Of the group you've offered in the poll, I'd go for ENT/eye. I'm not actually concerned about the ENT part, you can pick it up in the ED. Eye is a discipline with a very different set of diseases and a very different set of diagnostic tools. I think EPs need to be able to use a slit lamp and visualize the fundus with either a lens or a panoptic scope. They need to know the eye emergencies as well as the eye annoyances. People are much less able to tolerate a painful but minor condition in the eye than any other system. Therefore we see a lot of it. You can get these skills as well as the ability to write up an exam correctly in about two weeks of work.
On the US issue, I've got a really different take on US than FF. Over the ten years since it started to be available bed side, we've had a lot of back and forth on it at our shop. We're still divided in our enthusiasm. Anyway, this is what
I think:
1. Getting adequate images and interpreting them is far more of an art and operator dependent than other forms of imaging. It takes U/S techs 1 year of full time work to get minimally competent at just creating the images. How many EPs are going to have that much time? How much could you learn in one month?
2. Surgeons and OBGs are not going to be willing to take patients to the OR on the basis of your US, unless the findings are obvious fluid on a FAST. For everything else they will require a confirmatory study on a permanent medium read by a radiologist. They may take unstable patients to the OR, but they are doing it for the instability, not the bedside views.
3. You are going to want the confirmatory studies to support your diagnosis most of the time, since you won't have a permanent record if you just use the bedside machine.
4. People don't talk about US of the globe much, even though the Eye guys have been doing it for many years. It's quick and for a non-eye doc is much easier than fundoscopic exam for finding a interocular foreign body or retinal detachment.
5. It's really useful in the middle of the night to be able to do a quick bedside on a lady with first trimester bleeding. If you can clearly see a viable IUP, you're done. The problem is there have been a fair number of tubal and cornual ectopics that were thought to be IUP.
6. There is a national movement to make diagnostic capabilities available around the clock. It's being driven by the errors movement and by the concept of equity. Radiology is feeling this more than any other group. In fact, I have an US available 20 feet from the ED 24/7. That will be the standard 10 years from now. When you've got this capability, you can even get expert views of the aorta and pericardial sac in a couple of minutes in the resucitation room with a first quality machine. If you practice in such an enviroment, why would you want to do it yourself? How much of a risk would be subjecting your patient to if you did not use the most expert people with the best machines?
7. There is lot of discussion of accreditation/local certification. We looked into it extensively a couple of years ago with the aim of determining if we could get residents who were interested certified during the program. The details are a whole other rant, but suffice it to say that to get either the AIUM physician cert or the RDMS tech cert is not going to happen within a 3 year curriculum. It might happen in a 4 year if you devoted all of your electives to US, otherwise it'll take a fellowship.
There is a tradition in EM that goes something like "If you guys aren't going to take care of it, I'll do it myself." I can remember doing my own filiforms and followers, DPLs, split-bronchial intubations, burr holes, etc. It was quicker, easier and far more fun than arguing with a cranky doc in the middle of the night. Whether it was the right thing to do is a different issue. That's how I feel about US by nonexperts.
