Which programs have the most opportunities to do procedures?

[EC3]

I'm finding that i really like doing procedures but some residents have told me that certain places have vastly different levels of procedural experience. For instance they were saying that some friends training at one program hadn't done even one chest tube while they had done almost 10. Are there any programs that are known for having lots of hands on and not having a "waiting line" of people needing to get their procedures checked off? Thx.

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[waterski232002]

IMO... the more county-like, more ghetto fabulous hospitals, and the more power the ED has within the hospital, will dictate who will do the procedures. At these places, the subspecialty residents are generally very overworked, and they appreciate the ED doing their reductions, chest tubes, etc. They've got enough to do on the floor, unit, OR, and clinic. In more affluent hospitals, there are far less procedures in general, and the ortho, surg residents tend to do all the ED procedures b/c they may not see them elsewhere. This is just a very vast generalization. But generally, with the high influx of indigent patients and high volume at these EM programs, residents tend to sacrifice some supervision (may be viewed as good or bad) and education/teaching.

Again, just a generalization I noticed when I looked at programs a couple years ago. Just figure out which program has the things you find important to your training and happiness.

 

[EctopicFetus]

most of our residents complete their required procedures by the end of intern yr. I am on my way...

 

[JackBauERfan]

IMO... the more county-like, more ghetto fabulous hospitals, and the more power the ED has within the hospital, will dictate who will do the procedures. At these places, the subspecialty residents are generally very overworked, and they appreciate the ED doing their reductions, chest tubes, etc. They've got enough to do on the floor, unit, OR, and clinic. In more affluent hospitals, there are far less procedures in general, and the ortho, surg residents tend to do all the ED procedures b/c they may not see them elsewhere. This is just a very vast generalization. But generally, with the high influx of indigent patients and high volume at these EM programs, residents tend to sacrifice some supervision (may be viewed as good or bad) and education/teaching.

Again, just a generalization I noticed when I looked at programs a couple years ago. Just figure out which program has the things you find important to your training and happiness.

I think thats definitely true and also I think you have to look at ED volume and number of residents. Less residents equal more work for you, but also probably means more access to various procedures. Any thoughts?

 

[EctopicFetus]

I think thats definitely true and also I think you have to look at ED volume and number of residents. Less residents equal more work for you, but also probably means more access to various procedures. Any thoughts?

The numbers can be misleading.. We rotate thru 2 hospitals. At one of them we are the ONLY resident on. As such attendings are really happy to let you do whatever procedures come up. also you have to look at acuity. if you are at a place that doesnt have a lot of ICU admits that usually means you wont be able to do quite as many invasive procedures. Look for places with sick patients and a lot of trauma.

 

[membsr-8890]

I've done about half of my interviews and I have yet to visit a program where I'd be concerned about not getting enough procedures. While the already mentioned generlizations certainly have some truth to them, "the RRC has very strict requirements for EM, yakity yak yak" so everyplace will meet minimum standards for procedural proficiency.

 

[JackBauERfan]

I've done about half of my interviews and I have yet to visit a program where I'd be concerned about not getting enough procedures. While the already mentioned generlizations certainly have some truth to them, "the RRC has very strict requirements for EM, yakity yak yak" so everyplace will meet minimum standards for procedural proficiency.

definitely true I mean the RRC guidelines have requirements otherwise residencies wouldnt' be in place or stay in place. I think what ectopic said is also definitely true, and thats what is hard to find out about without probing a program a bit, cause most have experiences at different hospitals.

 

[deleted109597]

I was recently at a place where at the beginning of they day, they threw out the spiel that "All EM programs have the RRC, so the training is at least the minimum at all accredited...., so to decide, base it on things outside of the department"

But then, later in the day, any questions about extracurricular stuff were summarily dismissed as not being in the RRC requirements and therefore not being important to EM.

 

[dlung]

most of our residents complete their required procedures by the end of intern yr. I am on my way...

Really? What about DPLs? I think that's the biggest RRC question mark I have... who does DPLs anymore except for hypothermia and maybe if the ultrasound machine is broken?

 

[DrQuinn]

I do think that if you want the MOST # of procedures, go to a brand new program (or a program that only has 1 or 2 years in it). I'll tell you why.

When I was an intern at USF, I was the ONLY intern in the ED. Any cool cases or cool procedures were ALWAYS given to me by the attendings. Even did 3 DPLs my intern year. Tons of lines, tons and tons of intubations, conscious sedations, reductions, blah blah. Even assisted on a thoracotomy as an intern.... but anyways, it was because there was no one to take the procedures away from me. Think of it, a 70k ED with only one intern to do all the cool stuff....

Then when I became a second year, I had so many procedures under my belt, I let all the interns do the procedures. I only did them when the intern couldn't get it.

As a senior PGY3 I never did the procedures unless it was my patient only or someone needed help.

Now that I'm at Georgetown, I see the same things happening. Our interns get ALL the procedures, even if its not "their patient." If they want to do the line or the intubation or the reductino or whatever, its offered to them. I have a feeling when the second class comes in, they'll do what I did.

Q

 

[waterski232002]

who does DPLs anymore except for hypothermia and maybe if the ultrasound machine is broken?

R/o occult diaphragmatic injury, and when the trauma surgeon perfers DPL over FAST. If he won't take the pt to the OR based on your FAST, than it becomes a useless tool (the surgeon has to trust that you know what the hell you're doing).

 

[The White Coat Investor]

[

 

[WakeMedHeel]

I've got to agree with waterski...the more countyesque, the more likely you'll be doing to the procedure.

 

[NinerNiner999]

Perhaps more important than the number of procedures is how aggressive you are towards getting the experience. Confident residents who aren't bashful and don't have a problem getting that chest tube set up, elbowing their way to the patient, and making it known they are doing the procedure will get far more than the less gung-ho residents who stand in the back wishing that procedure was theirs.

This doesn't mean you have to be arrogant or a jerk (I hope nobody takes it that way), but the more aggressive you can be, I think the more procedures you will gain exposure to.

Unless you are in a high-volume, low-staff ED, it will be very rare that procedures are "handed" to you (and even at those big places they may not be). You will need to look for these opportunities on your own. One of the biggest changes between medical school and residency is that there is a very high level of self-direction and study, often without any structure.,,

 

[deleted109597]

It depends on the program itself how aggressive you can be. Some will let you be aggressive, others will say that you have an ego, and send you to the principals office.
But for the most part, the newer the place, the more procedures. The more patients, the more procedures. The more adept the resident, the more procedures. And then there is some luck. If you are on for trauma-rama night, you'll get a ton. If you are on for party night where nobody shows up in the ED, you'll get 0.

 

[waterski232002]

I do not agree with newer programs having more procedures. In general, hospitals already have a "distribution of power/procedures" and when a new EM programs pops up, the procedures do not drastically change all at once. For instance, anesthesia may intubate traumas.... surgery may put in all chest tubes... ortho may do all reductions. It may take many years for hospital subspecialists to start to allow the new EM program to steal some of the procedures for teaching purposes. After all, it does decrease the subspecialty services revenue when the EM resident does the procedure.

Usually more established programs have established a reputation in the hospital and have sorted these issues out over many years, thus the procedures which are done by the EM residents are more clearly deliniated. Thus, you don't have to "argue" or "beg" for procedures like a med student..... they are yours, and everyone knows it... or they are not yours, and everyone knows it. Most established programs know exactly where they stand on procedures.

 

[DrQuinn]

I do not agree with newer programs having more procedures. In general, hospitals already have a "distribution of power/procedures" and when a new EM programs pops up, the procedures do not drastically change all at once. For instance, anesthesia may intubate traumas.... surgery may put in all chest tubes... ortho may do all reductions. It may take many years for hospital subspecialists to start to allow the new EM program to steal some of the procedures for teaching purposes. After all, it does decrease the subspecialty services revenue when the EM resident does the procedure.

I respectfully disagree. Having been the first class of a new EM program, and now a faculty at a new EM program with its first class, I've seen it happen, twice. I will put any intern at a new program at this point up against an intern at a well established program in a procedure, the new program will win anytime.

Think about it. In the ED now, its me, two other ED attendings, and ONE intern (and maybe an IM intern or an MS4). Who do you think wants to get all the procedures, and who do you think does them? My EM interns.

Q

 

[southerndoc]

Unless you are in a high-volume, low-staff ED, it will be very rare that procedures are "handed" to you (and even at those big places they may not be). You will need to look for these opportunities on your own.

Having done more than 60 LP's, 100 central lines and nearly as many intubations, trust me, when an opportunity arises, I'm always looking for an intern or PGY-2 to do a procedure. I'm not in a very high volume ED, and we're adequately staffed.

I don't think we're alone either. I think there are plenty of places that get ample procedures where the senior residents try to give some of the action to the juniors. (I'm talking about when I'm in a critical care shift, grabbing an intern to do a line or tube for a patient they are not caring for.)

I really feel sorry for the medicine residents in my institution. We do nearly all the central lines in the ED. It's sad when a PGY-3 medicine resident has only done 1 subclavian and must be supervised by the PGY-1 ED resident on an off-service rotation because the PGY-1 is already certified in central lines whereas the medicine resident is not.

 

[waterski232002]

I respectfully disagree. Having been the first class of a new EM program, and now a faculty at a new EM program with its first class, I've seen it happen, twice. I will put any intern at a new program at this point up against an intern at a well established program in a procedure, the new program will win anytime.

Think about it. In the ED now, its me, two other ED attendings, and ONE intern (and maybe an IM intern or an MS4). Who do you think wants to get all the procedures, and who do you think does them? My EM interns.

Q

I understand where you're coming from... but in our ED there is only 1 EM intern on at a time, and they get 100% of the procedures (all intubations, taps, LP's, central lines, fiberoptics, dislocations, conscious sedations....regardless of who's patient it is) The only time more senior residents do the procedure is if is an absolute emergency and the EM intern happens to not be in the room (pt codes and needs immediate intubation). More senior residents get procedures only when the intern fails.... or if multiple time-sensitive procedures need to be done simulataneously (central line for septic pt in one room, and CT for PTX in a different room).

So regardless of a new or old program, interns can still get all the procedures...

 

[waterski232002]

I think there are plenty of places that get ample procedures where the senior residents try to give some of the action to the juniors.

I really feel sorry for the medicine residents in my institution. We do nearly all the central lines in the ED. It's sad when a PGY-3 medicine resident has only done 1 subclavian and must be supervised by the PGY-1 ED resident on an off-service rotation because the PGY-1 is already certified in central lines whereas the medicine resident is not.

I agree... this is how my hospital is. Procedures are vast, and nobody searches for them... Interns grow sick of doing lines and LP's b/c senior residents shovel them down the totem pole.

 

[thierryh]

I did 8 chest tubes last night. 2 DPLs. My record for thoracotomies in one night is 5. You can come do all of my chest tubes that you want. Really isn't that big of a deal once you've probably done like 3. Trauma really does get as easy as they say it does, pretty cookbook. You'll get plenty of lines and tubes whereever you go and WAY more LPs than you'll ever want.
The hard stuff is the complicated medical patient. The patient who is trying to die on you no matter what you do to try and stop them. Those are the ones you need to get comfortable with...

 

[nocallaochicas]

I did 8 chest tubes last night. 2 DPLs. My record for thoracotomies in one night is 5. You can come do all of my chest tubes that you want. Really isn't that big of a deal once you've probably done like 3. Trauma really does get as easy as they say it does, pretty cookbook. You'll get plenty of lines and tubes whereever you go and WAY more LPs than you'll ever want.
The hard stuff is the complicated medical patient. The patient who is trying to die on you no matter what you do to try and stop them. Those are the ones you need to get comfortable with...

5 thoracotomies yourself? In the ED, in one night? 5 open thoractomies in the ED done by different people seems like a lot.
I am just an ignorant med student, but I have spent some time in a couple of ghetto/penetrating trauma-heavy EDs and when I hear that, I start to think: "Fatty..." (alternate use of FMcFP here)
Please harshly correct me if I am wrong, but come on.
ncc
and you did 2 DPLs just last night? Did someone steel the ultrasound?

 

[Dr. Will]

I did 8 chest tubes last night. 2 DPLs. My record for thoracotomies in one night is 5. You can come do all of my chest tubes that you want. Really isn't that big of a deal once you've probably done like 3. Trauma really does get as easy as they say it does, pretty cookbook. You'll get plenty of lines and tubes whereever you go and WAY more LPs than you'll ever want.
The hard stuff is the complicated medical patient. The patient who is trying to die on you no matter what you do to try and stop them. Those are the ones you need to get comfortable with...

Where are you at?

 

[nocallaochicas]

Where are you at?

I guess Baghdad.
Damn I am in an ornery mood!
Studying makes me crazy!
ncc

 

[The White Coat Investor]

I did 8 chest tubes last night. 2 DPLs. My record for thoracotomies in one night is 5. You can come do all of my chest tubes that you want. Really isn't that big of a deal once you've probably done like 3. Trauma really does get as easy as they say it does, pretty cookbook. You'll get plenty of lines and tubes whereever you go and WAY more LPs than you'll ever want.
The hard stuff is the complicated medical patient. The patient who is trying to die on you no matter what you do to try and stop them. Those are the ones you need to get comfortable with...

I topped that once. I did 32 thoracotomies, 67 chest tubes, and 23 DPLs in one night. That was after intubating like 300 patients, all of which had no neck and massive facial trauma. Several I intubated by throwing the ETT in from across the room in the next trauma bay. I was on fire!

 

[waterski232002]

I did 8 chest tubes last night. 2 DPLs. My record for thoracotomies in one night is 5. You can come do all of my chest tubes that you want. Really isn't that big of a deal once you've probably done like 3. Trauma really does get as easy as they say it does, pretty cookbook. You'll get plenty of lines and tubes whereever you go and WAY more LPs than you'll ever want.
The hard stuff is the complicated medical patient. The patient who is trying to die on you no matter what you do to try and stop them. Those are the ones you need to get comfortable with...

I smell.... what's that... code brown!!!

 

[thierryh]

Last night WAS extremely busy, but not unheard of.
Really depends on your surgery department and how agressive they are.
We actually still do quite a few DPLs when things get busy, US is negative or equivocal, and there are too many penetrating abdominal traumas at once for the scanner or to triage people for OR time especially when too unstable to go to CT. Plus our trauma surgeons are kind of old-school.
We get to do most of the thoracotomies and DPLs.
And as I said the 5 cracked chests (call it the day-after-st.patrick's-day massacre) was a record. We actually sent an ED resident to the OR to scrub in because there were too many patients and too few doctors. But you are more than welcome to all of those cracked chests if you are willing to tell all of those families that their kids and dads had died (all but one did). It sucked. You need to put these things in perspective.
And what is that fat person thing? Kind of like the hamburger residency thing???

 

[thierryh]

And didn't mean to sound like a dbag either. My point was that once you've done enough procedures to get comfortable with them that's all you need and in some cases want. And 99.5% of you people will match at places where you'll be very, very happy, stop stressing so much. I'll shut up now.
Happy Holidays!!!

 

[DrQuinn]

I topped that once. I did 32 thoracotomies, 67 chest tubes, and 23 DPLs in one night. That was after intubating like 300 patients, all of which had no neck and massive facial trauma. Several I intubated by throwing the ETT in from across the room in the next trauma bay. I was on fire!

Chuck????? Is that you?!?!?!?? I already knew you were a bad ass... Desperado, but didn't know you were Chuck!!!!!

Q

 

[edinOH]

Chuck Norris doesn't need to crack a chest. The chest opens itself under the pressure of his stare.

I think this guy must be a writer for NBC's ER.

 

[FLTDOC1]

Its been almost 15 years and 65,000 pts ago that I finished my EM residency. In my opinion- procedures you should know in order of importance/frequency

AIRWAY
AIRWAY
AIRWAY
IV access - periph, central & IO
Wound repair
Procedural sedation
Ortho - fx & dislocation reduction
Difficult foley insertion
Lumbar puncture
Emergent delivery - OB
Fecal Disimpaction


I work in a busy community ED ( 34k pts/yr). In community EM - there are no trauma teams, no anesthesia back up, very few ED consults unless your going to admit a pt. In summary - you do 98% of all procedures.

I maybe do 2 chest tubes a year. Unlike the TV program ER ( maybe 1-2 chests cracked per shift with a 50% success rate) and our friend from denver -I have done 5 thoracotomies in my career ( one actually worked). That would be 0.26/yr

 

[The White Coat Investor]

Last night WAS extremely busy, but not unheard of.
thing???

R U really going to stand there and claim that your share of the procedures from "last night" consisted of 8 chest tubes, 5 thoracotomies, and 2 DPLs? Don't any of the other residents/attendings every do anything there? I worked with a resident who came out of your program recently (who incidentally noted that you do crack chests frequently for ....let's say, questionable...reasons), but she never noted numbers like you're talking about.

 

[totalbodypain]

I spent some of the better young years of my life at DG and never saw numbers like that in one night let alone one week. It is for reasons like that, that I left for LA then NY. If your getting five Thoracotomies in one night then Denver has gone way down the tubes. They can keep it.

 

[JackBauERfan]

R U really going to stand there and claim that your share of the procedures from "last night" consisted of 8 chest tubes, 5 thoracotomies, and 2 DPLs? Don't any of the other residents/attendings every do anything there? I worked with a resident who came out of your program recently (who incidentally noted that you do crack chests frequently for ....let's say, questionable...reasons), but she never noted numbers like you're talking about.

Let me guess out of the 5 thoracotomies all of them lived right haha.

 

[lennox23]

I topped that once. I did 32 thoracotomies, 67 chest tubes, and 23 DPLs in one night. That was after intubating like 300 patients, all of which had no neck and massive facial trauma. Several I intubated by throwing the ETT in from across the room in the next trauma bay. I was on fire!!


HAHA you're hysterical! gotta love the "procedures" tally bs. hah.


Please no 5 ED thoracotomies in one night!! (please dont call it "cracked chest" what is this lame prime time TV?) the needle stick/scalpel injury rate is so high, and if you are doing 5, you are certainly doing them for "questionable" reasons. penetrating thoracic injury with loss of vital signs within 15 mins the ONLY indication..! They are not doing 5 per day in Baghdad! Its so wrong when they are done for "practice" and then someone ends up getting stuck ...they are always such **** shows that this does happen.>50% of our ER pts -and i suspect most trauma centers are this way are HIV or Hep B/C positive. Career ending injury for me (a surgeon)--


waterski a question...
i have never heard of DPL OR FAST being able to rule out diaphragm injury. Tell me how you do that...what kind of fluid in a DPL would suggest that there was a hole in the diaphragm? Diagnostic laparoscopy is really the only way (unless a huge injury...seen on CXR with viscera up in the chest)

 

[WilcoWorld]

The whole RRC requirement schpiel is so common because it is true. If a program wont get you enough procedures, they wont get accredited. As such, one (very rough) estimate of procedural availability is years of accreditation. Does the program regularly get the max number of years for accreditation? If so their residents are probably getting plenty of procedures. That being said, when it comes to numbers there's enough, then there's plenty, and then there's a smorgasbord.

Here at Christ most of us have filled procedure requirements well before our 3rd year. For this reason seniors will often happily give up their procedures to interns & med students. Last week I heard a med student say that he did more procedures in his one month at Christ than he'd done in all the rest of med school. The same was true for me when I rotated here as a student.

However, as much fun as tubes, lines & reductions are, there is a whole lot more to EM than procedures. Don't make the error my family & friends make & assume that because you're an "ER Doc" that "You must do a lot of surgery".

 

[WakeMedHeel]

I did 8 chest tubes last night. 2 DPLs. My record for thoracotomies in one night is 5. You can come do all of my chest tubes that you want. Really isn't that big of a deal once you've probably done like 3. Trauma really does get as easy as they say it does, pretty cookbook. You'll get plenty of lines and tubes whereever you go and WAY more LPs than you'll ever want.

We get about 60 to 70 percent of the trauma in Boston and we crack, at most, 5 to 10 chests a year. Now we're not a violent city by any stretch of the imagination, but what you're claiming is ridiculous.

 

[lennox23]

there it is again "crack" chests
argh the sound of that!!
resuscitative ED thoracotomy...so much more civilized.

crack?

--a surgeon obsessed with semantics

PS: along the semantics line, no such word as "surgeries"!!

 

[Wahoo]

PS: along the semantics line, no such word as "surgeries"!!

What do you mean there is no such word as "surgeries?" I'm no surgeon, but you may want to check the dictionary on that one.

 

[southerndoc]

there it is again "crack" chests
argh the sound of that!!
resuscitative ED thoracotomy...so much more civilized.

crack?

--a surgeon obsessed with semantics

PS: along the semantics line, no such word as "surgeries"!!

We each have our own pet peeves, but I can assure you, people will continue to say "crack a chest" for a long time. Even after reading your post, I will still say crack a chest, a-line, throw in a central line, tube, tap (LP), pleural tap, etc.