ED docs consulting everything!

[shigaT]

Hey all,

I've been interested in EM since day 1 but where I go to school (large academic university) it seems that ED docs consult everything. for example, trauma surgery is waiting for all MVA patients and run the show, ortho takes care of all fractures, ent for all facial lacs, etc....Now, I don't want to go through 4 years of med school and 3+ years of training to be a glorified triage nurse. Please tell me it's different at other programs.

Shiga, MSIII

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[The White Coat Investor]

Alas, the double-edged sword of working in an academic center. The benefits: You always have subspecialty consultants to all in. The downside: They expect to be called in.

Its worse at some places than others, but most EPs work in a community setting, where at night they are the only doc in the hospital...and often are responsible for running codes on the floors and in the ICU, handling deliveries if the OB can't make it on time, running traumas, casting, and everything else. If you want a consult, you gotta call someone out of bed. Don't dismiss EM as a field simply because you don't like the way it looks in an academic center. Go rotate in a small community hospital.

 

[flEM]

It is also way different at county hospitals, where there often aren't enough consultants around regardless. Even if ortho and ENT is in house, they are often too busy with their cases to come down and set a fracture, reduce a shoulder, or suture a facial lac.

At private academic centers the services are not as swamped. Trauma can handle waiting in the ED for action. Where I have rotated, trauma doesn't come down till they are paged, and usually they are so busy that it takes a little time.

I haven't rotated in a small community hospital setting, but it was my rotations in large county hospitals that convinced me of the impact that emergency physicians have. You should set up a rotation at a high volume county hospital as well.

 

[m and m]

Originally posted by shigaT
Hey all,

I've been interested in EM since day 1 but where I go to school (large academic university) it seems that ED docs consult everything. for example, trauma surgery is waiting for all MVA patients and run the show, ortho takes care of all fractures, ent for all facial lacs, etc....Now, I don't want to go through 4 years of med school and 3+ years of training to be a glorified triage nurse. Please tell me it's different at other programs.

Shiga, MSIII

I suggest you do an away rotation for sure. It sounds like your ED gets pushed arround by more established specialties. In the community ED docs do a lot on their own, particularly if they can bill for it (lacs, reductions, etc). Anybody who calls an ED doc a glorified triage nurse is just bitter because they have to get up in the middle of the night to admit a patient.

 

[southerndoc]

The EM guys at my school also consult everything... even ridiculous stuff (like simple bacterial vaginosis).

One must realize a couple of things though:

1. These specialties (e.g., OB/GYN, medicine, surgery) are readily available. Some expect to be consulted.

2. It may be a liability issue to not consult these services on some things, even if the EM physician can handle it. A PGY-1 in surgery with only 6 months experience actually has more surgical expertise than most emergency physicians. A PGY-3 definitely has more expertise than any EM doc since they concentrate on nothing but surgery, whereas EM physicians concentrate on everything.

3. Things work differently in a community hospital where there are no residents nearby. For instance, where I used to work as a paramedic, the EM physician handled everything, including trauma. The attendings were consulted when they were needed. Basically they were consulted for admissions or procedures (e.g., surgery). The EM docs did the central lines, full workups, etc. Where I am at now, the EM doc frequently doesn't even do a full workup. Why bother if you have residents in house? Afterall, they need to learn to work these patients up. The EM doc is practicing at a teaching institution in these cases.

There is one thing that I have gathered throughout my third year rotations. EM physicians are trashed by nearly every specialty, primarily because they consult the residents for mediocre stuff all the time.

It's a double-edged sword. Consult them, and you look like an idiot that can't handle "simple" things. Don't consult them, and you not only deprive the resident of an education, but you also run the risk of being liable for not consulting an in-house specialist whose only job is to deal with situations that you are treating.

My question is what do places with EM residencies do? My school doesn't have an EM residency. I'm curious if they also consult like crazy. If so, then the EM resident is getting robbed of an education unless he or she maintains an active role in the patient's care after being consulted.

 

[shigaT]

geek medic,

my school has an em residency and as you can read from my original post, they still consult everything. i've also wondered about the quality of training at big university programs because of this reason.

shiga

 

[orthoguy]

This all depends upon where you are and how strong/how old and established the ED is where your school is at not about what school/university you are at. At my school (large NYC hospital) the tramuas (for example) are run by a trauma team that consists of senior emergency residents and Senior surgery residnets.......every 3 days they take turns as to who is in charge (ie for 3 days the Senior ER physician runs the trauma/next 3 itts surgery)......the ED staff does all the procedures in the ED (intubations/chest tubes/central lines).......

Medical issues are consulted only when there will be an admission or when there is a patient with a presentation that the dept can not figure out (vaginosis is certanily not on that list)

Again it depends on your program........if you go to a program with a strong surgery staff and strong medicine dept you will not get your hands on much (this is why people do not flock to Yale/Cornell etc for EM)........but our program is the oldest in NYC with a very strong and respected presnece in the hospital...it all depends

 

[DocWagner]

That kinda sucks...
But since you are an MS3, I suppose you haven't seen the BAJILLION consults that medicine makes (renal, pulm, endo, cardio) or surgery (IM, endo, cardio, renal) or ortho (anyone with a stethoscope).
It really happens all over the place, but even more so at the highly specialized university hospitals (I would hate EM at Duke or Mayo etc)...the programs with EM as a high profile residency or in a community base, may be the program for you.
I don't think we consult much at all...probably only if we are going to admit or we think they may need admission...certainly not for bacterial vaginosis, come on! Hell, we look at our own slides at Good Samaritan!

 

[Annette]

Hammered into my brain many times, at many places, from many faces. (sorry, not enough caffeine today). You should know what your consult is going to tell you before you call the consult! And, if they tell you something different, they had better be able to back up what they tell you. So, just because you may call alot of consults, doesn't mean you don't know what you are doing, or aren't getting the training.

 

[southerndoc]

Originally posted by DocWagner
certainly not for bacterial vaginosis, come on! Hell, we look at our own slides at Good Samaritan!

That was an actual consult while doing an OB/Gyn rotation. Seriously!

Interesting facts surrounding the case:
1. ED doc was getting off at 0200.
2. Area of ED (fast track) was scheduled to shut down at 0200.
3. ED doc was backed up a couple of patients.
4. OB/Gyn consulted at 0130.