Any EM Proceduralists?

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Over the past 3-4 years, there's been more talk and effort to establish proceduralists at hospitals, primarily to decrease procedure-related complications, and also to have a readily available second set of hands to perform necessary procedures, be they elective or emergent.

I know many hospitals already utilize Anesthesia and Surgery respectively (intubations, running codes, central lines, taps, etc). Curious of any EM physicians are the proceduralists at their hospital, and if so, any feedback? I doubt its a full-time gig, but definitely something I'd be very interested in doing nonetheless, even if it's on the side.

To clarify, by proceduralist, I don't mean you have privileges to perform procedures in the ED. I'm referring to a job in which you're credentialed and requested to perform procedures anywhere in the hospital, as needed. That's your primary function (vs. seeing patients).

TIA!

Originally Posted by FDNewbie

Over the past 3-4 years, there's been more talk and effort to establish proceduralists at hospitals, primarily to decrease procedure-related complications, and also to have a readily available second set of hands to perform necessary procedures, be they elective or emergent.

I know many hospitals already utilize Anesthesia and Surgery respectively (intubations, running codes, central lines, taps, etc). Curious of any EM physicians are the proceduralists at their hospital, and if so, any feedback? I doubt its a full-time gig, but definitely something I'd be very interested in doing nonetheless, even if it's on the side.

To clarify, by proceduralist, I don't mean you have privileges to perform procedures in the ED. I'm referring to a job in which you're credentialed and requested to perform procedures anywhere in the hospital, as needed. That's your primary function (vs. seeing patients).

TIA!

This is a bad idea. Separating the medical knowledge from the procedure is dangerous. There are many times where my intimate knowledge of the patient and his/her co-morbidities inform my choices and technique when it comes to doing procedures. From how I approach an airway, to the lines I do, the pigtails vs. chest tubes I insert....

Would one really want to throw away all that training to be a technician? I guess for some (shrug). I'd consider you less of a doctor, though.

Originally Posted by emergiQ

This is a bad idea. Separating the medical knowledge from the procedure is dangerous. There are many times where my intimate knowledge of the patient and his/her co-morbidities inform my choices and technique when it comes to doing procedures. From how I approach an airway, to the lines I do, the pigtails vs. chest tubes I insert....

Would one really want to throw away all that training to be a technician? I guess for some (shrug). I'd consider you less of a doctor, though.

1) It's not a full-time gig, so you're not throwing away your clinical training. You're providing a limited service for a limited amount of time.

2) Just cuz you're a proceduralist doesn't mean you swoop down and start performing random procedures, blinded to the situation at hand. If anything, the advantage of a proceduralist is when the average EM/IM/FP physician doesn't have the time, experience, or comfort level to perform the procedure, he can consult someone who's done the procedure *hundreds* of times, inform him of why help is needed (we're in dire need of a line, but I'm tied up with other patients, or I'm not comfortable doing the line with an elevated INR, or the last time I did an abdominocentesis was in residency, etc etc). So it would be an SBAR signout just like any other situation.

Or, the proceduralist serves as the primary code team physician. No need to call both Anesthesia & Surgery if it's an EM physician though, cuz you can manage the airway AND perform invasive procedures.

Another case is when you need to sedate someone for a test or procedure:
- Ortho needs a Propofol reduction
- A combative patient (or very young patient) needs Propofol for a CT or MRI

But you're single coverage and can't afford to step away for a prolonged period of time, or you're not credentialed to perform the procedure, you can ask someone to do that for you.

Basically, I'm not sure why you assumed performing the procedure and understanding the situation and indications of the procedure are mutually exclusive. I've routinely been called to perform procedures on patients by other specialties; I'm just limited to being credentialed to do them within the ED. A proceduralist allows you to help out with such procedures hospital-wide (even something as simple as ultrasound-guided IV starts are often needed). I still go over the patient with the physician, introduce myself, do a procedure-related limited exam, obtain a consent, and then proceed based on informed decision making, just like you would if it were your patient - unless this was emergent, and they needed it done NOW, and others have failed multiple times.

Unfortunately in my shop the ER docs have become this role by default. We have to go upstairs to run all the codes. At nights especially but occasionally during the day as well we have to go upstairs to intubate, place a central or art line. Our hospital has anesthesia on call but I think they tend to abuse us because we are always in house. What really ticks me off is why a hospitalist can't run their own code. They see us going to code their patient and they turn around and walk the other way. Infuriating! You're a physician. You're an internist. You are ACLS certified? Run your own code!! I have 20 patients downstairs. I don't have time to do both our jobs.

Originally Posted by diphenyl

Unfortunately in my shop the ER docs have become this role by default. We have to go upstairs to run all the codes. At nights especially but occasionally during the day as well we have to go upstairs to intubate, place a central or art line. Our hospital has anesthesia on call but I think they tend to abuse us because we are always in house. What really ticks me off is why a hospitalist can't run their own code. They see us going to code their patient and they turn around and walk the other way. Infuriating! You're a physician. You're an internist. You are ACLS certified? Run your own code!! I have 20 patients downstairs. I don't have time to do both our jobs.

I have seen that at more rural EDs where the ED Physician becomes the on-call code physician. But this extends beyond that, to completely non-emergent but indicated procedures (eg the sedations, the taps, etc). And again, you wouldn't be juggling between your own patients and anyone else's, because your job is solely to perform the requested procedure on the requested patient. And after that, it's no longer your patient...you move on to the next.

Bad idea.
In our ED (community hospital, 45K visits, ~20%admit rate, minimal trauma, single coverage from 4a to 12 noon, but do have a PA half that time), we respond to all CODES (arrests) in the hospital. We are also expected to do intubations, even during day time, when the Pulm may be one floor down.
Procedures are fun, I get that, but can also be very risky. Maybe you are not a resident any more, maybe you are, but as you get in to private practice, you want to keep your risk exposoure to a minimum. Just be happy/content with the procedures that you do during your shift, IMHO.

One of my partners came up with a foolish idea of having a group of ED docs who would take call for the hospital for all such procedures (excluding codes, emergent intubations)....Needless to say, out of 14 in the group, he was the only one interested!!

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Originally Posted by FDNewbie

Over the past 3-4 years, there's been more talk and effort to establish proceduralists at hospitals, primarily to decrease procedure-related complications, and also to have a readily available second set of hands to perform necessary procedures, be they elective or emergent.

I know many hospitals already utilize Anesthesia and Surgery respectively (intubations, running codes, central lines, taps, etc). Curious of any EM physicians are the proceduralists at their hospital, and if so, any feedback? I doubt its a full-time gig, but definitely something I'd be very interested in doing nonetheless, even if it's on the side.

To clarify, by proceduralist, I don't mean you have privileges to perform procedures in the ED. I'm referring to a job in which you're credentialed and requested to perform procedures anywhere in the hospital, as needed. That's your primary function (vs. seeing patients).

TIA!

Originally Posted by Birdstrike

This already exists. They are called interventional radiologists.

IR runs codes and intubates? At least they can use fluoro to confirm ETT placement.

Originally Posted by diphenyl

Unfortunately in my shop the ER docs have become this role by default. We have to go upstairs to run all the codes. At nights especially but occasionally during the day as well we have to go upstairs to intubate, place a central or art line. Our hospital has anesthesia on call but I think they tend to abuse us because we are always in house. What really ticks me off is why a hospitalist can't run their own code. They see us going to code their patient and they turn around and walk the other way. Infuriating! You're a physician. You're an internist. You are ACLS certified? Run your own code!! I have 20 patients downstairs. I don't have time to do both our jobs.

As part of the rapid response team, I've had the same experience of primary teams not staying in the room. It's annoying when I'm trying to get the history and they're nowhere to be found.

Originally Posted by diphenyl

Unfortunately in my shop the ER docs have become this role by default. We have to go upstairs to run all the codes. At nights especially but occasionally during the day as well we have to go upstairs to intubate, place a central or art line. Our hospital has anesthesia on call but I think they tend to abuse us because we are always in house. What really ticks me off is why a hospitalist can't run their own code. They see us going to code their patient and they turn around and walk the other way. Infuriating! You're a physician. You're an internist. You are ACLS certified? Run your own code!! I have 20 patients downstairs. I don't have time to do both our jobs.

Originally Posted by FDNewbie

I have seen that at more rural EDs where the ED Physician becomes the on-call code physician. But this extends beyond that, to completely non-emergent but indicated procedures (eg the sedations, the taps, etc). And again, you wouldn't be juggling between your own patients and anyone else's, because your job is solely to perform the requested procedure on the requested patient. And after that, it's no longer your patient...you move on to the next.

We work under the same situation mentioned by diphenyl so we already fill the "proceduralist" role to a large degree. I know you're talking about a different set up but that fact is important to my point here.

We have looked at trying to have someone who runs around doing the procedures. We just can't make the dollars work out. The collections for doing the procedures comes out to less than a quarter of an hour in the ER. Throw in the procedures that the residents want to do and the fact that the admitting doctors would dump the unpaid procedures on us and consult their buddies for the insured patients makes it even worse. In short it wouldn't work for us unless it was subsidized by the hospital or someone else. Since we're already doing this the hospital has no interest in buying a cow they've been getting milk from for free.

I for one would like to do this. It would be lower tempo and a breeze compared to an ER shift. But I wouldn't go below about half of what I make in the ED to do it. With the factors I mentioned the money doesn't work for me.

Oh, this would also create some med mal and credentialing issues. We aren't currently credentialed to do elective procedures in the hospitals. It has be be at least arguable that it's an "emergency intervention." We also aren't covered by our med mal to function that way. Those two factors could be fixed but it would take work.

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Originally Posted by Birdstrike

It might not be such a foolish idea if you were at a hospital big enough, and busy enough that you could work procedure shifts, without having patient care responsibilities in the ED and without having to be on call.

If there were enough procedures out there to scavenge, and stay busy during an 8 hour day, there is potential there.

I think the idea has potential if modified.

The hospital I did residency at did this with an intensivist. You called them up on floor patients, and they would come in and walk you through/do the line. I'm not sure this would make sense in a non-academic hospital because it let them capture all the lines that were previously done without attending supervision and thus couldn't be billed.

A few years ago the radiologists actually asked us to look in to doing exactly that. LP's had reached the point that nobody upstairs(hospitalists, neuro, etc...) was doing them. They just ordered fluoro guided LP's The radiologist actually said the landmarks were so obvious on some they just started doing them without fluoro to save everyone the exposure. We looked into setting up a procedure service for inpatients that would do mostly ultrasound guided lines and LP's. It sounded like fun for those of us who like procedures and could have meant more income. Unfortunately as DocB pointed out we could never get the economics to work out if we had to have an extra doc in hospital just for procedures. The only way we could see making it work was if the patients were brought to the ER so the doc in the ER could fit them in around their other patients. For some reason the hospital could never figure out how to make that work and the whole idea just died out. We still respond to codes at a few of our hospitals but the presence of 24 hour intensivists has limited our usefulness there.

anesthesiologist here. we basically do this at one small hospital. we go to all codes, do ICU intubations and place ICU art and central lines (no intensivists here). Also occasionally do LP's in the ICU and even the ED as well as epidural blood patches for PDPH. Have been called to floor and iCU for PIV starts as well. Of course, this is in addition to our OR, L&D and acute pain responsibilities, so it gets a bit old sometimes (esp. in the middle of the night). At night, the only in-house physicians are us, the hospitalist and a solo-coverage EP who is pretty busy in the ED. I often find myself cursing the IM hospitalists covering ICU and claiming CVP placement and LP are "outside their scope of practice". If we are busy in the OR, I will have the patient transferred to the OR holding area for the procedure if they're stable enough; otherwise they have to wait.

Originally Posted by B-Bone

At night, the only in-house physicians are us, the hospitalist and a solo-coverage EP

A couple of things, and only a drive-by here (not intending to derail): first, for a doctor to put in a peripheral IV on the floor - bogus, period, full stop. At my last hospital, the floor would call the ED for the nurses to start PIVs, and I thought THAT was bogus - especially when they hadn't even tried. I mean, I put in IVs sometimes just for expediency (and larger than what the nurses do - where they go for 20s, I put in 18s, and 16s where they're going for 18s and 20s in dry patients). However, to take another professional to do what is in their job description is bogus.

Second, if you are in house, but there are no intensivists, are you mostly there for L&D? I'm guessing not a lot of trauma, and no residents.

When I was a student at the University of Miami, Jackson Memorial Hospital had a procedure team run by the department of internal medicine. Anyone could call them up for a central line, LP, paracentesis, etc. I'm not sure how the economics worked. Since Jackson is frequently in the red by several million dollars, I don't think that it mattered too much.

Originally Posted by deuist

When I was a student at the University of Miami, Jackson Memorial Hospital had a procedure team run by the department of internal medicine. Anyone could call them up for a central line, LP, paracentesis, etc. I'm not sure how the economics worked. Since Jackson is frequently in the red by several million dollars, I don't think that it mattered too much.

Attending supervision allows for billing of procedures, otherwise all those lines, etc are lost RVUs. It's also more economical than pulling a surgeon out of the OR to do it, especially if it's a non-emergent procedure that is necessary to continue the work-up.

docB, I thought you might (I saw an old post of yours expressing interested in this.

Originally Posted by Arcan57

Attending supervision allows for billing of procedures, otherwise all those lines, etc are lost RVUs. It's also more economical than pulling a surgeon out of the OR to do it, especially if it's a non-emergent procedure that is necessary to continue the work-up.

A lot of people on this thread are arguing over whether or not this is smart, feasible, financially viable, etc etc. And with all due respect to them, that's really not my question.

Proceduralists are a FACT. A LOT of places don't have Critical Care Medicine/Anesthesia/Surgery available to be consulted for various procedures. And if you Google "proceduralist," you'll find several articles about how the bigger name institutions have *already* moved to this approach, at least with the major claim being better patient satisfaction secondary to more skilled hands performing the procedures = less pain & complications.

So it's not really a matter of "hey guys do you think we can/should do this?" It's more of hey, it's *already* happening. And as Arcan said, why tie down multiple people (Anesthesia and Surgery) when we can serve dual roles (airway, procedures, sedations, etc)?

So again, the point of my thread was mainly curiosity if there are any EM-trained docs doing this, and any feedback they may have.