EM Collective Wisdom: Jason Wagner

Author: Jason Wagner, MD (@TheTechDoc, EM Residency Program Director / Director of Augmented Learning, Assistant Professor of Emergency Medicine, Washington University in St. Louis School of Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

1) Why still Emergency Medicine?

Many things contribute to my continued love of EM. I think foremost is variety; it’s invigorating to come to work not knowing what the day will be like. One shift might allow me to clean out my inbox (rare), while another may bring me 11 GSW’s (thankfully rare as well). I imagine variety coupled with acuity is akin to an addict “chasing the dragon.” Never quite getting that first high but coming close. I also really enjoy the variety of tasks I get to do as a residency program director. One day I’m a film editor, the next I’m a traumatologist.

2) Most impactful case?

It’s really a pair of cases. As an intern, I was part of a “nearly” failed trauma airway. After attempts by the EM Jr. resident, EM Sr. resident, Trauma Sr. resident, 2 ED Attendings, the Trauma Attending, the Anesthesia resident; the Anesthesia attending was called down and successfully intubated the patient with the longest Miller blade I’ve ever seen. In my naiveté, I couldn’t understand why I wasn’t allowed an attempt with a lighted stylet; a device no one (including me) really knew how to use (I’d seen it used once). That event galvanized in me the desire to become an airway expert, in an effort to NEVER have to have anesthesia bail me out. This resulted in my first niche in EM (airway and technology). I worked diligently during residency to enhance my airway expertise. Finally, in my third year I was vindicated on a cold winter morning when a trauma assault came into the ED. She had a mandibular dislocation after an assault to her face with a landscaping keystone with copious blood and mangled-crumbling teeth. She also happened to be in VFib arrest. No one could intubate her due to the mandibular dislocation. By this time, I’d done enough intubations with the lighted stylet (way before the routine use of fiberoptics; it was the early 2000’s after all) that I was comfortable. Wielding the majestic light wand, and despite the teeth crumbling from her dislocated mandible; I was able to intubate our patient. Shortly thereafter we got ROSC. She proceeded to go into VFib 2 more times in CT, and trauma surgery actually gave up on her and left. We continued with ACLS, obtained, and sustained ROSC. That night she self-extubated and was discharged a few days later!

We all lived happily ever after….

About a year later, as a new attending I was alerted that we had a drop-off GSW to the chest. Running into the room, the patient turned towards me, and I was face to face with the woman I had saved just months before. She again survived her wounds to discharge.

A few years after that, Ms. X and my fates crossed paths once again when I was called to a Level 1 stab to the chest. I again came into the room to see that mangled grin. She once again survived and became a recurrent customer for a variety of issues (none as dramatic as her first few), visiting us every few weeks.

I’ve not cared for Ms. X for several years now, but she taught me a lot. She helped me develop my niche and my confidence. She also showed me, that while Ms. X and I live only miles away; our lives might as well be on different planets. I can’t imagine any one of the events that brought her to our ED, but for her it was just everyday life.

3) Most important career decision leading to satisfaction?

Deciding to forgo the financial benefits of community EM for academics. Despite being $250,000 in debt, my day-to-day joy in coming to work is worth so much more than the pay difference. To each their own; follow your passions and interests and not just the money (unless that’s your passion).

4) What does future of EM look like?

Unfortunately, I worry that it looks a lot like working in a factory. Patients are widgets, and we are all measured by our RVU’s. Corporate groups staff ED’s at the bare minimum, in order to maximize profits. We can fight this through our advocacy. I respect the groups that set Pt/Hr maximums rather than minimums.

5) Greatest achievement / why giving back is important?

Becoming the Residency Program Director at WashU in St. Louis. It allows me to exponentially impact future patients through my contact with the future of EM.

6) Favorite failure?

USMLE Step 2.

Yup, I failed it. I didn’t take the test seriously and didn’t study for it. Because of my failure I didn’t match, but I was able to Scramble (now called SOAP) into a new program in St. Louis (WashU). This allowed me access to an incredible educational journey treating some of the sickest patients in the country. It’s also why the answer to question 5 was able to happen.

7) One thing you would change about our field?

Universal healthcare coverage. We all subsidize the healthcare of the un/under-insured. Why can’t we just be honest about this and pay for it up front? Instead hospitals provide “charity” care, yet somehow make enough money to keep creating new towers.

8) Something that you love that has indirectly impacted your EM career?

Technology. Writing on Medicine and Tech got my foot in the door of the national education scene and was a ton of fun. It’s also a significant part of my education philosophy; the meaningful integration of tech into education and clinical care.

3 people you’d like to see fill this out

1) Rob Rogers

2) Maia Dorsett

3) Alex Koyfman

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