Single Coverage ER but anesthesia at the ready - Call them for a code?

[vengaaqui]

Hi all. Sorry for bombarding the board with new attending questions.

I work in a single coverage 20 bed community based ED. It was insanely busy tonight and of course just when I thought I couldn't take much more with an hour left to go before my relief came on, a periarrest came in sating in the 60s that we pulled out a private vehicle in our entrance way. Slapped on NRB, NC high flow yada yada brought pt up to low 80s, tachycardia, borderline BPs. Concern for saddle PE based on hx versus flash pull edema. Trying to run periarrest, also get consultants on board since I was concerned the pt needed to be transferred to a higher level of care, especially in the case of saddle PE which we're just not equipped to deal with. Calling pharmacy for TPA as pt looks like **** and I'm scared my periarrest is getting ready to arrest, put fluids wide open to try to get some extra volume on board in case I tank my preload with BiPAP and try to BiPAP to bring that O2 level up so I'm not starting in the 70s with intubating. Don't think I'm going to have trouble with the airway anatomy as looks easy, but worried pt is gonna tank and trying to coordinate rest of her care.

If you have anesthesia at the ready 24/7 and they can come down to the ED in less than a minute happily do you call them in that scenario? As a new attending I did but then felt like a chump standing there while they tubed my patient and I was calling for transfer and ordering other stuff and then getting a line instead of dealing with the airway myself. Pt improved, stabilized. End of the day it's a win in that regard but did I sell myself/our profession short by not going for the tube and worrying about the rest later? How do you balance single coverage, "running things" and also needing to transfer as soon as possible with procedures needed to stabilize patient? I got so spoiled in residency because whenever there was a code one resident would run it and the other would be the proceduralist. And, we were also the "mecca" in residency so transferring with MD to MD discussion wasn't an issue.

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[deleted109597]

If it's more than you can handle, call them. I'm not judging. One code in a busy dept, two simultaneous codes, whatever. Nobody is superman (woman). Doesn't matter what they think. It's better for patients overall.
If it's routine for them to help, then call sooner.

 

[gro2001]

If you have anesthesia at the ready 24/7 and they can come down to the ED in less than a minute happily do you call them in that scenario? As a new attending I did but then felt like a chump standing there while they tubed my patient and I was calling for transfer and ordering other stuff and then getting a line instead of dealing with the airway myself. Pt improved, stabilized. End of the day it's a win in that regard but did I sell myself/our profession short by not going for the tube and worrying about the rest later? How do you balance single coverage, "running things" and also needing to transfer as soon as possible with procedures needed to stabilize patient? I got so spoiled in residency because whenever there was a code one resident would run it and the other would be the proceduralist. And, we were also the "mecca" in residency so transferring with MD to MD discussion wasn't an issue.

Don't feel bad for using all the resources available to you, particularly when it is better for the patient. Just because you CAN do it by yourself, does not mean it is always the best course of action. No one is going to judge you. Or at least no one should judge you. We all need help sometimes. Even better, bring it up as a question at some hospital committee to see if the ED and anesthesia can come up with some agreement on what the expectation is. Maybe they all hate helping with codes, or maybe they all love it. Either way, no one thinks twice about it once its understood to be the agreed upon way of doing things.

 

[Daiphon]

Don't feel bad for using all the resources available to you, particularly when it is better for the patient. Just because you CAN do it by yourself, does not mean it is always the best course of action. No one is going to judge you. Or at least no one should judge you. We all need help sometimes. Even better, bring it up as a question at some hospital committee to see if the ED and anesthesia can come up with some agreement on what the expectation is. Maybe they all hate helping with codes, or maybe they all love it. Either way, no one thinks twice about it once its understood to be the agreed upon way of doing things.

Agree.

Think of it this way - if you had US 24/7, would you even blink at ordering one vs bedside? Or IR if available to drop a PICC instead of a TLC? Or let the tech place a splint?

Single coverage is all about resource allocation. Getting sucked into a procedure that can be done by others is a surefire way to lock the room, as then you aren't seeing/dispoing new peeps.

If you had a code, and knew you needed to transfer, then your #1 priority is dispo - make the calls, tidy the package, & ship out. If you have the resources to offload some of the patient's needs, then do it.

Don't get me wrong - procedures are fun & a large part of what makes EM great; but dispo is king. From a purely fiscal standpoint, what you collect from any procedure pales in comparison to 2-3 level 3-5 encounters... this level 5 meets CC criteria, and involving anesthesia counts as consultation.

-d

Semper Brunneis Pallium

 

[Angry Birds]

You're a complete wuss for calling anesthesia.

No, I'm just kidding. I agree with what others have said above.

Whatever you do, do it with confidence. So, if you call anesthesia, call it out confidently, and then move on to the next thing. Nurses and staff just want to see decisiveness. They want a leader.

The only thing I would say is that you could also just ask your colleagues at work, "Hey man, we have anesthesia on-call 24/7. Do we use them during codes ever or is that like never done?"

Even if the answer is negative, however, this doesn't mean *you* should never use the resource if you really need it on a particular given day.

 

[deleted547339]

The thought of using a consultant to do something you can do seems entirely reasonable. I'll have plastics take care a of a massive facial lac that I *could* do that would take me an hour, but they can knock out in 20 mins.

This may seem dumb to more experienced docs, but it doesn't seem like this is really that scenario. Airway takes a few minutes. It's not like you're sedating a kid for 45 minutes for a complex lac repair or doing an LP on a huge patient that could take forever. Airways are quick so long as you have the RN and RT get everything ready for you.

 

[Rendar5]

Would I have called anaesthesia for this? No, I probably would've just tubed the guy myself in the first 5 minutes of arrival with fluids wide open and not even thought about getting backup. That doesn't mean you're wrong or a wimp for asking for assistance. As said above, whatever you do, do it with decisiveness, use resources at your disposal. There are multiple ways to do anything in medicine, and most of them are just as correct as the other. Out of curiousity why did you need to transfer this? Were you a freestanding ED? or lacking intensivists at your hospital?

 

[sawboned]

Great thread. You cover 20 ED beds single coverage? Do you have advanced practice providers? How many patients an hour are you seeing?

In my 11 bed ED, single coverage, I personally try not to call anesthesia, because I can't always rely on them. They may be in another case or up to 45 minutes away. Working towards Independence from anesthesia as a goal is laudable but not necessary particularly early on or with the sizable volume it sounds like you have to contend with.

 

[shoal]

i agree 20 bed single coverage is insane. we have 25 beds and were single coverage 5 hours and its still miserable. otherwise double or triple coverage.

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[Xerxes1729]

I imagine this is different for different people, but I tend to talk myself out of doing things, rather than talk myself into doing them. So with consultants (and imaging, etc), my rule is that if I find myself thinking a couple times, "Should I talk to XYZ?", I make myself do it, even if I think it's a weak consult. I sleep much better at night. I'd much rather deal with a complaint to my medical director that I woke someone up for something stupid than a complaint that I harmed a patient by not getting them involved sooner.

 

[Arch Guillotti]

We all need help sometimes.

There have been a lot of times I have needed help but I have never called for anyone from the ED and don't ever plan on it.

 

[The White Coat Investor]

I wouldn't have called anesthesia in that scenario but I also wouldn't take a job in a 20 bed single coverage ED. I assume it isn't usually single coverage when the 20 beds are full?

 

[e30ftw]

There have been a lot of times I have needed help but I have never called for anyone from the ED and don't ever plan on it.

Honestly quite dissapointed at this quote coming from an SDN administrator.

You quoted an example of an emergency physician stating that "all (ER docs) need help sometimes" which is a statement of our willingness to put aside ego to ask for help from consultants for the sake of our patients, and respond you would never need the help of an ER doc, which as a specialist, is disrespectful of your physician colleagues. Troll somewhere else.

I probably would not have called anesthesia in the original case and actually have never called anesthesia for anything other than a blood patch in residency, which they refused to do. But if you feel like the capacity of the ED is dangerously high and you cannot safely take care of your patients, call for help.

 

[Apollyon]

There have been a lot of times I have needed help but I have never called for anyone from the ED and don't ever plan on it.

In the rare chance that you delete this inappropriate post (which contributes nothing, except depicting you, as stated above, as sullying the perception of SDN administration), I just wanted to get it here.

 

[docdragon]

The above answers reflect the decision split - shove a tube down fast and get that done, or get the tube done with a phone call. The tube got done. All machismo aside, it sounds like you mobilized your resources & are lucky to have a fast response anesthesia team.

The bigger picture you describe is end of night shift, absolutely slammed, decision fatigue, complex physiologic stress. All of that makes tunnel vision more likely, makes you more likely to miss a tube and makes you more likely to fail to abort a failing intubation attempt for >60 seconds while the O2 sats drop to 60, 40, and you don't hear your nurse saying anything... Would it have happened? No idea. Either way, you got done what needed to be done.

I get the essential stabilization done ASAP and tell my secretary to get advanced transport ready & rolling ASAP, ideally with a FYI "the doc needs to call you back but says we need to transfer patient X" to the transfer center. If I have basic acceptance or the transport team arrives, I can deal with the rest of the conversation while we package. Of course they don't actually leave until I have my acceptance.

 

[Arch Guillotti]

Honestly quite dissapointed at this quote coming from an SDN administrator.

You quoted an example of an emergency physician stating that "all (ER docs) need help sometimes" which is a statement of our willingness to put aside ego to ask for help from consultants for the sake of our patients, and respond you would never need the help of an ER doc, which as a specialist, is disrespectful of your physician colleagues. Troll somewhere else.

I probably would not have called anesthesia in the original case and actually have never called anesthesia for anything other than a blood patch in residency, which they refused to do. But if you feel like the capacity of the ED is dangerously high and you cannot safely take care of your patients, call for help.

My apologies if you are disappointed. I promise you that I am not trolling.

No way I am deleting this post

I will come down to the ED gladly to do a blood patch, very occasionally a peripheral nerve block, manage a difficult airway, whatever.

Just don't call me because you are busy. I am too.

 

[filhodeinferno]

.

 

[GeneralVeers]

Honestly quite dissapointed at this quote coming from an SDN administrator.

You quoted an example of an emergency physician stating that "all (ER docs) need help sometimes" which is a statement of our willingness to put aside ego to ask for help from consultants for the sake of our patients, and respond you would never need the help of an ER doc, which as a specialist, is disrespectful of your physician colleagues. Troll somewhere else.

I probably would not have called anesthesia in the original case and actually have never called anesthesia for anything other than a blood patch in residency, which they refused to do. But if you feel like the capacity of the ED is dangerously high and you cannot safely take care of your patients, call for help.

I'm all for calling for help, but I'm curious as to what consultant will come to "help" especially at night? I don't think any anesthesiologist would come to the ER for an intubation, or a surgeon would come in to help sew up lacs. Perhaps in a large tertiary care center with tons of residents and specialists this may be the case. For the vast majority of of us in the community hospitals, we are completely on our own, with single coverage at night. Most of the time if the ED is slammed, I tell the nurses to let me know about any "sick patients", all of whom I take care of first. The dental pains, abdominal pains, anxiety, etc. get to wait either until I am done with the emergencies, or the next doctor comes in at 6AM.

 

[Arch Guillotti]

In the rare chance that you delete this inappropriate post (which contributes nothing, except depicting you, as stated above, as sullying the perception of SDN administration), I just wanted to get it here.

I thought I was already sullied? What gives?

 

[Arch Guillotti]

I don't think any anesthesiologist would come to the ER for an intubation

I do sometimes.

 

[Arch Guillotti]

You quoted an example of an emergency physician stating that "all (ER docs) need help sometimes" which is a statement of our willingness to put aside ego to ask for help from consultants for the sake of our patients, and respond you would never need the help of an ER doc, which as a specialist, is disrespectful of your physician colleagues. Troll somewhere else.

The OP was dealing with ONE crashing patient with a straightforward airway.

 

[deleted547339]

There have been a lot of times I have needed help but I have never called for anyone from the ED and don't ever plan on it.

Thanks for that?

 

[RustedFox]

My apologies if you are disappointed. I promise you that I am not trolling.

No way I am deleting this post

I will come down to the ED gladly to do a blood patch, very occasionally a peripheral nerve block, manage a difficult airway, whatever.

Just don't call me because you are busy. I am too.

This is a good point. I was in a situation my "first year-out" where the ER is packed, and I've gotta do an LP on a 140 year old kyphotic/scoliotic patient with fever/AMS. The directions that I got from my site medical director were "call radiology to come in an do it". I called our radiologist (who, I play golf with regularly). The only reason he came in to help is because it was "me", and that's what buddies do for one another. Then, there was a whole ****storm ignited about who to call and why, and the fact that it "was busy" and "the wait times were already high" weren't legit reasons to call in the subspecialist, and admin got their panties in a twist, and I was "counseled" and whatever.

Its an eternal struggle between what admin wants (low door-to-doc times) and what the docs want (a sensible work environment, based on true need and not buffing of some meaningless number)

 

[Apollyon]

I thought I was already sullied? What gives?

What, are you doubling down on the offensive? Are you saying you are sullied for posting in this forum?

As the Terms and Rules say:

Positive interactions between medical communities. The Student Doctor Network encourages members to engage in the wide variety of medical fields represented on the Forums. Open dialogue between medical professions promotes better understanding and working relationships. Please note, members that engage in attacking a specific field of medicine within that field’s forum may receive a warning or be banned from that forum. Forum members should encourage positive discussion between the professions.

Considering how moderation goes, an argument that you are attacking EM could be made. Of course, we can deal with it, because no thread is complete on SDN without MFing EM. It's just new ground that an administrator does it in our own forum.

 

[e30ftw]

I'm all for calling for help, but I'm curious as to what consultant will come to "help" especially at night?

You're right, of course, essentially none. I staff an 18-bed ED with single coverage from 11p-7a. Calling for help means calling the transfer center to get your patient on a truck going downtown..

The OP was dealing with ONE crashing patient with a straightforward airway.

Most of us have said we likely would've just intubated the patient, but no one can judge without having been there. So just say "As an anesthesiologist I don't like being called just because you're busy because I'm busy too and imo you should've at least attempted an airway." This replies to the OP. Saying you would never ask an ER doc for help and you never plan to is inflammatory to the specialty in general.

To the OP. If you know you did the right thing for your patient and sleep better because of it, there's no shame in using the resources available.

 

[gro2001]

There have been a lot of times I have needed help but I have never called for anyone from the ED and don't ever plan on it.

I am not sure if you meant it this way, but your post certainly comes across as gratuitous ED bashing. The fact that you have never called the ED for help (presumably to the OR, floor, or ICU) is obvious given the unidirectional flow of care at most hospitals.

However, aside from that though, are you saying that you have never called any other specialty for help? You have never needed anyone's help with a surgical airway? You have never needed a GI doc to come band some varices in the ICU? You have never needed a surgeon to do... well... anything surgically life saving to your patient? If you don't see the parallel to the ED doc calling for help with an anesthesia procedure on a complex patient (even if his airway did not appear particularly challenging), then I don't know what to tell you.

I realize calling an ED doc would be extremely unusual. But say you are the overnight ICU guy in the hospital and the only other doc is the ER doc (ie: exactly like about half the jobs I've interviewed for). And someone codes on the floor that you are supposed to go to at the same time as someone is crumping and needs to be intubated in the ICU. You wouldn't call the ED doc to help with the floor code under any circumstance?

 

[Arch Guillotti]

What, are you doubling down on the offensive? Are you saying you are sullied for posting in this forum?

As the Terms and Rules say:

Positive interactions between medical communities. The Student Doctor Network encourages members to engage in the wide variety of medical fields represented on the Forums. Open dialogue between medical professions promotes better understanding and working relationships. Please note, members that engage in attacking a specific field of medicine within that field’s forum may receive a warning or be banned from that forum. Forum members should encourage positive discussion between the professions.

Considering how moderation goes, an argument that you are attacking EM could be made. Of course, we can deal with it, because no thread is complete on SDN without MFing EM. It's just new ground that an administrator does it in our own forum.

Doubling down on what, my opinion? I may have been pretty blunt but no reason to get twisted up all over it.

I am well aware of the TOS.

 

[filhodeinferno]

I am not sure if you meant it this way, but your post certainly comes across as gratuitous ED bashing. The fact that you have never called the ED for help (presumably to the OR, floor, or ICU) is obvious given the unidirectional flow of care at most hospitals.

However, aside from that though, are you saying that you have never called any other specialty for help? You have never needed anyone's help with a surgical airway? You have never needed a GI doc to come band some varices in the ICU? You have never needed a surgeon to do... well... anything surgically life saving to your patient? If you don't see the parallel to the ED doc calling for help with an anesthesia procedure on a complex patient (even if his airway did not appear particularly challenging), then I don't know what to tell you.

I realize calling an ED doc would be extremely unusual. But say you are the overnight ICU guy in the hospital and the only other doc is the ER doc (ie: exactly like about half the jobs I've interviewed for). And someone codes on the floor that you are supposed to go to at the same time as someone is crumping and needs to be intubated in the ICU. You wouldn't call the ED doc to help with the floor code under any circumstance?

The ICU where I work consults the ED for Minnesota tube placement after hours. The floor consults us for central lines. There's even an order in epic "Consult to Emergency Medicine." The PCP 'consults' us every time they send one of their patients to our dept after hours.

The surgeon consults the anesthesiologist when he needs the table up or down.

In the end, we all give a little and take a little.

 

[Arch Guillotti]

Most of us have said we likely would've just intubated the patient, but no one can judge without having been there. So just say "As an anesthesiologist I don't like being called just because you're busy because I'm busy too and imo you should've at least attempted an airway." This replies to the OP. Saying you would never ask an ER doc for help and you never plan to is inflammatory to the specialty in general.

My apologies if you feel this is inflammatory but it's true. Perhaps I am just feeling a little ornery today. I have called for a specialist for something in the OR before so I am not immune to calling for help and also have relied on my partners before. But if I am the lone anesthesiologist in the hospital and patient is crumping then I deal with it myself, no matter how tired I am or what else I am covering.

 

[Arch Guillotti]

The ICU where I work consults the ED for Minnesota tube placement after hours. The floor consults us for central lines. There's even an order in epic "Consult to Emergency Medicine." The PCP 'consults' us every time they send one of their patients to our dept after hours.

The surgeon consults the anesthesiologist when he needs the table up or down.

In the end, we all give a little and take a little.

This is true. Unfortunately, I am consulted to the ED more often than I would like oftentimes for something that the ED doc can't/won't do or (very rarely) because they are busy.

 

[Arch Guillotti]

However, aside from that though, are you saying that you have never called any other specialty for help? You have never needed anyone's help with a surgical airway? You have never needed a GI doc to come band some varices in the ICU? You have never needed a surgeon to do... well... anything surgically life saving to your patient? If you don't see the parallel to the ED doc calling for help with an anesthesia procedure on a complex patient (even if his airway did not appear particularly challenging), then I don't know what to tell you.

This case as presented seems to be bread and butter EM. Not clear why ED doc couldn't handle it. The OP is a new ED doc so it's understandable the approach he took. I don't agree with it, but it's understandable. This is relatively minor in the grand scheme of things. the ED doc who called me in the middle of the night for a central line only to find him surfing the internet is another matter though. Bashing each other really doesn't do any good though. That's what Sermo is for!

 

[filhodeinferno]

This is true. Unfortunately, I am consulted to the ED more often than I would like oftentimes for something that the ED doc can't/won't do or (very rarely) because they are busy.

You are such a boss.

 

[Arch Guillotti]

The surgeon consults the anesthesiologist when he needs the table up or down.

Touche.

Or when they are exsanguinating the patient.

 

[vengaaqui]

Thanks for the perspectives. I think I probably should have attempted the tube and told the transfer center I would call them back and to just anticipate us coming for X but in the moment it was a little too much and perhaps clouded by seeing 25 patients in 6.5 hours (busier than usual). Had nothing to do with getting back to seeing other patients like someone said above although I did also have to do that. I stood there while anesthesia tubed dealing with transfer and then stayed there confirming placement, working on sedation, etc.

Yes, we have PAs sometimes. Most are great and autonomous and fast. Last nights' not so much.

 

[Angry Birds]

EDIT: Mrmmm....never mind.

 

[gro2001]

But if I am the lone anesthesiologist in the hospital and patient is crumping then I deal with it myself, no matter how tired I am or what else I am covering.

Do you really not see the difference between:

A: One anesthesiologist dealing with a crumping patient,

and

B: One ED physician dealing with a crumping patient AND a 20 bed ED on an unusually busy night at the tail end of seeing 20+ patients in 6 hours?

I realize that we all signed up for B over A by choosing EM, but implying you are somehow superior to the physician in scenario B because you would never call for help in scenario A is ludicrous. And, as you admit above, not actually true.

 

[GeneralVeers]

The ICU where I work consults the ED for Minnesota tube placement after hours. The floor consults us for central lines. There's even an order in epic "Consult to Emergency Medicine." The PCP 'consults' us every time they send one of their patients to our dept after hours.

The surgeon consults the anesthesiologist when he needs the table up or down.

In the end, we all give a little and take a little.

I would never work in the place you described. At most, I am willing to do intubations and code blues outside the ED. Anything else in the hospital needs to be done by the on-call specialists. Ain't Nobody got time for none of that!

 

[Rendar5]

I'm still curious about why the need for a transfer of a PE pt.

 

[iish]

ED docs put in Minnesota tubes after hours? I don't think I will ever put one in during residency outside of a sim situation. Don't think you want me as you blakemore consult

 

[goodoldalky]

Haha... one of the things I learn working in the pit and reading SDN are how many doctors seem to have Axis II diagnoses.

 

[future_dr_house]

To the OP, I probably would have started the same treatment with BIPAP for preoxygenation. If you're worried about hypotension use some push dose pressors and ketamine for induction. I'm not sure I would have called anesthesia as it seems within our realm, however, it was good to recognize limits initially in single coverage situations. In general though, arranging transfer for someone like this works in parallel. Page out as you are taking care of the airway and using bedside US looking for PE, etc. If they call back during your intubation obviously they have to wait. As for other procedures I would suggest either a mix of lidocaine and bupivacaine or just bupivacaine. Gives you a good excuse to do things piece wise. "I have to wait 10-15 minutes until it is numb. I will be back shortly to check if it worked." Step out and see a few more and throw in orders. Sew in batches. I tend to use a running stitch to improve speed if I'm slammed.

As to Arch's comment, I get what you're saying but it seems pretty dismissive. Overall our specialties overlap in skill sets quite a bit and of course you have generally a more controlled environment. If I was anesthesia I probably would not consult EM either but I don't think a statement like that is pertinent to this conversation. The question was whether or not you would help a colleague in over their head with what they felt was a periarrest intubation and needed coordination of care. I would hope someone would help me with a perceived difficult airway that needed awake nasotracheal intubation. Where's the collegiality? I help out our pulm CC colleagues who are not in house on nights in ICU with lines and codes. I would see that situation the same as with you finding someone surfing the Internet after a consult. This is a site specific issue we are dealing with but all I'm saying is it goes both ways.


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[Rendar5]

Well there are these really cool therapies called catheter-directed thrombolysis and even thrombectomy's. Hell, even ECMO. Most places do not have these capabilities.

Still sounds like a risky transfer, if OP is saying they are that unstable.

I'm well aware of the therapies and work at a tertiary care
one now. I've only heard of one request for a Ed transfer and that was because someone was scared to give tpa because the patient was on heparin. The cardiologist reviewed the criteria and advised them that it was not a contraindication. I've worked in non tertiary care and never heard of a transfer out for this. At least from the Ed. If they were unstable at least in my state it's a matter of tpa and not transfer. I was actually more wondering if there was lack of an intensivist, specialists, or if this was a freestanding ER

 

[link2swim06]

I'm well aware of the therapies and work at a tertiary care
one now. I've only heard of one request for a Ed transfer and that was because someone was scared to give tpa because the patient was on heparin. The cardiologist reviewed the criteria and advised them that it was not a contraindication. I've worked in non tertiary care and never heard of a transfer out for this. At least from the Ed. If they were unstable at least in my state it's a matter of tpa and not transfer. I was actually more wondering if there was lack of an intensivist, specialists, or if this was a freestanding ER

At our hospital patients in the grey area of "almost massive" PEs will get often catheter directed TPA by IR while they aren't quite at that point where you would want to give them systemic TPA (as the ED doc). This might not even be an option at a smaller hospital.

Although your point is valid...as I have never seen an ED to ED transfer for a PE.

 

[filhodeinferno]

I would never work in the place you described. At most, I am willing to do intubations and code blues outside the ED. Anything else in the hospital needs to be done by the on-call specialists. Ain't Nobody got time for none of that!

For the central lines we begrudgingly send a resident. The Minnesota tubes are rare.

 

[ballinsncbirth]

Im sorry , but as an ER attending im going to have to be honest, this is EXTREMELY weak . Doesnt matter how many patients are in the ER , or what coverage you have. THIS pt is the sickest person there and needs YOUR attention. The rest of the ER can wait. This is why we are Emergency attendings, these are the patients you are specifically trained to treat. THIS IS YOUR PATIENT. Calling an anesthesiologist becase your too busy "calling consults, and coordinating care" when a patient is in extreme distress is pretty ridculous. Thats what secretaries are for. Calling an anethesiolgist to the ER should be a very rare event. Calling without even attempting to intubate (save a horrible angioedema or huge thorat mass) is pretty horrible.
The reason you felt like a chump is because that was a chump move.

Im not sure why you are even waisting time calling other people, or ordering TPA on an undifferentiated respiratory distress. TUBE THE PT , it takes maybe 5 minutes. Once tubed THEN you can focus on WHY the patient is in respiratory distress (save a pneumothorax) . Why are you even thinking of trasffering this patient ? Are you at a standalone ER ? Do you not have an ICU ?. Tube the patient, get a CT of chest, admit and move on .

and dont kid yourself, the anethesiologist(and nurses,techs etc ) no matter how nice, will think less of you (as he/she should) and you will quickly get a name for yourself throughout the hospital , and when you ACTUALLY need anesthesia they will be hesitant to help you.

These are the situations in young attendinghood that forge your skills, make you a better decisionmaker, time manager, and eventually a better attending. Dont pawn them off on someone else.

 

[ballinsncbirth]

Im sorry , but as an ER attending im going to have to be honest, this is EXTREMELY weak . Doesnt matter how many patients are in the ER , or what coverage you have. THIS pt is the sickest person there and needs YOUR attention. The rest of the ER can wait. This is why we are Emergency attendings, these are the patients you are specifically trained to treat. THIS IS YOUR PATIENT. Calling an anesthesiologist becase your too busy "calling consults, and coordinating care" when a patient is in extreme distress is pretty ridculous. Thats what secretaries are for. Calling an anethesiolgist to the ER should be a very rare event. Calling without even attempting to intubate (save a horrible angioedema or huge thorat mass) is pretty horrible.
The reason you felt like a chump is because that was a chump move.

Im not sure why you are even waisting time calling other people, or ordering TPA on an undifferentiated respiratory distress. TUBE THE PT , it takes maybe 5 minutes. Once tubed THEN you can focus on WHY the patient is in respiratory distress (save a pneumothorax) . Why are you even thinking of trasffering this patient ? Are you at a standalone ER ? Do you not have an ICU ?. Tube the patient, get a CT of chest, admit and move on .

and dont kid yourself, the anethesiologist(and nurses,techs etc ) no matter how nice, will think less of you (as he/she should) and you will quickly get a name for yourself throughout the hospital , and when you ACTUALLY need anesthesia they will be hesitant to help you.

These are the situations in young attendinghood that forge your skills, make you a better decisionmaker, time manager, and eventually a better attending. Dont pawn them off on someone else.

 

[Angry Birds]

Im sorry , but as an ER attending im going to have to be honest, this is EXTREMELY weak . Doesnt matter how many patients are in the ER , or what coverage you have. THIS pt is the sickest person there and needs YOUR attention. The rest of the ER can wait. This is why we are Emergency attendings, these are the patients you are specifically trained to treat. THIS IS YOUR PATIENT. Calling an anesthesiologist becase your too busy "calling consults, and coordinating care" when a patient is in extreme distress is pretty ridculous. Thats what secretaries are for. Calling an anethesiolgist to the ER should be a very rare event. Calling without even attempting to intubate (save a horrible angioedema or huge thorat mass) is pretty horrible.
The reason you felt like a chump is because that was a chump move.

Im not sure why you are even waisting time calling other people, or ordering TPA on an undifferentiated respiratory distress. TUBE THE PT , it takes maybe 5 minutes. Once tubed THEN you can focus on WHY the patient is in respiratory distress (save a pneumothorax) . Why are you even thinking of trasffering this patient ? Are you at a standalone ER ? Do you not have an ICU ?. Tube the patient, get a CT of chest, admit and move on .

and dont kid yourself, the anethesiologist(and nurses,techs etc ) no matter how nice, will think less of you (as he/she should) and you will quickly get a name for yourself throughout the hospital , and when you ACTUALLY need anesthesia they will be hesitant to help you.

These are the situations in young attendinghood that forge your skills, make you a better decisionmaker, time manager, and eventually a better attending. Dont pawn them off on someone else.

Drops mic...

 

[Janders]

I'm on the drop mic side of this one.

So is the OP. He felt like a "chump" because he realized he'd called for help when he really could have handled it himself.

Its ok, better too conservative than reckless. But I've worked in a lot of single cover shops, and sometimes 20pt show up in 2 hours, and sometimes two arrests show up within 5 minutes, and sometimes there is horrible angioedema and no one else is within a 30 minute drive of your ER. You CAN handle it. Some other patients must wait, the secretary and the nurses need to step up... but you are a well trained MACHINE created for the entire purpose of pulling people from the very edge of death back into the warmth and light of life... AND IMMEDIATELY ADMITTING THEM, via speaker phone, while running the next code, and then discharging an ankle sprain before they even get the sheets of the gurney warm.

Tell the unit coordinator to call your consultant. Tell them you're too busy to get on the line but you need them for XYZ. Tell the nurse to arrange ALS xfer for you. You can off load all of that work, and focus on the resus of your patient.

I suspect this is just new attending cold feet. Also it points to the benefit of training environments that give you a taste of what its like to be "alone", be it though rough community rotations or opportunities to moonlight in "austere" environments.

All that blathering aside, remember RULE NUMBER ONE: "Do what is right for the patient". If you always follow rule number one, instead of your ego or your consultants desires or ridiculous hospital policies, you'll be OK.

 

[FirstNobleTruth]

You are a well trained MACHINE created for the entire purpose of pulling people from the very edge of death back into the warmth and light of life...

Yes. Yes. Yes.