What kinds of procedures do you do as an EM attending?

seelee said:

Read an old thread where everyone talked about what kinds of procedures they did in EM. However, it seemed that most of the procedures were done on the various rotations, and not actually in the ED (or is it the same thing)? Do EM docs do these procedures in the ED as well or do they just call in a consult (Gas, Trauma, Plastics, etc.)

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That is going to be individual and institution dependent. Intubation, central lines, chest tubes, lac repair, art line, LP? I do these on a fairly regular basis. Burr hole, eye lid repair, extensor tendon repair, lateral canthotomy? I can do these, but I'm not going to. I'm going to defer these to the specialty services most of the time. For some of them like the canthotomy and the burr hole, I'll do them if there will be a delay for the specialty people to arrive. The other ones can wait a little.

A M4 buddy of mine was turned off to EM because, he said, that every time a real 911 case came in, the Trauma Surgeons came in and took over, so that the EM docs only handled the minor stuff. Is this common?

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They came down and took care of the asthmatic patient needing intubation? The patient in septic shock? Wow, those are some broad reaching surgeons.

Pardon my sarcasm for a bit, but you are looking through the colored glasses of a 4th year medical student. Many medical students are enamored with the blood, guts, and speed of trauma. There is plenty more "real 911" stuff that comes through that is medical.

Now, that being said, what is the EP role in trauma? Stabilize and hand off. What do I do for a GSW to the belly? Intubate if necessary, get large bore IV access, resuscitate and then had off the patient to the surgeons as s/he needs their belly explored surgically. GSW to chest? Intubate if needed, chest tube if needed, large bore IV access, resuscitate and OR if needed. The key with trauma is that if they need an operation, they need an operation and that is outside the prevue of EM.

What your buddy also didn't see was these patients languishing on the surgical service for weeks. These patients can get pretty sick and they hang out in the hospital for prolonged periods of time. The daily trauma surgery rounds can be longer and more annoying than rounds on the medical services.

What is the procedure load like as an attending? Do you stand in the back ground and teach everyone else how to do it, or do you get your fair share of procedures?

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Most EP don't work in academia (the quoted number is about 90% work in community jobs). There is no one else in the ED to do the procedures. You have the choice to do them, or to consult other services. Some of that is individual and some of that is going to be based on institutional politics.

I work at an academic facility, so i'm supposed to let the residents do the procedures, however I still do a few here and there. If you teach the procedures, you better be darn facile at them. Not only can the residents tell when you are bull****ting, but they pick off all the moderate to easy ones. When it is your turn, it means that a resident or two has missed it.

I work in a community hospital. No med students, no residents. It's just me and my partners. I do all my own procedures. If it's a difficult reduction, I'll recruit another ED doc - one with bigger muscles than I have, but for the most part, my patients = my procedures.

As as BAD nicely pointed out, there is far more medical "Real 911" stuff than surgical. Trauma does get old - I don't work at a trauma center, so I see very little major trauma. Still, I have to be able to stabilize it to transfer it. I can put in the chest tubes, the central line and do the cric if I need to. Stuff like that hits the door, and my partners (all EM trained) pitch in if needed. Same goes for pedi codes, and really crashing patients where you need someone getting a central line and an airway at the same time.

I can't really count on specialists in a timely fashion - I can GET anesthesia in the middle of the night, or surgery, or ortho, but chances are, I'll be doing whatever needs to be done.

Case in point: We go solo coverage late at night. One night, my partner left a little early because things were well under control. Then a sick kiddo rolls in. Over the next couple hours, I ended up tubing, scanning, tapping and transferring a toddler... with appendicitis.

The kid was in status epilepticus. I was the one with appendicitis. No one else to do it.

All aforementioned procedures are also done by us where I work. To that list, I also do all my own fracture and dislocated joint reductions.

Ortho sees these patients in their office anywhere from 2-7 days later. I'm not joking.

To that end, if it's a fractured hip, for example, I'll make sure there's no neurovascular impairment, have them admitted, and ortho will see them the next day for their ORIF. On a fractured & dislocated joint, I usually ask ortho to see them first. With that said, I have reduced fractured/dislocated shoulders before.

Plastics rarely comes in as well. It has to be a pretty extensive laceration that either needs flaps or an OR washout/debridement of a heavily contaminated wound. Otherwise, I'll handle it all myself. Just last week, I had a degloving laceration that took an hour and a half to fix up. Yes, I unfortunately did back up the department. That part sucked.

Our specialty will become useless the day that every specialty of medicine/surgery has a representative sitting in the ER for 24 hours at a time. Obviously, this will never happen.

Great quote from one of the local ER docs..."jack of all, master of none"... (well with the exception of ACLS/PALS)

seelee said:

I realize that, that is why I wanted to get information from the horses mouth.

I understand the scope of the EM doc as "stabilize and hand off", but I was given the impression that even chest tubes, LPs, etc were done by the surg residents. Maybe that is just my institution.

Some more specific questions about suturing and joint reduction. At what point does the EM doc pass a case of to a plastic surgeon or a ortho (respectively).

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lemme guess, surgery residents told you that...

I work in the community, perform all of the typical EM procedures (intubations, lines, LP, reductions, sedation/regional anesthesia, suture, I&D, occasional PIV, chest tube etc). One cricothyrotomy and one lateral canthotomy in two years as an attending. GS residents - our hospital does host a couple of residency programs - put in most of our chest tubes but we still do them enough to remember how. Very few shifts go by that I don't use my hands.

I am a community emergency physician. I was called to the ICU yesterday to intubate a patient, not because the intensivist wasn't there, but because the intensivist couldn't.

I admitted a patient today to the hospitalist with TCA overdose. He asked me how to manage the patient.

The cardiologist transferred his patient to me today when the patient came to him with a complication from his procedure.

A patient came to see me today after a primary care physician told him he didn't have appendicitis yesterday. I sent him to the OR with the surgeon to have his appendix out.

Don't kid yourself that emergency medicine isn't a specialty. There is a specific body of knowledge and a specific set of skills involved. We are experts in emergency airway management, the diagnosis of acute, undifferentiated symptoms, toxicology, EMS, trauma care, disaster medicine etc. Do we consult a lot? Sure. Do we transfer care to other physicians a lot? Absolutely? Are we experts in everything? No way. But we're the best at what we do for a reason-knowledge, training, and experience. Don't let anyone tell you otherwise. Acute chest pain, acute abdominal pain, acute dyspnea, acute mental status, cardiac arrest, status epilepticus? You want an emergency physician on the case.

How about rural hospitals (i.e. level 3)? Would it be more common to perform more invasive procedures like pericardiocentesis than in level 1 hospitals or less?

I have much for EM docs, they really are the only ones that do serious procedures that cross many specialties. I work at a large academic center and honestly, its a rare day that a surgeon is coming down to do procedures, and if they are, its because the patient is a private patient and the attending wants it that way. I have yet to see a surgeon have to come bail out an EM physician.

Some of the procedures that I have seen here include:

Intraventricular cath insertion for ICP monitoring
emergency C-sections/vaginal deliveries
chest tubes
insertion of transvenous pacemakers
chest tubes
pericardial/thoracentesis
crichotomy
thoracotomy
central line/arterial line
intubations (anesthesia only comes if there is a seriously messed up airway)
moderate sedation using any meds they want (believe it or not, depending on the hospital, some EM docs are not allowed to use propofol or anything more than a touch of valium, ridiculous I know!)

This is just a few things I have seen them do, without any assistance from surgery. Like anything else, depending on the particular hospital, what is and isn't done in the ER is going to be different.

skatertudoroga said:

How about rural hospitals (i.e. level 3)? Would it be more common to perform more invasive procedures like pericardiocentesis than in level 1 hospitals or less?

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If you mean a "Level 3 Trauma Center," that's an American College of Surgeons designation, and only refers to surgical coverage, and if I'm not mistaken, it's a designation you apply for if you want it. My hospital is not any "level" on that scale. I have gen surg on call 24/7, but not in house.

A truly rural hospital (like a critical access hospital) may not have BC EM docs. But I don't know the answer to your question.

NYRN said:

Intraventricular cath insertion for ICP monitoring

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I would argue that is outside the scope of practice of an emergency physician. Perhaps I'm the exception in that I was never trained on it, but I've never heard of an emergency physician inserting a "bolt" for ICP monitoring.

southerndoc said:

I would argue that is outside the scope of practice of an emergency physician. Perhaps I'm the exception in that I was never trained on it, but I've never heard of an emergency physician inserting a "bolt" for ICP monitoring.

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I have only had a handful of patients that had this (thank god), and they were all placed in the ED. The neuro PA's place them in my hospital, but I have seen one where the resident placed it with the assistance of the PA. If this is not routine, than I stand corrected.

EMS5 said:

Great quote from one of the local ER docs..."jack of all, master of none"... (well with the exception of ACLS/PALS)

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I too have heard many EM physicians and others speaking about EM say this, but my personal view is that it is misrepresenting us entirely. We are masters! We are masters of emergency medicine. Emergency medicine is acute stabilization of critical situations. This means, we specialize in the acute management of every specialty's most critical patient situations.

This is a key point, because to say we are not masters is to say that in every situation there is a master who could do better. This is just not true. One example is, a cardiologist managing chest pain....not the expert. They dont specialize in differentiating the numerous interdisciplinary diagnoses that can kill the patient....that is our expertise. We are the masters of the dangerous, of the acutely crashing or potentially crashing patient.

Just my $0.02

seelee said:

Read an old thread where everyone talked about what kinds of procedures they did in EM. However, it seemed that most of the procedures were done on the various rotations, and not actually in the ED (or is it the same thing)? Do EM docs do these procedures in the ED as well or do they just call in a consult (Gas, Trauma, Plastics, etc.)

A M4 buddy of mine was turned off to EM because, he said, that every time a real 911 case came in, the Trauma Surgeons came in and took over, so that the EM docs only handled the minor stuff. Is this common?

What is the procedure load like as an attending? Do you stand in the back ground and teach everyone else how to do it, or do you get your fair share of procedures?

Forgive me if these questions are stupid.

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COPIED from my previous Post in March, 2010:

I would add the following procedures as well...

Ultrasound (echo, vascular, retinal, abdominal, pneumothorax, etc.)
Pericardiocentesis
Thoracotomy (not usually a comforting situation however)
Lumbar puncture
Arthrocentesis
Cricothyrotomy
Needle thoracostomy
Ocular (& general) foreign body removal
Lateral Canthotomy
Thoracentesis
arterial line placement
perimortem cesarean section
Anoscopy (not my favorite, but valuable)
Bronchoscopy
Splinting / Casting
nasopharyngoscopy
fasciotomy
escharotomy
Diagnostic Peritoneal Lavage

....there are plenty, plenty more! [MAN I LOVE THIS SPECIALTY!]

These are procedures that EM physicians do in the ED. If the patient is stable, and there is an in house specialist, they may get involved, but these procedures are within the scope of EM and need not be deferred. These are not done on a rotation, but in ED's everyday, everywhere, by EM physicians.

As for the trauma surgeons taking the glory....
Well, if someone wants to be a trauma surgeon and take out spleen's, and pack the abdomen, runt he bowel, etc...yes, you are right, we do not do this. If you want to be involved in trauma, each place is different as to what extent you will be as an ED physician. Trauma is a very easy thing as for as EM goes....you follow a recipe and stabilize the patient....at most this involves an ETT or surgical airway (which EM can perform), needle and tube thoracostomy, pericardiocentesis, DPL, FAST, dislocation reduction, fasciotomy, and finally thoracotomy...all of which in my mind are more exciting than running the bowel. These are the things we do for a trauma patient, and yes, when things get stabilized....we send them away to the floor, ICU, or OR. Its rather annoying to be taken away from the real diagnostic and management challenges to have to be a part of this algorithmic care at times....but most juniors (pre-medical, medical students, and some junior / off-service residents) think these are the most sick patients.

Please tell your friend....have fun with the bowel

TL

southerndoc said:

I would argue that is outside the scope of practice of an emergency physician. Perhaps I'm the exception in that I was never trained on it, but I've never heard of an emergency physician inserting a "bolt" for ICP monitoring.

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you DONT do bolts? I thought everybody did those. weak.


(that was sarcasm, my new thing)

We actually got a transfer over the weekend for a head bleed from an outlying hospital that claimed not to have a neurosurgeon available. Interestingly enough, the patient arrived with a ventriculostomy and had regained use of his left side as a result of the drainage. Either they were lying about having a neurosurgeon, or that ED doc is one bad mother.

Arcan57 said:

We actually got a transfer over the weekend for a head bleed from an outlying hospital that claimed not to have a neurosurgeon available. Interestingly enough, the patient arrived with a ventriculostomy and had regained use of his left side as a result of the drainage. Either they were lying about having a neurosurgeon, or that ED doc is one bad mother.

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Considering that that would be a COBRA violation (and $50K out of the transferring doc's pocket), either s/he's really, really stupid, or, like you say, all that and a bag of chips.

The hospital he was coming from is a for-profit and has sent out some pretty questionable stuff in patients who failed a wallet biopsy. They usually turf them to us or Nashville, I think because the other hospital in town(not-for-profit) calls them on their BS.

dchristismi said:

I work in a community hospital. No med students, no residents. It's just me and my partners. I do all my own procedures. If it's a difficult reduction, I'll recruit another ED doc - one with bigger muscles than I have, but for the most part, my patients = my procedures.

As as BAD nicely pointed out, there is far more medical "Real 911" stuff than surgical. Trauma does get old - I don't work at a trauma center, so I see very little major trauma. Still, I have to be able to stabilize it to transfer it. I can put in the chest tubes, the central line and do the cric if I need to. Stuff like that hits the door, and my partners (all EM trained) pitch in if needed. Same goes for pedi codes, and really crashing patients where you need someone getting a central line and an airway at the same time.

I can't really count on specialists in a timely fashion - I can GET anesthesia in the middle of the night, or surgery, or ortho, but chances are, I'll be doing whatever needs to be done.

Case in point: We go solo coverage late at night. One night, my partner left a little early because things were well under control. Then a sick kiddo rolls in. Over the next couple hours, I ended up tubing, scanning, tapping and transferring a toddler... with appendicitis.

The kid was in status epilepticus. I was the one with appendicitis. No one else to do it.

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did i read this right? you performed an appendectomy?

reedman said:

did i read this right? you performed an appendectomy?

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No, dchristismi had appendicitis and had to treat a kid in status. In a lot of private practice, you only call in for death (or intractable vomiting). It becomes less a macho BS thing, and more a "I don't have any choice" thing.

No - I needed the appendectomy. But I got sick on solo coverage, and even though I could barely stand, there was no one else to stabilize the kid. The nurses picked up on it before I did actually - they knew something was quite wrong. I was still blaming the hospital chicken salad I'd had around 3 am.

Imagine the doc (me) perched on a chair with the R knee pulled to the chest, performing a lumbar puncture. It ain't easy, but I didn't exactly have anyone to take over.

I don't know that you really call in for intractible vomiting - I thought that meant "take 2 zofrans and get a bag of IVF between patients." I called in, as it were, the next day, only because I couldn't walk - I had been calling partners to try to find someone to cover my shift. I had insisted on going home after my grueling night shift. But by noon, I couldn't stand up straight and had a pretty classic psoas sign. It wasn't until one of said partners suggested (using his Dad Voice) that I get checked out that I admitted I might be seriously sick. I had nice textbook labs, too. At least I can say that I DID read the textbook.

thats pretty awesome! i suppose desperate times call for desperate measures, but i would have thought you would be a patient at that point.

seelee said:

A M4 buddy of mine was turned off to EM because, he said, that every time a real 911 case came in, the Trauma Surgeons came in and took over, so that the EM docs only handled the minor stuff. Is this common?

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On the flipside, the surgeons are summoned even when they're not needed or used. They must be annoyed with that.

Just because they don't go to the op room doesn't mean they weren't needed, or at least somewhat useful

I'm at a level 3 center, community based. Surgeons only come when called to take the patient to the OR, or to admit. I do all the trauma etc.
Float pacers, central lines, chest tubes, a lines, LP's, codes (on the floors as well), reductions, conc sedation, US guided FB removal, paracentesis, etc.

You do end up doing a lot of procedures in the real world.

TysonCook said:

You do end up doing a lot of procedures in the real world.

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This is very true.