Denver Health's legendary emergency medicine residency

[alpinism]

Pretty embarrassing considering this is supposed to be one of the best emergency medicine residencies in the world.

Link: Why are there so many emergencies here? • LITFL • ER Doc Walkabout

Quote from the article:

"In the setting of seeing fewer patients per day than at home, I placed more chest tubes, did more electrical cardioversion, sepsis resuscitation, managed more major traumas, had more positive bedside ultrasound exams, etc. during 3 months in Australia – than I would in several years at any of the hospitals where I work in the US. Each shift provided the volume of true emergent care that I would expect to see in several months at home. I tend to prefer caring for sick patients, doing procedures, using technology and I was in heaven in Australia. In many ways Australia reminded me of the US of 25-30 years ago before the shift in social paradigm: from ER’s are for emergencies, to “it’s OK to go to an ER for a chronic condition, they’ll take care of you, no matter what.” And, I wish that I could have brought some of my own residents with me because they would have gained far more experience in a short time than they do at home."

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[RustedFox]

Yep.

Here in the US, we don't practice Emergency Medicine (largely). Instead, we practice demand-based, high-anxiety, customer care.

 

[carbonizedeyesockets]

I don’t know why you or anyone else would think Denver to somehow be different or more special than other comparable EDs.

 

[coachB]

Pretty embarrassing considering this is supposed to be one of the best emergency medicine residencies in the world.

Well, he says he's at the University hospital, not Denver Health, which is quite a different environment. But his main point is likely still true.

 

[GeneralVeers]

Yep.

Here in the US, we don't practice Emergency Medicine (largely). Instead, we practice demand-based, high-anxiety, customer care.

We could just save the U.S. healthcare system billions if we had a vending machine in the lobby that dispensed:

1. Work notes
2. Percocet #6
3. Z-packs
4. Attention

 

[throwaway1939]

Well, he says he's at the University hospital, not Denver Health, which is quite a different environment. But his main point is likely still true.

I went to Denver as an IM resident. DH is similar to the university hospital but with maybe a bit more trauma. It's really mostly substance abuse, homeless, and socially complex patients. Denver isn't the rough and tough city it was in the 70s and 80s. Now it's full of yuppies and tech. A literal crackhouse will sell for 300,000+ so the people moving there mostly take care of themselves or have money (and therefore don't go to DH and go to something like St Joes, the University, NJ, or Skyline). High rents and home prices have made a large homeless population with lots of substance abuse but they aren't terribly sick as compared to where like TN or MI where people have much more medical comorbidities. I'm a cards fellow in the Midwest now and I've seen more STEMIs in my first couple months than my entire time in residency despite doing like 6 months of CCU and 2-3 months of cards consults.

 

[TheSingularity]

Ha that's funny. They sell themselves as this crazy amazing place to train for EM. Also have a reputation for working their residents super hard. Glad I didn't match there.

I went to Denver as an IM resident. DH is similar to the university hospital but with maybe a bit more trauma. It's really mostly substance abuse, homeless, and socially complex patients. Denver isn't the rough and tough city it was in the 70s and 80s. Now it's full of yuppies and tech. A literal crackhouse will sell for 300,000+ so the people moving there mostly take care of themselves or have money (and therefore don't go to DH and go to something like St Joes, the University, NJ, or Skyline). High rents and home prices have made a large homeless population with lots of substance abuse but they aren't terribly sick as compared to where like TN or MI where people have much more medical comorbidities. I'm a cards fellow in the Midwest now and I've seen more STEMIs in my first couple months than my entire time in residency despite doing like 6 months of CCU and 2-3 months of cards consults.

Sent from my Pixel 3 using SDN mobile

 

[RustedFox]

We could just save the U.S. healthcare system billions if we had a vending machine in the lobby that dispensed:

1. Work notes
2. Percocet #6
3. Z-packs
4. Attention

Regarding (#4). I have said to Mrs. Fox that what I really need at work is a hologram of myself to go and entertain people and answer their meaningless questions so I can ignore them, finish the chart, and go back to doing things worthy of my time.

 

[throwaway1939]

FWIW I did fellowship in Denver and had a lot of interaction with the EM program. And I was far more impressed with their residents and their residency program than I was with where I trained or where I’m an academic attending now. So yeah the state of medicine in the US in general is a mess, but the training in Denver and the residents they put out is still pretty impressive IMO. Also UC Hospital and DH (residents rotate at both) are very different beasts.

Ya the training I got at UC was amazing and compared to where I'm at currently the residents are definitely not as strong nor confident as UC residents.

 

[SamtheWise]

Ha that's funny. They sell themselves as this crazy amazing place to train for EM. Also have a reputation for working their residents super hard. Glad I didn't match there.

Sent from my Pixel 3 using SDN mobile

Disclaimer: not a Denver grad, but am familiar with the reputation

That's kind of an unfair statement, I think it makes total sense that in a country with no EMTALA, a more robust primary care system and a population with a lower diabetes and obesity prevalence fewer patients present to an ED with primary care needs. That doesn't somehow lessen the training at Denver health. In fact, the author seems pretty dang well prepared to handle these emergencies, so clearly he was well trained at some point.

There are more thoracotomies per shift in a Cape Town emergency department than LA county does in a week, so I guess you're saying every MS4 should pack their bags and apply for South African citizenship?

 

[TheSingularity]

Nah just that you don't need to exhault Denver health for no reason

Disclaimer: not a Denver grad, but am familiar with the reputation

That's kind of an unfair statement, I think it makes total sense that in a country with no EMTALA, a more robust primary care system and a population with a lower diabetes and obesity prevalence fewer patients present to an ED with primary care needs. That doesn't somehow lessen the training at Denver health. In fact, the author seems pretty dang well prepared to handle these emergencies, so clearly he was well trained at some point.

There are more thoracotomies per shift in a Cape Town emergency department than LA county does in a week, so I guess you're saying every MS4 should pack their bags and apply for South African citizenship?

Sent from my Pixel 3 using SDN mobile

 

[EctopicFetus]

Denver historically was a premium program. Then everyone else got better. I dont view denver as some residency training thats superior to other good places. (Note this excludes any HCA site)

 

[DrGasPasser]

Denver historically was a premium program. Then everyone else got better. I dont view denver as some residency training thats superior to other good places. (Note this excludes any HCA site)

I know a faculty member at the U who says they’ve had some resident attrition in the past 2-3 years; at least a couple of residents did not complete their training. The program and department leadership do not want to acknowledge a problem with the environment. I think one of the big problems is that the residents work a ton of shifts per month with little or no decrease across the 4 years. At the U, faculty are getting hammered by a metrics-driven leadership that has embraced morale and bonus killers like physician-in-triage. Denver health has also been struggling both financially and with retaining clinical talent in recent years.

To be honest, I suspect these issues are cropping up at programs across the country. I had some real concerns at my last EM shop due to dilution of the training environment by boarding, infiltration of MLPs, and provider in triage. It’s hard to learn EM seeing 1 patient per hour when everything is ordered for you by the provider it triage in most cases.

 

[Porfirio]

We could just save the U.S. healthcare system billions if we had a vending machine in the lobby that dispensed:

1. Work notes
2. Percocet #6
3. Z-packs
4. Attention

5. Malpractice Lottery payouts

 

[deleted109597]

We could just save the U.S. healthcare system billions if we had a vending machine in the lobby that dispensed:

1. Work notes
2. Percocet #6
3. Z-packs
4. Attention

It wouldn't save money. It would flat out make money. By the scads.
Of course, it's basically what telemedicine is now. You want to make money, make an app where you charge $50 a pop for those things. You can do it from your house in your underwear.

That's kind of an unfair statement, I think it makes total sense that in a country with no EMTALA, a more robust primary care system and a population with a lower diabetes and obesity prevalence fewer patients present to an ED with primary care needs. That doesn't somehow lessen the training at Denver health. In fact, the author seems pretty dang well prepared to handle these emergencies, so clearly he was well trained at some point.

Correct, they don't have EMTALA, but they do have relatively similar rules about seeing and evaluating emergencies. Unlike, say, Mexico or China, where it's cash up front or you die if you don't have the national insurance.

There are more thoracotomies per shift in a Cape Town emergency department than LA county does in a week, so I guess you're saying every MS4 should pack their bags and apply for South African citizenship?

It would be educational. And after doing more crics in Africa than I ever did in the US, I highly recommend this method honestly.

 

[DrGasPasser]

It would be educational. And after doing more crics in Africa than I ever did in the US, I highly recommend this method honestly.

Yep. I graduated from a program that was pretty trauma heavy back 15 years ago as the only Level 1 for about 3 million people. I thought that I had seen it all in residency - GSWs anywhere you could imagine, MVCs off cliffs, guys cut in half by trains, people who “fell” into wood chippers, etc.

Then, I got deployed to Al Anbar Iraq back in 2006 and my eyes were opened. The IED will redefine your notion of trauma - especially when it’s 5 guys in 1 vehicle that were blown to hell and 3 more shot to **** with small arms during the ensuing ambush. Rinse and repeat in Afghanistan.

 

[jw3600]

Yep. I graduated from a program that was pretty trauma heavy back 15 years ago as the only Level 1 for about 3 million people. I thought that I had seen it all in residency - GSWs anywhere you could imagine, MVCs off cliffs, guys cut in half by trains, people who “fell” into wood chippers, etc.

Then, I got deployed to Al Anbar Iraq back in 2006 and my eyes were opened. The IED will redefine your notion of trauma - especially when it’s 5 guys in 1 vehicle that were blown to hell and 3 more shot to **** with small arms during the ensuing ambush. Rinse and repeat in Afghanistan.

I mean yeah. There is trauma and then there is trauma. Reality is 99% of docs are never gonna see people messed up by high grade military weapons.

 

[TXEMC344]

Yep. I graduated from a program that was pretty trauma heavy back 15 years ago as the only Level 1 for about 3 million people. I thought that I had seen it all in residency - GSWs anywhere you could imagine, MVCs off cliffs, guys cut in half by trains, people who “fell” into wood chippers, etc.

Then, I got deployed to Al Anbar Iraq back in 2006 and my eyes were opened. The IED will redefine your notion of trauma - especially when it’s 5 guys in 1 vehicle that were blown to hell and 3 more shot to **** with small arms during the ensuing ambush. Rinse and repeat in Afghanistan.

 

[TXEMC344]

Thank you for your service.

 

[DrGasPasser]

Thank you for your service.

Your welcome.

 

[TheComebacKid]

The residents at Denver Health seem very well trained. I understand why people want to go there. But to act like this is THE mecca of EM training is such a gross overexaggeration. The SDN circle jerk for this place and the utility of the phrase POWERHOUSE to describe every aspect of the program is excessive. Same with LAC+USC, Cook, Parkland, etc.

We as a specialty, IMO, should stop sensationalizing county training to the degree that we do. I remember rotating at a famous county hospital as a medical student only to realize that the people around me were practicing minimal emergency care. With the exception of the every so often GSW or stab wound, I saw a lot of drunks, foot pain, medication refills, sandwich seekers, and patients who always said, "can you just discharge me in an hour?".

If you agree with the mission of county training and want to serve the underserved etc, by all means, these places will train you well. But you are grossly mistaken if you think that county training is all high acuity stuff. I would argue that many facets of academic programs make them optimally positioned to train residents well to take care of sick patients.

Equally prioritized in medical training IMO should be places that place emphasis on providing social work resources, shelter info, mental health counseling provided by other trained individuals so you can spend your residency learning how to practice EM.

 

[Fox800]

The residents at Denver Health seem very well trained. I understand why people want to go there. But to act like this is THE mecca of EM training is such a gross overexaggeration. The SDN circle jerk for this place and the utility of the phrase POWERHOUSE to describe every aspect of the program is excessive. Same with LAC+USC, Cook, Parkland, etc.

We as a specialty, IMO, should stop sensationalizing county training to the degree that we do. I remember rotating at a famous county hospital as a medical student only to realize that the people around me were practicing minimal emergency care. With the exception of the every so often GSW or stab wound, I saw a lot of drunks, foot pain, medication refills, sandwich seekers, and patients who always said, "can you just discharge me in an hour?".

If you agree with the mission of county training and want to serve the underserved etc, by all means, these places will train you well. But you are grossly mistaken if you think that county training is all high acuity stuff. I would argue that many facets of academic programs make them optimally positioned to train residents well to take care of sick patients.

Equally prioritized in medical training IMO should be places that place emphasis on providing social work resources, shelter info, mental health counseling provided by other trained individuals so you can spend your residency learning how to practice EM.

I trained at a POWERHOUSE of providing microwaved breakfast sandwiches and crappy apple juice.

 

[TheSingularity]

County training is way overrated. I had a colleague come from such a "knife and fun club." Placed 3 chest tubes in all of residency

The residents at Denver Health seem very well trained. I understand why people want to go there. But to act like this is THE mecca of EM training is such a gross overexaggeration. The SDN circle jerk for this place and the utility of the phrase POWERHOUSE to describe every aspect of the program is excessive. Same with LAC+USC, Cook, Parkland, etc.

We as a specialty, IMO, should stop sensationalizing county training to the degree that we do. I remember rotating at a famous county hospital as a medical student only to realize that the people around me were practicing minimal emergency care. With the exception of the every so often GSW or stab wound, I saw a lot of drunks, foot pain, medication refills, sandwich seekers, and patients who always said, "can you just discharge me in an hour?".

If you agree with the mission of county training and want to serve the underserved etc, by all means, these places will train you well. But you are grossly mistaken if you think that county training is all high acuity stuff. I would argue that many facets of academic programs make them optimally positioned to train residents well to take care of sick patients.

Equally prioritized in medical training IMO should be places that place emphasis on providing social work resources, shelter info, mental health counseling provided by other trained individuals so you can spend your residency learning how to practice EM.

Sent from my Pixel 3 using SDN mobile

 

[EctopicFetus]

County training is way overrated. I had a colleague come from such a "knife and fun club." Placed 3 chest tubes in all of residency

Sent from my Pixel 3 using SDN mobile

Was it from a lack of effort?

 

[The Knife & Gun Club]

I know a faculty member at the U who says they’ve had some resident attrition in the past 2-3 years; at least a couple of residents did not complete their training. The program and department leadership do not want to acknowledge a problem with the environment. I think one of the big problems is that the residents work a ton of shifts per month with little or no decrease across the 4 years. At the U, faculty are getting hammered by a metrics-driven leadership that has embraced morale and bonus killers like physician-in-triage. Denver health has also been struggling both financially and with retaining clinical talent in recent years.

To be honest, I suspect these issues are cropping up at programs across the country. I had some real concerns at my last EM shop due to dilution of the training environment by boarding, infiltration of MLPs, and provider in triage. It’s hard to learn EM seeing 1 patient per hour when everything is ordered for you by the provider it triage in most cases.

I actually interviewed there this season. They work 20 eight hour shifts/4 week block.

Is that a lot by residency standards? A few of the other places I’ve interviewed work more than that. Carolinas works 22/month, reducing to 20 by PGY3.

Only problem there from my impression was that they do circiadian scheduling, with 2 AM, 2 swing, 2 nights, 1 day off/post call. Which doesn’t leave a ton of time to recover.

 

[DrGasPasser]

I actually interviewed there this season. They work 20 eight hour shifts/4 week block.

Is that a lot by residency standards? A few of the other places I’ve interviewed work more than that. Carolinas works 22/month, reducing to 20 by PGY3.

Only problem there from my impression was that they do circiadian scheduling, with 2 AM, 2 swing, 2 nights, 1 day off/post call. Which doesn’t leave a ton of time to recover.

160 hrs / block is very reasonable.

 

[Rekt]

I actually interviewed there this season. They work 20 eight hour shifts/4 week block.

Is that a lot by residency standards? A few of the other places I’ve interviewed work more than that. Carolinas works 22/month, reducing to 20 by PGY3.

Only problem there from my impression was that they do circiadian scheduling, with 2 AM, 2 swing, 2 nights, 1 day off/post call. Which doesn’t leave a ton of time to recover.

Month to month > blocks. The extra month gained is almost always useless and at the expense of days off. And the 2-2-2 schedule is absolute garbage. I prefer the "random" schedule type as it emulates reality more.

 

[alpinism]

The residents at Denver Health seem very well trained. I understand why people want to go there. But to act like this is THE mecca of EM training is such a gross overexaggeration. The SDN circle jerk for this place and the utility of the phrase POWERHOUSE to describe every aspect of the program is excessive. Same with LAC+USC, Cook, Parkland, etc.

We as a specialty, IMO, should stop sensationalizing county training to the degree that we do. I remember rotating at a famous county hospital as a medical student only to realize that the people around me were practicing minimal emergency care. With the exception of the every so often GSW or stab wound, I saw a lot of drunks, foot pain, medication refills, sandwich seekers, and patients who always said, "can you just discharge me in an hour?".

If you agree with the mission of county training and want to serve the underserved etc, by all means, these places will train you well. But you are grossly mistaken if you think that county training is all high acuity stuff. I would argue that many facets of academic programs make them optimally positioned to train residents well to take care of sick patients.

Equally prioritized in medical training IMO should be places that place emphasis on providing social work resources, shelter info, mental health counseling provided by other trained individuals so you can spend your residency learning how to practice EM.

The big problem with county programs and the leadership they produce is that they believe the primary purpose of an ER is to act as a safety net for literally everything and anything in the community. This leads to the situation you describe where these hospitals function as basically glorified homeless shelters and rehab clinics. I trained at one of these places and this mindset was deeply ingrained in our attendings. As a result during the winter and especially on night shifts the tracking board was literally half "cold exposure" and "alcohol intoxication." Now for the more naive medical students and residents out there rather than helping these patients we largely hurt them by enabling their behavior. You see we had plenty of shelters and clinics in Detroit but in order to use them you couldn't be drunk or high while on the property. So of course all the patents would use the ER instead because we cant turn anyone away and they get a warm bed and food until they sober up in the morning. Now besides the fact that this is huge waste of time and money it also takes away from learning emergency medicine and caring for sick patients. This is especially true because many of these county hospitals are poorly staffed and funded meaning that what few beds and nurses are available are now being used for them instead of the back pain from an aortic dissection still in the waiting room.

Here's the thing though after working at academic hospitals I'm not sure its any better training. In my experience these patients are just replaced with nonemergent chronic disease exacerbations. Basically instead of homeless drunks you get noncompliant CHFers and COPDers presenting every day for worsening leg swelling and shortness of breath. None of them are actually sick or need to be resuscitated but they all get admitted and then of course everyone says "we see lots of high acuity patients look at our admission rate!" but its all bull$hit. Regardless its basically the same situation which is a huge waste of time and money that also takes away from learning emergency medicine and caring for sick patients. Unfortunately what many people fail to realize is that as a result its becoming harder every year for residents to get hands on experience managing patents with actual life threatening emergencies.

 

[The Knife & Gun Club]

The big problem with county programs and the leadership they produce is that they believe the primary purpose of an ER is to act as a safety net for literally everything and anything in the community. This leads to the situation you describe where these hospitals function as basically glorified homeless shelters and rehab clinics. I trained at one of these places and this mindset was deeply ingrained in our attendings. As a result during the winter and especially on night shifts the tracking board was literally half "cold exposure" and "alcohol intoxication." Now for the more naive medical students and residents out there rather than helping these patients we largely hurt them by enabling their behavior. You see we had plenty of shelters and clinics in Detroit but in order to use them you couldn't be drunk or high while on the property. So of course all the patents would use the ER instead because we cant turn anyone away and they get a warm bed and food until they sober up in the morning. Now besides the fact that this is huge waste of time and money it also takes away from learning emergency medicine and caring for sick patients. This is especially true because many of these county hospitals are poorly staffed and funded meaning that what few beds and nurses are available are now being used for them instead of the back pain from an aortic dissection still in the waiting room.

Here's the thing though after working at academic hospitals I'm not sure its any better training. In my experience these patients are just replaced with nonemergent chronic disease exacerbations. Basically instead of homeless drunks you get noncompliant CHFers and COPDers presenting every day for worsening leg swelling and shortness of breath. None of them are actually sick or need to be resuscitated but they all get admitted and then of course everyone says "we see lots of high acuity patients look at our admission rate!" but its all bull$hit. Regardless its basically the same situation which is a huge waste of time and money that also takes away from learning emergency medicine and caring for sick patients. Unfortunately what many people fail to realize is that as a result its becoming harder every year for residents to get hands on experience managing patents with actual life threatening emergencies.

So what model would you suggest is the ideal?

 

[deleted547339]

I trained at a POWERHOUSE of providing microwaved breakfast sandwiches and crappy apple juice.

you had breakfast sandwiches!?!!??

 

[ShockIndex]

So what model would you suggest is the ideal?

you had breakfast sandwiches!?!!??

It’s the same turkey sandwichs that every ED has - just put in a microwave and served between the hours of 6-8 AM.

 

[ShockIndex]

So what model would you suggest is the ideal?

A program that has both county and private hospital training sites. Indiana, Pitt, Metro/CCF, Emory, etc. have that. Denver also has that to some extent as the residents spend time at Denver Heath (county) and University of CO (wealthy referral). There are plenty of others that have a robust community experience in addition to Life in the Hood.

A few programs like CMC and Christiana kinda have that in 1 hospital. They are private hospitals with inner city pathology but also high payer mix and a community physician presence.

 

[Groove]

Traumatology is so incredibly cookie cutter. I've also found that it's the most resilient EP skill set to non utilization atrophy. I still get gang bang drop offs and KSWs in my community non trauma ED and find myself still checking my brain out while I run through the motions, often times thinking about what I'm going to have for dinner that night. Unfortunately, most of the public considers that to be what emergency medicine is all about and I'm sure some of you have had friends of family who seem little disappointed when you tell them you don't work at the local major trauma center <eye roll>. I find the "other stuff" to be much more intellectually stimulating. I also don't miss the sucking vortex singularity of an alpha trauma case where you find yourself stuck in there for over 1-2 hours and all your other patients are pissed off where no amount of explaining or management is going to make them happy.

 

[alpinism]

So what model would you suggest is the ideal?

There really is no ideal hospital and each has their own pluses and minuses.

Having said that while county hospitals have major downsides they also generally see the sickest patients. At most academic hospitals the patients are followed by an army of specialists and will come in as soon as their symptoms worsen rather than wait till the last possible moment. Due to this you end up seeing a lot more patients who have never seen any specialists with advanced stages of diseases at county hospitals.

 

[Dr Mantis Toboggan]

I spent years at a Level 1 academic trauma center, at a Level 3 now. For me there was definitely some reality to use it or lose it.

Traumatology is so incredibly cookie cutter. I've also found that it's the most resilient EP skill set to non utilization atrophy. I still get gang bang drop offs and KSWs in my community non trauma ED and find myself still checking my brain out while I run through the motions, often times thinking about what I'm going to have for dinner that night. Unfortunately, most of the public considers that to be what emergency medicine is all about and I'm sure some of you have had friends of family who seem little disappointed when you tell them you don't work at the local major trauma center <eye roll>. I find the "other stuff" to be much more intellectually stimulating. I also don't miss the sucking vortex singularity of an alpha trauma case where you find yourself stuck in there for over 1-2 hours and all your other patients are pissed off where no amount of explaining or management is going to make them happy.

 

[deleted109597]

What you need to see is enough kids under 28 days with fevers to get proficient at neonatal LPs. I hadn't done one in awhile. I've done 4 in the last month though.
Trauma is easy.
Sepsis is easy now too, since the nurses protocolize everything.
You need to be reading EKGs, reducing fractures, and seeing people who aren't dying, since that's what you'll be doing in the real world.

 

[ShockIndex]

There really is no ideal hospital and each has their own pluses and minuses.

Having said that while county hospitals have major downsides they also generally see the sickest patients. At most academic hospitals the patients are followed by an army of specialists and will come in as soon as their symptoms worsen rather than wait till the last possible moment. Due to this you end up seeing a lot more patients who have never seen any specialists with advanced stages of diseases at county hospitals.

This is why I like programs that have 2 training sites with distinct patient populations. On the other hand, I’m not a big fan of much more than 2 as it becomes a bit more onerous learning all of the system nuances.

 

[Porfirio]

No perfect way to train. Best to just have a good broad exposure to as much disease pathology as possible. Lvl 1s become referral centers with a massive amount of transfers that offer little educational benefit to residents, however have pathology not seen in the community because Lvl 1 is where specialized patients go. Community is great for volume, onset of new (a lot of the time advanced stage) of disease, and learning to navigate with less resources from specialists and social work support.

Honestly, the best training is for the “grey” zone of discharge vs admit spectrum. Obvious admits are obvious, just like obvious discharges are obvious. Better to figure out “how can I justify this admit or discharge” in residency. Or you are going to have some very difficult interactions with consultants or lawyers.

 

[ShockIndex]

No perfect way to train. Best to just have a good broad exposure to as much disease pathology as possible. Lvl 1s become referral centers with a massive amount of transfers that offer little educational benefit to residents, however have pathology not seen in the community because Lvl 1 is where specialized patients go. Community is great for volume, onset of new (a lot of the time advanced stage) of disease, and learning to navigate with less resources from specialists and social work support.

Honestly, the best training is for the “grey” zone of discharge vs admit spectrum. Obvious admits are obvious, just like obvious discharges are obvious. Better to figure out “how can I justify this admit or discharge” in residency. Or you are going to have some very difficult interactions with consultants or lawyers.

Amen to that and bolded for truth. IMHO, there are 2 things killing the educational environment of many programs from within right now:

1) Clinical Decision Units / Observation Units that allow residents (and most of their attendings who never worked a day out of the crystal palace) to put all manner of ridiculous BS in observation status. It’s a tough transition for fresh grads when they learn that nobody is going to dispo their 50 year old patient with vasovagal syncope for them. This is why I refer to the CDU as the Can’t Decide Unit.

2) Provider in Triage where residents inherit a bunch of patient’s from the waiting room with complete or excessive work-ups. This is particularly insidious because residents who grow up under these systems begin to intuitively think that all this unnecessary crap is needed for safe dispositions.

Making matters worse, program director’s honestly think that this stuff is a positive for their trainees...often because they never ventured outside of the crystal palace.

 

[TheComebacKid]

Traumatology is so incredibly cookie cutter. I've also found that it's the most resilient EP skill set to non utilization atrophy. I still get gang bang drop offs and KSWs in my community non trauma ED and find myself still checking my brain out while I run through the motions, often times thinking about what I'm going to have for dinner that night. Unfortunately, most of the public considers that to be what emergency medicine is all about and I'm sure some of you have had friends of family who seem little disappointed when you tell them you don't work at the local major trauma center <eye roll>. I find the "other stuff" to be much more intellectually stimulating. I also don't miss the sucking vortex singularity of an alpha trauma case where you find yourself stuck in there for over 1-2 hours and all your other patients are pissed off where no amount of explaining or management is going to make them happy.

I'm not sure why we propagate the myth that trauma is cookie cutter. While I agree the medicine is not terribly difficult i.e. if they are bleeding give them blood, if they have a pneumo put in a chest tube, etc. however the cognitive load that comes with taking care of sick crashing trauma patients with a team of people (nurses, surgeons, anesthesiologists) is not easy.

At our inner city level 1 trauma center, the acuity is so high that our trauma cases are routinely the most QA'd in our department.

The definition of trauma is also very broad. The stable tib/fib fracture in an MVC is very different than managing the patient who rolls into your ED peri-arrest after multiple GSWs to the chest.

 

[TheComebacKid]

No perfect way to train. Best to just have a good broad exposure to as much disease pathology as possible. Lvl 1s become referral centers with a massive amount of transfers that offer little educational benefit to residents, however have pathology not seen in the community because Lvl 1 is where specialized patients go. Community is great for volume, onset of new (a lot of the time advanced stage) of disease, and learning to navigate with less resources from specialists and social work support.

I have not practiced as an attending in the community, so I can't really speak much to the acuity at all community sites. I'm sure it varies. But in residency the hospitals we rotate at in the community are pretty much glorified urgent care centers where people with PMDs come in to get their sore throats looked at on holidays. When there is a single critically ill patient, people start panicking. I personally think these types of places have drawbacks for residency training as well. There are very few intubations at these sites, (put them on BIPAP and send up to the ICU ASAP), everyone is getting peripheral pressors (the thought of putting in a line in the ED is unheard of, etc). I hate working at these sites.

My feeling is that you should train where you will see the highest acuity, even if it means you compromise somewhat on lower acuity stuff. I've done several pericardiocentesis (pericardiosentesises?) in residency, including one yesterday that I feel confident doing this for a patient in tamponade. My distal radius reductions aren't pretty, but I'm working on them and am hopeful that I will get better with practice.

I postulate that it's difficult to manage one sick patient in the community if you did not train at a place that took care of lots of sick patients. I think while it's not easy per se, it's easier to pick up the skills managing not sick patients in the community if you come from a place where you saw high acuity stuff.

Agree the undifferentiated admit vs discharge patients are key wherever you go. But by and large, I lose sleep at the thought of not being able to crich someone. I don't lose sleep regarding the quality of my splint that the orthopedist will take off in clinic tomorrow AM.

While most people went into EM "to do it all" for me, I went into EM because of a passion for resuscitation. At the academic center, I'm resuscitating everyone on my own, doing all my own lines/intubations/chest tubes etc. I don't really care if I need to call a hand surgeon at the level 1 trauma center to rongeur off some bone, but I can see how that is unappealing to others who want "to do it all". But I like having resources to take care of those things I don't really care to do.

EDIT: also, why would anyone want to work somewhere with minimal social work support? That sounds horrible.

 

[Porfirio]

You might love picking up a few shifts out in the community (30 min - 1hr away from the Academic center). It is a whole different world from what you have experienced before, and I will never be able to explain it over a forum post.

 

[Janders]

I have not practiced as an attending in the community, so I can't really speak much to the acuity at all community sites. I'm sure it varies. But in residency the hospitals we rotate at in the community are pretty much glorified urgent care centers where people with PMDs come in to get their sore throats looked at on holidays. When there is a single critically ill patient, people start panicking. I personally think these types of places have drawbacks for residency training as well. There are very few intubations at these sites, (put them on BIPAP and send up to the ICU ASAP), everyone is getting peripheral pressors (the thought of putting in a line in the ED is unheard of, etc). I hate working at these sites

EDIT: also, why would anyone want to work somewhere with minimal social work support? That sounds horrible.

Odd. Typically I hear precisely the opposite concern-->

At the academic centers you see sick-as-balls patients, but many of them are transferred already lined/tubed/diagnosed, and even the new-arrivals get resucitated by you... AND the icu fellow, 17 surgical sub-specialists, 24-hr IV team, and IR.

In the community, its just you (the ER resident) and a billion patients and real life attendings. Cherry pick the sick stuff, and get to do a ton of procedures.

clearly these stereotypes are just that. Every site should be judged by what it offers the trainee, and multi-site training is >> single-site training.

 

[doggydog]

Odd. Typically I hear precisely the opposite concern-->

At the academic centers you see sick-as-balls patients, but many of them are transferred already lined/tubed/diagnosed, and even the new-arrivals get resucitated by you... AND the icu fellow, 17 surgical sub-specialists, 24-hr IV team, and IR.

In the community, its just you (the ER resident) and a billion patients and real life attendings. Cherry pick the sick stuff, and get to do a ton of procedures.

clearly these stereotypes are just that. Every site should be judged by what it offers the trainee, and multi-site training is >> single-site training.

IR willingly does stuff at your academic center? Crazy.

 

[RustedFox]

clearly these stereotypes are just that. Every site should be judged by what it offers the trainee, and multi-site training is >> single-site training.

My residency had three sites.

1. Academic Crystal Palace
2. Community General
3. Community downtown Trauma free-for-all

I loved it.

 

[Groove]

I'm not sure why we propagate the myth that trauma is cookie cutter. While I agree the medicine is not terribly difficult i.e. if they are bleeding give them blood, if they have a pneumo put in a chest tube, etc. however the cognitive load that comes with taking care of sick crashing trauma patients with a team of people (nurses, surgeons, anesthesiologists) is not easy.

At our inner city level 1 trauma center, the acuity is so high that our trauma cases are routinely the most QA'd in our department.

The definition of trauma is also very broad. The stable tib/fib fracture in an MVC is very different than managing the patient who rolls into your ED peri-arrest after multiple GSWs to the chest.

Of all the things we do, trauma resuscitation is the most algorithmic. Cognitive load for trauma? What cognitive load? Penetrating and blunt trauma management is anything but rocket science. It's also the easiest aspect of emergency medicine IMO, next to fast track. The only people who think differently are residents or academic attendings. Keep in mind, nothing works in the real world like it does in a big academic center. There you really have every available resource at your finger tips to the point of dispositions being spoon fed to you. Trauma is there for all your alpha's and available for consult on all your bravos. OB for your crowning mothers, urology for all the broke penis (penii? penises?), you get the picture... It's easy work. You're also largely cocooned from all the metric nazi administrators that tend to terrorize most community ED groups. Want a real challenge? Go out there and find a 17K single coverage ED out in the middle of nowhere next to a major freeway with no in house specialists past 7p.m. other than a hospitalist. You'll get some crazy drop offs in that kind of ED. Those guys are the real cowboys. Then the challenge becomes knowing what you need to do with the patient and initiating it with limited resources in your ED/hospital resulting in some incredibly creative approaches to specific cases before facilitating transfer. My residency was in a 4 year busy level 1 and some of my most memorable cases were in an ED where I moonlighted that was just like that one. Pediatric codes, exploding thoracic aneurysms, peds trauma, adult multi-system trauma, SCI, etc.. If your rotation sites are bandaid stations, you need a better site to give you a more accurate representation of a higher acuity community ED. I actually have more procedures in my community ED at my current gig then I did at the last trauma center that I worked at, simply because I don't have as many people willing to do all the procedures for me. In fact, at one busy level 2 where I worked, it was incredibly depressing. I functioned essentially like an air traffic controller. Third degree heart blocks got snatched by cards fellow's and whisked off for temporary pacer. Traumas were jumped on by surgery and the occasional resident. Lines were aggressively placed by the ICU and they would actually ask us not to place them in the ED so they could do them upstairs and bill for it, etc... Very depressing. Avoid those gigs if you can. Anyway, I got off on a tangent. Now I've got to go work in my community gig.

The worst trauma centers to work at are a few busy level 2's with no residencies. You get stuck with all the procedures, all the messy non critical bravo traumas, stuck with all the messy lacs that plastics wants you to close and send to their office the next morning, stuck with all the ortho trauma. It grinds you to a halt and you have limited help dealing with all the complicated cases. There is zero cognitive load to those cases, I can assure you. Meanwhile, the waiting room backs up and your patients are ridiculously pissed off. People start having strokes and MI's before they can be triaged. Avoid those gigs too if you can help it.

 

[deleted109597]

I have not practiced as an attending in the community, so I can't really speak much to the acuity at all community sites. I'm sure it varies. But in residency the hospitals we rotate at in the community are pretty much glorified urgent care centers where people with PMDs come in to get their sore throats looked at on holidays. When there is a single critically ill patient, people start panicking. I personally think these types of places have drawbacks for residency training as well. There are very few intubations at these sites, (put them on BIPAP and send up to the ICU ASAP), everyone is getting peripheral pressors (the thought of putting in a line in the ED is unheard of, etc). I hate working at these sites.

Your community sites sound like they are the country club community shops 2 blocks from county general.
Visit a real community site. Where you're the only hospital for 30+ miles in a city of 100,000. Where everything comes to you. Trauma, OB, STEMI, Stroke, ankle sprain, everything.
Places where the VIPs won't darken the door because it's too "dirty".

Ivory towers have their place. I'll never work at one.

 

[RuralEDDoc]

The worst trauma centers to work at are a few busy level 2's with no residencies. You get stuck with all the procedures, all the messy non critical bravo traumas, stuck with all the messy lacs that plastics wants you to close and send to their office the next morning, stuck with all the ortho trauma. It grinds you to a halt and you have limited help dealing with all the complicated cases. There is zero cognitive load to those cases, I can assure you. Meanwhile, the waiting room backs up and your patients are ridiculously pissed off. People start having strokes and MI's before they can be triaged. Avoid those gigs too if you can help it.

Reading this gives me flashbacks to previous gigs. So true. One of the loneliest places on earth is a busy single coverage ED with minimal backup. The work is so hard it’s almost indescribable. Correction - It can be described, but no one would believe unless they’ve done the work before. Community Emergency Medicine is not ankle sprains and runny noses at many places in this country. It’s hard and people die, every day, and it’s your job to tell the family, every day.
Note: most of these patients came in dead already - CPR in progress, etc. But a real percentage come in talking and still die, and all the wonderful ABEM certified care in the world can’t save them.

 

[ShockIndex]

Those 100K census community EDs with trauma and 20% admission rates are one of the times when I want a good PA. I don’t need them to see new Level 2 and 3 patients, but I instead deploy them to soak up the lacs, LPs, call admissions, etc. In other words, I want them to actually be my assistant...

 

[doggydog]

There is some real high horse **** going on in here.