Are ER docs disliked by other specialties?

[EM4life]

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I'm going to play devil's advocate just a little by saying that just like we are saying that there are some very incompetent senior consulting residents, there are most definitely a small proportion of EM physicians who will consult for small nonop issues or "reassurance" for the patient - and I'm not sure where that comes from, whether it's from where they trained or how many years they've practiced or lack of desire to take on any liability.

However, consultants must realize that EM docs like to take care of problems without consultants, we do all the time. I don't just call a consult because I can. The worst feeling for me is the feeling that I am the only advocate for the patient. If a consultant tries to block a consult without seeing the patient, it doesn't change the consult but it does change the whole tone of the interaction and if this repeatedly happens, it will change the tone of your entire residency. If consultants are reading this thread, don't be "that" resident who people hate calling or threaten to call your attending because you are always giving them attitude. Work together, consulting is your job, be nice, and you'd be surprised how much easier things seem in the ED when EM docs see you as an advocate for their patients too.

 

[neusu]

The worst feeling for me is the feeling that I am the only advocate for the patient. If a consultant tries to block a consult without seeing the patient, it doesn't change the consult but it does change the whole tone of the interaction and if this repeatedly happens, it will change the tone of your entire residency.

If we are willing to go on the record and leave a note that it is a case of NTD, what difference does it make to you if we physically see the patient?

It is a purely selfish motivated power play that you think it is an issue that warrants attention and are all butthurt that we tell you it is not.

While it may be the worst feeling to feel like the only advocate for the patient, it is a worse feeling to have to leave a more critically ill patient in order to appease the whims of a rude/entitled consult request who suddenly decides it is the number one priority. I realize you may have an irate patient who has been there for hours, but throwing me under the bus to save yourself is inappropriate at least and harmful to other patients at worst.

Don't get me wrong, I am a nice guy and well liked by our ER; most of the time I will come by to see the BS CYA calls. It can be frustrating though if I'm in the middle of a code, have an intubated multi-system trauma arriving, and am getting my ear chewed off because an NTD "has been here hours," it's not my fault you guys waited 12 hours to call me and if they waited that long they can wait a little longer.

 

[EM4life]

If we are willing to go on the record and leave a note that it is a case of NTD, what difference does it make to you if we physically see the patient?

Because that's good patient care.

It is a purely selfish motivated power play that you think it is an issue that warrants attention and are all butthurt that we tell you it is not.

Each one of the ED docs here have dozens of stories to tell about patients who were consulted on, deemed non-op, sent home or admitted and then either crumped on the floor or came back sicker or died. If every time a consultant told us over the phone that a patient did not need to be seen and we listened, patients would die.

While it may be the worst feeling to feel like the only advocate for the patient, it is a worse feeling to have to leave a more critically ill patient in order to appease the whims of a rude/entitled consult request who suddenly decides it is the number one priority. I realize you may have an irate patient who has been there for hours, but throwing me under the bus to save yourself is inappropriate at least and harmful to other patients at worst.

I think you missed the point on this one, I'm trying to defend consultants on this point. Just like there are varieties of consultants, some who made quick and accurate assessments and some within weeks of graduating who still cannot decide whether to take someone to the OR, there are EM physicians who have varying levels of comfort on different issues.

Don't get me wrong, I am a nice guy and well liked by our ER; most of the time I will come by to see the BS CYA calls. It can be frustrating though if I'm in the middle of a code, have an intubated multi-system trauma arriving, and am getting my ear chewed off because an NTD "has been here hours," it's not my fault you guys waited 12 hours to call me and if they waited that long they can wait a little longer.

It can be frustrating when we're in the middle of multiple codes, running multiple traumas, have 40 people in the waiting room who could drop dead at any moment and EMS calling us saying that they're on their way with STEMIs and strokes to spend hours on the phone back and forth between the consulting resident, calling their attending, following up on the consultation when the matter could have been resolved with a short consult, a telephone call, and a quick plan. This conversation can quickly deteriorate into whose time is more valuable and who is taking care of sicker patients, but in the end, this attitude will only hurt your relationship with your ED docs and result in pissed off patients.

 

[gro2001]

If we are willing to go on the record and leave a note that it is a case of NTD, what difference does it make to you if we physically see the patient?

It is a purely selfish motivated power play that you think it is an issue that warrants attention and are all butthurt that we tell you it is not.

While it may be the worst feeling to feel like the only advocate for the patient, it is a worse feeling to have to leave a more critically ill patient in order to appease the whims of a rude/entitled consult request who suddenly decides it is the number one priority. I realize you may have an irate patient who has been there for hours, but throwing me under the bus to save yourself is inappropriate at least and harmful to other patients at worst.

Don't get me wrong, I am a nice guy and well liked by our ER; most of the time I will come by to see the BS CYA calls. It can be frustrating though if I'm in the middle of a code, have an intubated multi-system trauma arriving, and am getting my ear chewed off because an NTD "has been here hours," it's not my fault you guys waited 12 hours to call me and if they waited that long they can wait a little longer.

I sincerely doubt there is any physician on this forum or otherwise that would want you to LEAVE A CODE to do a consult.

 

[DrRobert]

As an anesthesiologist, I have nothing but respect for EM guys. I know how stressful it can be trying to manage several life-threatening situations at the same time.

My only interactions with EM usually involve a bad airway. The glidescope has significantly decreased the amount of calls we get from the ER. However, I will caution that it is not the end-all-be-all of airway management. I know a couple EM docs in particular who think of it as a fail-safe and get themselves into trouble. I've done thousands of intubations and I still have the utmost respect for the airway. If you start to lose that respect, you WILL get humbled and it won't be pretty. I would much rather get called early to help with an airway than come into the middle of a cluster.

 

[deleted65604]

As an anesthesiologist, I have nothing but respect for EM guys. I know how stressful it can be trying to manage several life-threatening situations at the same time.

My only interactions with EM usually involve a bad airway. The glidescope has significantly decreased the amount of calls we get from the ER. However, I will caution that it is not the end-all-be-all of airway management. I know a couple EM docs in particular who think of it as a fail-safe and get themselves into trouble. I've done thousands of intubations and I still have the utmost respect for the airway. If you start to lose that respect, you WILL get humbled and it won't be pretty. I would much rather get called early to help with an airway than come into the middle of a cluster.

I agree. I've had a couple bad experiences in the past year. I had an ACE-induced angioedema with a big tongue that was getting worse. I called anesthesia, and asked them to do awake fiberoptic intubation. A couple anesthesiologists came down and just paralyzed her and sedated her. She was terribly edematous and I was literally seconds away from cutting her neck (scalpel in hand and neck prepped) as we watched the anesthesiologists struggle and listened to that eerie lowering pitched O2 sensors get lower and lower. Luckily, they got it after 3 tries, and we could bag her...barely. I wouldn't have bet my life on being able to bag her, as big as her tongue was.

 

[EM_Rebuilder]

If we are willing to go on the record and leave a note that it is a case of NTD, what difference does it make to you if we physically see the patient?

It is a purely selfish motivated power play that you think it is an issue that warrants attention and are all butthurt that we tell you it is not.

While it may be the worst feeling to feel like the only advocate for the patient, it is a worse feeling to have to leave a more critically ill patient in order to appease the whims of a rude/entitled consult request who suddenly decides it is the number one priority. I realize you may have an irate patient who has been there for hours, but throwing me under the bus to save yourself is inappropriate at least and harmful to other patients at worst.

Don't get me wrong, I am a nice guy and well liked by our ER; most of the time I will come by to see the BS CYA calls. It can be frustrating though if I'm in the middle of a code, have an intubated multi-system trauma arriving, and am getting my ear chewed off because an NTD "has been here hours," it's not my fault you guys waited 12 hours to call me and if they waited that long they can wait a little longer.

I've run into this on occasion... usually if I have a patient in the ED a long extended period of time, its because I have tried very hard to get them prepped to go home.. maybe labs and fluid and meds.. still having some issue... then add on a cat scan....comes back normal, maybe some more fluids... at some point, I cannot continue to manage the patient in the ED so I need a consultant to take over.. I also know, had I called within the first hour of this patients presentation, it would be an argument over how I did not attempt to 'fix her'... its a cat and mouse game that we cannot win.

I also think some consultants forget that its not always our job to have a 'diagnosis'. Ive seen it many times where I call a consultant and am like heres what going on, I do not have a clue what his problem is, but he does not need to go home.... this often upsets a consultant and they are like "what do you want me to do if you dont even know what his problem is"... Yet, I've seen IM or Surgery admit patients from their clinic and such and d/c without a diagnosis... yet I am supposed to make a dx in 2 hours...


And I agree... if the consultant I call is truly in a code, dealing with a very sick patient, etc... I understand being a bit delayed coming down. On the flip side, I think in a busy ED, I tend to have many more 'codes', STEMIs, traumas, etc etc etc than the typical hospitlist, general surgeon, etc etc...

 

[Daiphon]

...

I also think some consultants forget that its not always our job to have a 'diagnosis'. Ive seen it many times where I call a consultant and am like heres what going on, I do not have a clue what his problem is, but he does not need to go home....

And this is the crux of the argument. Diagnosis is nice, but disposition is the king in the ED. I may not know what's causing your chest/abdominal/back/ad infinitum pain, sir, but I know you can't go home.

-d

 

[WilcoWorld]

Also, sometimes we don't know what's causing your thoraco-abdomino-pedal-pilo-dento-pain-syndrome, but we do know that you MUST go home.

 

[Interpolfanclub]

I agree. I've had a couple bad experiences in the past year. I had an ACE-induced angioedema with a big tongue that was getting worse. I called anesthesia, and asked them to do awake fiberoptic intubation. A couple anesthesiologists came down and just paralyzed her and sedated her. She was terribly edematous and I was literally seconds away from cutting her neck (scalpel in hand and neck prepped) as we watched the anesthesiologists struggle and listened to that eerie lowering pitched O2 sensors get lower and lower. Luckily, they got it after 3 tries, and we could bag her...barely. I wouldn't have bet my life on being able to bag her, as big as her tongue was.

Had almost an identical case about a year ago. Post teeth whitening procedure, tongue huge, anesthesia came in, just paralyzed the guy and then couldn't get it. Unreal. I would never have dreamed of just paralyzing the pt. I did an awake nasal fiber optic bronch before anesthesia came in to see how much room I had and it wasn't much. I should've just loaded a 6.5 et tube on and given ketamine. But that patient almost died an airway induced death in our ER. Terrifying. One of the scariest things I've seen in my few years out.

 

[alphaholic06]

Had almost an identical case about a year ago. Post teeth whitening procedure, tongue huge, anesthesia came in, just paralyzed the guy and then couldn't get it. Unreal. I would never have dreamed of just paralyzing the pt. I did an awake nasal fiber optic bronch before anesthesia came in to see how much room I had and it wasn't much. I should've just loaded a 6.5 et tube on and given ketamine. But that patient almost died an airway induced death in our ER. Terrifying. One of the scariest things I've seen in my few years out.

Did you cric them?

 

[DrRobert]

Unless there is good reason to believe the airway will be easy, I agree that awake intubation is indicated for angioedema. Nasal or oral routes are both acceptable. When the ER calls me about these cases, the first thing I do is have them brought immediately to the OR and have them call ENT. Unless the patient is circling the drain, I won't do anything until ENT arrives. Then I try my awake look. If I can't get it, the neck gets cut.

Did these guys at least have advanced airway equipment with them when they paralyzed the patient?

 

[Interpolfanclub]

Unless there is good reason to believe the airway will be easy, I agree that awake intubation is indicated for angioedema. Nasal or oral routes are both acceptable. When the ER calls me about these cases, the first thing I do is have them brought immediately to the OR and have them call ENT. Unless the patient is circling the drain, I won't do anything until ENT arrives. Then I try my awake look. If I can't get it, the neck gets cut.

Did these guys at least have advanced airway equipment with them when they paralyzed the patient?

Yes, we had our ER supplies but we didn't specifically have what the anesthesiologist wanted. Which he didn't realize until after the patient was paralyzed and he was flailing. I forget what he called it, but it was essentially a bite block that he used as a fiberoptic port and intubated through. The patient's sats dropped on his initial attempts, he started to wake up, gagging, turning colors etc. It was bad. We almost never have ENT on call, so we're very much alone for these airway cases unless anesthesia happens to be in house. I saw the patient later for an unrelated complaint and he actually remembered the anesthesia doc's attempts. Not pleasant he said, but we saved his life so he was grateful.

 

[medstylee]

older topic but don't come on here often and just saw this...

i'm an ENT resident at a large teaching hopsital in a major city that has a big EM residency program. it's interesting to hear from ENT and EM residents and attendings from different hospitals. i think the bottom line is that this stuff is extremely hospital-dependent. i think the EM residents at my hospital are pretty good but their knowledge/training in ENT issues is piss-poor. it's to the point where i'm actually glad, for the patient's sake, that they call us in to drain PTAs almost universally. i've polled some of them and they all wish they could drain the abscesses but it's their attendings that won't allow them to. maybe 1 or 2 of their attendings will allow them to attempt and in turn that means that they get to attempt drainage once every few months or so. now, draining a PTA is not rocket science but there is somewhat of a learning curve. if you do it that infrequently, your success rate isn't going to be high. i've seen needle pokes in the posterior tongue.. the soft palate.. the posterior pharyngeal wall... it's a little concerning. now, at our county hospital, which has its own very reputable EM residency program, the residents there drain almost all of their PTAs and they are quite good. anyway, it is what it is.

 

[Birdstrike]

.

 

[Hamhock]

The measure of a good (or great) ER physician is not a matter of how good of an ENT doctor he or she is. It's a matter of how good an Emergency Physician he is. Some people will just never understand this very simple concept; that the measure of the quality of an Emergency Physician is not based on how closely he can approximate the practice of all of the dozens of other specialties and sub-specialties out there. That's an impossible task. It's a very simple concept that some people just cannot grasp, or don't want to grasp.

Bird:

True.

But that ENT's point should also be appreciated. Too many people in EM just can't "grasp or don't want to grasp" the concept that EM training and skill are incredibly variable.

Some of us are just embarrassing. I suspect the ENT resident is correct that at one program, EM residents are rarely draining PTAs and are sometimes sticking needles into the posterior pharyngeal wall.

We shouldn't be judged based on standards of a suspecialist, but we shouldn't be incompetent in EM-based procedures.

HH

 

[medstylee]

Both points well taken. I'm not expecting EM residents to be otolaryngologists or othopaedic surgeons, etc. It's not their job. I do think (I say "think" and not "know" because, hey, i'm not an EM physician and haven't read the texts or done the training) that there are some otolaryngologic procedures that fall into the realm of emergency medicine (anterior nasal packing, basic otoscopy). what i was trying to say in my first post is that what emergency medicine encompasses is clearly different at different hospitals/training programs. at my hospital, PTA drainage is clearly not part of standard EM practice. At our county hospital it is. Therefore, I don't expect my hospital's EM residents to attempt to drain them. Just as I don't expect any EM residents to approximate transected parotid ducts, re-attach amputated ears, etc. And, likewise, I don't think the university residents are any less than the county residents for that reason. I guess rather than to say my university's EM residents' training in ENT is piss-poor, I should have instead said that what those residents learn about assessing and treating ailments related to the ears, nose, neck, upper airway, face is pretty minimal. It's just not part of the curriculum and that's fine, I've accepted it.

 

[RustedFox]

i've polled some of them and they all wish they could drain the abscesses but it's their attendings that won't allow them to.

I think I may have said this exact same thing earlier in the thread. Sorry if I have.

There's eleventeen different things that I think I 'can' do, and that are well-within the 'ken' of EM, but that I just 'didn't' learn in residency because - "Oh, well... the 'other' service does that.... now get back to seeing all those patients, because our door-to-doctor time is so important."

Just sayin'.

 

[WilcoWorld]

I think I may have said this exact same thing earlier in the thread. Sorry if I have.

There's eleventeen different things that I think I 'can' do, and that are well-within the 'ken' of EM, but that I just 'didn't' learn in residency because - "Oh, well... the 'other' service does that.... now get back to seeing all those patients, because our door-to-doctor time is so important."

Just sayin'.

Yep - I don't consult orthopedics for a distal radius fracture because I can't handle it myself, or because I want the patient to wait in the ED for an extra hour awaiting the ortho chain of command to terminate. I do it because ortho refuses to see any ED referrals in clinic that weren't seen by a resident in the ED. It's stupid, and a waste of time, but it's mandated by the chair of orthopedics.

Of course, this would stop immediately if they didn't have residents to do the grunt work.

 

[docB]

older topic but don't come on here often and just saw this...

i'm an ENT resident at a large teaching hopsital in a major city that has a big EM residency program. it's interesting to hear from ENT and EM residents and attendings from different hospitals. i think the bottom line is that this stuff is extremely hospital-dependent. i think the EM residents at my hospital are pretty good but their knowledge/training in ENT issues is piss-poor. it's to the point where i'm actually glad, for the patient's sake, that they call us in to drain PTAs almost universally. i've polled some of them and they all wish they could drain the abscesses but it's their attendings that won't allow them to. maybe 1 or 2 of their attendings will allow them to attempt and in turn that means that they get to attempt drainage once every few months or so. now, draining a PTA is not rocket science but there is somewhat of a learning curve. if you do it that infrequently, your success rate isn't going to be high. i've seen needle pokes in the posterior tongue.. the soft palate.. the posterior pharyngeal wall... it's a little concerning. now, at our county hospital, which has its own very reputable EM residency program, the residents there drain almost all of their PTAs and they are quite good. anyway, it is what it is.

I've mentioned this before but in many situations the determinant of how far EPs will venture procedurally into a particularly specialty's turf has a lot to do with the back up that specialty will give us. With regard to PTAs specifically no one in my group does them. This goes back to a case where our EP tried to drain one, it didn't work and while he didn't bag the artery the patient developed more swelling afterward. The ENT then refused to see or consult on the patient because it was "someone else's" complication. So forever after no PTAs drained in the ED.

In a similar vein we had an ortho refuse to see a patient 2 days out from an ED reduction because he hadn't been called and agreed to see it the night of the ED visit. So now we call every ortho on every fracture no matter what or what time it is. "Hi Dr. Bones, I see you're on call so I'm sending this non-displaced Colles fracture to your clinic. Sure I know what time it is, it's 0230. No I don't think it's necessary to wake you at this hour for this but it's policy. If you want to voice a complaint talk to your department chair or call Dr. Bonehead who started playing games. Night night."

Anyways, the moral of the story is that if you back up the ED well you'll get a couple of calls a year with "Hi, I tried a bunch of things and I just couldn't fix this. I either need you to come in a deal with it or see it on the floor tomorrow morning." and you'll sleep peacefully through dozens of routine successful procedures.

 

[AmoryBlaine]

I've mentioned this before but in many situations the determinant of how far EPs will venture procedurally into a particularly specialty's turf has a lot to do with the back up that specialty will give us. With regard to PTAs specifically no one in my group does them. This goes back to a case where our EP tried to drain one, it didn't work and while he didn't bag the artery the patient developed more swelling afterward. The ENT then refused to see or consult on the patient because it was "someone else's" complication. So forever after no PTAs drained in the ED.

In a similar vein we had an ortho refuse to see a patient 2 days out from an ED reduction because he hadn't been called and agreed to see it the night of the ED visit. So now we call every ortho on every fracture no matter what or what time it is. "Hi Dr. Bones, I see you're on call so I'm sending this non-displaced Colles fracture to your clinic. Sure I know what time it is, it's 0230. No I don't think it's necessary to wake you at this hour for this but it's policy. If you want to voice a complaint talk to your department chair or call Dr. Bonehead who started playing games. Night night."

Anyways, the moral of the story is that if you back up the ED well you'll get a couple of calls a year with "Hi, I tried a bunch of things and I just couldn't fix this. I either need you to come in a deal with it or see it on the floor tomorrow morning." and you'll sleep peacefully through dozens of routine successful procedures.

That is sociopathic behavior, and it sounds like a bad culture where you are.

For the non-EM people reading this thread: WE CAN'T WIN THIS GAME.

I have had a surgical consultant ream me out for late-consulting and early-consulting (both non-emergent conditions) within the same month.

Why don't you guys stop being such dicks?

 

[RustedFox]

"Hi Dr. Bones, I see you're on call so I'm sending this non-displaced Colles fracture to your clinic. Sure I know what time it is, it's 0230. No I don't think it's necessary to wake you at this hour for this but it's policy. If you want to voice a complaint talk to your department chair or call Dr. Bonehead who started playing games. Night night."

What, no "Dr. Boner" joke ?

I am disappoint. 🙂

 

[Arcan57]

In residency (a couple of years before my time), a 20 something woman medically arrested and an EM attending cracked the chest and got her back. A several hour long fight with CV surgery ensued because they didn't want to close her because they didn't do the procedure.

 

[RustedFox]

In residency (a couple of years before my time), a 20 something woman medically arrested and an EM attending cracked the chest and got her back. A several hour long fight with CV surgery ensued because they didn't want to close her because they didn't do the procedure.

I hear this nonsense from surgery regularly. "Duh-huh... if you're gonna put in the chest tube, then you're gonna have to take care of it on the floor... duhh-huhh."

No, bonehead. Its gonna be in there for a few days. I'm not waiting for you to take your sweet time coming down here to place the tube, either.

 

[Apollyon]

I hear this nonsense from surgery regularly. "Duh-huh... if you're gonna put in the chest tube, then you're gonna have to take care of it on the floor... duhh-huhh."

No, bonehead. Its gonna be in there for a few days. I'm not waiting for you to take your sweet time coming down here to place the tube, either.

When I worked in SC, had a guy one night come in with a spontaneous pneumo. The surgeon on-call only did nights and weekends, and, for that, he didn't have to have office hours. I put the tube in, called Stanley and told him, and he said "thanks", mumbled some orders, and went back to sleep. His colleagues rounded on the patient the next morning. I don't think Stan even saw the guy.