frequency of procedures in the ED

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gdk

gdk

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i'm an MS1 interested in EM and i was wondering how frequently you perform certain procedures that i *think* fall between very frequently and very rarely, such as:

lumbar punctures
pelvic exams
chest tubes
tracheotomy
any others?

i would consider "very frequently" something like 5 or more times a shift
pls excuse the lack of correct medical terminology, and feel free to set me straight if i'm totally off on procedure frequency at your hospitals

thanks
 
gdk said:
i'm an MS1 interested in EM and i was wondering how frequently you perform certain procedures that i *think* fall between very frequently and very rarely, such as:

lumbar punctures
pelvic exams
chest tubes
tracheotomy
any others?

i would consider "very frequently" something like 5 or more times a shift
pls excuse the lack of correct medical terminology, and feel free to set me straight if i'm totally off on procedure frequency at your hospitals

thanks
Click to expand...
5 or more trachs per shift? Not likely.....not unless you happen to be working the night that shrimp is served at the National Anaphylaxis Patients Association meeting during an epinephrine shortage.....

You might see 5 chest tubes per shift in a busy trauma center on a rough night, but in most ED's probably not more than a few per week (if even that often). As for the pelvics and LP's you'll have to rely upon others for that info.

Sounds more like you're interested in trauma surgery than EM....just calling it as I see it from your procedure oriented approach to things...
 
I easily do 5 pelvics/shift. most female pts with low abd pain will require one......
most typical em procedures:
lac repair(suture/staple/dermabond)
fx/dislocation reduction
I+d abscess
fb removal
slit lamp exam +/- fb removal
nasal packing for epistaxis
joint aspiration
dental and other regional blocks to assist in procedures
conscious sedation

less common: (although a busy dept may do several of these/day)
lp's
intubation
cardioversion/defibrillation/pacing
paracentesis/thoracentesis
chest tubes
central lines
IO's
cut downs

some depts also do treadmills regularly on low risk chest pain pts after 2 sets of neg enzymes and 2 neg ekg's before sending folks home
 
thanks for the replies. i figured lacerations, headache, abdominal pain were pretty common... i was wondering about the things you might do (at a busy ed) 2-5 times a shift


unless you happen to be working the night that shrimp is served at the National Anaphylaxis Patients Association meeting during an epinephrine shortage

are you speaking from experience?
 
when i'm feeling in an especially giddy mood, i call the orthopedics resident tell them a bus full of osteogenesis imperfecta 5 year olds fell off an embankment and need to be evaluated.

Q
 
gdk said:
unless you happen to be working the night that shrimp is served at the National Anaphylaxis Patients Association meeting during an epinephrine shortage

are you speaking from experience?
Click to expand...
Well sorta, in that I didn't do the surgical airways myself....it actually happened while I was at a conference...went to dinner with a couple of colleagues (one an FP doc) when the people at the next table starting freaking out. Turned out it was a family whom all of them were deathly allergic to shrimp and somehow they wound up getting hors d'oeuveres that had shrimp in them. Do the math, 4 patients, 2 epi-pens between them. The doc wound up criking one of them and was about to crike a second one when the medics showed up. It gets brought up everytime the three of us get together.
 
QuinnNSU said:
when i'm feeling in an especially giddy mood, i call the orthopedics resident tell them a bus full of osteogenesis imperfecta 5 year olds fell off an embankment and need to be evaluated.

Q
Click to expand...
WITH hemophilia! You forgot the hemophilia! He'd probably want to know about that beforehand, too.
 
I can think of few procedures that I've ever done 5 of in a single day in the ED. Pelvic exams don't count, as that's just part of the physical exam. I've maybe done 5 I&Ds of abscesses in a shift perhaps a few times. I work at a busy city ED, mostly medical cases, with minor trauma. I used to work in a major tertiary care facility and regional trauma center.

At the trauma center, on average:

- intubation one every two shifts, sometimes much more, sometimes much less
- LP probably once every couple weeks (we had a great NP who saw most of the peds cases) and a children's hospital across the street
- trach? once in 2 years. percutaneous trach kits are the bomb
- joint dislocation/reduction: probably a couple per week, sometimes several per day during the summer.
- lacs : our PA did most of those. maybe one a day that the PA couldn't get to. sometimes a lot more depending on the season and PA coverage.
- chest tubes: uncommonly as we had a trauma surgeon in house or a short distance away 24/7. probably no more than a couple a month.

Where I work now most of those are lower frequency, except lacerations (as I do all my own now) and abscesses. Lower acuity population in general.
 
You are going to find an incredible variation to this awnser because ED's are set up different. In terms of support staff/patient population/volume.

-Chest Tubes- I have done 4-5 in the two years I have been in residency. *yawn* I had to needle decompress one tension PTX.
-ED thoracotomy- 1. and one was enough for me. (personal feeling is this is virtually a useless procedure that puts staff at high risk for sticks etc with almost zilcho results)
-Intubations- I cant even count them, there are so many. >100. Some weeks it seems like everybody needs a tube, other weeks, no one. Its worse int he winter.
-Lacs- Tons. Although less now, as our juniors and interns do the vast majority of these.
-Joint taps- enough I don't feel the need to do more.
-I&D- tons
-Reductions: especially shoulders... again, lots.
-LP's: plenty. again some weeks more than others.
-Chrich- I have done one and hope to never have to do another. It went well but I will always take a nonsurgical airway over a crashing airway.
-We have started using nitrous oxide. It has greatly reduced my number of consious sedations. This makes me happy. CS is such a pain in the arse. Ties up the nurses and backlogs our ED.
-Splints- plenty
-Central lines- enough. I push my juniors to do IJ/subclavians. Again, more in the fall/winter. With our new sepsis protocol, the number will probably increase
 
roja said:
-We have started using nitrous oxide. It has greatly reduced my number of consious sedations. This makes me happy. CS is such a pain in the arse. Ties up the nurses and backlogs our ED.
Click to expand...
I've never been at a hospital that had nitrous available in the ED. Would be nice sometimes. As an alternative to procedural sedation for painful procedures (abscesses especially) try IV fentanyl. Since you're not using any sedative, it's simply pain control yet it works fantastically for many cases. You also have the IV available if you need sedation. Sure works better than the Brutaine that I see some of my colleagues using.
 
I've used fentanyl before. I am in love with the nitrous. Self administered, easy to use, almost no side effects. works great. Kids/adults. I"m sold
 
gdk said:
i'm an MS1 interested in EM and i was wondering how frequently you perform certain procedures that i *think* fall between very frequently and very rarely, such as:

lumbar punctures
pelvic exams
chest tubes
tracheotomy
any others?

i would consider "very frequently" something like 5 or more times a shift
pls excuse the lack of correct medical terminology, and feel free to set me straight if i'm totally off on procedure frequency at your hospitals

thanks
Click to expand...

Lps--3/month
Pelvic 1-3/shift
Chest Tubes 1/month
Tracheotomy-None on a live human patient yet
 
roja said:
I've used fentanyl before. I am in love with the nitrous. Self administered, easy to use, almost no side effects. works great. Kids/adults. I"m sold
Click to expand...

Yo, Roja...

You do realize that you're supposed to give it to the patient, right?

Take care,
Jeff
 
Obviuosly I'm biased, but I bet the most frequent procedure many of you have performed is an ED ULTRASOUND!!!


Paul
 
ED whatrasound? Never heard of it. 🙂
 
peksi said:
Obviuosly I'm biased, but I bet the most frequent procedure many of you have performed is an ED ULTRASOUND!!!

Paul
Click to expand...
Seeing as one of my prior jobs is as an echocardiographer, that would be correct. 😀 :laugh:
 
Jeff698 said:
Yo, Roja...

You do realize that you're supposed to give it to the patient, right?

Take care,
Jeff
Click to expand...

Umm, Jeff, as a former paramedic you do realize that it is very difficult to track how much nitrous is used on a run (one for you, three for me! 😛 ). Unless you are like my former station manager and have stacks of empty blue D-cylinders under your desk...

- H
 
FoughtFyr said:
Umm, Jeff, as a former paramedic you do realize that it is very difficult to track how much nitrous is used on a run (one for you, three for me! 😛 ). Unless you are like my former station manager and have stacks of empty blue D-cylinders under your desk...

- H
Click to expand...

Ahhhhhh. that brings back the memories of the 'ole medic days. I used to love "checking" the nitrous in the morning. Have to see if the demand valve works right? how else can you test it? aaahhhhh yes.......the memories.
 
Jeff698 said:
Yo, Roja...

You do realize that you're supposed to give it to the patient, right?

Take care,
Jeff
Click to expand...



Damn, no wonder the patients were yelling in pain. :laugh:



Seriously though, yesterday, we had a dislocated shoulder>36 hours. The attending asked to if I had used nitrous... we decided to use mso4 and nitrous. The ortho resident was like 'well, my chief told me not to reduce this without valium'.

Me: have you ever used nitrous before? the patients get really floppy.
him: no but I know its not a muscle relaxant
Me: but youve never used it, right?
him: but my chief said there is no way it will go in without valium
Me: well, I know your chief and he hasn't used it yet, so why don't we try it first with nitrous. if it doesn'tn work, we can always shoot some valium in.
him: but its not a muscle relaxant.
Me: I know. but I have used it and why don't we give it a try.


took less than 3 minutes to get the shoulder in WITHOUT valium, no concious sedation... its great stuff. The ortho guy was so shocked when the shoulder thunked in.
 
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