Emergency doctors concerned about their Ophtho skills

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DrZeke said:
http://www.forums.studentdoctor.net/index.php?threads/The-Eye-in-the-Community-ED.1177462/

This is pretty cool.
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I offered my ED residency to do ophtho lectures (with even the offer if they thought it was useful to make it a regular thing) and slit lamp training and they said no.

When I was in the ED (and got consulted for ruptured globe when it turns out to be a 20/25 k abrasion and sub conj heme) I offered to show the resident the slit lamp and they say "that's ok I'll never use that thing anyway."

I gave up trying to educate them. I just give them grief when they ask for stupid consults, but it doesn't seem to matter.

Its nice to see that there are some ED docs out there who care.
 
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When I was in residency, we offered to teach ER docs and ER residents how to property calibrate and use tonopen. After several frantic middle of the night calls with "pressure of 92" and a few corneal abrasions due to using tonopen without a cover, that effort was abandoned.
 
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eye love lamp said:
I offered my ED residency to do ophtho lectures (with even the offer if they thought it was useful to make it a regular thing) and slit lamp training and they said no.

When I was in the ED (and got consulted for ruptured globe when it turns out to be a 20/25 k abrasion and sub conj heme) I offered to show the resident the slit lamp and they say "that's ok I'll never use that thing anyway."

I gave up trying to educate them. I just give them grief when they ask for stupid consults, but it doesn't seem to matter.

Its nice to see that there are some ED docs out there who care.
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At our program we set up some lectures for them, but I'm not sure how well it stuck. Anytime I try to educate even at 4 and 5 in the morning, the only person listening is the med student. funny since I'm the one that isn't a shift worker, so I'm actually tired at 4 am. Many of them have never seen a Seidel sign, and diagnose an open globe with a CT scan...

Honestly I've learned to just see most things, be polite and move on. I used to argue with them, but some of them are so set in their ways and don't wanna learn a damn thing. They just wanna dump it on you and some of them have gotten to the point where they no longer want to even formulate a differential.

I had viral conjunctivitis being treated with erythromycin the other day and they called me because it wasn't getting better. they thought it wasn't getting better because he was using too much erythromycin. doc was convinced he didn't have viral conjunctivitis despite the guy mentioning 2 sick contacts and the exact trail of the infection. ED docs should understand the basic epidemiology of "pink eye". I'm happy to take a look, but that's basic in terms of a differential diagnosis.

I have many stories so I could keep going, but I will say this. I don't mind that people don't know my trade. In fact that's one of the reasons I love Ophtho- it's so specialized and exciting. But common things are common in medicine and if you do ED or family practice you should be able to create a working differential on classic eye problems. No ifs and or butts. I've been to ED where they have wills manual brand new and I've not seen a resident even open it....

I agree, it's refreshing to see that thread.
 
Not to sound like the biggest jerk of all time, but most of my classmates that went into EM were not (and still are not) the most intellectually curious in the world. Most of them went into EM because they liked the idea of shift work, a fast-paced workplace, and not having to deal with patients long-term. So I am not surprised that many EM doctors could care less about refining their ophtho skills. It takes much less effort to just call up the on-call ophtho doc than to read after-hours about the differential diagnosis of a red eye.

For god-knows-why, I still take the occasional call at our local hospital. They are pretty good overall, but occasionally I get a demanding ER doctor that tells me that "...the patient could have a retinal detachment vs. acute angle closure glaucoma vs. an open globe...so you better get in here right away." I would just be happy if the ER could measure visual acuity and IOP accurately, and maybe just send me a cellphone snapshot of the eye.
 
LightBox said:
Not to sound like the biggest jerk of all time, but most of my classmates that went into EM were not (and still are not) the most intellectually curious in the world. Most of them went into EM because they liked the idea of shift work, a fast-paced workplace, and not having to deal with patients long-term. So I am not surprised that many EM doctors could care less about refining their ophtho skills. It takes much less effort to just call up the on-call ophtho doc than to read after-hours about the differential diagnosis of a red eye.

For god-knows-why, I still take the occasional call at our local hospital. They are pretty good overall, but occasionally I get a demanding ER doctor that tells me that "...the patient could have a retinal detachment vs. acute angle closure glaucoma vs. an open globe...so you better get in here right away." I would just be happy if the ER could measure visual acuity and IOP accurately, and maybe just send me a cellphone snapshot of the eye.
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I agree those seemed to be the motivations of most people going into EM.
 
LightBox said:
Not to sound like the biggest jerk of all time, but most of my classmates that went into EM were not (and still are not) the most intellectually curious in the world. Most of them went into EM because they liked the idea of shift work, a fast-paced workplace, and not having to deal with patients long-term. So I am not surprised that many EM doctors could care less about refining their ophtho skills. It takes much less effort to just call up the on-call ophtho doc than to read after-hours about the differential diagnosis of a red eye.

For god-knows-why, I still take the occasional call at our local hospital. They are pretty good overall, but occasionally I get a demanding ER doctor that tells me that "...the patient could have a retinal detachment vs. acute angle closure glaucoma vs. an open globe...so you better get in here right away." I would just be happy if the ER could measure visual acuity and IOP accurately, and maybe just send me a cellphone snapshot of the eye.
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I think you are being unfair to ER doctors. They are under time pressure, legal pressure, and never ending patient satisfaction scores. Eye stuff is minor to them as they juggle multiple patients at the same time trying to keep some from dying. I don't blame them for thinking about worst case scenario sometimes- K abrasion with subconj heme referred as open glove, etc. I bet even you will have trouble seeing an occult rupture in some cases. I also don't agree that ER attracts not the most intellectually curious. It's a great specialty for an MD entrepreneur- more time to dedicate to other stuff, consult, get involved in IB, etc.
 
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LightBox said:
Not to sound like the biggest jerk of all time, but most of my classmates that went into EM were not (and still are not) the most intellectually curious in the world. Most of them went into EM because they liked the idea of shift work, a fast-paced workplace, and not having to deal with patients long-term. So I am not surprised that many EM doctors could care less about refining their ophtho skills. It takes much less effort to just call up the on-call ophtho doc than to read after-hours about the differential diagnosis of a red eye.

For god-knows-why, I still take the occasional call at our local hospital. They are pretty good overall, but occasionally I get a demanding ER doctor that tells me that "...the patient could have a retinal detachment vs. acute angle closure glaucoma vs. an open globe...so you better get in here right away." I would just be happy if the ER could measure visual acuity and IOP accurately, and maybe just send me a cellphone snapshot of the eye.
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You DO sound like a jerk. Here's a thread about ER docs asking for help on the eye exam (intellectually curious enough for you?) and your bashing them for it? Medicine has moved towards specialization and we are all really good at what at we do. I'm ok with an ER, family practice or general surgery doc asking for my help when it comes to the eye. I'm also ok with sending that patient back to manage their systemic disease since that's not what I do. Unless you are willing to manage their heart failure, stroke or acute MI, I would consider thanking your colleagues for their kind referal as it's likely helping keep you in business.
 
MstaKing10 said:
You DO sound like a jerk. Here's a thread about ER docs asking for help on the eye exam (intellectually curious enough for you?) and your bashing them for it? Medicine has moved towards specialization and we are all really good at what at we do. I'm ok with an ER, family practice or general surgery doc asking for my help when it comes to the eye. I'm also ok with sending that patient back to manage their systemic disease since that's not what I do. Unless you are willing to manage their heart failure, stroke or acute MI, I would consider thanking your colleagues for their kind referal as it's likely helping keep you in business.
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Was I ever bashing the creation of that ER thread? No, I wasn't. I was responding/agreeing with Dr. Zeke's post where he remarked that ER residents/docs didn't really care about learning basic eye stuff. If you want to be dragged out of bed for a subconjunctival hemorrhage, all the power to you. But I prefer to have patients triaged appropriately and being able to see patients the next morning in the office.

And lastly, if someone is relying on ER referrals just to stay in business, then he/she may want to find other avenues of patients referrals :)
 
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MstaKing10 said:
You DO sound like a jerk. Here's a thread about ER docs asking for help on the eye exam (intellectually curious enough for you?) and your bashing them for it? Medicine has moved towards specialization and we are all really good at what at we do. I'm ok with an ER, family practice or general surgery doc asking for my help when it comes to the eye. I'm also ok with sending that patient back to manage their systemic disease since that's not what I do. Unless you are willing to manage their heart failure, stroke or acute MI, I would consider thanking your colleagues for their kind referal as it's likely helping keep you in business.
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Lightbox- sounding like a jerk??? Nooooo, you must be joking!!!
 
Eyefixer said:
Lightbox- sounding like a jerk??? Nooooo, you must be joking!!!
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Ahhh "Eyefixer"... I know you love my posts. It gives you hope for the future. Best luck in 2016 to you.
 
DrZeke said:
I agree those seemed to be the motivations of most people going into EM.
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Not everyone. Some of us like the work, not just the hours. Though this year's Christmas Eve and Day overnight SHIFT sucked donkey balls.

That being said, my no-name residency required a month of ophtho clinic, where I did slit-lamp daily. I can use a Tono pen, ultrasound for retinal detachment, I still struggle with the ophthalmoscope, my pan-optic skills are marginally better, I've seen Seidel sign, I routinely remove corneal FB and on occasion remove rust rings with an Alger brush.

As a specialty, EM is routinely criticized for not knowing enough, being reckless cowboys, not doing a complete workup, doing too much of a workup, calling unnecessary consults, not consulting soon enough. I'm either doing things that I shouldn't be doing because I'm a reckless cowboy, or don't know things that should be obvious to any ophtho, ortho, surgery, uro intern. We are looked down on for being generalists, but scolded for not having enough outside specliaty knowledge. We just can't win. But that's okay - I knew this before I went into EM. Eyes wide open, so to speak.
 
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LightBox said:
Ahhh "Eyefixer"... I know you love my posts. It gives you hope for the future. Best luck in 2016 to you.
Click to expand...

Thanks buddy. Be sure to come look me up when you venture out to a big city.
 
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LightBox said:
Was I ever bashing the creation of that ER thread? No, I wasn't. I was responding/agreeing with Dr. Zeke's post where he remarked that ER residents/docs didn't really care about learning basic eye stuff. If you want to be dragged out of bed for a subconjunctival hemorrhage, all the power to you. But I prefer to have patients triaged appropriately and being able to see patients the next morning in the office.

And lastly, if someone is relying on ER referrals just to stay in business, then he/she may want to find other avenues of patients referrals :)
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You certainly bashed them for not being intellectually curious, on a thread started by ER docs for an intellectually curious purpose! Guess your irony filter is turned down a few notches.

I must be in a community with primo ER docs because I have never been called for a subconj heme. Mostly painless vision loss with negative work up. 9 times out of 10 I see them the next day without issue.

I don't mean to say that ER docs alone are your referal base, rather, the non eye medical community at large. Especially in a smaller community, your reputation as a condescending ahole may spread quickly if you voice these attitudes. But I doubt you do.
 
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tkim said:
Not everyone. Some of us like the work, not just the hours. Though this year's Christmas Eve and Day overnight SHIFT sucked donkey balls.

That being said, my no-name residency required a month of ophtho clinic, where I did slit-lamp daily. I can use a Tono pen, ultrasound for retinal detachment, I still struggle with the ophthalmoscope, my pan-optic skills are marginally better, I've seen Seidel sign, I routinely remove corneal FB and on occasion remove rust rings with an Alger brush.

As a specialty, EM is routinely criticized for not knowing enough, being reckless cowboys, not doing a complete workup, doing too much of a workup, calling unnecessary consults, not consulting soon enough. I'm either doing things that I shouldn't be doing because I'm a reckless cowboy, or don't know things that should be obvious to any ophtho, ortho, surgery, uro intern. We are looked down on for being generalists, but scolded for not having enough outside specliaty knowledge. We just can't win. But that's okay - I knew this before I went into EM. Eyes wide open, so to speak.
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Those are the criticisms of EM - it's true. I do feel for you guys on that front. Like you said though, you weighed the pros and cons of that criticism before you chose it as a specialty. Our specialty too gets criticized, as does everyone's. I think your program and that training sounds awesome from an Ophtho standpoint. At our program they used to have EM residents rotate with us and that is no longer. I have met motivated residents who want to learn and I have met unmotivated residents who don't want to know anything about my specialty. There are all kinds and I was impressed by ED thread discussing their motivation for knowing more about the eye in a constructive fashion.

My home med school did not have an EM residency and we did not have a lot of faculty involved in teaching or research. I really only saw EM from that point until I went to residency and rotated in my prelim year. At that time I met awesome faculty who knew a lot about everything.

In residency, I rotate at a few different hospitals and each ER is really different.
 
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Asking the questing, doesn't revolve around lack of skills... It's a majority of people trying to save someone (re: specialist) a phone call at 2am, or a stat transfer to a larger hospital several miles away. I call it honing skills, not a concern for lack of skill.
 
EM intern question for y'all. Medial canthus lacerations, do y'all usually see these in clinic the next day? We were taught that these should be treated as an optho emergency (meaning optho consult to the ER) due to concern for lacrimal duct laceration; however, I have now seen two of these and both were d/c'd with next day f/u in optho clinic.
 
Zebra Hunter said:
EM intern question for y'all. Medial canthus lacerations, do y'all usually see these in clinic the next day? We were taught that these should be treated as an optho emergency (meaning optho consult to the ER) due to concern for lacrimal duct laceration; however, I have now seen two of these and both were d/c'd with next day f/u in optho clinic.
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In the private world, or even in general they can be seen the next day.

However, reason they are usually treated as an emergency is because the canalicular lac usually implies trauma and so other things like open globe should be ruled out. Also, in the world of residency many of us cannot refuse consults to the emergency room like that so we end up seeing these right away. This is regardless of whether or not our staff decides to take them to the OR for repair emergently or waits till normal OR time. In fact at my residency we see all lid lacerations and repair them then and there as long as they don't require a tube/stent.
 
Zebra Hunter said:
EM intern question for y'all. Medial canthus lacerations, do y'all usually see these in clinic the next day? We were taught that these should be treated as an optho emergency (meaning optho consult to the ER) due to concern for lacrimal duct laceration; however, I have now seen two of these and both were d/c'd with next day f/u in optho clinic.
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The big issue with lid lacs is that you never know what you'll get and how extensive the repair without ophtho involvement, hence the urgency issue. It's also more of a logistics issue than anything else.
You can fix margin-involving lid lacs with no duct involvement on the spot, but it's easier to do it in the OR or a minor procedure room (spending almost an hour in a cramped ER room at 3 am with an uncooperative patient is not fun).

If the duct is involved, sometimes you have to take them to the OR, but better to get all your ducks lined up in clinic before doing so. Also with any trauma, you gotta do a full eye exam. It's basically easier for the eye team to just take over, hence the urgency of the consult.
 
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