EM day to day work

[Blue Frog]

I really like to do things...take action...use my hands, and have been thinking about EM. I've heard some say that EM docs don't really do much with their hands and its all coughs and colds, and anything "exciting" gets handled by the trauma surgeons. I was just wondering if anyone could comment on what percent of time you send a patient home w/o need for treatment vs. treat medically vs. treat procedurally (broken bones, sutures, pneumothorax). Also how does this vary with location (rural/urban)? Thanks!

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[southerndoc]

Let's see, last night (and ONLY last night)'s procedures:

- IJ central line
- I&D facial abscess
- I&D L axillary abscess
- complicated closure of a severe finger/palm laceration in a professional pianist
- another thumb laceration (minor)
- fractured foot with a complicated laceration (open fracture) - turfed to ortho though
- laceration to the forehead
- lumbar puncture

I've done as many as six intubations in one 12-hour shift, and as many as ten central lines in a 12-hour shift. All of the above was during a senior 9-hour shift. I only did 1 I&D (facial), the LP, and the central line because my junior residents were getting slammed and I wanted to move patients out of the department quickly.

There are plenty of opportunities to do procedures in the emergency department. No, you will not be opening anyone's abdomen or doing surgery in the ED. However, no matter where you practice, you will get your share of fracture reductions, conscious sedations, chest tubes, etc.

Many patients are managed medically, but even then you still get procedures. Pneumothoraces are either watched if they are small, aspirated and watched if they are medium, or get a chest tube.

Perhaps that's why I like emergency medicine though. Instead of just doing procedures all day long like many specialties, you also get a lot of medical patients and a chance to try to play detective. Granted you never make a definitive diagnosis on many of your patients (some of which never have a definitive diagnosis), but it's rewarding nonetheless.

 

[Blue Frog]

Let's see, last night (and ONLY last night)'s procedures:

- IJ central line
- I&D facial abscess
- I&D L axillary abscess
- complicated closure of a severe finger/palm laceration in a professional pianist
- another thumb laceration (minor)
- fractured foot with a complicated laceration (open fracture) - turfed to ortho though
- laceration to the forehead
- lumbar puncture

I've done as many as six intubations in one 12-hour shift, and as many as ten central lines in a 12-hour shift. All of the above was during a senior 9-hour shift. I only did 1 I&D (facial), the LP, and the central line because my junior residents were getting slammed and I wanted to move patients out of the department quickly.

There are plenty of opportunities to do procedures in the emergency department. No, you will not be opening anyone's abdomen or doing surgery in the ED. However, no matter where you practice, you will get your share of fracture reductions, conscious sedations, chest tubes, etc.

Many patients are managed medically, but even then you still get procedures. Pneumothoraces are either watched if they are small, aspirated and watched if they are medium, or get a chest tube.

Perhaps that's why I like emergency medicine though. Instead of just doing procedures all day long like many specialties, you also get a lot of medical patients and a chance to try to play detective. Granted you never make a definitive diagnosis on many of your patients (some of which never have a definitive diagnosis), but it's rewarding nonetheless.

Sounds exciting. May I ask what type of ED you work in? (City/suburban) Is it Trauma I?

 

[GeneralVeers]

Typically if you're in a trauma center or county facility you will do more invasive procedures. Most community hospital EPs are limited to laceration repairs and I&D with the occasional central line.

At our county facility we do tons of Oral surgery procedures, central lines, peritoneal taps (get sick of these real fast), fracture reductions, splinting, etc. Seems that everyone in our neighborhood likes to beat up on everyone else.

 

[Apollyon]

Typically if you're in a trauma center or county facility you will do more invasive procedures. Most community hospital EPs are limited to laceration repairs and I&D with the occasional central line.

Just to clarify, a hospital can be both a community hospital AND a trauma center and county facility (my main hospital functions as such). What Gen Veers refers to is a suburban hospital.

 

[EM2BE]

I know this is thinking way ahead for me, but it is somewhat related. For internships and/or residencies, would you recommend working in a city setting for the chance to see a wide variety, or would you recommend working in the type of setting (rural, city, trauma level I/= or II) in which you would want to work?

Just to clarify, a hospital can be both a community hospital AND a trauma center and county facility (my main hospital functions as such). What Gen Veers refers to is a suburban hospital.

 

[Apollyon]

I know this is thinking way ahead for me, but it is somewhat related. For internships and/or residencies, would you recommend working in a city setting for the chance to see a wide variety, or would you recommend working in the type of setting (rural, city, trauma level I/= or II) in which you would want to work?

That's only one piece of a big pie, and your priorities may change as you advance through residency. One way or another, you'll be exposed to the things you need to in residency (either hands-on in the knife-and-gun clubs, or in lecture/education in places that aren't as high-volume).

Even though they have different flavors, every program sees at least 40,000 patients per year (which is a rule set by the EM RRC - Residency Review Committee), and most see much more. You will get what you need. There is one school of thought, though - some people feel that it is better to go to a high-volume, high-stress place for residency and get your ass kicked, in that you learn how to deal with it, and, no matter where you go after residency, you can handle it (either at the same volume, or less), instead of going from a lower-volume program to a job where you're seeing a higher-volume: it's the "easier to trade down than trade up" philosophy.

 

[BKN]

some people feel that it is better to go to a high-volume, high-stress place for residency and get your ass kicked, in that you learn how to deal with it, and, no matter where you go after residency, you can handle it (either at the same volume, or less), instead of going from a lower-volume program to a job where you're seeing a higher-volume: it's the "easier to trade down than trade up" philosophy.

Agree with that, but . . .No matter where you train, you'll be a lot slower when you get out then you think you are. Thought I was fast when I finished, but noone wanted to follow me because I was always 2 hours behind at the end of shift (back in the days of single coverage in big EDs). Two years later, I couldn't stand to follow the newbies.

 

[GeneralVeers]

Even though they have different flavors, every program sees at least 40,000 patients per year (which is a rule set by the EM RRC - Residency Review Committee), and most see much more. You will get what you need. There is one school of thought, though - some people feel that it is better to go to a high-volume, high-stress place for residency and get your ass kicked, in that you learn how to deal with it, and, no matter where you go after residency, you can handle it (either at the same volume, or less), instead of going from a lower-volume program to a job where you're seeing a higher-volume: it's the "easier to trade down than trade up" philosophy.

I agree completely. Having been exposed to both county, and suburban ED experiences, I can say that if you train at a busy county facility, get your ass kicked for 3 years, you'll be ready for anything.

 

[EM2BE]

I agree completely. Having been exposed to both county, and suburban ED experiences, I can say that if you train at a busy county facility, get your ass kicked for 3 years, you'll be ready for anything.

Thank you all!

 

[Hard24Get]

I agree completely. Having been exposed to both county, and suburban ED experiences, I can say that if you train at a busy county facility, get your ass kicked for 3 years, you'll be ready for anything.

Are there academic places to get one's ass kicked at?

 

[Dr. Wexler]

Agree with that, but . . .No matter where you train, you'll be a lot slower when you get out then you think you are. Thought I was fast when I finished, but noone wanted to follow me because I was always 2 hours behind at the end of shift (back in the days of single coverage in big EDs). Two years later, I couldn't stand to follow the newbies.

Is there a general rule on how the hand-off works between attendings or does it vary from place to place? Are there some instances when the doc will stay late to finished up stuff that he 'should' have gotten done? I'm guessing that "overtime" would be more tightly regulated if you are paid by the hour and less so at a place where compensation was based on production.

What is the proper etiquette at shift change?

 

[arrowsmith2]

...and anything "exciting" gets handled by the trauma surgeons.

True dat.

 

[GeneralVeers]

Are there academic places to get one's ass kicked at?

Probably, however the chaos, volume, and general decrepitness of the health of patients at a county hospital nearly guarantees an ass-kicking.

 

[BKN]

Is there a general rule on how the hand-off works between attendings or does it vary from place to place? Are there some instances when the doc will stay late to finished up stuff that he 'should' have gotten done? I'm guessing that "overtime" would be more tightly regulated if you are paid by the hour and less so at a place where compensation was based on production.

What is the proper etiquette at shift change?

Yes it varies. If paid by the shift or hour rather than by the RVU, the physician has less reason to stick around.

Etiquette at our place for hand off (by residents or attendings):
1. Appropriate H&P done completely and documented,
2. Completed studies documented
3. Diagnosis and differential generated, necessary diagnostic studies ordered
4. If consultation needed, leaving doc calls (since she knows the case). If consultant wishes something back before he comes (discouraged), he's told reciving doc will call him when ready.
5. Plan developed to a point where receiving doc can be told If lab A comes out positive do b, If negative do c.
6. If it's very clear what is likely to happen, leaving doc does scrips and discharge instructions on computer to be modified if necessary and printed later.

In short, handoffs are one of the most dangerous things that happen in EM (contributing factor in at least 1/3 of suits). The handoff needs to be greased on skids. The receiving doc should have very little to do and it should not require much thought. He has new patients to see and he doesn't have all the info that caused the leaving doc to do what he did. Even so, I often go back, rework the patient and come to opposite conclusions. So does everyone else.

 

[Jeff698]

re: hand-off:

Other rules.

1) Never, I repeat, never, hand off pelvics. Very poor form.
2) Diagnostic procedures should be done, ie LPs.
3) Have a plan.
4) Have a solid plan.
5) Be sure the oncoming resident knows the plan
6) If you're the oncoming resident, be sure you know the specific plan of the off going resident

Did I mention the importance of THE PLAN?

About the only exception to this is the 'sick' patient that comes in 5 minutes prior to shift change. You know, the ones you can't ignore until the new guy gets there? For these patients, I think its OK to take care of the ABCs and get labs cooking and then let the oncoming guy reassess and develop the specifics of the plan.

Take care,
Jeff