. The sort of immediate gratification, somebody comes in with a problem, you can sometimes fix it or figure out what it’s not and the shift work was nice and I was always involved in team sports throughout my life and college and The way that we all work together, the nurses, the paramedics, the EMTs, the physicians, you know, it’s a really cool camaraderie down there.

Lara [00:03:11] Yeah. I like that idea of it being a team sport. Yeah. Yeah.

Mandy [00:03:14] I don’t think you can survive without your team down there. From what I’ve seen. Yes. Chaos. Yeah. So describe for the listeners like what a typical shift looks like for you.

Courtney [00:03:28] Can we use the word typical?

Tyler [00:03:30] There’s really no such thing as typical. I mean, emergency medicine in general, most places we work anywhere from eight hours to some of the more remote emergency departments might have 24-hour shifts. But most places are probably somewhere between eight and 12-hour shifts. Usually you’ll come on and the person was there before, if they’ve got some patients who aren’t quite dispositioned, meaning that like they’re set up to get made to the hospital or they’re going to get discharged, you’ll kind of take sign out from them and then it’s you know, whoever walks through the door. And it depends on the emergency department you work in. You know, where I work, we primarily see just adult patients. There are specific children’s hospitals that might see primarily just pediatric patients. And then there’s some that see, you know, everything from a newborn baby to somebody well over 100 years old, and the range of complaints can be, you know, from anything, so.

Mandy [00:04:32] That seems daunting to have to keep that much in your bank, in your brain.

Tyler [00:04:37] It can be, but it’s, you know, that’s where some of the best teachers of emergency medicine, I mean, our approach in general for emergency medicine is think about, you know, what I, when I tell, you know, working with students or trainees is think about what’s likely to kill this patient the next two minutes, the next two hours, next two days, next two months, you know. So, what are the things, somebody comes in with chest pain, the first thing to think about is, Is this a heart attack? Is this, you know, a orc dissection, you know, that just, you know, affected, you know, the senator? Is this, you know, they’ve got a blood clot in their lungs, something along that. It’s not, oh, they pulled a muscle. It may end up that they pulled a muscle, but we approach it that way as opposed to some of our other colleagues in, you know, primary care who know patients for a long time and have built that relationship. they may know the first thing to ask is, were you playing tennis this weekend? Did you do that backhand and straight?

Mandy [00:05:34] Yeah, because you’ve done this 50 times. That’s an excellent way of looking at it. The most acute thing right now, and then work your way down from there. What’s the most common misconception people have about your specialty?

Tyler [00:05:52] I would say lately that people attribute the crowding and boarding to misuse of the emergency department. A lot of people would think, oh, the ED is so crowded because people are using it as, you know, their urgent care or their primary care. And since, you know, I’ve been in the practice for over, you know, 25 years now. You know, when it started, there were a lot more kind of lower acuity kind of patients that would come through, but now that we have walk-in clinics, urgent cares, you know, on many corners, you’ve really siphoned off a lot of those patients. So the majority of the patients that we see are quite sick or have a complaint that can’t be worked up. And while those urgent cares, you know, most urgent cares can’t do like a CT scan if you develop sudden right lower quadrant abdominal pain and you’re worried about your appendix. That’s something you generally need to come to emergency department or if you suddenly have bad chest pain and you’re worried about heart attack. Most, you know, urgent carers aren’t gonna be able to do all the tests that you need to be able to kind of exclude the bad things we just talked about. But it’s rare that we’re seeing patients that don’t need to, don’t need to be there at all. You know, somebody’s just coming in for, you know, sniffles or something like that. Occasionally, if we do, it’s because it’s a patient maybe has no other place to go. You know, they can’t – they don’t have a primary care doctor. They don’t have other resources that they can go. And so, maybe there are some social determinant kind of factors there. But the majority of time why, you know, some of your listeners might come and there’s a large number of people in the waiting room and they have to wait many hours to get back, it’s just the sheer volume of patients who need emergent care, especially in Tennessee in part because we’ve had a lot of hospitals close, a lot of rural hospitals. It’s not uncommon for us to have patients drive hours to come to our hospital because they need certain specialty care that they just can’t get anywhere close to their home.

Mandy [00:08:12] Yeah, that, you know, I wouldn’t, that doesn’t wouldn’t surprise me about like, a specialty visit, or, you know, a cancer visit, but I’m sort of surprised about the ER that, because to me, ER is acuity, and it’s get there fast. And that doesn’t equal a two hour drive. Right. But I guess if there’s nothing between you and the quality of the ER you need, hospitalized, that’s what you’ve got to do.

Tyler [00:08:34] And especially if you have some specific illness, you know, if you have a type of cancer or you have some type of autoimmune disease or you’re a transplant patient or some advanced, you know, heart, lung disease that you know you need to see your specialist for, then that’s going to lead you to have to go to a hospital that has those resources because… Now, to your point, even if you have that and you suddenly have, you know, you’re thinking you’re having a stroke, you’re having a heart attack, like, don’t drive past that. Most of them can do some things that will be important and then if they need to get you an ambulance, get you in a helicopter. Yeah. Occasionally we get some patients that show up and be like, I drove past all its places. I was like, I wish you did it. Might’ve been able to do a little bit more. I had to stop there. Yeah.

Mandy [00:09:31] Yeah. Great point. Okay. Well, this is the question that since Maida told me that you were coming, I was wanting to just talk about, so I grew up watching ER as all of us probably at the table bed every Thursday night, nine o’clock. That’s where I was. I now watch The Pit because obviously Dr. Carter has become a new person and now he is much more troubled than he used to be, but that’s okay. Has anything changed for you in terms of maybe people talking about it maybe like to you asking you questions like outside of patients or anything or even patients do patients bring it up ever do patients i brought it up with some nurses one time and She said, well, everything on there is real, except that most of the time the nurses are doing what the doctors are portrayed as doing on that show. She’s like, don’t even think that those doctors are doing whatever she said. They pass that off on us. And I was like, okay, well noted. But I just, I’m curious before and after the pit, because you were obviously younger when ER was going on, but now seeing that have come out, what has changed? Anything, nothing?

Tyler [00:10:53] The most practical thing is it’s the first time that either of my kids have actually asked about what I do. My younger son watches it with us. My older son does not.

Mandy [00:11:06] So you do watch it, because I’ve heard of some of your docs who don’t want to watch it.

Tyler [00:11:09] No, I’ve watched it. So I did my residency out on the West Coast, and many of the writers for the show were some of my faculty mentors. And so that’s why I’ll say that it is incredibly realistic. Now, like any show like that, the number of things that happen in one episode, and obviously that they make it.

Mandy [00:11:34] Everything is high, high, high.

Tyler [00:11:36] And since they sort of follow like the 24, like each episode is an hour, there’s a lot of things condensed in, but they do a really good job. The actual, the writers and Noah Wiley, and I think a couple of the, I think maybe one of the producers, came to our national meeting in Salt Lake City last fall, actually, were the guest speakers, and then walked around sort of the exhibition hall and got ideas for things. Now, having trained at a county hospital cracks me up when I see, I mean, one of the unrealistic parts is, you know, it’s a county hospital, it’s supposed to be in Pittsburgh. And they pull out these like devices, I was like, there is no way. The county administrators were gonna approve that. I was like, I was excited when I had, you know, it’s like, you know, some, like, great new equipment. But not.

Mandy [00:12:37] So ER maybe was a little more realistic in terms of, because they had very little equipment. They were very much like, we’re the poor people on this side of town.

Tyler [00:12:46] Yeah, I think they pulled out some, like, retinal scanner thing. I’m like, really? But a lot of the use of ultrasound is very realistic to what we’re doing in emergency departments. A lot of the chaos is realistic. And unfortunately, I think some of the other sensitive issues that they’ve hit, like the violence towards staff. your nurse friends you talk to, I mean, they’re right. Our ED nurses are unbelievable, what they do and what they have to put up with. And, you know, I think it seems like post pandemic, patients lost a little bit of their humanity and not just patients, but like their family and their friends are with them. Like none of us want to make patients wait. None of us want to ignore them. It’s just, there’s just so many people. I will say the other thing, we, as a specialty, you know, our numbers kind of dropped off a little bit after COVID. I think there were people who were like, I don’t want to necessarily, you know, I mean, we were, I was taking care of patients in a former parking garage, as were many of my colleagues across the country in tents and all other places. And so I think some medical students were like, oh, this doesn’t sound right.

Mandy [00:14:16] It kind of addresses that whole, like, because the main character, they’re all dealing with PTSD from that.

Tyler [00:14:21] Yeah, I will say those are the scenes that, the flashbacks to COVID are the scenes that give me sort of that, that’s the part that’s like anxiety provoking.

Mandy [00:14:31] You can watch them cut somebody’s like, you know, up their side. There’s usually one scene that’s way intense in terms of like bloodiness. And I’m sure it’s because it’s expensive to have all those fake things. And we’ll be like, okay, don’t watch right now. Okay, now turn back.

Tyler [00:14:50] Okay, all right. One of my favorite stories with the pit after it first came out was I have a good friend who is a, he’s a highly specialized surgeon, leads a department and our sons are good friends. And he texted me and he’s like, are you home? I was like, no, he’s like, I just watched the first episode, Pitt, I wanted to come over and give you a hug.

Mandy [00:15:13] He didn’t know, he didn’t have any idea, day to day was like that.

Tyler [00:15:18] No, he was like, I didn’t realize that’s what you all put up with. But no, it’s been great. I think it’s been nice to sort of address some of the issues, a lot of the moral injury and sort of the stress on the physicians and nurses and everybody down there.

Mandy [00:15:38] How about the med student who walked out? Did you watch that one? That was controversial.

Tyler [00:15:43] I know. I read some stuff on that.

Mandy [00:15:46] A med student gets to the end of her 12 hours or whatever, and everybody else has to stay behind to do charting because the electronic charts were down that day. And so they all had to, which was hysterical to watch them. Having watched ER, it was funny to watch because all of a sudden they were writing on the board and whatever. But anyway, she was like, nope, it’s my 12 hours. I’m out. And everybody online was like, what? And even the people on it that were like residents were like, hold on. Yeah. How many hours a week do you work on average? Like what’s your normal?

Tyler [00:16:24] So our normal, you know, full time for most it’s, you know, normally it’s like between 13 and 14, nine hour shifts a month.

Mandy [00:16:34] Okay.

Tyler [00:16:34] So it’s usually about three, three to four shifts a week is how, you know, most emergency physicians, again, some, some, if they’re doing 12s may do a little bit less, you know, but usually it’s, It depends on some of our younger physicians. They may want to work more early on and try to pay off med school loans. I thought you were going to say the opposite. And then, you know, I think a lot of us, as you get kind of further on in your career, you’ll, you know, a lot of times kind of balance with, you know, some other things.

Mandy [00:17:12] Sure, it’s great. Yeah. Do you see any, we always ask this question, do you see any threat to your field with AI or benefit? Like what, what is, what’s the word on the street in the ED?

Tyler [00:17:27] I don’t see a threat. AI is never going to be able to intubate a patient. Okay. The, I will say one of the things that it has changed for me is I am much more receptive when family members or, you know, or even patients suggest a diagnosis that might seem you know, totally out of left field. It’s like, do you think this could be this? And, you know, five or 10 years ago, I might have been a little bit more like, yeah, it’s definitely not that. But now I’ve sort of, you know, taken the approach of, you know, everything’s on the table, we’re going to make sure we rule out these really serious things first, and then it could be and, you you know, because some of those tools are really good at, people type in all their symptoms, and I had a case recently where I had a family member, you know, their patient had been dealing with something for months, and could this be blah, blah, blah, and I was like, I’ve seen that like twice in my entire career, and I almost was like, that’s like, could be I want to take care of your family member. They were incredibly sick. I was like, let’s get them. And then sure enough, I was following them a couple of days later. They were in the ICU. And a subspecialist sent off some tests. It’s a lot easier to make the diagnosis when you have the confirmatory test results. And sure enough, I saw it. They’re like, this is it. I was like, well, I’m really glad I didn’t tell the other family member. Of course it’s not that, because I’d be like, Yeah, I remember. But yeah, I mean, I think some physicians get kind of put off. I appreciate when patients do some research. I think you just need to look at reputable sources. Somebody comes in and tells me that they have some crazy

Courtney [00:19:26] TikTok disease. Virus, yeah, exactly.

Tyler [00:19:29] Or wants to refuse some important vaccine or something like that and be like, okay, well, you might be the second person to survive rabies, but. Yeah. I don’t know, she answered it better. More likely than not, no. But it’s up to you.

Mandy [00:19:54] So social media is something that you have found people talk about. They’ll say, well, I saw this, or I saw that. Do people say that, or do y’all not have enough time to get that far?

Tyler [00:20:04] I wouldn’t say, yeah, we definitely don’t have enough time to be talking to patients about their social media. I would say from our standpoint, it’s probably balanced on how it impacts. It gives some people awareness to things that they may not know. And then you’re going to have some people that I mean, the pandemic was a mess with that. Part of that was because no one knew what was real, what was false.

Mandy [00:20:34] Right. We talk a lot about mental load. This may be the emotional load. part that we get to because a part of our goal with this podcast is to really humanize doctors. I don’t mean you aren’t human, but I think sometimes we as patients can consider you to be, you know, all knowing and like a computer, we just put in all the things and then it just comes out with whatever, you know, protocol, whatever, whatever, you know, that kind of thing. But, What is your mental load like after you have a busy, after you work on the 4th of July or some long, you know, I’ve heard holiday weekends are harder, but is that, what does that feel like for you? Do you take it home?

Tyler [00:21:17] Yeah. , sometimes, I mean, some, some shifts, , I remember my wife always says, like one of, I had one shift where I diagnosed two young kids with leukemia on the same shift. And she will remember when I came home that shift, she’s like, you looked like a truck at you. And especially having had young kids. So I mean, some things, I think especially when you can sort of empathize with that patient, you know, when my kids were born. I remember when my wife was pregnant with our oldest, towards the end of my residency, I had, within one month, two SIDS cases come in. And so, of course, I had the motion detector monitor. I was like, the first time that alarm went off, I was like faster than Usain Bolt up those stairs, of course. But, yeah. You have to, I mean, to go into emergency medicine, and I think for like a lot of our other kind of intensivists and like our trauma surgeons, you have to be able to sort of compartmentalize. Is that always healthy? Not necessarily. But I mean, the fact of the matter is like you can’t, just focus on, I mean, there’s another patient or a dozen more patients. And we try to occasionally have deaths in the department when that happens. We try to take a moment and sort of just have a moment of kind of silence. people can do whatever they want during that moment. Some folks are religious, may say a prayer. Some folks may do something else. But just to take a minute and sort of remember that individual who kind of passed away. And I think a lot of places try to do that. We also then sometimes will have more formal debriefs if there’s a particularly, you know, difficult resuscitation. And a lot of times that might involve our colleagues, whether it’s, you know, I mean, sometimes we have some challenging obstetric patients who might be, you know, with our colleagues or trauma patients or cardiac. So that’s where I think, The team approach in emergency medicine is really important. And I think compared to maybe some other places, a hospital, like I’m on a first name basis with all my nurses, except for some of the really older ones who refuse to call me by my first name. Then I’ll go about half the shift trying to call them nurse Smith, nurse Jones, and then I just fall back into it and just give up. But I think that’s why we have a very egalitarian approach. It’s like everyone’s part of the team, everyone contributes, everyone feels safe to speak up if there’s something that they think that they can offer or can do. But yeah, I mean, it is, and it is one of the things that makes people leave the specialty early. I mean, we have the highest rate of burnout of any specialty, and we lost a fair number of people during the pandemic who left the profession.

Lara [00:24:40] Well, that rolled right into kind of our next question. How do you, how do your colleagues, how does your field, so kind of growing circles, address the burnout problem? Because we’ve all seen whatever the cause, the ED is full a lot. It’s a lot of work and it’s a lot of emotional depth. How do you guys deal with it?

Tyler [00:25:08] I mean, there’s, you know, I think a lot of departments have like wellness committees and try to do those things. But I think part of it goes to the personality of people who go into it. I mean, the classic, if you’ve seen the Instagram He actually spoke at one of our national meetings a few years ago, and he’s a trip. I mean, he’s also survived sudden cardiac death a couple times, so he’s a big fan of the ED.

Courtney [00:25:40] I guess so, rightly.

Tyler [00:25:42] But the classic, you know, biker’s helmet. I mean, we are. It’s to work hard and play hard. Yeah, adrenaline junkie. Oh, we’re all totally adrenaline junkies. And I mean, my advice to my colleagues who are starting out their careers is I think for any sort of clinical medicine balance. So you have to have something outside of your clinical shifts, whether that’s teaching, whether that’s some administrative role, whether that’s doing something in your community. I got really engaged with a lot of youth education, kind of related to opioids, and that was something that was really important to me. Just having seen, I mean, at the same time we had the COVID pandemic, we also had a huge uptick in opioid overdoses across the country. And we were seeing more and more of that. And as a father to some young student athletes, I was like, get involved, and so I did a lot of work in that area. And that was something that was really rewarding for me. And so when you have a rough shift or something like that, and then you have one of the parents on your kid’s team reach out and be like, OK, well, their teammate had to go to the emergency department, and they said, You know, the doctor said, don’t give me any of this stuff, because you’ll break your leg. You can have a little bit of pain medicine. You probably need that. But you know, ibuprofen and imanofen are fine for that sprained ankle. You know, a broken femur, you might need something a little bit stronger. But yeah, that’s kind of been my approach. And I think we also, Most emergency apartments nowadays, it’s rare that you’ve got that many except for some rural ones where you just have a single person. That was a big reason when I was deciding what kind of practice I wanted to end up in. I had done some with lighting during residency and I was like, I didn’t want to just like, it’s nice having that teammate, you know, having that colleague there. You can like, bad ideas back and forth about it and be like, hey, what do you think about this? You know, and kind of take a look. And so I think that’s part of it too. It’s like, rarely are you the only one who’s going to endure something. We always have, you know, somewhere else to be. Yeah.

Lara [00:28:07] That’s great. What’s the biggest change you’ve seen in emergency medicine over the last 20 years or so?

Tyler [00:28:15] Oh, well, I mean the capacity issues I think is, but the acuity and sort of complexity of the patients and by that I mean like the number of illnesses that people have and how sick people are coming in. At least anecdotally for me, like the number of younger patients I see who have some cancer is crazy. I mean I remember when I did residency I was on like a colorectal surgery and had a few young people who had 20s, 30s with like colon cancer then. I was like, oh, this is crazy. And now it’s just the number. I mean unfortunately… we’ve, it’s not uncommon for me to make a likely cancer diagnosis on a shift in the ED. You know, somebody who comes in with, you know, abdominal pain that’s been going on or, you know, a headache and then we get a scan and you’re like, which I will say that is, That is one of the worst parts of the capacity challenge, is being able to have a sensitive conversation with a patient like that. And we make the time. I mean, that’s where with our colleagues, we kind of would say, hey, I need to step away for a while to talk to this patient. But being able to find a physical location in a lot of places to like sit down and tell somebody, You know, that news is hard, and it’s hard in a lot of places. And then, you know, I think kind of going back to your question earlier, then also being able to say, I know you have a lot of questions right now about next steps, but being able to kind of tell the patient, and I’m going to get you in touch with the person. But from my own experience when my dad got sick, I learned some physicians like to fill that void. And say things when they may not necessarily know.

Mandy [00:30:28] It’s uncomfortable. It is.

Tyler [00:30:31] And I think, and in my own family member situation, it led to a, this is what the prognosis is going to be, boom, boom, boom, boom. And this other person’s like, Well, I don’t think, you know, I mean, very different, like skilled nursing facility for the rest of your life kind of thing, which was completely wrong. And so, it was a good experience for me from a learning experience. I actually, I now frequently would tell patients to say, I know you got a lot of questions, I don’t want you to get discordant information on the next steps. Because then it’s the, who do you believe? Do you believe the person who you might like better, but it’s wrong? Or the person who’s more expert, but maybe doesn’t have as great a bedside manner? And so I think it’s one of those things that I can tell that. So it’s not uncommon. I’ll tell people, I’ll be like, Hey, we’re going to get you to see the specialist again. I mean, because I also, you know, I think when you were asking earlier, like a loss, I mean. I know how to handle the acute, I’ll make that diagnosis, I don’t know things, but I mean, I don’t know what the latest treatment for X, Y, Z cancer is now. I mean, if I see a patient come in with new ovarian cancer, like, I don’t know what y’all are doing. I’m gonna be like, I don’t call them.

Mandy [00:31:54] Well, and the truth is, you don’t really know until you do a lot more testing, so like. It’s not even fair to say anything until you get all the way down to the bottom of that.

Tyler [00:32:05] Right, and it’s that delicate balance of you don’t want to minimize something because a patient may not get the necessary follow-up, but you kind of say, this could be a cyst, it could be a benign tumor, or it could be cancer. We don’t know yet, you need to do these kind of things. And for a lot of people, I was just having this conversation with my wife the other day, I said, I think for a lot of people, it’s hard, because they’re like, you just announced a tumor. get me in the hospital, like, let’s get it out. And they don’t realize that a lot of the workups for, you know, again, biopsies, these things are done in the outpatient setting. And I’ve, you know, I’ve had to explain to patients, it’s like, I can admit you, but

Mandy [00:32:55] They’re not going to do nothing.

Tyler [00:32:57] It’s not a whole lot that’s going to happen in the next couple of days.

Mandy [00:33:01] Well, and then that just has a trickle-down effect on slowing the system down even more.

Tyler [00:33:05] It does, and people don’t realize, for a lot of patients, especially if your immune system’s not great, the hospital’s not where you want to be.

Courtney [00:33:14] You don’t want to be here.

Lara [00:33:17] Interesting. What do you think is gonna change most in the next 10 years? Where are things headed with emergency medicine? What do you guys talk about at your conferences?

Tyler [00:33:29] I mean, I think AI is gonna take an increasing role. I mean, it seems like even in medical school, I mean, I think when we were in medical school, like there was still a whole lot of like rote memorization.

Lara [00:33:44] Yeah.

Tyler [00:33:45] There sure was, a lot of acronyms. You had to be able to spell off those things immediately off your brain. And now, I was like, well, that’s great and all, I can remember it, but I can also look at my phone or I can talk to my pharmacist right here who is much more expert on this latest drug and the dose and this person’s kidney function, what it should be. So I think that will help. Hospitals just need to figure out what to do with capacity. And it’s actually, it’s more of a healthcare system issue. I think one of the biggest things that contributes to our capacity crisis is we don’t have enough primary care doctors. Unfortunately for medicine, I don’t know that, you know, the most recent med school loan or professional school kind of loan caps that they’re putting in place are going to encourage a whole lot of students to want to go into a primary care specialty when, you know, will they make a good salary, but they may not make, you know, a 2, 3x salary that will help them pay off those loans if they go into the specialist. So, we need to figure that out. I mean, part of the thing that’s contributing to the acuity and complexity in our specialty is the aging of the population. I mean, we see a lot more 80-year-olds, 90-year-olds, even centenarians.

Mandy [00:35:12] And living longer, and there’s more of them.

Tyler [00:35:15] Exactly. how do you figure that out? There’s actually, over the past probably decade or so, there’s been a geriatric emergency department like certification. That has like specific, you know, specific things to try to improve their environment for geriatric patients. And so I think there are places that are kind of looking at that. You know, and I think ultimately they’ll be, they need to figure something out with the physical and verbal violence towards, you know, towards our nurses and towards our, you know, our physicians and staff, because I don’t know what the average, you know, tenure for an ED nurse is, but whatever it is now, it’s probably a lot less than it was 10 years ago, because they, you know, they take the brunt of it. So. Okay.

Lara [00:36:14] What scares you most in your field? So you’ve got the scanners for people who don’t know. A lot of times EMS or ambulances will radio in if they’ve got something coming to the emergency department and give you a little heads up about what may be coming through the door. What do you hear over the wire that you’re like, oh, shoot. Not today.

Tyler [00:36:42] That’s a great question.

Lara [00:36:45] Nothing. You’re invincible.

Tyler [00:36:48] No, honestly, I think the violent patient is the one and it’s not as much scaring me. But having one of my team members get assaulted, I’ve had some fantastic colleagues leave the specialty because they got physically assaulted. Two colleagues who were some of the best people I ever worked with, both, one got completely sucker punched and another one got assaulted and they left. And it’s sad because I mean it was it’s it’s bad, and that’s not infrequent You know obviously these will tell you

Mandy [00:37:36] got a wild one here or something like that.

Tyler [00:37:40] Or the police will be bringing them in. Yeah, okay.

Mandy [00:37:42] Some drug involved.

Tyler [00:37:44] Yeah, I mean, outside of that, the, you know, like a terrible, I mean, some sort of mass casualty would be the other thing. And not because, I mean, I’ll say where I work, has more resources than any other place I’ve worked to be able to kind of handle, and gosh forbid me or my family were involved in that, I would want them to come there. You know, the trauma surgeons, the other specialists I work with are the best in the country. But just the, you know, the tragedy of what you have to deal with for that, so.

Mandy [00:38:18] All right, if you’re working, what’s your least favorite day of the year? Courtney kind of alluded to it, but I want to know if there’s another one that’s the really… Anything that has a cloud about it.

Tyler [00:38:37] There’s no rhyme or reason anymore. I mean, I will say, July 4th is, I actually got asked, relative to the pit, do we have the betting board or something? I said, no, we don’t have betting boards. I was like, lots of emergency departments have bingo cards. Bingo cards for Halloween or July 4th.

Mandy [00:39:06] That was always a big one on ER, was Halloween.

Tyler [00:39:08] Yeah, I mean, Halloween is… I’m trying to think if there’s a particularly bad… I will say, actually, the Tuesdays after three-day weekends are usually just brutal capacity days. Because the clinics are closed, usually on Mondays, and then a lot of patients have decided, well, I didn’t want to go in on the holiday. They come in, and then they’re a lot sicker, and they’re in much worse shape.

Mandy [00:39:43] Is there a time of year, like a season that’s more?

Tyler [00:39:47] There used to be, not really anymore. I mean, trauma season typically, we say trauma season begins the first warm day of the spring, so that’s usually like early March around here. No, I mean, New Year’s Eve, you know, Christmas, July 4th, those kind of things. I mean, my residency program director, I think, said it well at one point. She’s like, when you’re emergency medicine doc, all holidays are flexible. She’s like, you know, she’s like, we might celebrate Mother’s Day on Saturday, or we might celebrate Christmas on the 26th, you know, or, you know, it’s like, it’s like, you know, because, you know, we kind of have a rotation, you kind of work one holiday or the other every other year, and so, Yeah, patients don’t seem to care what day it is. I mean, I always, I feel bad for, you know, patients when they’re, especially around like Christmas and the family, like if they are, I will personally try to do my best to kind of, if I’m working Christmas Eve, try to get patients home so I can spend Christmas at home if they can, because there’s not a whole lot that’s going to happen in a hospital on Christmas day. Oh, that’s true, that is true.

Mandy [00:41:02] You kind of alluded to a little bit of it, but if you could narrow it down to one piece of advice that you give your first year residents, what is that?

Tyler [00:41:14] I actually said this to one of my listeners. I said, know when to get help.

Lara [00:41:19] Oh, excellent. Yeah, good advice for our first year. And call often.

Tyler [00:41:23] Yeah, I think it’s at that point, you just need to know when you need help. And whoever that might be. A different patient may need different assistance. But that’s what I said to actually the resident I was kind of working with last night.

Mandy [00:41:42] What’s one piece of advice you would give patients regarding just ER in general or their health?

Tyler [00:41:48] I would say if you don’t have a primary care practitioner, get one. That’s a good one. Yes. If you can. And I think when you are outside of the something acute happened. I think I’m having acute stroke, I’m having acute chest pain, I’m worried it’s a heart attack, or I passed out, or my family member acutely passed out and I can’t rise, I’m like, call 911. Our EMS, I mean, they are, our first responders are the true heroes. I mean, the stuff that they do every day, they’re absolutely phenomenal. and they do a great job also kind of triaging patients and can actually activate a lot of things. moving head time. If they get on the scene, as you were kind of mentioning, the radio, they’ll call in and they’re like, hey, we think this person’s having a type of heart attack or STEMI that they need to go to cath lab. They can get things mobilized quicker. You may literally just go through the emergency department and kind of wave at us and go straight there. Or acute stroke, get things activated. But if you’re having something that’s been going on for, you know, for days or weeks and you’re otherwise, you know, okay, like talking to your primary care provider and seeing them if you can. The vast majority of my patients, it’s the first time I see them. And the next time they come to ED, it’s likely they’re gonna see somebody else. I’ve got a few folks who I see frequently who have, and not, they generally, it’s people who just have really chronic diseases that they have to come into the hospital frequently. And generally, they’re some of my favorite patients, because, I mean, they’re just appreciative and they hate being there, you know, they hate being in the hospital, but they know that’s what they need to get in. But I think talking to your primary care provider, because like I said, You know, that primary care doc who knows you, who knows your history, who knows things is going to be able to generally, you know, do a more kind of focused workup. Sure. And oftentimes, might be able to get some tests for the patient really needs that we can’t do, you know, we can’t generally do. like colonoscopies from the emergency department, or endoscopies, or, you know, I mean, we’ll have patients show up, but like, can I get an MRI of my knee? I was like, no. I was like, unless your knee is having a stroke. Or it’s spinal cord, and it’s your knee pain. I mean, those are pretty much the main reasons, you know, we’re going to do an MRI from the ED. And so, you know, I think using patients, even though it might seem like it’s going to take a little bit longer with the primary care dog is the better way. And having somebody who can quarterback the different specialists and the different tests. I mean, I feel for patients that we see occasionally who go from like hospital to a hospital, hospital, and they’ve had now four CT scans and a couple other ultrasounds. It’s like, you just don’t.

Lara [00:44:51] You need a medical home. Somebody needs to coordinate all this.

Mandy [00:44:54] Yeah, exactly. All right, last of my questions. So we’re in what would undoubtedly be called a party city.

Courtney [00:45:04] Which is probably, if you’ve been here a while, that’s changed. That was not the case. Nope. That definitely is not. What impact does that have on your patient loader experience in the ER?

Mandy [00:45:14] Bachelorette parties! Pedal to the metal backboard incidents.

Tyler [00:45:21] There have been several wedding photos that have been, you know, a lot of touch up because our bridesmaids have taken headers off of those scooters. So I’ll add to my comments of patience, don’t ride scooters.

Mandy [00:45:38] Don’t ride scooters. Do you do that like with your kids? Were you like, You are not allowed to ride a bicycle or think about a motorized scooter or whatever without a helmet for sure. Do you let them do like ATVs? Like what? Because I follow that side. My husband is also, he goes the other way, not the other way sometimes, he’s more lenient. And I’m like, oh my gosh.

Tyler [00:46:04] My wife tells the story of my oldest. I was working one day and I forget, I think he was like five or six and he had gone to a birthday party and they had a big trampoline, no netting or anything around it. And they got there and he just looked at it and was like, dad wouldn’t want me on this. So he stood around, he stood around the outside and kicked a soccer ball up to the kids on a trampoline who kicked the soccer ball back down.

Mandy [00:46:31] So yeah.

Tyler [00:46:32] And I was just, , so proud.

Mandy [00:46:34] Yeah.

Tyler [00:46:35] Yeah.

Mandy [00:46:36] At a young age. Yes.

Tyler [00:46:37] I think there’s like a WW, like, you know, a doctor would do. And, , yeah, it’s, , I mean, Yeah, some of those things, I mean, helmets, it’s…

Mandy [00:46:51] It’s a no brainer, pardon the pun.

Tyler [00:46:53] Yeah, completely. I mean, the difference between somebody wearing a helmet, you know, coming in after a bike accident or after a fall and not wearing… And wearing a legit helmet, like not these little skull cap things that… Yeah.

Mandy [00:47:10] I just think about golf carts. That’s something that you wouldn’t think you needed to wear. You don’t need to wear a helmet on that, but you stand up on one of those things and somebody takes it off. But you’re a kid, you’re nine years old, you don’t know. You know what I mean? So it’s like, oh gosh, so many of those things.

Tyler [00:47:26] I will say, when my kids started driving, that was a lot of anxiety. The Find My iPhone and the Life 360, those kind of things were definitely there. Yeah, I think it’s all within reason. And I’ve talked with some high school seniors and things before they went to spring break. And the sort of Nancy Reagan approach is not going to work. But I kind of say, let’s be pragmatic and make sure that these kids understand it’s a very different world out there now. I mean, I will say for as far as, you know, we see some of the partiers and those kind of things. We also see some wonderful tourists who are visiting who have acute medical issues and they’re just, you know, delightful to come in and they’re like, oh, it’s only, you know, X number of hours waiting. It’s like in our city, it’d be like three times that. It’s like, oh, well, that’s good. That’s good to know. But, you know, I think the approach I’ve kind of taken with my kids is, you know, try to prevent the things that you can prevent. And then just, you know, you gotta trust them to make the right decisions. They know there’s certain things that, you know, I will kill them. There’s Uber, there’s Lyft, there’s cars. If the person you’re with can’t drive or you can’t drive, don’t. We unfortunately see too many consequences of when people make bad decisions.

Lara [00:49:10] All right, speed rounds.

Tyler [00:49:12] -oh.

Lara [00:49:13] So these are fun. These are kind of fun, short questions.

Tyler [00:49:15] So like Final Jeopardy, too?

Courtney [00:49:16] Yes, Final Jeopardy. Just your first response. Double points.

Mandy [00:49:19] Your first thought. And it can be short, like one word, or it can be long if you want to. All right. All right, my favorite one.

Lara [00:49:26] And I’m very curious. I know.

Mandy [00:49:27] This seems like totally up your alley, maybe. Are you superstitious?

Tyler [00:49:36] On some things.

Lara [00:49:38] I’ve been surprised how many people have said no, because I am highly superstitious.

Tyler [00:49:41] I’m a huge college and pro sports fan. And with college and pro sports, I’m very superstitious. With the ED, it’s always a full moon. You see too much. You’re like the cynic. At that, it doesn’t. But with different sports teams, 100%. You’re wearing certain socks and not washing your shirt.

Lara [00:50:04] I got your rituals. Okay, what other specialty do you ask for help from the most?

Tyler [00:50:11] And this is interesting for you guys, because you’re consulting everybody. I would say in our department, I mean it would be probably trauma surgery, orthopedics, Probably neurology. We see a lot of neuro things there. Those would probably be the top three.

Lara [00:50:38] Most common. What’s a word or phrase you end up saying multiple times per day? Stats. It keeps coming out of your mouth. All shift long. Kim Seven. What is that? All your trainees can say it back to you.

Tyler [00:50:50] That’s a great question. I feel like you need to ask them. I think for me, it’s honestly, it kind of goes back to the team player. It’s like, how can I help you?

Lara [00:51:09] Okay, yeah, I can see that you walk in a room.

Tyler [00:51:13] I mean, in some ways, well, with patients, with the trainees, with patients, unfortunately, I will say, it seems the majority of the time I’m starting my conversation is sorry.

Mandy [00:51:24] Oh, sorry.

Tyler [00:51:26] And it’s just because usually it’s like, sorry you’re here, sorry you waited a while. I mean, that’s one of those things. And I think just sort of, you know, especially if somebody’s waited a while or they had a long drive or something or they’re frustrated, sometimes it just sort of diffuses.

Lara [00:51:41] Yeah, you’re expressing empathy that they’re not having their best day. Who in your inner work circle could you not live without? And you’ve mentioned how much you guys are a team, so there might not be one, but.

Tyler [00:51:58] My inner work circle, that’s changed multiple times. At one point, it would have been my sort of direct supervisor, my executive chemical director at that point, especially during the pandemic. And work circle.

Mandy [00:52:18] I like that you can’t think of somebody because it means that everyone is unhappy. They’re all unhappy.

Tyler [00:52:23] And I’ve gone through, in my professional career, I’ve gone through a bunch of different non-clinical roles. And so when I was in certain roles, there were certain people that I worked really closely with, like other kind of administrative leaders and nurse leaders. So that’s why it’s a little kind of hard to kind of think. I would say in general, just in the ED, the nurse who’s the flow nurse, they’re sort of like the person who kind of essentially is like your traffic control, especially like when we’re working like a shift in triage, like, you know, that’s your partner. It’s sort of like co-pilots, you know, just trying to, so probably the person that’s in that role.

Mandy [00:53:05] I want to make a joke so much. I want to say baby Jane Doe. That’s what she says. The person he’s talking about, the nurse, the charge nurse, she’s like, there’s this one. Sorry.

Lara [00:53:16] Courtney has a one drug mind over here. Sorry. If you could ask your boss or chair for one thing, what would it be? Small or big?

Tyler [00:53:26] I want my paternity time that I didn’t get to take when my kids were born. I think they didn’t have it when my kids were born, so I’m still waiting to take that.

Lara [00:53:41] I’ve heard of people taking a teenernity, have you heard of that? Taking a break to help your teen kids. Take a teenernity.

Tyler [00:53:51] I’m sure they’ll give me the unpaid, but I want my pay for turning time. I think you deserve it. I see all these people taking it, I was like, man.

Lara [00:53:58] Where was that when, yes, you should ask for it.

Tyler [00:54:00] I know, I’ve actually, I’m pretty sure they didn’t have it back when I had my kids. I was like, man. Now it’s new. I think you should ask for it.

Lara [00:54:10] What other medical specialties gross you out? or you couldn’t do. I was going to say out.

Tyler [00:54:19] Nothing grossed me out. I loved my OBGYN rotation in third year of med school.

Mandy [00:54:28] Of course you did.

Tyler [00:54:29] Yeah.

Lara [00:54:30] No one doesn’t.

Tyler [00:54:32] No, I mean, my chief resident was phenomenal, and I mean, I’ve delivered babies in different places. I’m sure you have, I’m sure you have. Not that you all trained me during that. No, nothing, I don’t, the ones, like, I couldn’t, I don’t think I could be, like, a diagnostic radiologist or, like, a pathologist. very much an extrovert. And I like that in that team approach. So I think a specialty, I know there’s, you know, like interventional radiology is obviously kind of different. And there’s some areas where, you know, like, you know, your former, you know, the blood bank, where you’ve got that team, but like, if it was like a specialty or where it was just like me, You know, like that, that wouldn’t be a good fit.

Mandy [00:55:17] It doesn’t gross you out. I’m glad.

Tyler [00:55:19] I think for emergency medicine, you kind of have to like, you have to like everything, especially like, I think most of us really like critical care, ICU, like had I not done emergency medicine, I was thinking like some sort of critical care.

Lara [00:55:34] A lot of parallels there. Yeah. Would you encourage your children to pursue a career in medicine?

Tyler [00:55:43] I didn’t discourage them. My oldest is going to be a high school teacher, which that’s awesome. I was so excited when he told me that. I had no idea. I wonder if the pit started earlier, if my youngest would have. Right now I think he’s leaning towards maybe law school. But I have a lot of mentees where I went to college who are undergrads and who are just recent grads. I actually had all four of them together on a Zoom call the other night. One’s just about to start med school. Two are applying right now. They just graduated. One is going to be a rising senior. And so I brought them all together. And I kind of just sat back and let them all gab with each other. No, I still would. I think it’s a great profession. It’s one of the things I do really love about practicing down here. I think there’s still a lot of respect for being a physician in this area that’s not necessarily as universal in other parts of the country. I think one of the things that I’ve kind of told folks before is, Every shift, you just need that one patient encounter that makes you… Makes it worth it. Yeah, and makes you wanna come back. And a lot of times it’s not hard. I mean, a lot of times, like, I had a lovely patient recently who was just kind of struggling with a lot of things. I was like, hey, made a difference, you know? And it’s having those kind of things. And it’s like, you know, we still make a difference every time. And sometimes we make more of a, life-saving difference and sometimes more of a, you know, just helping somebody feel confident that their concern is not their worst case thing and thinking both are equally important.

Lara [00:57:35] Do you have a joke about your area of medicine?

Tyler [00:57:39] Not that I’m going to tell in a podcast.

Mandy [00:57:46] Okay, well, you can tell when we turn the mics off. Yeah, you can tell us later. Fuckers. Tell us later. All right. Well, our last question. It’s not hard. I don’t think. I don’t know.

Courtney [00:57:56] Sometimes it might be for you guys, yeah. We’re a thousand dollars. Yeah, right?

Mandy [00:58:00] Do I get to bet first? If you could do any job in the world, not medical, and you would automatically have the training. You wouldn’t have to go back and do law school or go back and do something else. It would be successful overnight and you could support yourself and your family and all the thing. Nothing had to change. What would you choose?

Tyler [00:58:32] I’ll say the first thing that comes to mind is to be a bartender in Key West.

Courtney [00:58:35] There you go. That’s a good answer. That’s a really good answer.

Tyler [00:58:39] Margaritaville.

Courtney [00:58:40] There you go. That’s funny.

Tyler [00:58:42] There’s a guy who’s down there who I think is Polish, who I’ve seen a couple of times when I’ve gone down there. And so I was like, he seems to really have a nice life. Yeah, right? He’s still in the same place. He seems really happy. Came over here from Poland and in Key West, I was like, yeah.

Mandy [00:58:57] Super happy, there you go.

Tyler [00:58:58] I mean, how can you not be happy in Key West? Sure. Outside of when hurricane comes.

Mandy [00:59:02] Strong argument, strong argument. I mean, yeah, there could be sometimes, but yeah. Yeah. And that was our last question, but I just want to say on a personal note that in December of 2020, my family was visiting and my brother-in-law had a cardiac arrest. at a Airbnb down the street from us. I met them there, which is a very surreal feeling walking into your ER and seeing your loved one intubated on a table. And then he went to the cath lab, and ultimately he did fine. And he had no, he was 46, he had no neurologic anything. And I just credit your workplace and all the people that do the amazing things that they do with saving him and bringing him back to us. And so I really appreciate you, Tyler, and all the people you work with.

Tyler [00:59:49] Well, I appreciate it. I will say it’s one of the interesting things being an emergency doc is I’ll see individuals, places, and I take HIPAA very seriously. So obviously, people will be like, oh, yeah. And even my wife will have folks come up to me like, oh, thank you so much. And she just looks at me and she’s like, I have no idea what you’re talking about. They’re like, oh, he took care of so-and-so. I’m like, yeah. No, it is. It’s one of the things I think is unique to our specialty. And it’s a really cool opportunity. And unfortunately, we see. patients and families in some of their worst times and but you know hopefully more often than not they have good endings. You get to be the helper.

Mandy [01:00:38] Mr. Rogers says look for the helpers in all the bad times. So y’all are the helpers. Well we’re so glad that you joined us today and we’re glad all of you listeners have listened and make sure you are following us on Instagram and we will be back soon. See ya. Bye bye.

Tyler [01:00:53] Thank you.

Mandy [01:00:54] This podcast is intended for informational and educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. The views and opinions expressed by the host and guests are their own and do not constitute medical guidance for any individual case. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or health concerns. Never disregard professional medical advice or delay seeking it because of something you have heard on this podcast. By listening to this podcast, you acknowledge that the hosts, guests, and producers are not responsible for any decisions or actions you take based on the information discussed.