I want to discuss a case 'we got wrong' with an attending w/o looking like I'm Monday Morning QB'ing

[theWUbear]

Hi all, looking for a quick piece of advice from the perspective of someone with more experience than the med student on his first EM month.

I've been told throughout M3 that as a future EM physician it is imperative that I look back at the cases I signed out to see how they were worked up in the hospital, etc.

Last shift I presented to the attending an impressive pharyngitis, L > R, that I thought was an abscess. He felt it was simple strep throat and did a rapid strep and shot of bicillin and we signed out to next team.

Next team noted his change in voice, ordered a CT, it was a peritonsillar abscess, they consulted ENT.

I would like to discuss the case with my attending to ask how I could better have presented, the things that leaned him toward GAS vs PTA, and takeaway points from the case. I would not like to come off as "hey attending. I was right. I am gloating".

Should I just put my head in the books and not say anything or is it common and good practice to bring up/talk about the case? I would like for him as one of our APDs to know that I'm following my cases to improve my clinical skill and understanding of the management of my cases

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[dotcb]

If you made the Dx and treated the patient, why did you sign the patient out?

PTA is a diagnosis that should usually be made clinically or with an endocavitary US. The only time to CT would be if the patient has too much trismus to open mouth. Often patients with trismus will be much more able to open their mouth after analgesia. Most PTA's should be able to be drained or at least attempted drainage by EM.

I would continue the practice of following up patients, but would not bring it up again with that attending. Their colleague probably already told them. As a medical student, punking the attending is not well received but it is good you were correct in your Dx.

 

[theWUbear]

We were waiting for bicillin to arrive from the hospital pharmacy and the patient was seen right before a shift change.

I will heed your advice and not bring this up. To reiterate my thought process, as a student getting a SLOE from the rotation I want to instill in my PD/APDs that I am following up my patients, and learn from their clinical knowledge, but I understand that this could be interpreted poorly in this instance and by going back to Step Up to Emergency Medicine and UpToDate on PTA after reviewing the chart I am doing well in reading up on the patient

Edit: may I ask for clarification on your recommendation for US? UTD says CT w contrast is the "preferred imaging modality" and the Step Up EM textbook only mentions CT. Is this an example of the latest in EM practice being ahead of the textbooks, or personal preference, or something else?

 

[Birdstrike]

Hi all, looking for a quick piece of advice from the perspective of someone with more experience than the med student on his first EM month.

I've been told throughout M3 that as a future EM physician it is imperative that I look back at the cases I signed out to see how they were worked up in the hospital, etc.

Last shift I presented to the attending an impressive pharyngitis, L > R, that I thought was an abscess. He felt it was simple strep throat and did a rapid strep and shot of bicillin and we signed out to next team.

Next team noted his change in voice, ordered a CT, it was a peritonsillar abscess, they consulted ENT.

I would like to discuss the case with my attending to ask how I could better have presented, the things that leaned him toward GAS vs PTA, and takeaway points from the case. I would not like to come off as "hey attending. I was right. I am gloating".

Should I just put my head in the books and not say anything or is it common and good practice to bring up/talk about the case? I would like for him as one of our APDs to know that I'm following my cases to improve my clinical skill and understanding of the management of my cases

The patient had two physician/student teams. One started the encounter, another finished. The patient was diagnosed & treated. What was "missed"?

Apparently nothing. If you hadn't had left and you were the one to notice the voice change, and the patient still had gotten correctly diagnosed, what would have changed? Nothing.

There was no "miss" here except that your attending assumed you were over diagnosing, but regardless, there was no missed diagnosis, no delay in diagnosis, no malpractice, no harm to the patient. There's no M&M. There's nothing here.

It sounds like you're trying to reconcile how it was an "almost miss" but more so irritated that your attending talked you out of your diagnosis. But it wasn't a miss, so move on. If anything, learn from it that you should trust your instincts a little more and don't be so easily talked out of a diagnosis you're convinced of. People will try to do this your entire career, from consultants to radiologists, up and down the medical staff., patients and family members. If you know what a patient's got, say why and stick to your guns, but know why you're sticking to your guns.

One question, though. Why would a simple presumed "strep screen, bicillin and out the door" need a sign out? That's basically a one-and-done.

 

[goodoldalky]

The strangest thing about this case is that y'all signed out a "pharyngitis".

 

[Janders]

Yeah weird sign out but I can imaging signing this out as "I already discharged a strep throat but he's waiting for his bicillin". Then perhaps the discharging nurse noting muffled voice and asking the oncoming team to look at him, or a friendly resident reading him his discharge instructions and noticing his muffled voice.

Regardless, I think it is hard for you to bring it up without looking bad... possible but difficult

CT w/ IV is helpful in these, but endo-cavitary U/S is just as helpful, and MUCH faster, zero radiation, etc.

90% of these I dx clinically and stick a needle / slice it open myself. I find the majority of people who CT them find only a lot of cellulitis/edema/very early phlegmon without a drainable collection. My guess is they are CT'ing them a day-or-two before they are "ready" for drainage as the patient has presented earlier. As you look in more and more throats, your S/S will improve. Nothing wrong with sticking a needle in a maybe abscess as well....

 

[MSmentor018]

there's the "board answer" from step up to medicine then there's the clinical reasoning. I like that you're reflecting on the case. as an attending ,I still look at admitted pts chart to see what the consultants found, got worse/better, meds they used for X, ct rst....etc. you'll never know what you'll learn so keep it up.

as for presenting I don't think you or the attending did anything wrong. regardless of your assessment I am hoping your attending saw the pt, did the exam and made up their own mind which is what the other team did. still not sure about the sign out, usually you'd order the PCN, discharge, RN's do the rest. I am sure there were multi-factorial reasons why the attending chose the dx. personally I try not to let the student, RN, or resident change my practice management. I am guessing you're kinda cranked that you got it right but you're the student with no medical responsibilities and learning under an attending so respect the relationship and move on.

google "3 min ER presentation pdf". it's a quick read, I tell all my students to do it before starting

so what happened to the pt??

 

[smq123]

Hi all, looking for a quick piece of advice from the perspective of someone with more experience than the med student on his first EM month.

I've been told throughout M3 that as a future EM physician it is imperative that I look back at the cases I signed out to see how they were worked up in the hospital, etc.

Last shift I presented to the attending an impressive pharyngitis, L > R, that I thought was an abscess. He felt it was simple strep throat and did a rapid strep and shot of bicillin and we signed out to next team.

Next team noted his change in voice, ordered a CT, it was a peritonsillar abscess, they consulted ENT.

I would like to discuss the case with my attending to ask how I could better have presented, the things that leaned him toward GAS vs PTA, and takeaway points from the case. I would not like to come off as "hey attending. I was right. I am gloating".

Should I just put my head in the books and not say anything or is it common and good practice to bring up/talk about the case? I would like for him as one of our APDs to know that I'm following my cases to improve my clinical skill and understanding of the management of my cases

1. Did you notice a change in voice, or was that something that only the next team noticed?

2. Did the attending see the patient at all? And you are a medical student, correct?

 

[theWUbear]

Thank you all for the insight! I am just an eager beaver finally having started my M4 EM rotation and love gaining insight on all patients I see. And my attending does a lot of teaching during presentations for which I am grateful. CT showed a small PTA, patient went home after clinda per ENT recommendation

 

[gro2001]

Thank you all for the insight! I am just an eager beaver finally having started my M4 EM rotation and love gaining insight on all patients I see. And my attending does a lot of teaching during presentations for which I am grateful. CT showed a small PTA, patient went home after clinda per ENT recommendation

So the patient ended up getting an expensive, time consuming test (plus a little ionizing radiation to the thyroid) and a time consuming consultation that didn't change management or outcome apart from maybe an increased risk of c.diff?

 

[WilcoWorld]

my attending does a lot of teaching during presentations

This can go both ways. Sometimes it means the attending interrupts you frequently to drop "pearls" that are really just esoteric knowledge turds.
On the other hand, stopping you to make sure you understand the significance of certain aspects of the case can be incredibly helpful. (e.g.: "What does the patient mean by dizzy? Vertiginous, lightheaded, loss of control of the legs? These three have very different differentials.")

If the faculty member is of the 1st kind, and is the type of attending who signs out pharyngitis cases, I would NOT mention this case again. You're probably dealing with a douchecanoe.

 

[alpinism]

The main take away points are:

1. Its best not to pick up these patients just before shift change. They can wait another few min for the next team.
2. Try not to sign out minor stuff like PTA/pharyngitis. Stay and finish the job if they're getting ready to be discharged.
3. Ordering a CT then consulting ENT for PTA is completely unnecessary. Any suspected PTA can be diagnosed using U/S.

 

[Birdstrike]

Thank you all for the insight! I am just an eager beaver finally having started my M4 EM rotation and love gaining insight on all patients I see. And my attending does a lot of teaching during presentations for which I am grateful. CT showed a small PTA, patient went home after clinda per ENT recommendation

See....


ENT didn't even do anything. Went home with antibiotics, which is what you had planned on. They changed to clinda. Big deal.

No harm, no foul.

 

[e30ftw]

Sounds like the patient would've been better off just getting an Rx for augmentin called in by their pcp..

 

[TooMuchResearch]

All these calls for ultrasound are only useful if you have a tiny ultrasound probe. Many (most?) do not.

 

[deleted109597]

All these calls for ultrasound are only useful if you have a tiny ultrasound probe. Many (most?) do not.

Uh, no?
Endocavitary works just fine for this. Transcutaneous from the outside is probably not ready for primetime, but can also be done.

 

[TooMuchResearch]

Uh, no?
Endocavitary works just fine for this. Transcutaneous from the outside is probably not ready for primetime, but can also be done.

And for the likely majority of us without endocavitary probes, this is not feasible.

 

[Akail]

Where I trained, (tertiary care big academic center) there was no endocavity probe among the 4-5 sono's we had in the department. None of us really drained them. I asked one of my senior attendings if I could try it on a patient with no trismus and good analgesia and denied promptly. The majority of the time if we made the diagnosis clinically, we could call ENT and see if they wanted the CT (which they did 95% of the time). All of these went to the OR and the majority got an overnight stay.

 

[deleted109597]

So, I trained before the advent of US everything, but had to do 40 to graduate. Up until recently, I worked a shop with 2 residencies, and 5 hospitals without them. Every hospital but the peds hospital had endocavitary in the department. It's literally the only thing I use it for, as I'm not ruling out ectopics on my own. And I'm not a big US guy, I'm the guy rolling my eyes when people say they can determine ETT placement, or do ED dopplers for DVTs. But it works well for this, and didn't know that people out there had $50K instruments but left off probes.
And honestly, I don't mind them getting the CT. But only when you can see or have symptoms of it, not just the "sore throat" thing. If it's less than 1.5cm, there's nothing to do.

 

[deleted547339]

Dude. Let it go. The patient is fine. There is no way this attending will walk away thinking "hey, I'm glad that diligent med student showed me my mistake."

The response will be somewhere between "that med student is annoying" to "I will destroy him." Probably the former, but you never know if someone is ornery or having a bad day.

 

[gman33]

The mistake was getting a scan that didn't change anything.

Don't bring it up.

 

[MSmentor018]

Uh, no?
Endocavitary works just fine for this. Transcutaneous from the outside is probably not ready for primetime, but can also be done.

yep works fine, just flick off the pubes before you use it in their mouth

 

[MSmentor018]

And for the likely majority of us without endocavitary probes, this is not feasible.

attach linear probe to tongue blade or you can use the shaft on the large vaginal swabs or those wooden q tips. the view is obviously narrowed so sweep left/right before sticking the needle in to avoid big red

 

[deleted109597]

yep works fine, just flick off the pubes before you use it in their mouth

Every hospital I've worked at has a huge "sterilization" protocol for these probes. Also, we put condoms (Actual condoms, not probe covers) on them for every exam.

 

[Rendar5]

Dunno but I never found u/s or CT incredibly useful for diagnosis unless there's severe trismus preventing diagnosis (in which case there are probably a few things on the differential including dental abscesses)

I don't really care if there's uneven tonsils or voice changes. If there's uvular deviation (at the base) + trismus I stick a needle in there and aspirate. If they don't have the latter they get antibiotics and probably steroids and a diagnosis of peritonsillar phlegmon. I don't care if there's a super tiny PTA to be picked up on CT or u/s. Those don't need needles or I&D.

 

[Rendar5]

Dunno but I never found u/s or CT incredibly useful for diagnosis unless there's severe trismus preventing diagnosis (in which case there are probably a few things on the differential including dental abscesses)

I don't really care if there's uneven tonsils or voice changes. If there's uvular deviation (at the base) + trismus I stick a needle in there and aspirate. If they don't have the latter they get antibiotics and probably steroids and a diagnosis of peritonsillar phlegmon. I don't care if there's a super tiny PTA to be picked up on CT or u/s. Those don't need needles or I&D.

This is coming from someone who does use ultrasound routinely on skin to determine phlegmon vs abscess

 

[shookwell]

I agree with a bunch of people above. Almost always diagnose clinically, or put a needle in a see if anyything comes out. I do occasionally use endocavitary probe. I've tried using linear from the outside, but if I don't see anything I don't consider it ruled out. No reason to do a CT for PTA in a patient who can open their mouth.


Also, don't mention it to the attending, way higher chance of that being seen as a negative than you gaining anything.

 

[gro2001]

Ok, this thread has taught me two things:

1) PTA drainage by EM residents is even rarer than I thought. I trained at a big academic center where I thought we consulted on everything, and I still got to do a few PTA drainages. Guess its even worse at some places.

2) Endocavitary US is even less accessible than I thought. In residency we did a lot of endovaginal ultrasounds ourselves, and I realize how at a place with different resources it may make sense to never do them yourself, but even if the EM attending/residents aren't doing them, someone still had to do it, whether the US tech or the gyn consultant. Surely, they must have access to an endocavitary probe?

 

[gro2001]

What does that mean? We need better ultrasound? Or this technique is "yet to be perfected?" It seems like it either works or it doesn't.

Unfortunately with something like bedside US its not that simple. There are a couple of issues:

1) Even if we know X can sometimes be diagnosed using US, until it's studied properly (ideally in several different settings, using operators with different levels of experience, on different machines, with different patients), we can't really know what the sensitivity and specificity of US for this application is and whether these numbers are acceptable/useful for our clinical practice.

2) An US guru may be able to diagnose lots of things on US, but until they try teaching others and QCing the results, they can't know if its something that can really be taught to EM residents relatively quickly and for them to be able to perform the scan reliably.

3) Until a particular US application has been around (and, again, formally studied) for a bit we can't know what the pitfalls are going to be or diagnostic cut offs.

 

[Apollyon]

I don't really care if there's uneven tonsils or voice changes. If there's uvular deviation (at the base) + trismus I stick a needle in there and aspirate. If they don't have the latter they get antibiotics and probably steroids and a diagnosis of peritonsillar phlegmon. I don't care if there's a super tiny PTA to be picked up on CT or u/s. Those don't need needles or I&D.

Dude, putting the two bolded together, the worst thing that comes to mind for me is retropharyngeal abscess. I don't believe you are casual or flippant, but that is how it sounds. I missed one in residency, but, to be honest, that was a case that was black-letter training, because my attending missed it, too, and she told me afterwards what she had missed. That guy came back, went to the OR, and did well.

 

[shookwell]

Dude, putting the two bolded together, the worst thing that comes to mind for me is retropharyngeal abscess. I don't believe you are casual or flippant, but that is how it sounds. I missed one in residency, but, to be honest, that was a case that was black-letter training, because my attending missed it, too, and she told me afterwards what she had missed. That guy came back, went to the OR, and did well.

You are correct. This thread has changed to talking about PTA. Trismus and voice changes raise suspicion for more significant pathology.

 

[TooMuchResearch]

Ok, this thread has taught me two things:

1) PTA drainage by EM residents is even rarer than I thought. I trained at a big academic center where I thought we consulted on everything, and I still got to do a few PTA drainages. Guess its even worse at some places.

2) Endocavitary US is even less accessible than I thought. In residency we did a lot of endovaginal ultrasounds ourselves, and I realize how at a place with different resources it may make sense to never do them yourself, but even if the EM attending/residents aren't doing them, someone still had to do it, whether the US tech or the gyn consultant. Surely, they must have access to an endocavitary probe?

I will attempt aspiration x3 and if I don't get anything and still think it's there, I call ENT. That's pretty standard in my program from what I can tell.

But no endocavitary probe. I can get a radiology transvaginal ultrasound done 24 hours/day in under an hour (while I do other work) though.

 

[txterp98]

So many confusing things about this thread. I'll try to sum it up for you because there are some key features being said here and some that you might not be catching when reviewing the final chart.

1. Don't say anything to your attending. They didn't miss anything.

2. Like other posters said, it's doubtful this patient was signed out. As someone said, a nurse probably grabbed a different attending (since yours was now gone) and asked them to eyeball the patient. The new attending likely went off the report of the nurse saying voice changes were now present as the new attending had no prior reference point.

3. Like Apollyon said, that CT was likely being performed to look for far greater pathology than a PTA. I absolutely agree that they were likely scanning for a retropharyngeal abscess or possibly epiglottitis. If the new attending had thought it was a PTA, they likely would've put a needle in the peritonsillar fluctuance or performed a bedside ultrasound.

4. The CT confirmed what your attending thought....no procedures needed. And I doubt that ENT was consulted to perform a procedure even with the report of the presence of a small PTA. The new attending likely realized the abscess was either too small for drainage or was still in the phlegmon stage and that close follow-up with ENT was needed. ENT likely chimed in to put the patient on Clindamycin (and may have also advised Decadron in the ER and a Medrol Dosepak to go).

5. Without bringing up this specific case, ask some of the residents if they drain their own PTA's. I'm betting yes.

Hope that helps.

 

[Jlaw]

And for the likely majority of us without endocavitary probes, this is not feasible.

Just use the transvaginal

 

[WildcatS11]

Just use the transvaginal

Transvaginal = endocavitary

Please clean them well.

 

[DeadCactus]

You look at the case and see a missed PTA. Others look at the case and see some patient who got needlessly irradiated because his primary team bailed on him instead of just completing his care and getting me out.

 

[WilcoWorld]

You look at the case and see a missed PTA. Others look at the case and see some patient who got needlessly irradiated because his primary team bailed on him instead of just completing his care and getting me out.

What we've got here is failure to discharge. Some docs just can't dispo. So, you get what we had here last week.

 

[n2b8me]

http://www.entjournal.com/sites/ent...om/Media/PublicationsArticle/LAMKIN-10_06.pdf

Read this article on an outpatient medical treatment protocol for peritonsillar abscess.

 

[canigetawhatwhat]

I trained at a big academic residency where we had in house ent residents. "Standard of care" was calling ENT.

My last year there, I just stopped calling them. Started draining my own. Its not a hard procedure, and very safe, especially if you just needle it with an 18 gauge a few times.

Its amazing that residency doesnt teach it anymore.

-jigga

 

[VisionaryTics]

You are correct. This thread has changed to talking about PTA. Trismus and voice changes raise suspicion for more significant pathology.

Not really -- trismus and muffled voice are pathognomonic for PTA. I've seen trismus and muffled voice with a fair proportion of phlegmons as well. If I get a patient with trismus or voice changes and an exam that shows no PTA and a CT scan that shows no PTA -- I still drain it. Patients feel much better >95% of the time.

My ENT residency covers seven EDs with 4 EM residency programs among them. I would say 75% of the time I get called for a PTA, the patient has underwent a CT scan before I'm called (aside from pediatric ED). I've never seen anyone use an ultrasound in diagnosis, and I've never had an ER resident or attending say "yes" when I ask whether they are comfortable draining it themselves. Because of this, pretty much every community ED in the area sends their PTAs to EDs with on-call ENT coverage.

In terms of drainage, neither I nor any other resident or attending I know uses a needle as anything other than a diagnostic tool. If a patient has an abscess (or even a severely symptomatic phlegmon), I put a knife in it. With good local (1% lido with epi in the muscle, not just in the mucosa, I don't use topical), the patients barely feel it.

With regards to whether something was missed, I agree with the above in saying no, nothing was missed. A small/early PTA or early phlegmon is a difficult diagnosis without a scan (which I don't think is necessary unless you're worried about retropharyngeal abscess). Sometimes it's reasonable to treat and see how the patient responds. Part of diagnostics is seeing how patient's symptoms change over time. This isn't a stroke...time is not tonsil.

 

[WilcoWorld]

Not really -- trismus and muffled voice are pathognomonic for PTA. I've seen trismus and muffled voice with a fair proportion of phlegmons as well. If I get a patient with trismus or voice changes and an exam that shows no PTA and a CT scan that shows no PTA -- I still drain it. Patients feel much better >95% of the time.

My ENT residency covers seven EDs with 4 EM residency programs among them. I would say 75% of the time I get called for a PTA, the patient has underwent a CT scan before I'm called (aside from pediatric ED). I've never seen anyone use an ultrasound in diagnosis, and I've never had an ER resident or attending say "yes" when I ask whether they are comfortable draining it themselves. Because of this, pretty much every community ED in the area sends their PTAs to EDs with on-call ENT coverage.

In terms of drainage, neither I nor any other resident or attending I know uses a needle as anything other than a diagnostic tool. If a patient has an abscess (or even a severely symptomatic phlegmon), I put a knife in it. With good local (1% lido with epi in the muscle, not just in the mucosa, I don't use topical), the patients barely feel it.

With regards to whether something was missed, I agree with the above in saying no, nothing was missed. A small/early PTA or early phlegmon is a difficult diagnosis without a scan (which I don't think is necessary unless you're worried about retropharyngeal abscess). Sometimes it's reasonable to treat and see how the patient responds. Part of diagnostics is seeing how patient's symptoms change over time. This isn't a stroke...time is not tonsil.

I believe that you're reporting your experience accurately, but you do have a spectrum bias. That's to say that you didn't get called on the cases where the ED diagnosed the PTA, drained it, gave decadron and discharged the patient on augmentin. So my patients weren't included in your denominator unless they were the rare case that couldn't tolerate drainage without general anesthesia or those that needed admission for some secondary reason.

 

[VisionaryTics]

I believe that you're reporting your experience accurately, but you do have a spectrum bias. That's to say that you didn't get called on the cases where the ED diagnosed the PTA, drained it, gave decadron and discharged the patient on augmentin. So my patients weren't included in your denominator unless they were the rare case that couldn't tolerate drainage without general anesthesia or those that needed admission for some secondary reason.

Of course there's some that are being treated without calling us (why would they call to let us know we're not needed?). But it's usually a resident or NP/PA calling me, and I'm never hearing "I would, but this attending doesn't do them" or "I would, but there's a lot of trismus" or "I poked a needle in, and didn't get anything" or "could you take a look at a scan, I'm not sure whether I should drain it".

Like the above poster said, I think the "best practice" at a lot of places is just call ENT.

 

[shookwell]

It's interesting how difference practice is in different EDs. I never call ENT for PTAs, and why would you give antibiotics if you already drained the abscess?

 

[erdoc00]

I trained at a big academic residency where we had in house ent residents. "Standard of care" was calling ENT.

My last year there, I just stopped calling them. Started draining my own. Its not a hard procedure, and very safe, especially if you just needle it with an 18 gauge a few times.

Its amazing that residency doesnt teach it anymore.

-jigga

Everyone is afraid of the liability.

also it's great to hear from an actual ent. I feel like too often in emergency medicine we are relying on the experience of our colleagues for advice when the reality is that we should be getting advice from the specialists that actually perform the procedures much more frequently and thoroughly.

So many ER attendings have this grave fear of damaging the carotid artery yet ENTs rarely seem to share this same fear in my experience. I think this leads to a lack of good training due to the attendings not being comfortable to let the residents do them in the er. It's also why I think residency off service months are some of the most important training opportunities.

 

[Doctor Bob]

So many ER attendings have this grave fear of damaging the carotid artery yet ENTs rarely seem to share this same fear in my experience.

This is likely due to who will have to manage the complication. If the EM doc stabs the carotid and starts getting a lot of spurting blood, they have to call someone else (even if it's 1 time in 500). If the ENT doc stabs the carotid they fix their own complication.

That isn't a reason for us not to do them (I do my own, except at one shop where the director mandated that we call ENT even if we drained them ourselves... and I figured if I have to call them anyways, I might as well give them something to do). But perhaps its why there's some fear amongst EM docs.

 

[gro2001]

This is likely due to who will have to manage the complication. If the EM doc stabs the carotid and starts getting a lot of spurting blood, they have to call someone else (even if it's 1 time in 500). If the ENT doc stabs the carotid they fix their own complication.

That isn't a reason for us not to do them (I do my own, except at one shop where the director mandated that we call ENT even if we drained them ourselves... and I figured if I have to call them anyways, I might as well give them something to do). But perhaps its why there's some fear amongst EM docs.

There is a good argument to preferentially call ENT for PTAs, not just from fear, but from patient centered care. In fact, the same can be said for most procedures if we take our hubris out of the equation.

I have done 10-20 PTA drainages. I am not particularly scared of the complications, especially if I can take a look at the carotid with an US first. Given this, am I the best person to drain a PTA? It depends. If the patient would have to wait a day to see an ENT, then I am the best option. I can provide symptom relief now. If there is an ENT resident in house who has done 100-200 of them, then surely he would be the better option. He may have some tricks to make the procedure more tolerable, be more likely to have success on the first attempt and maybe even facilitate follow up. If there is an in house ENT resident but its July and really they are a PGY2 on their first month of consults, then maybe the patient is better off with me doing the procedure after all.

So there is no one size fits all for what's best for the patient. Sometimes its an EP doing the procedure, sometimes its calling a specialist. This is why its so unfortunate when medical students and residents seem to think that the main thing that separates us from IM or FM are our procedural skills. This makes us 'the doc of the gaps': the best trained people but only when there are no specialists around. While in fact we are uniquely trained in an entirely separate field, one that has more to do with patient advocacy, logistics, public health, community outreach, mental health, helping patients navigate the system, and only incidentally does procedures.

 

[Birdstrike]

we are uniquely trained in an entirely separate field, one that has more to do with patient advocacy, logistics, public health, community outreach, mental health, helping patients navigate the system, and only incidentally does procedures.

Very interesting synopsis of Emergency Medicine in 2016. Striking, in that "emergencies" and "life saving" are not only not at the top of the list, but not even on the list. Yet, I don't doubt for a second, that this description is accurate, with the possible except of "customer service" being omitted.

 

[gro2001]

Very interesting synopsis of Emergency Medicine in 2016. Striking, in that "emergencies" and "life saving" are not only not at the top of the list, but not even on the list. Yet, I don't doubt for a second, that this description is accurate, with the possible except of "customer service" being omitted.

What year(s) was EM ever primarily about life saving though? I know its part of our foundation mythos, but really it seems doubtful that there was ever a time when the majority of patients coming to the ED were ones whose lives we could claim to have saved. I wasn't around in the 'good old days' but from talking to old timers and reading a little of the history of our specialty it seems that back in the day it was mostly about keeping private docs sleeping at home so that docs of dubious reputation could do their scut work and admit all these after hours patients. And only occasionally was it about saving a life. Or do you think it was all intubations, CPR and cracking chests?

Now we have a legit role in the house of medicine, and still occasionally get to 'save' someone. Probably more than we used to before, actually. Its still hard to make the argument that EM is all about saving lives though. Think of the median EP: works about 1400 hours/year, seeing 2.5 pts/hr, so around 3,600 patients/year. Maybe 10% are critically ill, so 360/year. Some will despite our best efforts. Many of the ones who will be saved will be either saved by the system at large (did I really save that guy by activating the cath lab for the STEMI? Or was it his daughter, who called EMS, the medic who brought him in, the cardiologist who stented him, the other cardiologist who cared for him afterwards, the NP who made sure he was sent home with the right meds, the FP who made him take his BP meds) or are gomers. I don't think getting ROSC on a patient who should have long been DNR is the type of save you are talking about. Yes, occasionally there is a case where we get to honestly save someone. But its so rare that it is self destructive to define your specialty around those few cases.

 

[Birdstrike]

What year(s) was EM ever primarily about life saving though? I know its part of our foundation mythos, but really it seems doubtful that there was ever a time when the majority of patients coming to the ED were ones whose lives we could claim to have saved. I wasn't around in the 'good old days' but from talking to old timers and reading a little of the history of our specialty it seems that back in the day it was mostly about keeping private docs sleeping at home so that docs of dubious reputation could do their scut work and admit all these after hours patients. And only occasionally was it about saving a life. Or do you think it was all intubations, CPR and cracking chests?

Now we have a legit role in the house of medicine, and still occasionally get to 'save' someone. Probably more than we used to before, actually. Its still hard to make the argument that EM is all about saving lives though. Think of the median EP: works about 1400 hours/year, seeing 2.5 pts/hr, so around 3,600 patients/year. Maybe 10% are critically ill, so 360/year. Some will despite our best efforts. Many of the ones who will be saved will be either saved by the system at large (did I really save that guy by activating the cath lab for the STEMI? Or was it his daughter, who called EMS, the medic who brought him in, the cardiologist who stented him, the other cardiologist who cared for him afterwards, the NP who made sure he was sent home with the right meds, the FP who made him take his BP meds) or are gomers. I don't think getting ROSC on a patient who should have long been DNR is the type of save you are talking about. Yes, occasionally there is a case where we get to honestly save someone. But its so rare that it is self destructive to define your specialty around those few cases.

It never was "only emergencies." Never.
But, it used to be: "Focus on the emergencies first. They're #1. The other stuff can wait."

Now, it's: "Obsess about instant gratification of the quickest, easiest, most irrelevant cases, because they're good for business. The only mortal sin is to let those un-sick folks wait more than "X" minutes, because after all Medicine is a business and only about maximum mad-cash and quarterly bonuses for us (administrators). And, oh --ck. I guess you do have to find a way to do the impossible and save lives while you see an unlimited amount of non-emergencies in a limited & ever shrinking amount of time, and be liable for them. Oops, we never factored that in. Wow, sucks to be you. I guess you should've gone to MBA school, huh?

Did I mention department door-to-doctor times and Press Ganey's dropped a quartile this past month?

-Thanks.
Love,
Admin "



(Edit: I should add that the entirety of Medicine is being affected in these ways, to some degree. It's not just EM, by a long shot.)

 

[leviathan]

Was at a good talk by Scott Weingart who made the distinction between Emergency Medicine and the reality of the specialty which should actually be called Emergency Department Medicine.