Procedures

[HLxDrummer]

So I've shadowed in the ED a decent amount and haven't really seen any procedures except one central line (in vertical care lol). How often do you guys do procedures?

For example how often do you intubate, run a code, chest tube, deliver babies, etc? Part of the appeal of the specialty to me is procedures so I'm just wondering.

Thanks!

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[deleted547339]

Depends on the setting. Low acuity ED? Probably a lac repair, fracture reduction or other small procedures almost every shift. Intubation, central line? Once a month. In a high acuity shop, intubate, procedurally sedate, run a code regularly.

Chest tubes are kind of hard to come by. More things are being managed with pigtails.

Central lines - with the new ProCess trial, I feel like the indications for them are going down. Plus, with the availability of ultrasound and IOs, access isn't as much of an issue.

Delivering babies? Never (hopefully). That's a nightmare. No EM doc wants that.

 

[Doctor Bob]

Delivering babies? Never (hopefully). That's a nightmare. No EM doc wants that.

Oh, but think of all the RVUs you'd get...

 

[Old_Mil]

So I've shadowed in the ED a decent amount and haven't really seen any procedures except one central line (in vertical care lol). How often do you guys do procedures?

For example how often do you intubate, run a code, chest tube, deliver babies, etc? Part of the appeal of the specialty to me is procedures so I'm just wondering.

Thanks!

Intubate/code, central line, chest tube, babies would probably be the frequency of it with a big drop off from central line to chest tube and an even bigger drop off to babies. I haven't touched a baby since my OB rotation first year of residency...and I want to keep it that way.

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[RPedigo]

So I've shadowed in the ED a decent amount and haven't really seen any procedures except one central line (in vertical care lol). How often do you guys do procedures?

For example how often do you intubate, run a code, chest tube, deliver babies, etc? Part of the appeal of the specialty to me is procedures so I'm just wondering.

Thanks!

I would say I do a few central lines, codes, lumbar punctures, reductions, procedural sedations, complex lacerations, and intubations a week. I delivered a baby in the ED in the past month. Chest tubes are rare and I have done maybe 5 this year so far, mostly pigtails. I am at a residency training program, though (PGY3).

 

[TrumpetDoc]

I will say that this is actually something aspiring EM resident should pay attention to. Like most I went to a very high acuity residency program. There was constant barrage of codes, sick, septic, shocky patients. Lots of trauma. We were constantly going upstairs to intubate, do procedures and such. We actually delivered several babies in the department over my residency.
However when you become an attending this changes. I stayed on as attending at my residency program and while it may seem cool to be an academic attending at an extremely high acuity program, you actually do not get to do almost ANYTHING for the most part. Residents do all the work and all the cool procedures. There's very few times where you need to step it as the attending and actually do the procedure.
Stepping out into the community I was at a high acuity place as well, with a 25-30% admission rate. There were a fair amount of intubations there, once every day or every other day. Chest tubes are actually fairly scarce even a high acuity places, and when you're out in a very busy shop if the patients not unstable these get done by interventional radiology or surgery majority of the time there is just no time at 3+ pph.
I Agree with the above that central lines are more and more rare now given the ultrasound peripheral line, midlines, PICCs.

I am a very procedure oriented person, I am also one who if I'm not seeing in managing very sick people I get very upset with work. This was actually a huge reason why I left my academic position because I was not actually really managing anything - more of a distant supervisor - boring! The job I was at that was very high acuity but had such an incredible stress level as far as the ED volume (pressure to see and dispo ppl too quickly in my opinion), very bitchy hospitalists/specialists, metrics by the corporate group, that it was just unbearable to that regard. Now the truly sick people are more rare and procedures so sparse that I just go crazy.
If I could financially I would change to CCM or something more hands on all the time...oh well.

As someone eluted to in a previous post, my residency ,as many like it, did not prepare me for the realities of real-life emergency medicine. I believed my higher acuity ER where I trained was just how it was going to be.



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[HLxDrummer]

Thanks for the replies! I am perfectly ok with no deliveries haha I figured most women get sent to L&D but wasn't sure how much time that takes. I am also ok with sutures and small procedures on a regular basis, especially if I can do bigger things on a weekly basis.

I'm a med student at a level 1 right now and anticipate working at a community level 2. So hopefully I would be able to do a decent amount of stuff there as an attending.

I'm on peds now and while I like kids a lot, I can't imagine my only procedure being a monthly LP if that. Boring!

 

[namethatsmell]

Another resident chiming in (pgy2). During an average week I'll do at least 3 following (often times way more): intubate, central line, lumbar puncture, complex lacs, reduction, sedation. Some of the less common things (maybe once every month or two) include chest tubes and cardioversion. More rare stuff (maybe once or twice a year) include bartholin's gland I&D w/word catheter placement, PTA drainage, deliver a baby, and other random things.

As others have said, the need for central lines is plummeting. Additionally, the number of intubations is dropping thanks to BiPAP.

 

[RustedFox]

As others have said, the need for central lines is plummeting. Additionally, the number of intubations is dropping thanks to BiPAP.

My God, BiPAP for the win! My average 'critical patient' is a 68 year old female end-stage COPD'er. At least 2-3 times daily. I instruct EMS to slap the BiPAP on them PTA and pre-oxygenate them from there. Tubes are way easier than they used to be.

 

[EctopicFetus]

Agreed with all above.

However, this week I did 3 conscious sedations, an elbow dislocation, a chest tube and an LP. One US guided IV. One lac repair since most are done by PAs. no central lines or codes this week.

no tubes, saved one by using bipap.

 

[RustedFox]

Anyone else aggravated by LPs?

They're not terribly difficult in the anatomically "normal", but when your average patient is 60-80 years old and has advanced degenerative spine/disc disease and TurboScoliosis.... its taxing. Bedside ultrasound for the win.

 

[deleted547339]

Anyone else aggravated by LPs?

They're not terribly difficult in the anatomically "normal", but when your average patient is 60-80 years old and has advanced degenerative spine/disc disease and TurboScoliosis.... its taxing. Bedside ultrasound for the win.

I. Hate. LPs.

 

[EMIM2011]

+1

 

[RustedFox]

I only ever "need" to do LPs on Stage 3-4 turboscoliosis patients. Everyone else is 'too young and healthy'.

#justmyluck.

 

[Birdstrike]

I. Hate. LPs.

LPs used to be hard for me, too. If you can, go and do (or watch) a few under fluoro with either anesthesia, or int rads. Once you see how large the interlaminar space is, and see that you can starr paramedian at the level below your target level, you'll be embarrassed by your former self and you'll never miss an LP again. If you're doing these blind, inter-spinous you're making this procedure unnecessarily hard. This is equivalent to aiming to hit where the lines cross (inter-spinous space; much smaller) on a sideways 8, versus aiming for the circles on either side (interlaminar space on either side; much larger). Use at least a 5 inch needle on all adults (3.5 inch will be too short on many medium to large patients) and go paramedian.

Learn it:

http://www.pitt.edu/~regional/Epidural/epiduralinsertion.jpg

 

[Groove]

Depends on the shop. Last month I did 5 intubation, 3 LPs, lots of lacs and I&Ds, couple joint aspirations, reduced a couple shoulders, reduced some fxs, maybe 3 central lines, 1 chest tube and an open thoracotomy (extremely rare), pericardiocentesis (also very rare), couple codes, few nerve blocks (alveolar, digit, wrist), etc.. It felt like a busy month. Some months are busier/slower than others so I feel that it can vary quite a bit along with the procedures. I wouldn't worry about not being able to do procedures. You'll get enough no matter where you work but if you work in a higher acuity place..you'll get more. Good luck in your EM endeavors. The last baby I delivered was in residency and I'm just fine with keeping it that way. I seemed to have a lot of critical peds stuff while moonlighting in residency out in these remote EDs/middle of nowhere. The last really sick one I can remember outside residency was a septic NEC baby that ended up tubed/transferred last year. I'm really just fine with not seeing a lot of the critical peds cases.

 

[Groove]

As for the LP's, I personally enjoy them but I find that I sit most of my pt's up these days. I had a guy a couple weeks ago who's back was nothing but muscle and fat. I couldn't feel anything. I blind stabbed and got my bearings and just got lucky on that one. I watched a few videos using US for landmarks but found it much more difficult in practice, so I never use it. I may try the para approach more often.

 

[Perrin]

Oh, but think of all the RVUs you'd get...

And think of all the documentation you'll have to do to cover a precipitous delivery. A while back I did a perimortem c-section. For days I was talking to admin on the phone and writing emails. Thankfully, ED director read my voluminous note and said everything looks tight, you made the right choice, and said I didn't need to attend the resultant 'discussions'.

 

[Groove]

And think of all the documentation you'll have to do to cover a precipitous delivery. A while back I did a perimortem c-section. For days I was talking to admin on the phone and writing emails. Thankfully, ED director read my voluminous note and said everything looks tight, you made the right choice, and said I didn't need to attend the resultant 'discussions'.

Can you talk more about the case? I hope I never have one of those.

 

[Doctor Bob]

If I could financially I would change to CCM or something more hands on all the time...oh well.

Not getting to actually do the procedures when I was an academic attending was a part of my decision to go back to fellowship. At least now as the fellow I have the right of first refusal on procedures in the ICU, and the program expects that all airway procedures will be done by me (trachs, ETTs, bronchs, etc). I suppose as an attending I had the right of first refusal as well, but if I took advantage of it, then there would have been no reason to be at a teaching institution.

bartholin's gland I&D w/word catheter placement,

I don't use word catheters any more... too much discomfort on the part of the patient, they fall out, etc. Instead I put in a vessel loop and have the person leave it in for 3-4 weeks. The followups have all been good.

A while back I did a perimortem c-section. For days I was talking to admin on the phone and writing emails. Thankfully, ED director read my voluminous note and said everything looks tight, you made the right choice, and said I didn't need to attend the resultant 'discussions'.

Urgh; that's one procedure I wouldn't do.

 

[shookwell]

Depends on where you are. Here is a list of the procedures I did in the first 2 years of residency. There are some anomalies, for example I didn't know I was supposed to log arthrocentesis, so I didn't log any until 3rd and 4th year. I also slacked off on logging after hitting all the requirements for graduation.

 

[e30ftw]

lots of procedures in EM.

in an average string of shifts I'll intubate, do central lines, dislocation reductions, complex lacs, blah blah..

in 2 yrs of EM residency: ~100 intubations, > 35 central lines, ~20 chest tubes, 15 vag deliveries, countless lac repairs, > 30 sedations not to mention countless lacs/foreignbodies/dislocationreductions/resus etc. lots of cardioversion, probably my favorite is intubating and cardioverting unstable rhythms.

 

[deuist]

15 vag deliveries

Were these deliveries performed in the emergency department or labor and delivery? If you did them in L&D, I wouldn't count them as EM procedures.