Community ED vs Tertiary Care University ED

[pinipig523]

Hey all,

Just had a question...

How much different is it to work in a regular run-of-the-mill community ED (not one in bumble, but a decent one) vs the feel of working in a tertiary care hospital with every subspecialty on-call?

The reason I ask is because I just started a rotation in a tertiary care university hospital and coming from a county hospital - I feel like I'm forced to consult everybody (and I mean.... everybody). I can't even send a kid home with a probably patellar tendon sprain because ortho has to come down, evaluate the kid, and place him in a knee immob + crutches (which was what I was going to do in the first place)!

I want more hands off but I also want the consult services there just in case I'm in trouble.

Is the community hospital different?

(I'm trying to remember how it was rotating in a community ED as a med student but I know there's a big difference between how a med student practices EM vs a resident so I can't trust my judgement on that...)

Thanks.

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[Arcan57]

Working in a community ED, very few patients I see are seen by another physician prior to leaving the ED (either upstairs or home). There's less perceived medicolegal risk if the specialist comes down and documents their exam. I have no idea how risky it actually is to have a consultant available in-house 24 hrs a day and not consult them on something that arguably falls within their area of expertise.

In the community a lot of the CYA consults don't get called, due to both consultant factors ("splint it and I'll see it in the morning) as well as increased pressure to turn-over patients. On the downside, it can be tougher to get a consultant to see a patient for something "you should be able to handle". Whether it's a urinary retention that you've tried a 24 Fr on or a shoulder dislocation that's >8 hrs old, sometimes its nice to have a resident at your beck and call.

 

[DrQuinn]

Working in a community ED, very few patients I see are seen by another physician prior to leaving the ED (either upstairs or home). There's less perceived medicolegal risk if the specialist comes down and documents their exam. I have no idea how risky it actually is to have a consultant available in-house 24 hrs a day and not consult them on something that arguably falls within their area of expertise.

In the community a lot of the CYA consults don't get called, due to both consultant factors ("splint it and I'll see it in the morning) as well as increased pressure to turn-over patients. On the downside, it can be tougher to get a consultant to see a patient for something "you should be able to handle". Whether it's a urinary retention that you've tried a 24 Fr on or a shoulder dislocation that's >8 hrs old, sometimes its nice to have a resident at your beck and call.

Agreed. Having worked in teh academic setting for 2.5 years and am now in the community setting, I did a helluva lot more consults in the academic setting. Part of it is for resident education, but part of it for just tha'ts how it works. Here in the community I rarely consult anyone (besides the admitting team such as hospitalists or admitting FPs), maybe 2-3% of the time. I tend to call PCPs more than I do consultants. Depends on your level of comfort.

Q

 

[southerndoc]

Agreed. Having worked in teh academic setting for 2.5 years and am now in the community setting, I did a helluva lot more consults in the academic setting. Part of it is for resident education, but part of it for just tha'ts how it works. Here in the community I rarely consult anyone (besides the admitting team such as hospitalists or admitting FPs), maybe 2-3% of the time. I tend to call PCPs more than I do consultants. Depends on your level of comfort.

Q

It's a lot easier to consult a resident when they are in-house. Hardly any consultants are in-house in the community setting. I'm lucky that we have cardiology PA's in house, so it makes it easier to get cardiology consults 24/7.

 

[Jeff698]

I'm in a community hospital. I consult when I truly don't know something, need advice or need an admit. Short of that, I do it myself. The longer I'm out of residency, the less I consult.

We have hospitalists so I very rarely call a PCP.

Take care,
Jeff