Sure, there's nothing wrong with medicine in the UK

[RustedFox]

Agree completely. Due to "poor patient satisfaction", one of my EmCare sites has now mandated that EVERY patient be seen by a physician. That means the level 4 tooth pain, or the level 5 med refill that is seen by an APP has to sit and wait until a physician comes to say hi. We are not really sure how this going to work yet as the patient volume is already very high just for the physicians. Would seeing a physician increase patient satisfaction moreso than than the extra hour wait would tend to decrease it?

I've basically stated that at his point I don't need an APP. If I have to see all the patients, just give me the $70/hour that they make, plus two scribes.

This. QFT. I could see all the low-level nonsense faster than an APP could. Just don't expect them to be satisfied. You have a bruise? Okay, that's great; suck it up. You're fine.

You have a toothache? Congratulations; you're in the wrong shop. I'm not a dentist. Here's your 12 percocet and 30 amoxicillin. Now GTFO.

You have a lac that you waited 8 hour to come have repaired? You're going to wait another 2-3 hours.

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[RustedFox]

Agree completely. Due to "poor patient satisfaction", one of my EmCare sites has now mandated that EVERY patient be seen by a physician. That means the level 4 tooth pain, or the level 5 med refill that is seen by an APP has to sit and wait until a physician comes to say hi. We are not really sure how this going to work yet as the patient volume is already very high just for the physicians. Would seeing a physician increase patient satisfaction moreso than than the extra hour wait would tend to decrease it?

I've basically stated that at his point I don't need an APP. If I have to see all the patients, just give me the $70/hour that they make, plus two scribes.

I am dying to know how this policy of "every patient is seen by the MD/DO" turns out.
It clearly ruins the other metrics that they mense over (door-to-dispo, dispo-to-depart).
I'm sure that docs are leaving that site left and right, driving up the hourly rates for PT/locums.
I would not agree to such an arragement, unless the rate were TURBOsweet, and there were no other expectations of me.

 

[RustedFox]

I'll go one further.
At my primary job site; "satisfaction" on the inpatient side is so poor that the C-fux mandated that we, the "ER docs" go do "inpatient rounds" on our admitted patients during our next shift.

Are we paid for this? No.
Are we expected to keep Door-to-doc times down? Yes (even though we're not in-department... somehow).
Are we exposed to liability for this? Likely, yes.
Do the patients bother us for additional pain meds and dietary changes and other things that we can't (and should not) control? Yes.
Are they satisfied when we can't meet their demands? Likely not.
Will this meet the C-Fux goal of impoving inpatient satisfaction? Probably not.

 

[alpinism]

Lol

So much for never having to round in EM.
Now you'll have to write progress notes on all these patients.
Remember if you never documented it then it never happened.

 

[Birdstrike]

I'll go one further.
At my primary job site; "satisfaction" on the inpatient side is so poor that the C-fux mandated that we, the "ER docs" go do "inpatient rounds" on our admitted patients during our next shift.

Are we paid for this? No.
Are we expected to keep Door-to-doc times down? Yes (even though we're not in-department... somehow).
Are we exposed to liability for this? Likely, yes.
Do the patients bother us for additional pain meds and dietary changes and other things that we can't (and should not) control? Yes.
Are they satisfied when we can't meet their demands? Likely not.
Will this meet the C-Fux goal of impoving inpatient satisfaction? Probably not.

Oh, sweet Jesus, tell me you were drunk and/or trolling when writing this post. Please.

 

[Birdstrike]

Agree completely. Due to "poor patient satisfaction", one of my EmCare sites has now mandated that EVERY patient be seen by a physician. That means the level 4 tooth pain, or the level 5 med refill that is seen by an APP has to sit and wait until a physician comes to say hi. We are not really sure how this going to work yet as the patient volume is already very high just for the physicians. Would seeing a physician increase patient satisfaction moreso than than the extra hour wait would tend to decrease it?

I've basically stated that at his point I don't need an APP. If I have to see all the patients, just give me the $70/hour that they make, plus two scribes.

Exactly. If they take all autonomy from the PAs & NPs then they're rendering them as no more than a scribe. Seems like too many administrators want NP/PAs to be functioning at one extreme or another: Either function as a physician with little to no supervision to get max patient flow out of the department, or give them no autonomy so that they can stamp every visit with the "seen by physician" label, hoping that boosts patient sat. What you need is to hit the sweet spot of supervised autonomy, but after all that would require common sense, and that's something that, well, you know the rest.

 

[Birdstrike]

But my well run ED admin keeps pointing at my locums place (same big national hopital chain) and want us to throw a ML in triage. I can't argue with stupidity anymore

Do you have any choice otherwise?

 

[WilcoWorld]

I'll go one further.
At my primary job site; "satisfaction" on the inpatient side is so poor that the C-fux mandated that we, the "ER docs" go do "inpatient rounds" on our admitted patients during our next shift.

Are we paid for this? No.
Are we expected to keep Door-to-doc times down? Yes (even though we're not in-department... somehow).
Are we exposed to liability for this? Likely, yes.
Do the patients bother us for additional pain meds and dietary changes and other things that we can't (and should not) control? Yes.
Are they satisfied when we can't meet their demands? Likely not.
Will this meet the C-Fux goal of impoving inpatient satisfaction? Probably not.

WTF!?

Leave. Now.

 

[RustedFox]

Oh, sweet Jesus, tell me you were drunk and/or trolling when writing this post. Please.

I'm off shift. I was three Moscow Mules deep when posting; but was not "clinically drunk".
I was not trolling.

For realsies, though - that is the directive that has come down from the C-Fux. Have I done inpatient rounds? No. Have I documented any visit that I have made to an inpatient? No. Have I visited people out of the kindness of my heart during their inpatient stay? Yes ... but that's where it stops.

The Dao of RustedFox says: "Visit the sick and infirmed, comfort them, counsel them, and express solidarity."
The Dao of RustedFox does NOT say: "Document your spiritual rounds, for the attorneys to discover."

The Dao of the Fox... might become its own thread.
The Fox can be wrong.

 

[BoardingDoc]

Have I done inpatient rounds? No. Have I documented any visit that I have made to an inpatient? No.

As long as this is not something which is actually enforced, I suppose it's fine. That said, I would absolutely be looking for another job if this became a requirement at whatever shop you're working in.

 

[shookwell]

I'll go one further.
At my primary job site; "satisfaction" on the inpatient side is so poor that the C-fux mandated that we, the "ER docs" go do "inpatient rounds" on our admitted patients during our next shift.

Are we paid for this? No.
Are we expected to keep Door-to-doc times down? Yes (even though we're not in-department... somehow).
Are we exposed to liability for this? Likely, yes.
Do the patients bother us for additional pain meds and dietary changes and other things that we can't (and should not) control? Yes.
Are they satisfied when we can't meet their demands? Likely not.
Will this meet the C-Fux goal of impoving inpatient satisfaction? Probably not.

I would quit immediately if any hospital tried to make me do this.

Also, moscow mules are awesome, but kentucky mules are awesomer. I've been experimenting with mules and so far rye and mezcal (with jalapeno garnish) are my favorite.

 

[GeneralVeers]

RustedFox, sounds like your admin is as bad as mine. I would definitely quit if they made me round on inpatients, so keep up the good fight!

We are not sure how it's going to work with seeing every APP patient. Right now I wait for them to collect 5-6 patients, then round with the APP twice per shift and just say hi to everyone. It definitely decreases the patients I can see by 2-3 per shift. The patients definitely wait longer to be discharged because the nurse cannot discharge them until I clear the "Physician Eval" event from Cerner after I've seen them. It's one of those "Panic Directives" adopted by admin with no thought to how it will actually work. I suspect the policy will be revised when they find out it's making things worse.

 

[MSmentor018]

I work in a well run ED by most standards. Our door to ED doc/provider time is less than 10 minutes but they want to bring this down even more.

I work at a locums place that has presentation to provider time of prob 1 minute.

10 min, thats exceptional and they want it lower? talk about greed and aggression. maybe they get a larger bonus for having the best time in town. or at least penis bragging rights at the AHA gala
1 min? what's next, roller skating in the parking lot like at sonic and placing orders while they park the car?

Agree completely. Due to "poor patient satisfaction", one of my EmCare sites has now mandated that EVERY patient be seen by a physician.

don't know if satisfaction will go up (I think studies have shown it does) but billing sure will

 

[MSmentor018]

I'll go one further.
At my primary job site; "satisfaction" on the inpatient side is so poor that the C-fux mandated that we, the "ER docs" go do "inpatient rounds" on our admitted patients during our next shift.

Are we paid for this? No.
Are we expected to keep Door-to-doc times down? Yes (even though we're not in-department... somehow).
Are we exposed to liability for this? Likely, yes.
Do the patients bother us for additional pain meds and dietary changes and other things that we can't (and should not) control? Yes.
Are they satisfied when we can't meet their demands? Likely not.
Will this meet the C-Fux goal of impoving inpatient satisfaction? Probably not.

you gotta f!@#in be kidding me. on what time frame do they expect this to happen during your shift?
if they want the whole "rainbows and unicorn farts" campaign they should have the CMO wear a spankin newly pressed white coat and do rounds. or hire a brand new PA and do it. a puppet is a puppet

isn't there a liability/guideline issue with rounding on pt's that isn't yours anymore? even on a courtesy visit, if there's something wrong you're going to be on the hook. I can see this scenario "yes your honor, dr redfox did visit me, I told him about the weakness but nothing was done so now my dad's in a nursing home". like you said there maybe the expectation of meds/change meds, do you have authority to override/give orders outside the ED?

 

[RustedFox]

you gotta f!@#in be kidding me. on what time frame do they expect this to happen during your shift?
if they want the whole "rainbows and unicorn farts" campaign they should have the CMO wear a spankin newly pressed white coat and do rounds. or hire a brand new PA and do it. a puppet is a puppet

isn't there a liability/guideline issue with rounding on pt's that isn't yours anymore? even on a courtesy visit, if there's something wrong you're going to be on the hook. I can see this scenario "yes your honor, dr redfox did visit me, I told him about the weakness but nothing was done so now my dad's in a nursing home". like you said there maybe the expectation of meds/change meds, do you have authority to override/give orders outside the ED?

I hear y'all: inpatient rounds are a no-go... but there's no way I'll quit this job.
I love this job site.

Its not HCA, and there's no metrics madness which cuts into your paycheck.
Expectation is door-to-doc of 30 minutes. We reguarly clock the 10-14 minute range; and that's an HONEST timestamp... not MLP in triage.
75% of the patients are literate, responsible, and non-drug seeking.
The charting system (Cerner + Dragon) is slick. I rarely leave the shift with unfinished charts.
The work is pretty easy. The acuity is low to moderate.
My only stress is self-imposed.

I've made "spiritual rounds" for certain inpatients that needed some hugs and prayers and whatever.
I didn't document anything; its just a visit from another human being - not a medical progress check.

We will see how this goes.

 

[RustedFox]

I would quit immediately if any hospital tried to make me do this.

Also, moscow mules are awesome, but kentucky mules are awesomer. I've been experimenting with mules and so far rye and mezcal (with jalapeno garnish) are my favorite.

Your Kentucky mule sounds good; but I cannot drink whiskey of any variety. The headache and sour stomach are so not worth it. Just can't do it.
Maybe it makes me a loser. Whatever.

That jalapeno garnish, though... now you're talking my language.

 

[emergentmd]

10 min, thats exceptional and they want it lower? talk about greed and aggression. maybe they get a larger bonus for having the best time in town. or at least penis bragging rights at the AHA gala
1 min? what's next, roller skating in the parking lot like at sonic and placing orders while they park the car?


don't know if satisfaction will go up (I think studies have shown it does) but billing sure will

That is why admin is so stupid. you can't even get a 10 min door to provider time when you have an appt at your PCPs office.

 

[WilcoWorld]

That is why admin is so stupid. you can't even get a 10 min door to provider time when you have an appt at your PCPs office.

Below 10 min this metric becomes non-sensible. In fact, the patient's I need to see immediately will probably have a door-to-doc time over 10 minutes.

Someone comes in unstable V-tach. I meet EMS at the door. We put pads on the patient, I assess the airway, and we start bagging. We shock into NSR. The patient is still not breathing regularly so I intubate. We get an ECG to see if there's a STEMI. I finally sign up for the patient in the EMR to enter labs and the LOS is now at 12 minutes.

Guess I should've waited for the patient to get registered first.

 

[emergentmd]

Below 10 min this metric becomes non-sensible. In fact, the patient's I need to see immediately will probably have a door-to-doc time over 10 minutes.

Someone comes in unstable V-tach. I meet EMS at the door. We put pads on the patient, I assess the airway, and we start bagging. We shock into NSR. The patient is still not breathing regularly so I intubate. We get an ECG to see if there's a STEMI. I finally sign up for the patient in the EMR to enter labs and the LOS is now at 12 minutes.

Guess I should've waited for the patient to get registered first.

Our door to provider goal is 10 min. They look at the easiest fix is to put someone PA in triage to time stamp instead of fixing all of the other functional issues like inpatient holds.

Anyhow, all of these metrics are dumb but sure looks great on the websites. I have learned in all of this is you have to look out for yourself and stopped kidding myself that I will fix anything. When they put stupid metrics that get beat over our heads at every meeting instead of working on inpatient holds, having up to date equipment/charting system, etc... I realize that I just need to worry about me.

So if they are paying me $500+/hr, I can care less what metric or requirements they put on me. I punch my clock and make my 500+/hr. I can care less if it is seeing pts, going up stair to round, calling pts back. At the end of the day, I am collecting 5k for 10 hrs of work.

But in my main gig paying $225/hr, they better not ask stupid things of me.

I put my foot down at calling pts back when they tried. If they want me to start calling pts back or round on the floor, they better jack that up to $400/hr.

 

[BAM!]

I hear y'all: inpatient rounds are a no-go... but there's no way I'll quit this job.
I love this job site.

Its not HCA, and there's no metrics madness which cuts into your paycheck.
Expectation is door-to-doc of 30 minutes. We reguarly clock the 10-14 minute range; and that's an HONEST timestamp... not MLP in triage.
75% of the patients are literate, responsible, and non-drug seeking.
The charting system (Cerner + Dragon) is slick. I rarely leave the shift with unfinished charts.
The work is pretty easy. The acuity is low to moderate.
My only stress is self-imposed.

I've made "spiritual rounds" for certain inpatients that needed some hugs and prayers and whatever.
I didn't document anything; its just a visit from another human being - not a medical progress check.

We will see how this goes.

Rounding on inpatients: What I can't get past is that this is out of our scope of practice. We aren't trained or boarded in this type of medicine. Seems like an even bigger liability for the hospital, which has deeper pockets.

 

[erdoc00]

I think it's amazing that you guys put up with some of this crap.

Community emergency medicine has to be one of the most soul sucking endeavors ever created. I hope the pay is worth it since we've all sold out and are going to pay dearly for this in the years to come.

they say jump, we say how high...

 

[GeneralVeers]

Agree completely with emergentMD. I punch the clock, make my $$$ and jump through the hoops they need. Want a 10 minute door-to-doc? I'll happily click on the patient to sign up....the patient may still sit in the waiting room for 2 hours and not see an MD, but I'm making the numbers look good.

The line of what we will/won't do is different for everyone. I have no problem with something like clicking to sign up. I draw the line at rounding on inpatients. That would be a no-go for me unless they were paying over $500/hour.

Yesterday I had the lazy ICU doc who hadn't seen the patient request I place a "Trialysis Catheter". I had never heard of such a thing. At any rate it's not a procedure I do and the patient did not need emergent dialysis. She had multi-organ failure from GI bleed and hypovolemia but dialysis wasn't going to fix any immediate issue. I politely told them that placing dialysis catheters is no in my skillset, and to have IR or the ICU doc do it. I always have no problem refusing to do something that I feel is unnecessary or will take up too much of my time.

 

[BoardingDoc]

request I place a "Trialysis Catheter"

FYI it's just a brand name dialysis catheter that also can be used as a standard CVL and will allow IV contrast injection. It looks basically identical to a regular HD cath. That said, if the patient didn't need emergent HD I have no idea why the hell they were asking you to place it in the ED.

 

[UKEMdoc]

They're nice for a bleeding patient 2*200ml/min lumens and a third line for infusions

 

[emergentmd]

I think it's amazing that you guys put up with some of this crap.

Community emergency medicine has to be one of the most soul sucking endeavors ever created. I hope the pay is worth it since we've all sold out and are going to pay dearly for this in the years to come.

they say jump, we say how high...

You must be delusional that only EM docs have to deal with admin Crap. If your practice requires work in the hospital, you have similar hoops. I hear complaints all of the time from Surgeons, Gas, radiologist, hospitals, OB about Admin guidelines and metrics.

Anyone will jump at the right rate. You don't think a surgeon would not round if they get $500/hr just to say hi? I can tell you that rounding on pts and chit chattting would be easier than working in the ED.

 

[emergentmd]

Agree completely with emergentMD. I punch the clock, make my $$$ and jump through the hoops they need. Want a 10 minute door-to-doc? I'll happily click on the patient to sign up....the patient may still sit in the waiting room for 2 hours and not see an MD, but I'm making the numbers look good.

The line of what we will/won't do is different for everyone. I have no problem with something like clicking to sign up. I draw the line at rounding on inpatients. That would be a no-go for me unless they were paying over $500/hour.

Yesterday I had the lazy ICU doc who hadn't seen the patient request I place a "Trialysis Catheter". I had never heard of such a thing. At any rate it's not a procedure I do and the patient did not need emergent dialysis. She had multi-organ failure from GI bleed and hypovolemia but dialysis wasn't going to fix any immediate issue. I politely told them that placing dialysis catheters is no in my skillset, and to have IR or the ICU doc do it. I always have no problem refusing to do something that I feel is unnecessary or will take up too much of my time.

Some crap that are nonstarters for me at my main job that I have seen Admin ask EM docs to do

1. Call back patients
2. Be the central line doc for the hospital
3. Deliver babies in the hospital

But if they want me at $500/hr to spend an hr of my shift calling pts back, then by all means.......

 

[deleted77919]

…

 

[Hamhock]

You must be delusional that only EM docs have to deal with admin Crap. If your practice requires work in the hospital, you have similar hoops. I hear complaints all of the time from Surgeons, Gas, radiologist, hospitals, OB about Admin guidelines and metrics.

True.

However, I think the "metrics" are more ridiculous and the "hoops" more numerous for community EM than most other specialties...but that is more a function of CMGs. Hospitalists employed by CMGs are in pretty similar situations (sometimes worse).

Private physicians and democratic groups in the community still have hoops, but these are closer to the academic world, in my experience.

HH

 

[Hamhock]

Agree completely with emergentMD. I punch the clock, make my $$$ and jump through the hoops they need. Want a 10 minute door-to-doc? I'll happily click on the patient to sign up....the patient may still sit in the waiting room for 2 hours and not see an MD, but I'm making the numbers look good.

Exactly how I felt in my locums position. I saw this stuff as just a silly game to get paid plenty. I wasn't invested and I was paid plenty: this provided such a carefree sense.

HH

 

[Hamhock]

the lazy ICU doc who hadn't seen the patient request I place a "Trialysis Catheter". I had never heard of such a thing. At any rate it's not a procedure I do

Not sure if you are saying this request made the ICU doc "lazy" or if he was "lazy" for other reasons. And there may not have been an indication for emergent dialysis in this case, but, in general: an ICU doc asking an EM doc to place an emergent/urgent dialysis catheter is not that 'out of bounds'...and plenty of us are trained to do exactly this. In fact, I tend to to the opinion that this should be an expected skill for an EM-trained doc.

Running CRRT or ordering iHD, perhaps not...but there are plenty of hospitals with nephrologists who can't place such a line safely and patients who will die without emergent renal replacement.

Of course, Veers, if it is not within your skill set (or any other EM doc's), it is also acceptable to tell the ICU doc this...if there is actually an intensivist...but it is not that crazy of a request.

HH

 

[emergentmd]

Not sure if you are saying this request made the ICU doc "lazy" or if he was "lazy" for other reasons. And there may not have been an indication for emergent dialysis in this case, but, in general: an ICU doc asking an EM doc to place an emergent/urgent dialysis catheter is not that 'out of bounds'...and plenty of us are trained to do exactly this. In fact, I tend to to the opinion that this should be an expected skill for an EM-trained doc.

Running CRRT or ordering iHD, perhaps not...but there are plenty of hospitals with nephrologists who can't place such a line safely and patients who will die without emergent renal replacement.

Of course, Veers, if it is not within your skill set (or any other EM doc's), it is also acceptable to tell the ICU doc this...if there is actually an intensivist...but it is not that crazy of a request.

HH

Never done one, never will. I have never seen an ED doc do this but I have never worked in the back woods.

 

[GeneralVeers]

Never done one, never will. I have never seen an ED doc do this but I have never worked in the back woods.

I've seen a couple of docs do them, but in general 75% of us won't. Theoretically I could do one, but I'm not going to put the patient at risk by "learning" on the job in a critical procedure. In this case the ICU doctor was lazy. She had already gone home, and didn't want to come back to take care of HER critical patient. If I have to do a non-emergent central line, it takes me out of seeing patients for 3o minutes to an hour. In a 55K facility, this can cause the rest of the department to seriously suffer.

Back to the original question of this thread. Medicaid, Medicare, and VA health don't work so well, and the metrics generally look bad for the NIH in things like cancer survival. Why do we think government is suited to run something as complex and personal as medical care?

 

[deleted109597]

Never done one, never will. I have never seen an ED doc do this but I have never worked in the back woods.

Eh, it's a central line with two dilators. That's it. Placing it femoral with US guidance is as close to zero risk as anything we do.
Of course, I used to a surgery resident, and we put these things in nearly every day.

 

[TooMuchResearch]

Never done one, never will. I have never seen an ED doc do this but I have never worked in the back woods.

It's just a central line with a larger diameter. There's nothing fancy about it. We do them in the ED of our large referral center if they're needed. If you can obtain Central vascular access, you can place a temporary dialysis catheter.

 

[UKEMdoc]

Basically a trialysis line is mislabelled. It's a triple lumen central line where two of the lumens happen to be rather wide bore. Five minutes glove to glove time assuming it's all been set up for you and a co-operative/tubed patient. I like them because I'm salaried, they're fun and keep my skills up.

 

[UKEMdoc]

I wouldn't mind doing an occasional central line list in theatre assuming I was paid properly and it didn't impact on the ED - expecting me to leave the ED to put one in on ITU/the wards ain't happening sonny but an occasional theatre list is a stress free way of spending a morning with frequent opportunities for coffee while waiting for patients to be tracked down for theatre(critically ill IVDUs tend to be outside smoking whenever you need them for procedures)

 

[BoardingDoc]

I've seen a couple of docs do them, but in general 75% of us won't. Theoretically I could do one, but I'm not going to put the patient at risk by "learning" on the job in a critical procedure. In this case the ICU doctor was lazy. She had already gone home, and didn't want to come back to take care of HER critical patient. If I have to do a non-emergent central line, it takes me out of seeing patients for 3o minutes to an hour. In a 55K facility, this can cause the rest of the department to seriously suffer.

Back to the original question of this thread. Medicaid, Medicare, and VA health don't work so well, and the metrics generally look bad for the NIH in things like cancer survival. Why do we think government is suited to run something as complex and personal as medical care?

I've put in a handful of these. Some while rotating in the ICU, some in the ED. If the patient needs emergent HD, we'll sometimes do it. That said, if the patient doesn't need HD for say, 3-4 hours and they're going to the ICU, the ICU can do it. If you don't have an actual intensivist running the ICU then I guess that could be a problem.

 

[emergentmd]

Eh, it's a central line with two dilators. That's it. Placing it femoral with US guidance is as close to zero risk as anything we do.
Of course, I used to a surgery resident, and we put these things in nearly every day.

I am sure I could do it, and in a Pinch I would. There is always Youtube. But if its just a larger bore central line, it sounds no different than a cooling catheter which I do all the time.

We must resist doing more crap just b/c its more convenient for the hospital/specialists not to come in. That is what they are paid to do and paid to be on Call. Once they figure out that "the ED doc will do it", we are screwed. I have seen request to be the central line doc, the delivery doc, the LP doc.

If they are in the ED, and I am caring for the pt then I will do the above. When they are on the floor, that is not my patient.

Now if I worked in the backwoods and I am the only doc, i would be happy to go to the floor and do everything b/c I am the best fit. I will do what is best for the pts. But I am not putting in any lines if there are docs who can do it.

 

[mimelim]

It's just a central line with a larger diameter. There's nothing fancy about it. We do them in the ED of our large referral center if they're needed. If you can obtain Central vascular access, you can place a temporary dialysis catheter.

As someone who has placed several hundred quintons and dealt with the complications of people ****ing up quinton placements, they are certainly a larger central line. But they are different. And lacking an appreciation for the differences is how people end up with complications. It isn't as simple as, "the hole is bigger, so if you screw up, the problem is bigger". The dilators are stiffer and larger. The risk of vein perforation is much higher when the vein being accessed is not perfectly straight.

I feel comfortable with my current MS3 placing central lines. Does not mean that they should be placing a left IJ quinton without extra guidance.

 

[WilcoWorld]

there are plenty of hospitals with nephrologists who can't place such a line safely and patients who will die without emergent renal replacement

I agree with the rest of your post, but doesn't the fact that "there are plenty of hospitals with nephrologists who can't place such a line safely" strike you as not OK?

 

[gman33]

I'll go one further.
At my primary job site; "satisfaction" on the inpatient side is so poor that the C-fux mandated that we, the "ER docs" go do "inpatient rounds" on our admitted patients during our next shift.

Are we paid for this? No.
Are we expected to keep Door-to-doc times down? Yes (even though we're not in-department... somehow).
Are we exposed to liability for this? Likely, yes.
Do the patients bother us for additional pain meds and dietary changes and other things that we can't (and should not) control? Yes.
Are they satisfied when we can't meet their demands? Likely not.
Will this meet the C-Fux goal of impoving inpatient satisfaction? Probably not.

So when are you leaving that job?

 

[RustedFox]

So when are you leaving that job?

I'm not. The job is pretty much otherwise awesome. Hi-pay, low stress. I thought I posted this above, but maybe I didn't.
I'm just going to remain oppositional-defiant when it comes to "inpatient rounds".

 

[em1234]

I am sure I could do it, and in a Pinch I would. There is always Youtube. But if its just a larger bore central line, it sounds no different than a cooling catheter which I do all the time.

We must resist doing more crap just b/c its more convenient for the hospital/specialists not to come in. That is what they are paid to do and paid to be on Call. Once they figure out that "the ED doc will do it", we are screwed. I have seen request to be the central line doc, the delivery doc, the LP doc.

If they are in the ED, and I am caring for the pt then I will do the above. When they are on the floor, that is not my patient.

Now if I worked in the backwoods and I am the only doc, i would be happy to go to the floor and do everything b/c I am the best fit. I will do what is best for the pts. But I am not putting in any lines if there are docs who can do it.

I always think it is funny that we are the only branch of medicine that has a seemingly expansive and never ending scope of our abilities, especially after 5pm. Dialysis catheter...no problem, ED doc can do it. L and D triage is full...no problem, we'll just put this 35wk preg lady in the ED and the ED doc can watch them and triage them up as they get closer to delivery, pt in the ICU needs a central line...call the ED doc, code on the floor (even though there is an in-house hospitalist 24/7)...call that ED doc.

All the while, every other specialist is contracting the patients they will see.

Oh sorry 1234, I only do general ortho, I don't do hand. Oh 1234, I wish I could help, but I only do gyn, not OB. You need EP, I'm only a general cardiologist. The list goes on. I think emergentmd is right, we need to keep a tight eye on "ED creep", the fact that we are there 24/7 and probably can do the procedure doesn't mean we should. I probably could cath someone. I could probably do an ERCP in a pinch. I'm sure I could do endoscopy, bronch, etc. Again, just because I probably could, doesn't mean I should, and doesn't mean I should just because I'm the most convenient option.

 

[emergentmd]

As someone who has placed several hundred quintons and dealt with the complications of people ****ing up quinton placements, they are certainly a larger central line. But they are different. And lacking an appreciation for the differences is how people end up with complications. It isn't as simple as, "the hole is bigger, so if you screw up, the problem is bigger". The dilators are stiffer and larger. The risk of vein perforation is much higher when the vein being accessed is not perfectly straight.

I feel comfortable with my current MS3 placing central lines. Does not mean that they should be placing a left IJ quinton without extra guidance.

And this is why I would not do a "larger central line". Maybe I would do it correctly 99% of the time, but when that 1% and pt has a bad outcome, I am sure admin would not stand behind me when there was a surgeon available. I am sure the surgeon would say, "why didn't he call me?"

Now in BFE, I will do anything to save the patient

 

[Hamhock]

I agree with the rest of your post, but doesn't the fact that "there are plenty of hospitals with nephrologists who can't place such a line safely" strike you as not OK?

Not trying to be evasive, but I am just not sure if that is "not OK" with me.

I never encountered a nephrologist) even after working at county and ivory tower academic hospitals and both rural and urban community sites) who placed their own dialysis lines. I have only seen EM docs, ICU docs, IR docs, and surgeons place these lines.

I am not sure if it is "not OK" with me...mostly just my unexamined reality.

I'll ask around the nephrology forum, if there is anyone actually in there.

Will try not to derail this thread too much more.

HH

 

[bashwell]

I'm in Sydney, Australia. Medical education and training beyond are very similar to the UK.

Heaps of UK and Ireland docs have moved here. According to the many I've talked to Australia is much better than working in the NHS on almost every level (e.g. pay, hours, work/life balance, trainee progression), but to be fair that could be bias since they were the ones who moved Down Under after all.

From what I can gather though the NHS seems to be a sinking ship. There's apparently even talk of privatising the NHS, but I have no idea if that's just talk or something more serious.

That said Australia has its own problems, many of which seem similar to what's happening in the UK. But it might be another generation or longer before these problems become as manifest as seems to be the case with the NHS now.

 

[GeneralVeers]

That said Australia has its own problems, many of which seem similar to what's happening in the UK. But it might be another generation or longer before these problems become as manifest as seems to be the case with the NHS now.

There is currently only one real advantage to PRACTICING in America versus UK or Australia. Being on the receiving end of healthcare is a different story.

The advantage is the pay. Especially for EPs we are now making double in some areas what docs make in Australia, and much much more than what they make in the UK. If that pay advantage were to decrease, I could see our doctor shortage getting worse, and have a lot of people considering leaving for another country. If I'm getting paid the same with similar taxes (under a President Clinton) then it makes no sense to stay in our highly-litigious, patient-satisfaction-driven country.

 

[hundreddaysoff]

Not trying to be evasive, but I am just not sure if that is "not OK" with me.

I never encountered a nephrologist) even after working at county and ivory tower academic hospitals and both rural and urban community sites) who placed their own dialysis lines. I have only seen EM docs, ICU docs, IR docs, and surgeons place these lines.

I am not sure if it is "not OK" with me...mostly just my unexamined reality.

I'll ask around the nephrology forum, if there is anyone actually in there.

Will try not to derail this thread too much more.

HH

Interesting. At my medical school, nephrology attendings and fellows were the only people I ever saw place dialysis lines. They would come down to the ED emergently to do so with the dialysis machine in tow. I assumed that this was a basic part of nephrology training.

 

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[GeneralVeers]

You would think so, but in the dozen or so hospitals I have rotated through, worked in, etc I have never seen or heard of nephrology putting in their own lines.

This is a request we get all the time at my current place (at least we do on patients we are admitting from the ED).

I've never seen a nephrologist put one in either. They are always done by ICU, or surgery, or sometimes IR.