EM doctors abilities...

[docfos]

Hi everybody
From the first moment that I have considered EM , I had this question in my mind; how much independency an ep has in managing the patients in er? In other words, up to what point they manage their patients without calling surgeons or internists?
Thanx.

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[Sessamoid]

Hi everybody
From the first moment that I have considered EM , I had this question in my mind; how much independency an ep has in managing the patients in er? In other words, up to what point they manage their patients without calling surgeons or internists?
Thanx.

It's our patient until they leave the ED, technically. Functionally, consultants don't have any say until we call them. Until they need admission or surgery, we do what we feel is best for the patient.

 

[docfos]

It's our patient until they leave the ED, technically. Functionally, consultants don't have any say until we call them. Until they need admission or surgery, we do what we feel is best for the patient.

Thanx Sessamoid...,but I didnt get the point. Let me give you an example; A patient comes in with acute abdominal pain. EP does the h&p and orders basic labs, but he cant come to a diagnoses! At this point does he usually call the surgeon, or he orders more specific tests and keeps the patient in ED for more evaluation and coming to some reasonable ddx?( I am talking about a stable patient who is not dying!! )

 

[NinerNiner999]

Essentially - you've already given the answer. No need to call a surgeon until the acute abdominal pain reveals itself to be acute surgical abdominal pain. Keep doing the workup, get some films, and if you are convinced it is a surgical abdomen, call in the surgeon. Otherwise, as Sessamoid suggested, keep doing what is best for the patient (fluids, serial abdominal exams, etc.). If the patient improves with your management, send them home without consulting Surgery. If they stay the same or get worse after reasonable managment on your part, consider a consult or follow-up with their PMD assuming all testing has been negative.

 

[docfos]

Essentially - you've already given the answer. No need to call a surgeon until the acute abdominal pain reveals itself to be acute surgical abdominal pain. Keep doing the workup, get some films, and if you are convinced it is a surgical abdomen, call in the surgeon. Otherwise, as Sessamoid suggested, keep doing what is best for the patient (fluids, serial abdominal exams, etc.). If the patient improves with your management, send them home without consulting Surgery. If they stay the same or get worse after reasonable managment on your part, consider a consult or follow-up with their PMD assuming all testing has been negative.

Good response, thanx. is there a limmited time to keep the patient in ER?

 

[beyond all hope]

If you want to make diagnoses on non-critical patients, than EM is probably not a great field for you. In EM we focus on patient management and disposition. If you have belly pain/chest pain/headache/back pain/dizziness/whatever, I only have two questions 1) Do you need immediate treatment? 2) Do you need to be admitted or can you go home with symptomatic treatment and see your PMD later? If I'm doing any more than that I hold up the flow in the ED.

If you jump to a diagnosis in the ED, you can get yourself into a lot of trouble if you're wrong. Non-specific belly pain is a common diagnosis. If you say Gastroenteritis and then it turns out to be an appy you're in trouble.

Often you can actually make a Dx, but it's not your main goal, and you rarely get to find out if you're right or not because you don't follow up on the patient.

 

[docfos]

If you want to make diagnoses on non-critical patients, than EM is probably not a great field for you. In EM we focus on patient management and disposition. If you have belly pain/chest pain/headache/back pain/dizziness/whatever, I only have two questions 1) Do you need immediate treatment? 2) Do you need to be admitted or can you go home with symptomatic treatment and see your PMD later? If I'm doing any more than that I hold up the flow in the ED.

If you jump to a diagnosis in the ED, you can get yourself into a lot of trouble if you're wrong. Non-specific belly pain is a common diagnosis. If you say Gastroenteritis and then it turns out to be an appy you're in trouble.

Often you can actually make a Dx, but it's not your main goal, and you rarely get to find out if you're right or not because you don't follow up on the patient.

Thanx for clear explanation. But, if the EP is afraid of being in trouble, then who makes the DDX between GE and appy?! If a sergeon makes that mistake, will his or her responsibility be less?!

 

[Freeeedom!]

I guess I am lost in your question.
So many of my patients in given night are abdominal pain, and other than overt pathology, it doesn't matter who you call in...abdominal pain will go undiagnosed!!
Ask any surgeon, and they will tell you that often times they go without a diagnoses...and they see the more defined belly pains that come in!! Pelvic pain diagnoses (cysts, ectopics, PID) generally go to OB/GYN and those diagnoses are made in the ED.
At the institution where I train, the EM residents do virtually everything...example:

A critical patient arrived via EMS from an oncology office.
Patient was in resp distress, septic in appearance, febrile, a dialysis patient with a history of CHF and unable to make urine...altered mental status.
I tubed him...I gave the vent settings, I put in the NG, I gave the orders for antibiotics, I cultered and removed his PICC line, I started the EJ line, he went into SVT and I cardioverted him, I got the CT, I gave him the albumin and hydrocortisone for the persistant hypotension, I talked to the family and changed his code status...

IM did pretty much nothing other than write admitting orders and will see him in the ICU tomorrow....and usually it takes them WAY WAY WAY too long to do that! Many times I would love the help, but often that doesn't come...IM is too busy sitting in the cubby hole writing an H and P.

 

[JattMed]

Stop fighting! Or Jesus will never return!

 

[Sessamoid]

Hmmm interesting..... so by your comments I assume you feel specialists should:
1. See the patient from initial presentation in the ED
2. Stabilize him
3. Work-up and admit the patient

I don't know where exactly you inferred that from the parent post. He's just saying he wouldn't mind some help occasionally. It was a typical problem in residency for me that the IM resident would come down and spend his whole time writing a 5 page long H&P while procedures on the patient needed to be done and the patient's family needed things explained to them. That generally fell to the EM residents, since we also generally spoke better English.

Contrary to your comments, more often I see the converse situation in which the ED doc has no idea why the patient is here, has not examined the patent or obtained a history, has not stabilized the patient and has instead ordered 30 labs/studies(most of which are completely inappropriate). Their favorite line to consult specialists is "we don't know what's going on".

You're in LA, right? Christ, let me know what hospital you work at with such incompetent emergency docs so I can go and take their contract! I'd be honestly surprised if was true that most of the patients admitted to your service had never talked to nor been examined by the emergency physician.

And yeah, I just love saying "I have no idea what's going on." That's definitely my favorite line. I really enjoy the crap I'm gonna take for saying that, but sometimes it's true. I don't have the benefit of lots of time to make a decision. Please...

 

[spyderdoc]

No habla espanol, senor? Hehehe yes, since we non-EM doctors don't speak english as well as you, we let you do all the explanations
Actually, most of the patients admitted to IM can't remember a single word the EM physician ever said to them other than "the specialist(s) are going to see you". I have no problem with that since the information given to patients by EM tends to be incorrect.

With regards to which LA hospital ED docs, take your pick My favorite is definitely the Cedars-Sinai ED students(oops doctors)

Finally, thanks for confirming you don't know...

Oh, lord. Another god complex on our hands......
If only I had a dollar for everyone of these guys, my med school loans would be paid in full....

 

[Freeeedom!]

IM/Gas,

Sessamoid apparently read the post and understood...I can't seem to understand why you didn't or can't.

I have been in situations where I have admitted a patient to Medicine for the ICU...did everything except intubate the patient, 3 hours later (IM resident tooling around writing a H&P and reading about the causes of Hyponatremia), It was left to me to intubate.
The reality of the situation across the country is that EM is becoming the "go-to" specialty. The specialty that does virtually every procedure is EM. More and more, the EM is the 800 pound Gorilla of the hospital...whether that is answering codes on the floor or running the traumas or helping teach IM residents how to put in triple lumens!!.

The initial question was 'are EM doctors independent', my answer is "hell yeah, and there are times we wouldn't mind a bit of timely help once and a while...the ED is too busy for us to do EVERYTHING!'

 

[Sessamoid]

No habla espanol, senor? Hehehe yes, since we non-EM doctors don't speak english as well as you, we let you do all the explanations

At my residency, most of the IM residents were non-native English speakers. They sure as hell didn't speak much (if any) Spanish, which was our primary patient base. So I'm just as valid in generalizing my limited experience of IM docs as you are your limited experience of EM docs.

Actually, most of the patients admitted to IM can't remember a single word the EM physician ever said to them other than "the specialist(s) are going to see you". I have no problem with that since the information given to patients by EM tends to be incorrect.

Actually, judging from my experience, most patients can't even remember the name of their internist, even if they've been seeing them for years. Whether they're bright enough to remember their own names is debatable, but not remembering much the EP said isn't exactly surprising then.

With regards to which LA hospital ED docs, take your pick My favorite is definitely the Cedars-Sinai ED students(oops doctors)

Really? Care to put your real name behind those accusations or are you only this brave behind the veil of anonymity? Take my pick? So you have extensive experience with every hospital in LA county? I find that rather hard to believe, given the number we have here.

Anyway, welcome to my killfile.

 

[Sessamoid]

Oh, lord. Another god complex on our hands......
If only I had a dollar for everyone of these guys, my med school loans would be paid in full....

Flashbacks to another offensive poster who kept that awful monologue from Malice in his sig....

 

[VienneseWaltz]

What's that smell? ... Ah yes, I see the low post-count now ... That confirms it--no mistaking the odor of a troll ...

 

[spyderdoc]

LOL. I am God

If you had a clue for every single one of your quotes... well you know...

Well, if this god don't mellow out, we will see if he can resurrect his deleted posts after Neo, or myself delete them. Mellow out dude, or you will be shut down. This is a forum that we like to maintain on a friendly, collegial manner. Lighten up or be gone my friend.
Mark

 

[roja]

docfos- I think you will find that different institutions have different policies regarding when consultants are called. and like everything in medicine, it can be very attending dependent.

In general, it is the job of the EP to stabilize a patient, determine the cheif complaint, begin a workup based on the likely diagnosis, with particular emphasis on life threatening (or if left untreated, life threatening outcomes). And then based on the H&P, initial work up, the EP will then decide who, if any, a consult is needed.

Now, take belly pain. I just heard an interesting story from a fellow from a cali program. The surgeons and radiologists decided that the EP's were ordering entirely to many CT's. The surgeons felt that they were better able to decide who needed a CT and who didn't. And thus a new policy was initiated that ALL pt's with abdominal pain had to be seen by surgery before anything was ordered. (labs, rads, etc) Needless to say, this lasted approximately 3 weeks before the surgeons realized that an INCREDIBLE amount of patients are dealt with without CT's and without surgical consult.

So, the autonomy of the EP is very broad. You will decide what consultants you want, when you want them, and you will work in conjunction with them while the patient is in the ED.

You will often manage your ICU patients (especially in a residency hospital) as if there is an emergent issue, the medicine residents are usually busy on the floor and can't get down in time to deal with it.

Hope that helps.

 

[grouptherapy]

masters of triage. masters of resuscitation

 

[Sessamoid]

masters of triage. masters of resuscitation

MASTERS OF THE UNIVERSE!!!

whew... got that out of my system. Time for a beer...

 

[FoughtFyr]

MASTERS OF THE UNIVERSE!!!

whew... got that out of my system. Time for a beer...

Is the "Power of Grayskull" a WMD?

- H

 

[grouptherapy]

speaking of beer, i just hosted poker night at my place. at the bar was corona, heineken, mgd, sharps, bottled water and a wide assortment of liquor. everyone went for the corona. this demonstrates the power of marketing

 

[Sessamoid]

speaking of beer, i just hosted poker night at my place. at the bar was corona, heinekin, mgd, sharps, bottled water and a wide assortment of liquor. everyone went for the corona. this demonstrates the power of marketing

Yuck. There's a great bar (that's gone to the yuppies in recent years) here in Santa Monica called "Father's Office." They don't serve mass market beers. The most highly distributed beer they sell is Guinness. There is a popular story around here about an exchange between some marketing-fed yuppie and the bartender at Father's Office, which goes something like this:

Yuppie: Do you guys have Heineken?

Bartender: No.

Yuppie: Well, do you have anything that tastes like Heineken?

Bartender: Let's hope not.

 

[Febrifuge]

speaking of beer, i just hosted poker night at my place. at the bar was corona, heinekin, mgd, sharps, bottled water and a wide assortment of liquor. everyone went for the corona. this demonstrates the power of marketing

Yeah, I dunno. Not to be a dill-hole about it, but maybe it demonstrates the power of having no good beer choices. Given that selection, I'd drink the water and/or liquor (...and lose all my money).

 

[roja]

What a horrible selection! I definately got spoiled working at a place that had 60 on tap adn >100 in the bottle.....

 

[docfos]

I guess I am lost in your question.
So many of my patients in given night are abdominal pain, and other than overt pathology, it doesn't matter who you call in...abdominal pain will go undiagnosed!!
Ask any surgeon, and they will tell you that often times they go without a diagnoses...and they see the more defined belly pains that come in!! Pelvic pain diagnoses (cysts, ectopics, PID) generally go to OB/GYN and those diagnoses are made in the ED.
At the institution where I train, the EM residents do virtually everything...example:

A critical patient arrived via EMS from an oncology office.
Patient was in resp distress, septic in appearance, febrile, a dialysis patient with a history of CHF and unable to make urine...altered mental status.
I tubed him...I gave the vent settings, I put in the NG, I gave the orders for antibiotics, I cultered and removed his PICC line, I started the EJ line, he went into SVT and I cardioverted him, I got the CT, I gave him the albumin and hydrocortisone for the persistant hypotension, I talked to the family and changed his code status...

IM did pretty much nothing other than write admitting orders and will see him in the ICU tomorrow....and usually it takes them WAY WAY WAY too long to do that! Many times I would love the help, but often that doesn't come...IM is too busy sitting in the cubby hole writing an H and P.

your response was great. thanks.
Can you tell me which progaram are you in? and/or put a list of programs that you think are almost the same as yours ( EM residents do everything)? I appreciate that.

 

[roja]

your response was great. thanks.
Can you tell me which progaram are you in? and/or put a list of programs that you think are almost the same as yours ( EM residents do everything)? I appreciate that.

There are so many EM programs like this (mine included) that you really are goign to have to narrow down to a degree.

Do you want a 1-3, 1-4 or 2-4 year program. Where do you want to live? Big city? east coast? south? west coast?

 

[docfos]

docfos- I think you will find that different institutions have different policies regarding when consultants are called. and like everything in medicine, it can be very attending dependent.

In general, it is the job of the EP to stabilize a patient, determine the cheif complaint, begin a workup based on the likely diagnosis, with particular emphasis on life threatening (or if left untreated, life threatening outcomes). And then based on the H&P, initial work up, the EP will then decide who, if any, a consult is needed.

Now, take belly pain. I just heard an interesting story from a fellow from a cali program. The surgeons and radiologists decided that the EP's were ordering entirely to many CT's. The surgeons felt that they were better able to decide who needed a CT and who didn't. And thus a new policy was initiated that ALL pt's with abdominal pain had to be seen by surgery before anything was ordered. (labs, rads, etc) Needless to say, this lasted approximately 3 weeks before the surgeons realized that an INCREDIBLE amount of patients are dealt with without CT's and without surgical consult.

So, the autonomy of the EP is very broad. You will decide what consultants you want, when you want them, and you will work in conjunction with them while the patient is in the ED.

You will often manage your ICU patients (especially in a residency hospital) as if there is an emergent issue, the medicine residents are usually busy on the floor and can't get down in time to deal with it.

Hope that helps.

Thanks Roja, very good explanation. I see that you are in NYC, can you please put an overal rank list of EM programs there, as if you want to go to a residency again. ( with emphasis on training ).Appreciate that.

 

[docfos]

There are so many EM programs like this (mine included) that you really are goign to have to narrow down to a degree.

Do you want a 1-3, 1-4 or 2-4 year program. Where do you want to live? Big city? east coast? south? west coast?

Well, number of years doesnt matter, but preferably 1-4 or 1-3. About the place; CA, PA, NJ, NY, VA. But I havent limited myself to any states, means that I would be happier to work in a good program in any other states than in a "not good" program in those 5 states. I appreciate your responses.

 

[roja]

docfos- well, I wasn't very informed in terms of programs in NYC as no one I knew was familiar with the programs. I just applied to all the programs in NYC. I have a list of generalized summaries of the places that I interviewed at. Feel free to PM me.

 

[Freeeedom!]

Yeah, I go to Wright State...we are the 800 pound gorilla of residencies in our city.