TEE

[EMIM2011]

Is anyone aware of any certification pathways for EPs in TEE?

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[fahimaz7]

Why would we do a TEE? We don't even do full TTE's...

 

[EMIM2011]

A few places are doing it. Good to guide advanced resuscitation, and eCPR in particular.

 

[Instatewaiter]

A few places are doing it. Good to guide advanced resuscitation, and eCPR in particular.

How would a TEE be better than doing a TTE other than possibly causing an esophageal perf and another reason to have the patient decompensate...

 

[gman33]

As a resident, I loved cc.
Now if I'm even vaguely thinking a patient needs this kind of stuff, they should have been out of my department an hour ago.

 

[Modafinil]

This is serious? Nope. Not happening from me.

 

[Groove]

That would be a waste of a fellowship and I can't fathom how I would use it. CV gonna page me to run up, scrub in and perform during a heart case? Not happenin. It's sure as hell not happening in the ED. We have no business doing tee's.

 

[fahimaz7]

You guys don't drop in a TEE prior to your elective afib cardioversions? I thought that was standard of care from the ED..

 

[engineeredout]

I heard about some pathway for this. I think it's called a "Cardiology Fellowship"

 

[EMIM2011]

Why all the hatred?

 

[Tenk]

Because it doesn't make logistical sense. TEE's aren't like an ultrasound probe that you just wipe off and use on the next guy. A TEE requires expensive equipment that would be a huge waste in the ED and would need to be sterilized on every patient or you would have to buy the expensive disposable ones that I doubt are a whole lot better than TTE for ED resuscitation. Both reasons you listed I do fine with just a TTE.

Case in point: A TEE would just be more time consuming/expensive and not change my management at all.

 

[gman33]

This kind of stuff sounds awesome when you hear about it in a podcast.
In the correct setting, maybe it would be good to have.

A code comes in and you have multiple docs available for the resus.
One guy is doing a TEE and somebody else is placing a femoral a line and you titrate meds to precise hemodynamics.
After running the code for an hour, the patient magically wakes up, gives you a hug, and then walks out of the ED with his family.

The reality of most practice settings is that this will never happen.
Even if I had the skill to do this kind of stuff, which I'm sure is not that hard, my dept would turn into a total disaster if I ever tried any of this stuff.
I actually know of docs who got fired at my job for spending too much time on critical care.
My boss told me, that's why we have an ICU.
And I agree with that thought.

I love the detailed aspects of critical care.
I try to understand as much as I possibly can.
But I really focus my efforts on things that I can do that will make an immediate difference.
And that aren't too time intensive.

It's meant as a slam from inpatient docs, but I really pride myself on being a triage doc.
Once I know somebody needs a certain type of management, I get them admitted to the correct service and then I go see the next patient.

Docs who spend too much time screwing around with other stuff make the dept a disaster.

 

[EMIM2011]

Again, I agree with most of you that this is not about doing TEEs in the community ED or any "ED" per se for that matter. But in an ED ICU setting for example. There are some places who are looking into doing this. If anyone is aware of any pathways for EPs as per my original question, please let me know. No reason to get all worked up about it.

 

[gman33]

I think the ED ICU is a horrible concept.
At some shops, ICU admissions are difficult and critical care patients board forever in the ED.
Why would you want to build an ED ICU?
Just put those resources into building another inpatient ICU.
If an EM physician wants to work there, figure out some way to make that happen.

 

[canigetawhatwhat]

TEEs should never be done in an emergency department.
Period.

 

[Xerxes1729]

I cannot think of a scenario where a TEE in the ED would meaningfully change patient management.

Spend the money you'd waste on a TEE probe on a year's salary for an extra person to take patients to and from radiology and your department will be much better off.

 

[Robotic Wis-Hipple]

The benefits of and additional information TEE provides over TTE is far beyond the needs of resuscitation management. I'm not EM but volume status, effusion/tamponade, significant wma's, AS, and wide open MR/TR are all you need I'd think, and are typically easily assessed with TTE even in the obese. It's not like you need to calculate bioprosthesis gradients.

You can make the argument for cardioversion "clearance" I guess but it surprises me that that's in your guys practice at all.

But the only way to get the TEE advanced cert is via cardiology or adult cardiothoracic anesthesia. Basic cert requires 50 personally performed and 150 reviewed exams under a certified (or testamur) physician AT an accredited training site as far as I know but I'd imagine EM does not preclude you from getting the Basic if you so choose and can satisfy the requirements.

 

[Instatewaiter]

Probably reasonable to have a TEE in the ED to rule out dissection in someone who can't have a CT- but any hospital ED that is large enough to consider having its own ICU is probably a hospital large enough to have it's own cardiology department that already has the set up for TEE. It's probably best (and cheapest) to have the rare TEE in the ER be done by a cardiologist. Ensuring the LA is clear of thrombus is not as easy as it sounds and even if certified, would be hard to defend in court if you missed something big.

 

[deleted547339]

I cannot think of a scenario where a TEE in the ED would meaningfully change patient management.

Spend the money you'd waste on a TEE probe on a year's salary for an extra person to take patients to and from radiology and your department will be much better off.

Just pay an annual salary to someone to get urine....