What are the typical procedures that EM docs perform?

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CSRA

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What are the typical procedures performed by Docs in the ED? Thoracentesis? Paracentesis? Fracture reduction? Thoracotomy? I am a third year seriously considering EM, but I keep hearing that all EM docs do is pass off a patient to the next service or atleast this is the case at our hospital according to these info suppliers.

thanks,

CSRA
 
CSRA said:
What are the typical procedures performed by Docs in the ED? Thoracentesis? Paracentesis? Fracture reduction? Thoracotomy? I am a third year seriously considering EM, but I keep hearing that all EM docs do is pass off a patient to the next service or atleast this is the case at our hospital according to these info suppliers.

thanks,

CSRA
Click to expand...


yes, all of the above (including passing off patients when it is busy)
 
EM PGY1 with about 4+ months in the ER so far this year. My procedure log thus far:

20-25 central lines (I've supervised my senior resident in the MICU on overnights when we needed to place a line)
30+ intubations (~6 ER intubations, rest anesthesia month)
2 arthrocenteses (big toe and knee! They're cool!)
15-20 LPs
1 chest tube (done during CCU month actually, we get most of these during our trauma month I think)
12 Conscious sedations
4-5 paracentesis (all but 1 diagnostic instead of therapeutic)

It seems like PG2/3s in my program have done a few transvenous pacing wires as well in the ER while the PGY1s, based on our shifts (time, location) don't get yet.

I don't bother logging:
I+Ds, suturing, splinting, dislocation reductions because I'm doing them almost every shift. I don't know if you count these as "procedures"

In the ER, the only time I can remember us "consulting" a service for a procedure was a fluoro-guided LP on this crazy morbid obese lady with scoliosis. Seriously, I tried (with the attending wishing me luck), then my attending tried with no luck. That and fracture reductions which get done by the ER resident on the ortho month anyway. Oh, and the obnoxious person who requests plastic surgery to sew up the lack on his forearm from time to time 😉

I'm still waiting to do my first brain transplant in the ER, that's a procedure I haven't gotten yet and I could see us consulting out for.

I think your "sources" may have an axe to grind against EM. Seriously, as an intern I can guarantee that I'm more comfortable with procedures than interns in virtually any other residency in my hospital (except maybe surgical interns with chest tubes; and upper level anesthesia residents with difficult intubations).
 
WTF alreadyernd what ER are you at???????????????? That's insane. I was hoping for all of that after my first 2 years of residency. Im a 4th year student. I mean at the ED's Ive rotated at I didn't see the residents come close to those many procedures. You must be in the Golden ED. Either that or you're lying.😳
 
As a third year medical student during my EM rotation, I watched/assisted the residents with 3 conscious sedations, 3 closed reductions, 4 LPs, countless I&Ds, foleys, multiple suturing/staples. This even with competing with the SOCOM medics in-training who were rotating through our ED. Was a bit limited on the NG tubes and did not assist on a chest tube.

Also, Most of the patients that required intubation already had been intubated by EMS.

I have done 2 central lines so far on my surgery rotation but would love to have the procedure log of alreadylernd.
 
Look I appreciate your input but im calling bs on these numbers plain and simple. A reduction every shift please.. give me a break. I work in one of the busiest trauma hospitals in the country and I have about the same number of procedures as you do except more ED Tubes (gas ones are a waste of time IMO), more joints tapped (but thats boring), about the same number of lines including the ones I did in the ICU. Also more sedations but ive stopped counting cause I have my numbers there.

If you are doing all these procedures you must see no more than 6 patients a shift since they are all on the brink of death.

alreadylernd said:
EM PGY1 with about 4+ months in the ER so far this year. My procedure log thus far:

20-25 central lines (I've supervised my senior resident in the MICU on overnights when we needed to place a line)
30+ intubations (~6 ER intubations, rest anesthesia month)
2 arthrocenteses (big toe and knee! They're cool!)
15-20 LPs
1 chest tube (done during CCU month actually, we get most of these during our trauma month I think)
12 Conscious sedations
4-5 paracentesis (all but 1 diagnostic instead of therapeutic)

It seems like PG2/3s in my program have done a few transvenous pacing wires as well in the ER while the PGY1s, based on our shifts (time, location) don't get yet.

I don't bother logging:
I+Ds, suturing, splinting, dislocation reductions because I'm doing them almost every shift. I don't know if you count these as "procedures"

In the ER, the only time I can remember us "consulting" a service for a procedure was a fluoro-guided LP on this crazy morbid obese lady with scoliosis. Seriously, I tried (with the attending wishing me luck), then my attending tried with no luck. That and fracture reductions which get done by the ER resident on the ortho month anyway. Oh, and the obnoxious person who requests plastic surgery to sew up the lack on his forearm from time to time 😉

I'm still waiting to do my first brain transplant in the ER, that's a procedure I haven't gotten yet and I could see us consulting out for.

I think your "sources" may have an axe to grind against EM. Seriously, as an intern I can guarantee that I'm more comfortable with procedures than interns in virtually any other residency in my hospital (except maybe surgical interns with chest tubes; and upper level anesthesia residents with difficult intubations).
Click to expand...
 
Those numbers sounded about right to me, so I went back to check in our computer system to see what I did during my first year. I'm guilty of forgetting to log a lot of my procedures (our whole residency got a tongue-lashing about this from our leadership at the end of last year), but here is what I logged first year.

26 central lines
31 intubations - majority in ED
18 LPs
7 chest tubes
2 Conscious sedations (actual number much higher)
12 vaginal deliveries
12 reductions (actual number much higher than this)

I didn't track most other procedures that weren't part of the RRC procedure reqs.
 
Ectopic Fetus, I've checked my procedure log and I'm not lying. Want my e-value password or something 😉

Ok, maybe it only SEEMS like I+D/sutures/Splinting are done every shift, I mean, you get so comfortable with them so quickly they become pretty "countless" pretty fast (I stopped logging them). And I'm not quite sure how these patients are close to death. As for reductions, I'm looking and I've done 2 patellas (BS reductions, I know), 1 shoulder and attempted (and failed) a hip so maybe I got ahead of myself there, but seriously, I know second years (who do a month of ortho - ER consults) who essentially for a month do reductions all day, so I seriously expect to boost those numbers soon (intern year is almost over!).

The 30+ intubations are mostly coming from the anesthesia month by the way. And I have done CCU and MICU months (which also boosts my line numbers)

And yes, I do go to an awesome program 🙂 So awesome in fact Ectopic that my senior residents will grab me (or whichever intern is on) for procedures on patients I'm not primarily seeing (boosting my line numbers for example) but not "slowing" me down to 6 patients or whatever. Maybe you aren't so nice to your interns? 😉 And I agree that anesthesia tubes are worthless, but they're logged.

Thanks Hercules for backing me up! No one likes to be called a liar!
 
thanks for the input guys; this is what I was hoping to hear.

CSRA
 
Hercules said:
Those numbers sounded about right to me, so I went back to check in our computer system to see what I did during my first year. I'm guilty of forgetting to log a lot of my procedures (our whole residency got a tongue-lashing about this from our leadership at the end of last year), but here is what I logged first year.

26 central lines
31 intubations - majority in ED
18 LPs
7 chest tubes
2 Conscious sedations (actual number much higher)
12 vaginal deliveries
12 reductions (actual number much higher than this)

I didn't track most other procedures that weren't part of the RRC procedure reqs.
Click to expand...

In the ED??

That rarely happens at most of the places I've rotated at. They always just wheel them over to L&D really fast....
 
RockfordWF said:
In the ED??

That rarely happens at most of the places I've rotated at. They always just wheel them over to L&D really fast....
Click to expand...

that reminds me I've got to add up my procedures and see how many...i'm pretty sure i'm on track for those similar numbers as alreadymd; except i think i've done 54 chest tubes...err 55.

haha joking of course about the chest tubes.

I think he said just procedures during the first year, so either he got them on the OB rotation or Birmingham is filled with crazy 14 year olds that think they just 'got fat'.
 
Hercules said:
Those numbers sounded about right to me, so I went back to check in our computer system to see what I did during my first year. I'm guilty of forgetting to log a lot of my procedures (our whole residency got a tongue-lashing about this from our leadership at the end of last year), but here is what I logged first year.

26 central lines
31 intubations - majority in ED
18 LPs
7 chest tubes
2 Conscious sedations (actual number much higher)
12 vaginal deliveries
12 reductions (actual number much higher than this)

I didn't track most other procedures that weren't part of the RRC procedure reqs.
Click to expand...

Outside of central lines this sounds more appropriate. Also Hercules dont forget that already is in March of his intern yr. I guess much of this depends when you do your MICU and other ICU months. We do ours second yr when we are on all by ourselves. Other than that your numbers are about right. I also stopped logging I&Ds (required #=1), sutures (req 50 at) I hit 70+ pretty fast. I did a ton of reductions.

All I am saying is his numbers seem incredibly high. I pull our terns to do procedures and med students when we have them do them as well. I could pull my log but it would look a lot like hercules. Anyways sorry for calling you a liar but it does seem a little high. All the best to one and all. in the end just make sure you get good at doing procedures during residency. Already good luck in the last 4 months of intern year, it does get so much better going forward.
 
EctopicFetus said:
Outside of central lines this sounds more appropriate. Also Hercules dont forget that already is in March of his intern yr. I guess much of this depends when you do your MICU and other ICU months. We do ours second yr when we are on all by ourselves.
Click to expand...

True. We do our MICU, CCU, and junior trauma rotation during our first year (as well as ob/gyn). JackBauer, you went to school up here so you know we do indeed have an abundance of 14 year olds that think they got fat 🙂. Seriously, though, 10 of those deliveries were on my ob/gyn rotation. I've only had to do two deliveries in the ED.
 
Hercules said:
True. We do our MICU, CCU, and junior trauma rotation during our first year (as well as ob/gyn). JackBauer, you went to school up here so you know we do indeed have an abundance of 14 year olds that think they got fat 🙂. Seriously, though, 10 of those deliveries were on my ob/gyn rotation. I've only had to do two deliveries in the ED.
Click to expand...

I have yet to deliver a baby in either of our 2 EDs but about 1/2 of my colleagues have.. i got 16 or so on my 2 week ob rotation. I did more procedures this yr (2nd) but I was comfortable enough doing them as a pgy-1 cause we take call all alone so there is no real backup although someone can help but thats a call you dont want to make.
 
EctopicFetus said:
Outside of central lines this sounds more appropriate. Also Hercules dont forget that already is in March of his intern yr. I guess much of this depends when you do your MICU and other ICU months. We do ours second yr when we are on all by ourselves. Other than that your numbers are about right. I also stopped logging I&Ds (required #=1), sutures (req 50 at) I hit 70+ pretty fast. I did a ton of reductions.

All I am saying is his numbers seem incredibly high. I pull our terns to do procedures and med students when we have them do them as well. I could pull my log but it would look a lot like hercules. Anyways sorry for calling you a liar but it does seem a little high. All the best to one and all. in the end just make sure you get good at doing procedures during residency. Already good luck in the last 4 months of intern year, it does get so much better going forward.
Click to expand...

Just remember procedures like patient volumes and population very from program to program. I would have called those numbers ballpark for normal or even a little low. It is all just perspective.
 
Hercules said:
True. We do our MICU, CCU, and junior trauma rotation during our first year (as well as ob/gyn). JackBauer, you went to school up here so you know we do indeed have an abundance of 14 year olds that think they got fat 🙂. Seriously, though, 10 of those deliveries were on my ob/gyn rotation. I've only had to do two deliveries in the ED.
Click to expand...

haha yeah birmingham's crazy right...voted top 10 in crime rates per population! I was suprised to see that haha. Deliveries in the ED that are normal are nice, they get delivered and pretty fast dischare to labor and delivery.
 
Ugh, I still have a whole month of OB awaiting me...

🙂
 
Those numbers are about right, I'm 2/3 through pgy1 and have similar numbers. I also got to do a ventric, so technically I got to do brain surgery in the ED...
 
I think much of the variability comes down to when you do your ICU months and if you count anesthesia tubes. Other than that yeah those numbers are the same.

I think procedures available arent that different depending on where you end up (my opinion), the number depends more on the number of patients seen per resident cause then you have more opportunity.
 
EctopicFetus said:
I think much of the variability comes down to when you do your ICU months and if you count anesthesia tubes. Other than that yeah those numbers are the same.

I think procedures available arent that different depending on where you end up (my opinion), the number depends more on the number of patients seen per resident cause then you have more opportunity.
Click to expand...


I would have had similar numbers to the described when I was an aggressive intern. We did all of our ICU months in the second year--so that's not the explanation. The explanation was that I was at a busy regional trauma center and I worked my *** off. You are at a very "respected" place, but that doesn't mean you have the end-all-be-all of exposure to emergency medicine. To call someone a liar for doing more than you is fairly outrageous.


mike
 
We have a set up where our second years are the procedure peeps for the department. They manage all airways, do all lines, chest tubes (alternating with trauma which usually has one of our own), and occasionally do lp's depending on how busy others are (all on top of flying and running their own area 😉). They usually leave us 'terns with our own procedures and some have started to give up airways and lines b/c they're comfortable. I have about 15 airways (with most coming from 3 days of peds anesthesia...i had an off week there b/c other terns are getting 30+ from peds anesthesia), about 10 lines on my own patients, 10+ LPs, and plenty of suturing, reductions, i and d's. I still have 2.5 months of ED time of my 5 months and one major ICU rotation left for this year (MICU). I expect my numbers to really shoot up as June approaches and 2nd year begins as the procedure person. I actually like our set up as it ensures you procedures every shift as we do have patients being tubed on a daily basis, etc since we are the only major trauma center in a pretty large rural area.
 
Dr. Will said:
We have a set up where our second years are the procedure peeps for the department. They manage all airways, do all lines, chest tubes (alternating with trauma which usually has one of our own), and occasionally do lp's depending on how busy others are (all on top of flying and running their own area 😉). They usually leave us 'terns with our own procedures and some have started to give up airways and lines b/c they're comfortable. I have about 15 airways (with most coming from 3 days of peds anesthesia...i had an off week there b/c other terns are getting 30+ from peds anesthesia), about 10 lines on my own patients, 10+ LPs, and plenty of suturing, reductions, i and d's. I still have 2.5 months of ED time of my 5 months and one major ICU rotation left for this year (MICU). I expect my numbers to really shoot up as June approaches and 2nd year begins as the procedure person. I actually like our set up as it ensures you procedures every shift as we do have patients being tubed on a daily basis, etc since we are the only major trauma center in a pretty large rural area.
Click to expand...


This is a common set up, too. The culture at MetroHealth is for the second year to be the "critical care" person for the resusc but the procedures usually get punted down to the intern. Second years still end up doing a lot of procedures too. But we always grab interns and let them do lines, try airways, etc.
 
Wow, some of you guys are rocking with the procedures.

As an intern, I have gotten roughly:

2 Central lines
3 Intubations
1 RSI
4 Lac Repairs
1 Chest tube (I only witnessed)

And I actually heard that they had a Trauma resuscitation from a Gunshot victim, but I was off that day.

Detroit ain't what it used to be...
 
a_ditchdoc said:
Wow, some of you guys are rocking with the procedures.

As an intern, I have gotten roughly:

2 Central lines
3 Intubations
1 RSI
4 Lac Repairs
1 Chest tube (I only witnessed)

And I actually heard that they had a Trauma resuscitation from a Gunshot victim, but I was off that day.

Detroit ain't what it used to be...
Click to expand...

Seriously? Minus the one category I can't do (RSI) I've had more than that as a 4th year student. The tubes were in anesthesia, but yeah...
 
anothertbmember said:
Seriously? Minus the one category I can't do (RSI) I've had more than that as a 4th year student. The tubes were in anesthesia, but yeah...
Click to expand...

Well...I also did a lot of IV's...😳





:meanie:
 
a_ditchdoc said:
Wow, some of you guys are rocking with the procedures.

As an intern, I have gotten roughly:

2 Central lines
3 Intubations
1 RSI
4 Lac Repairs
1 Chest tube (I only witnessed)

And I actually heard that they had a Trauma resuscitation from a Gunshot victim, but I was off that day.

Detroit ain't what it used to be...
Click to expand...

yeah in the south bronx we had this one guy come in one time with a 'stab wound to the chest'...ended up being a scratch on the face...and I got to watch my upper level put a steri strip on him.

its crazy here.
 
During my last shift, I got to intubate and put an OG tube in a lady. I also placed a Presept (CVP/ScvO2) central line in using the ultrasound in a septic patient with a lactate of 6.9. I also got to repair 2 facial lacs. I did a large volume paracentesis. And finally, I got to place an EJ IV on a lady who needed blood for a Hgb of 4 with GI bleeding....

That is just one 8 hr shift...

So keep doing those procedures and get good at them! You surely will need your skills when you are done with residency......👍
 
the variation on here is quite high. i can say im pretty comfortable with all the "standard" procedures we do... even urgent care stuff like lacs, I&Ds, and toenail removal.
 
EctopicFetus said:
the variation on here is quite high. i can say im pretty comfortable with all the "standard" procedures we do... even urgent care stuff like lacs, I&Ds, and toenail removal.
Click to expand...

reallly those are minor procedures but you're right somebody has to do them and do them well. And even simple stuff like paronychias are not easily done by IM folks. I"m sure some of the more aggressive residents would learn how to do them, but I remember during my preliminary year a few times a patient would coincidentally have a paronychia (as well as their abdominal pain/chest pain that we would admit for) and I would show my upper levels how to do it. And even if they learn to do it, its not like they get a ton of them to do when they are done...
 
A large part of the variability depends on acuity/volume of the programs emergency departments, and the priority of which residents get procedures. Some programs delegate procedures to specific residents (PGY1 or PGY2), where some programs have every man for himself (if you see the patient, you get the procedure).

I'm a PGY 3 resident, and I do almost no procedures this year, although I supervise everything in the department. As an intern, my list had more numbers than alreadylrned (although no vag deliveries in the ER... had 3 since). But that's b/c our interns get every procedure in the department unless the senior hasn't done it or delegates it to a PGY-2 or himself (for whatever reason--but usually rare... pt unstable... time crucial... difficult anatomy... needs more practice). The only procedures I have taken from an intern this year have been airways they miss, central lines they can't get on coding patients, thoracotomy, transvenous pacer placement. Otherwise, if the intern can't get it, I send the PGY 2 in to help.

In fact... I am so tired of doing central lines/LP's/taps, I get annoyed if I have to waste 20 min to consent a patient, set up everything, and do it myself. I'd rather be running the room and teaching junior residents/med students.
 
Hi to all the vets,

I am an MS4 waiting to match and wondering what preparation you need prior to the intern year. I have done about 10 intubations, plenty of IVs and I&Ds, 10+ deliveries, but only 1 central line, 1 LP, 1 paracentesis, no reductions, and no conscious sedations. Is it expected you come in with these tools or are you taught? Is it common to be in the ICU prior to learnings? Thanks.
 
emoptions said:
Hi to all the vets,

I am an MS4 waiting to match and wondering what preparation you need prior to the intern year. I have done about 10 intubations, plenty of IVs and I&Ds, 10+ deliveries, but only 1 central line, 1 LP, 1 paracentesis, no reductions, and no conscious sedations. Is it expected you come in with these tools or are you taught? Is it common to be in the ICU prior to learnings? Thanks.
Click to expand...

This was also a concern that I had as a student. If you can get the experiences, great. If not, don't sweat it. Just do well on the rotation and ake a good impression. They train you from the ground up. You will get everything you need in your residency.
 
Agree... have fun and do what you like. You've got the rest of your life to practice emergency medicine.
 
Do all EM residents perform thoracotomies? If so, what are EPs trained to do after the chest has been opened? I thought this was something that only trauma did.
 
mmadnes18 said:
Do all EM residents perform thoracotomies? If so, what are EPs trained to do after the chest has been opened? I thought this was something that only trauma did.
Click to expand...

It depends on where you do your residency. If you are at a place that has an aggressive surgery residency, you may just be managing the airway. If, on the other hand, there is only a family medicine residency at your hospital---you'll do it all.

Thoracotomies can be done on non-trauma patients as well, however. We did one on an MI patient who had tamponade from a wall rupture.

The ED thoractomy is most often done in an arrest or near-arrest situation. If you actually get the patient to survive, you've likely passed them off to a cardiothoracic surgeon who will close the patient in the OR.
 
The message about thoracotomies is that, unlike most other EM procedures, cracking the chest does not stand on it's own. In other words, if you don't have someone to operate on the patient, don't crack the chest. There's been more than one EM resident moonlighting or newly minted attending that has done it, then has nowhere to go.
 
Here's my cut and past procedure log. I'm an intern. I have 3.5 months in the ED to go. I'm really bad at logging procedures (didn't log anything for the first 2-3 months (one being MICU another ortho!) and tried to add plus signs where appropriate. For example, I noticed I haven't logged any art lines and I've done over 5. Better do a little better job! As Dr. Will described out R3s run the resus bays and call the R2 over to do all the procedures, so our R2s log tons of intubations, lines, ART lines, etc. Plus, we start flying on the helicopter as R2s and we get tons of tubes, needles, and resuscitations on the bird.

Arthrocentesis (Emergency Medicine) 6
Central line, internal jugular (Emergency Medicine) 6
I & D, abscess (Emergency Medicine) 10++
Intubation, adult endotracheal (Emergency Medicine) 5 (all ED or helicopter)
Intubation, adult nasotracheal (Emergency Medicine) 1
Intubation, pediatric (<12 years) (Emergency Medicine) 18
Lumbar puncture (Emergency Medicine) 5+
Nasal packing, anterior (Emergency Medicine) 2
Nasopharyngoscopy, fiberoptic (Emergency Medicine) 3
Nerve block, digital (Emergency Medicine) 1+++ (oops bad logging)
Nerve block, inferior alveolar (Emergency Medicine) 3+
Nerve block, other (Emergency Medicine) 3
Paracentesis (Emergency Medicine) 2
Reduction, other (Emergency Medicine) 1
Reduction, shoulder (Emergency Medicine) 2
Resuscitation, adult med, participant (Emergency Medicine) 5
Resuscitation, adult medical, direct (Emergency Medicine) 5
Resuscitation, adult trauma, direct (Emergency Medicine) 1
Thoracentesis (Emergency Medicine) 1
Thoracostomy, needle (Emergency Medicine) 1
Ultrasound - aortic (Emergency Medicine) 36
Ultrasound - renal (Emergency Medicine) 39
Ultrasound, cardiac (Emergency Medicine) 40
Ultrasound, FAST (Emergency Medicine) 41
Ultrasound, pelvis trans abdominal (Emergency Medicine) 13
Ultrasound, pelvis transvaginal (Emergency Medicine) 8
Ultrasound, RUQ (Emergency Medicine) 37
US Guidance Vascular Access (Emergency Medicine) 3
 
CSRA said:
What are the typical procedures performed by Docs in the ED? Thoracentesis? Paracentesis? Fracture reduction? Thoracotomy?
CSRA
Click to expand...

One common, but not talked about procedure done often-disimpaction.
 
wow.... thanks for all the responses...
 
Last edited:
It all really depends on the setting also. I have comparable numbers to crewmaster (I have yet to log a number of things btw). I'm doing my community month and being the only resident there I get pretty much all the procedures. Just my shift yesterday (which for an intern at my program would be impossible at our main site unless you were very lucky)...central line, LP, Intubation, Pericardiocentesis. So it really depends on how things are set up in terms of where your numbers come from.
 
Dr. Will said:
Just my shift yesterday (which for an intern at my program would be impossible at our main site unless you were very lucky)...central line, LP, Intubation, Pericardiocentesis.
Click to expand...

You're such a pimp Dr. Will. Did you do all of those procedures at the same time with one hand tied behind your back? I bet so. You're a future cinci chief resident, gunner. :laugh:
 
crewmaster1 said:
You're such a pimp Dr. Will. Did you do all of those procedures at the same time with one hand tied behind your back? I bet so. You're a future cinci chief resident, gunner. :laugh:
Click to expand...

:laugh: Yes...and blindfolded. We missed you while you were on vacation crew (future chief). 😀
 
vtucci said:
As a third year medical student during my EM rotation, I watched/assisted the residents with 3 conscious sedations, 3 closed reductions, 4 LPs, countless I&Ds, foleys, multiple suturing/staples. This even with competing with the SOCOM medics in-training who were rotating through our ED. Was a bit limited on the NG tubes and did not assist on a chest tube.

Also, Most of the patients that required intubation already had been intubated by EMS.

I have done 2 central lines so far on my surgery rotation but would love to have the procedure log of alreadylernd.
Click to expand...

That's pretty good vtucci. I rotated there just as they switched over to the new ED. The old ED was better for students. It was smaller and you can get your hands in more procedures. The socom guys definitely cut down your numbers, but I figured these guys will be dodging bullets in Iraq or some third world country, so out of respect and patriotism I would often differ to them.
 
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