EM Future

[thegenius]

See; I hear you on this, amigo: but let me point this out.

The patient is then the one who suffers. Had a buddy call me last week, wife had a patellar effusion.

She went to her PMD, who sent her to the ER (?)
ER says "not an emergency, go back to your PMD."
PMD says: "lets send you to ortho in 6 weeks or so"

Just freaking tap the knee, people. Takes :60 seconds.


Sidebar: Patient was seen by a NP in the ED, who did an x-ray and sent labs, said "everything is normal" and sent her home.
As it was explained to me, the x-ray/labs were "to see if it's infected".
Patient was told by PLP that "its dirty here in the ER; so we won't tap it here" (What, send it to the OR?!)
Buddy sent me a picture. Uncomplicated, simple effusion.
You have to have a very smooth brain to wonder whether or not its "infected, lolz - bettr send labz. Look! I'm healthcaring".

It's not even so much the hot knee that is sent to the ER (the vast majority of these are not septic anyway. they can be tapped as an outpatient. Do you know how many septic knee arthritis diagnoses I make a year? Probably 1. And how many times does Ortho send someone to the ER to be admitted for septic arthritis? Less than 1 / year).

it's all of this other nonsense that gets sent like high blood pressure, i don't feel good, abdominal pain, my chronic leg wound is not healing, all that crap that we deal with that is not the pervue of Emergency Medicine.

It's so interesting that nobody seems to like doing procedures. I hate them because they are a time suck and I can see two other patients during that time. It's not worth my time. It's not worth PCP's time to get trained to do them. It's not worth Ortho's time because they won't come to the ER to tap a knee, for instance. It's like ER docs get all the crappy reimbursing procedure CPTs and all the fun high reimbursing ones (e.g. surgery)

It's just terrible for patients. They are paying more and more and the care they receive is getting ****tier and ****tier

---

Members don't see this ad.

 

[thegenius]

I don't tap them in the ER just for regular arthritic effusions. I only do it if there is concern for acute infection. Getting lidocaine, talking the patient through the procedure, finding the US, cleaning the US, and doing the procedure takes 20-30 minutes of time.

BTW, why is getting lidocaine from the nurses in the ED so tough?? I remember when we used to just have a drawer full of them and would grab what we needed.

because you can more easily bill for it.

The kaiser I work at has a cart on wheels with several drawers that have all suturing things needed
- lidocaine 1%, lidocaine 2%, lidocaine 1% with epi, lidocaine 2% with epi, bupivicaine
- all suture
- suture kits
- scalpels
- glue
- gloves
- steri strips
and everything else needed

just roll the cart into the room and you have what you need. don't have to involve nurses at all.

 

[Splenda88]

Volume.

A lot of physicians don’t appreciate this until they get out in the real world and practice. For PM&R, one of the most lucrative gigs is 1099 SAR (rounding at SNF’s); it’s at least 350k for like 20-24 hrs work/week. The reason is volume. You can round on a lot of SNF patients very quickly, much faster than an outpatient practice where you have to schedule patients into time slots and deal with logistical issues. Every time I need to perform an injection, it actually slows me down considerably.

You see this commonly in derm and optho as well. Clinics are high volume (even accounting for the procedures).

Why didn't I do PM&R? Why these opportunities do not exist in IM?

 

[Franzd'Epinay]

Not sure this is at all true. There is tremendous value in ownership. There are plenty of docs who dont have MLPs who do quite well. The issue as you alluded to is if you dont do this it is a loss for you.

The easiest example is Derm. The doc can only do so much so they hire some hottie Jenny Mcjennyson to do botox and whatever other BS people pay tons of cash for. The DERM MD can keep doing MD stuff and Jenny can do whatever nonsense cash folks will pay for. MD profits, Jenny makes more than most of her essential oil touting fellow grads.

other option for DERM MD is make less and see fewer patients and DERM MD 2 does this to her and her patients decide to go across town cause everything is done in 1 location.

I was recently driving home and saw a huge billboard for a "dermatology practice". As is usual with these things, there was a huge picture of the owner on the corner, along with their name: "So-and-so, APRN". I was honestly surprised that she didn't have a DNP to advertise herself as "Dr."--although I would bet money that she is currently enrolled in some online program to do just that.

There is a pretty good chance this person got her "training" doing what you described. Midlevels, as a group, will never be satisfied doing the "simple" stuff and getting the "simple" money.

 

[doctalaughs]

I was recently driving home and saw a huge billboard for a "dermatology practice". As is usual with these things, there was a huge picture of the owner on the corner, along with their name: "So-and-so, APRN". I was honestly surprised that she didn't have a DNP to advertise herself as "Dr."--although I would bet money that she is currently enrolled in some online program to do just that.

There is a pretty good chance this person got her "training" doing what you described. Midlevels, as a group, will never be satisfied doing the "simple" stuff and getting the "simple" money.

Definitely a problem across all medicine (aggressive encroachment by pretend doctors). Dermatologists I think are aware of the issue and fighting back— having seen where this leads in more far-along specialties (anesthesiology, EM):

https://www.mdedge.com/dermatology/article/211371/business-medicine/aad-members-vote-remove-board-member?sso=true

On the other side of the fight is PE-owned practices who love midlevels as it lines investor pockets. Of course there are greedy private practice owners who also overuse them to rake in more money as well. I manage all the books for my practice and you can easily bring home and extra 100k-150k/yr in your own pocket supervising a derm PA. The key is what you let them do (hint- not skin checks, surgery, skin cancer or rashes—- acne and warts which is less lucrative but more ethical).

 

[sloh]

Why didn't I do PM&R? Why these opportunities do not exist in IM?

Definitely not a glamorous job though. It’s important to have ample time for hobbies, passions, interests, relationships, family on the side if doing this type of work. What’s interesting is there is little to no exposure to subacute rehab in pretty much all PM&R residencies.

 

[Splenda88]

Definitely not a glamorous job though. It’s important to have ample time for hobbies, passions, interests, relationships, family on the side if doing this type of work. What’s interesting is there is little to no exposure to subacute rehab in pretty much all PM&R residencies.

I am assuming your job is a 1099 gig... Do you buy your own medical insurance? This could be quite expensive if you have a family.

 

[sloh]

I am assuming your job is a 1099 gig... Do you buy your own medical insurance? This could be quite expensive if you have a family.

Yeah I do. It’s important to factor in the benefits of W2 offers when debating between W2 and 1099. I used to work for Kaiser and the benefits, pension, etc. were awesome. That said, my gross on a slower month is 2x what a PM&R doc who has made partnership at Kaiser makes and I work like half the hours I did while at Kaiser—so I find it’s worth it for me. The autonomy and flexibility are priceless as well. At least for PM&R, I felt like a manipulable cog as a W2..and not even under the thumb of an actual physician.....a nurse.

 

[VA Hopeful Dr]

Seriously.
Only indication for the EP to tap a knee is for septic knee.

This should be done in the primary care setting. How it isn't baffles me. No disrespect to our FP colleagues on here.

Generally agreed here, or at least punt to ortho. It shouldn't go to y'all unless we have actual concerns for a septic joint which has been pointed out numerous times is pretty rare.

As for how it isn't - purely a time thing. I can see 2 follow ups in the time in takes to tap a joint. That's literally (for me at least) $100 that I would lose by tapping the joint versus seeing other patients. Don't get me wrong, 99% of the time I'll tap the joint no problem. But that's the main reasoning behind it.

 

[GeneralVeers]

Generally agreed here, or at least punt to ortho. It shouldn't go to y'all unless we have actual concerns for a septic joint which has been pointed out numerous times is pretty rare.

As for how it isn't - purely a time thing. I can see 2 follow ups in the time in takes to tap a joint. That's literally (for me at least) $100 that I would lose by tapping the joint versus seeing other patients. Don't get me wrong, 99% of the time I'll tap the joint no problem. But that's the main reasoning behind it.

The problem is that Jenny usually sees these in clinic, and all joint pain is "Rule out septic Arthritis" to her. This would be a great time for Jenny to prove she's the equal of a physician and tap the knee.

 

[thegenius]

The problem is that Jenny usually sees these in clinic, and all joint pain is "Rule out septic Arthritis" to her. This would be a great time for Jenny to prove she's the equal of a physician and tap the knee.

totally true
doctors do this crap too all the time. The county clinic sent me a teenage girl who just got back from africa 2 weeks ago for having blood diarrhea and abdominal pain for 2 weeks. They sent me the girl to "r/o appendicitis". They actually sent me the girl to just figure out the problem. They totally punted on taking care of the patient.

 

[Groove]

I don't mind any of the FM guys sending me patients and I'll tap knees all day long though I only tap septic ones these days. Does FM even have arthrocentesis requirements for residency? I doubt it's part of their training guys. I agree that it's not difficult but just remember...we're tapping tons of joints during residency where I doubt FM guys are doing any of that. They've got to have a well oiled process to turn over those rooms based on scheduling and just a few procedures would totally destroy their flow. I'm honestly perfectly fine to have the business in today's environment. You want to encourage them to send this type of stuff to the ED, not dissuade it. Remember, it's more business for us! I feel the exact same about the simple abscesses requiring I&D.

 

[jw3600]

See; I hear you on this, amigo: but let me point this out.

The patient is then the one who suffers. Had a buddy call me last week, wife had a patellar effusion.

She went to her PMD, who sent her to the ER (?)
ER says "not an emergency, go back to your PMD."
PMD says: "lets send you to ortho in 6 weeks or so"

Just freaking tap the knee, people. Takes :60 seconds.


Sidebar: Patient was seen by a NP in the ED, who did an x-ray and sent labs, said "everything is normal" and sent her home.
As it was explained to me, the x-ray/labs were "to see if it's infected".
Patient was told by PLP that "its dirty here in the ER; so we won't tap it here" (What, send it to the OR?!)
Buddy sent me a picture. Uncomplicated, simple effusion.
You have to have a very smooth brain to wonder whether or not its "infected, lolz - bettr send labz. Look! I'm healthcaring".

Lol. This is ****ing classic midlevel garbage.

 

[Rekt]

Why are we talking about arthrocentesis? We can go on for hundreds of pages about crap we see in the ED that other physicians should be able to handle but they can't or won't. Who cares, light us up. We need the business anyway. Thank you for this interesting intellectually stimulating consult.

We should get back to sulking and complaining about how much acep sucks.

 

[jw3600]

This is really short sighted and would essentially make 95% of the docs sell outs. 99% of the docs who are hospital employed have APCs working for them in some capacity. 90% of Private practices I know have APCs working for them in some capacities.

Does that make them all sell outs? We all have to have jobs and even if you owned your own group you still have to be competitive. Hiring APCs are essential for survival which is the economic reality. Either you sit on your high horse/refuse APCs and go out of business or you hire APCs to be competitive.

Imagine if two private Cardiology groups with 4 doc each across the street from each other with the same volume/revenue. Each doc takes home $1M/yr. Both groups volume explodes and volume has 4x. Insurance reimbursement plummets and revenue only goes up by 50%.

Group A, high horse group, hires all MDs now has 16 MDs with $6M in profits. Now each doc takes home $375K. Docs start to all quite and go work for the local hospital making 500K/yr with much less business hassle. Group goes bankrupt and closes down.

Group B, economically savvy, figure out that most of the work/overnight call can be handled by APCs. They hire 12 APCs and costs them 1.5M in salary. These 4 docs now share 4.5M in profits. Each now take home $1.1M.

Do you want to be the high horse group now working for a new master or the economically savvy group still calling the shots?

I would say the economically savvy group is doing more for their specialty by allowing a future outlet to hire cardiologist b/c they are economically sound. The other group just died on their high horse.

I would never pretend that I am any more moral than anyone else. Economics drives business which drives what you are able to do. I would love to turn back the clock 20 yrs when I started where we owned our private group making 400K/yr with almost complete autonomy. This is just not the reality so either you do what is best for you/your specialty or reality gets showed down your throat.

You act like we don’t understand what you're saying. We get it. It’s just messed up. It’s profits over patients at the expense of your colleagues. You just like your side of the fence.

 

[EMhawkeye]

Collaborating physician for nurse practitioner - About Us

Collaborating physician for nurse practitioner - We specialize in connecting collaborative physicians with practice clinicians!

collaboratingdocs.com

Someone helping to destroy our profession. Offering her "services" as a collaborating physician to np's. When a mistake happens, I hope the malpractice attorneys take her to the cleaners

 

[Splenda88]

Collaborating physician for nurse practitioner - About Us

Collaborating physician for nurse practitioner - We specialize in connecting collaborative physicians with practice clinicians!

collaboratingdocs.com

Someone helping to destroy our profession. Offering her "services" as a collaborating physician to np's. When a mistake happens, I hope the malpractice attorneys take her to the cleaners

Well, if you can't beat them, join them and try to rake in some $$$...

Don't leave it only to the surgeons to milk the system.

 

[Cinclus]

Why are we talking about arthrocentesis? We can go on for hundreds of pages about crap we see in the ED that other physicians should be able to handle but they can't or won't. Who cares, light us up. We need the business anyway. Thank you for this interesting intellectually stimulating consult.

We should get back to sulking and complaining about how much acep sucks.

I have a final story about arthrocentesis/septic joints, because apparently, arthrocentesis isn't even how you diagnose them. You see, I was recently transferred a patient from a nearby hospital with concern for septic knee. And this knee was very concerning. Why the transfer, you may ask? Because the other hospital's CT scanner was down.

This transfer made me actually dead. NP transfer.

 

[sloh]

I have a final story about arthrocentesis/septic joints, because apparently, arthrocentesis isn't even how you diagnose them. You see, I was recently transferred a patient from a nearby hospital with concern for septic knee. And this knee was very concerning. Why the transfer, you may ask? Because the other hospital's CT scanner was down.

The patient was transferred by an NP. I was enraged at the lack of knowledge.

The one saving grace is MLP's will help keep the radiology job market robust 😂

 

[oldtown]

The one saving grace is MLP's will help keep the radiology job market robust 😂

Until radiologists get squeezed out by AI. And, then AI will get squeezed out by MLAI’s

 

[GeneralVeers]

I have a final story about arthrocentesis/septic joints, because apparently, arthrocentesis isn't even how you diagnose them. You see, I was recently transferred a patient from a nearby hospital with concern for septic knee. And this knee was very concerning. Why the transfer, you may ask? Because the other hospital's CT scanner was down.

This transfer made me actually dead. NP transfer.

I would have refused that transfer, under the grounds that the sending facility had the capability to deal with that complaint.

 

[Franzd'Epinay]

Until radiologists get squeezed out by AI. And, then AI will get squeezed out by MLAI’s

"Brain of Wolfram Alpha, heart of Yahoo Answers"

 

[Cinclus]

I would have refused that transfer, under the grounds that the sending facility had the capability to deal with that complaint.

We have this wonderful auto-accept system. The docs aren't involved at all. I get these great, infuriating surprises all the time. Often, transferring facilities haven't even stabilized the patient before transfer. Tons of patients arriving with BPs 60/40. I love it.

"Nice to meet you. I am going to put a big IV in your neck now, even though I don't have time to be placing 4 central lines in unstable transfers while the ED backs up." - Actual recent shift. We were slammed, and we had about a million auto-accept transfers who were sent to us hypotensive without central access...not even getting peripheral pressors, a lot hadn't even received appropriate fluids. They got peripheral pressors for a while until I got around to placing lines they should have already had.

 

[bravotwozero]

We have this wonderful auto-accept system. The docs aren't involved at all. I get these great, infuriating surprises all the time. Often, transferring facilities haven't even stabilized the patient before transfer. Tons of patients arriving with BPs 60/40. I love it.

"Nice to meet you. I am going to put a big IV in your neck now, even though I don't have time to be placing 4 central lines in unstable transfers while the ED backs up." - Actual recent shift. We were slammed, and we had about a million auto-accept transfers who were sent to us hypotensive without central access...not even getting peripheral pressors, a lot hadn't even received appropriate fluids. They got peripheral pressors for a while until I got around to placing lines they should have already had.

It's stories like this that make me wonder that perhaps i'm better off in my (albeit lower paying) low volume FSED, at times. I'm sure a happy medium between these two extremes exists, but is becoming more difficult to find.

 

[thegenius]

I don't mind any of the FM guys sending me patients and I'll tap knees all day long though I only tap septic ones these days. Does FM even have arthrocentesis requirements for residency? I doubt it's part of their training guys. I agree that it's not difficult but just remember...we're tapping tons of joints during residency where I doubt FM guys are doing any of that. They've got to have a well oiled process to turn over those rooms based on scheduling and just a few procedures would totally destroy their flow. I'm honestly perfectly fine to have the business in today's environment. You want to encourage them to send this type of stuff to the ED, not dissuade it. Remember, it's more business for us! I feel the exact same about the simple abscesses requiring I&D.

No I hear what you are getting at, and I'm about to complain about a job I willingly took. It's very hard to make all patients happy all the time when they come into the ER anytime they want and want instant, full, and thorough medical care 24-7.

Surprisingly our flow gets totally disrupted too by doing just a few procedures, and most of the procedures we do are not emergencies. We do them because they are thrust upon us by others who don't want to do them. And as Rusted Fox wrote, it's the patients who suffer because they are not sent to the right place. I tap 1 knee every 2 months. Ortho has done more knee arthrocentesis in 1 year than I'll ever do in my lifetime.

Listen I understand that that referrals is what butters our bread. What I'm suggesting is my bread is already buttered enough. Most of the time I don't need more butter. it's gonna give me heart disease and cerebrovascular disease.

It's very hard to design a health care system where doctors do the right thing.

 

[thegenius]

I have a final story about arthrocentesis/septic joints, because apparently, arthrocentesis isn't even how you diagnose them. You see, I was recently transferred a patient from a nearby hospital with concern for septic knee. And this knee was very concerning. Why the transfer, you may ask? Because the other hospital's CT scanner was down.

This transfer made me actually dead. NP transfer.

I would have not accepted that transfer. If the patient was coming from an "Emergency Department", one of the skills of an Emergency Department should be to perform an arthrocentesis. I would have politely told the NP to contact their supervising physician for further instructions.

That is a lateral transfer, illegal under EMTALA

 

[RustedFox]

@GeneralVeers has tales of patella dislocation transfers and such from RLPs out in the community.

 

[GeneralVeers]

We have this wonderful auto-accept system. The docs aren't involved at all. I get these great, infuriating surprises all the time. Often, transferring facilities haven't even stabilized the patient before transfer. Tons of patients arriving with BPs 60/40. I love it.

"Nice to meet you. I am going to put a big IV in your neck now, even though I don't have time to be placing 4 central lines in unstable transfers while the ED backs up." - Actual recent shift. We were slammed, and we had about a million auto-accept transfers who were sent to us hypotensive without central access...not even getting peripheral pressors, a lot hadn't even received appropriate fluids. They got peripheral pressors for a while until I got around to placing lines they should have already had.

Meh. You can run pressors up to 24 hours in a peripheral. Start pressors and move on. ICU could actually help us out from time to time.....

 

[GeneralVeers]

@GeneralVeers has tales of patella dislocation transfers and such from RLPs out in the community.

It's fascinating that when you tell the sending Noctor that you will likely discharge the patient without every seeing an ortho, and they still choose to send.

 

[MechEDoc]

I would have not accepted that transfer. If the patient was coming from an "Emergency Department", one of the skills of an Emergency Department should be to perform an arthrocentesis. I would have politely told the NP to contact their supervising physician for further instructions.

That is a lateral transfer, illegal under EMTALA

In fairness, lots of small hospitals can't run a full set of synovial fluid studies outside of certain hours (i.e. when the pathologist feels like working). I can tap a knee multiple ways (medial, lateral, suprapatellar, +/- US), but I can't make the lab run the required studies at times. Which has led to transfers...

 

[Porfirio]

I will take all the patient volume. If COVID taught me anything, even I can be jobless if patients stop coming. Bring them all. Just staff us well.

 

[bravotwozero]

ICU could actually help us out from time to time.....

What a concept!!! At my previous gig, we reached an agreement with the ICU docs that during regular daytime hours, they will cover the floor codes. Makes sense since that patient is going to end up in the ICU anyway.

Well, floor codes kept happening, and ICU docs kept not showing up because 'clinic', or 'rounding'...So then we got told to 'assume' ICU doc won't be there and just do floor codes and intubations.

 

[southerndoc]

I would have not accepted that transfer. If the patient was coming from an "Emergency Department", one of the skills of an Emergency Department should be to perform an arthrocentesis. I would have politely told the NP to contact their supervising physician for further instructions.

That is a lateral transfer, illegal under EMTALA

Yes, but only if you accept it is it an EMTALA violation to them. If you don't accept it, it's an EMTALA violation to you.

Of course, like anything with EMTALA, it's all going to be up to the opinion of the CMS investigator assigned to your case. One CMS investigator told me if they request transfer to your facility, and you have the capacity to accept and the specialty needed to treat, then anything other than "yes" is an EMTALA violation. Even if it is the worst reason to transfer ever.

I'm surprised EMTALA hasn't weighed in on NP transfer to another ER to get an MD evaluation in those ER's that aren't staffed by an MD 24/7 (if they truly exist; I've only heard rumors).

 

[Franzd'Epinay]

I would have not accepted that transfer. If the patient was coming from an "Emergency Department", one of the skills of an Emergency Department should be to perform an arthrocentesis. I would have politely told the NP to contact their supervising physician for further instructions.

That is a lateral transfer, illegal under EMTALA

I still remember a nonsense transfer that I had to do.

Elderly lady with PNA and septic by the old definition on arrival (fever, tachycardia, lekocytosis), but never hypotensive. Tachycardia and fever resolved after treatment.

Went to admit the patient to the floor of this community hospital, but the NP covering the floor was adamant that the patient needed to go to the ICU because of reasons. The NP covering the ICU was in turn adamant that this hemodynamically stable patient needed a central line because of reasons.

I ended up just doing a direct admit to the regular floor of the mothership hospital.

 

[RustedFox]

I still remember a nonsense transfer that I had to do.

Elderly lady with PNA and septic by the old definition on arrival (fever, tachycardia, lekocytosis), but never hypotensive. Tachycardia and fever resolved after treatment.

Went to admit the patient to the floor of this community hospital, but the NP covering the floor was adamant that the patient needed to go to the ICU because of reasons. The NP covering the ICU was in turn adamant that this hemodynamically stable patient needed a central line because of reasons.

I ended up just doing a direct admit to the regular floor of the mothership hospital.

Dear Lord.

You're the physician, and you have two RLPs telling you where to place the patient?

What kind of madness is this?

 

[Franzd'Epinay]

Dear Lord.

You're the physician, and you have two RLPs telling you where to place the patient?

What kind of madness is this?

At a certain point I just thought it would be in the patient's best interest to not be admitted to that hospital if those would be the people in charge of her care.

 

[RustedFox]

At a certain point I just thought it would be in the patient's best interest to not be admitted to that hospital if those would be the people in charge of her care.

See; that would be it for me.
I would be in the c-suite, pointing out this shining example of RLPs not knowing how to medicine.

That's how you lose a job, fast.

 

[Apollyon]

See; that would be it for me.
I would be in the c-suite, pointing out this shining example of RLPs not knowing how to medicine.

That's how you lose a job, fast.

Dude - that's 3 times. What is "RLP"? I get the level provider, but, I can't come up with anything clever for the "R".

 

[RustedFox]

Dude - that's 3 times. What is "RLP"? I get the level provider, but, I can't come up with anything clever for the "R".

You speak French.
I know you do.

French word for "delayed".

 

[Apollyon]

You speak French.
I know you do.

French word for "delayed".

I didn't know that YOU did!

That certainly was not intuitive (to me, at least).

 

[RustedFox]

I didn't know that YOU did!

That certainly was not intuitive (to me, at least).

I don't speak French.
My Spanish is probably 7/10 and improving.

 

[MechEDoc]

I don't speak French.
My Spanish is probably 7/10 and improving.

If you're good with engines, it's the opposite of advancing the spark plug timing....

 

[Siggy]

Meh. You can run pressors up to 24 hours in a peripheral. Start pressors and move on. ICU could actually help us out from time to time.....

Yep... when I have 36+ patient encounters in a day, I totally have time to do the emergency physician's job in the emergency department stabilizing a patient with an emergency.

I guess the emergency physician hadn't completed the resuscitation fellowship (I always assumed that resuscitation was a core competency of emergency medicine residencies).

Advanced Resuscitation Training Program (ARTP) | Renaissance School of Medicine at Stony Brook University

The Advanced Resuscitation Training Program, or ARTP, is a fellowship program designed to provide EM physicians with advanced training in Resuscitation Medicine with a particular emphasis on Critical Care in the ED.

renaissance.stonybrookmedicine.edu

 

[Cinclus]

I would have not accepted that transfer. If the patient was coming from an "Emergency Department", one of the skills of an Emergency Department should be to perform an arthrocentesis. I would have politely told the NP to contact their supervising physician for further instructions.

That is a lateral transfer, illegal under EMTALA

We have auto-acceptance, unfortunately. It has caused all sorts of transfer horror.

 

[GeneralVeers]

Yep... when I have 36+ patient encounters in a day, I totally have time to do the emergency physician's job in the emergency department stabilizing a patient with an emergency.

I guess the emergency physician hadn't completed the resuscitation fellowship (I always assumed that resuscitation was a core competency of emergency medicine residencies).

Advanced Resuscitation Training Program (ARTP) | Renaissance School of Medicine at Stony Brook University

The Advanced Resuscitation Training Program, or ARTP, is a fellowship program designed to provide EM physicians with advanced training in Resuscitation Medicine with a particular emphasis on Critical Care in the ED.

renaissance.stonybrookmedicine.edu

You don't need a central line to stabilize. Pressors can be run for 24 hours through a peripheral line, and a PICC line can be ordered in the AM. Not sure why central line = resuscitation to so many. When you have 50 patient encounters in 10 hours including managing the Noctor's patients, you don't always have time to do every procedure that's not emergent.

 

[The Knife & Gun Club]

Yep... when I have 36+ patient encounters in a day, I totally have time to do the emergency physician's job in the emergency department stabilizing a patient with an emergency.

I guess the emergency physician hadn't completed the resuscitation fellowship (I always assumed that resuscitation was a core competency of emergency medicine residencies).

Advanced Resuscitation Training Program (ARTP) | Renaissance School of Medicine at Stony Brook University

The Advanced Resuscitation Training Program, or ARTP, is a fellowship program designed to provide EM physicians with advanced training in Resuscitation Medicine with a particular emphasis on Critical Care in the ED.

renaissance.stonybrookmedicine.edu

To be fair, that fellowship is a purely academic one. It’s meant for people who would’ve otherwise done the 2 year crit fellowship, then returned to EM to teach residents about crit or study acute resuscitation in a research context.

Not meant to teach resus for people in the community.

 

[Siggy]

You don't need a central line to stabilize. Pressors can be run for 24 hours through a peripheral line, and a PICC line can be ordered in the AM. Not sure why central line = resuscitation to so many. When you have 50 patient encounters in 10 hours including managing the Noctor's patients, you don't always have time to do every procedure that's not emergent.

1. Those are often US confirmed lines in the AC. How many people are just using any line the RN can get for their peripherial pressors? The nurses in one of the larger studies examined the IV site every 2 hours... do your nurses have time to properly monitor the site? I feel like long term peripherial pressors falls into the "we read an abstract that we agree with... therefore we do it... but we never take any of the precautions involved with that actual study."

2. Why are people complaining when Outside ED sends you something that people think is awesome?

3. If you come into the ICU for your family member and they've been on peripherial pressors through a questionable IV for 20 hours while waiting for the PICC line, would you be happy?

 

[HemorrhagicShock]

3. If you come into the ICU for your family member and they've been on peripherial pressors through a questionable IV for 20 hours while waiting for the PICC line, would you be happy?

In a lot of cases I would actually be pretty satisfied with that as long as the IV and site were being checked frequently. If those 20 hours or so of pressors are enough to stabilize and reverse the underlying pathology and potentially be taken off pressors, then absolutely! It saves my family member a central line which carries its own lot of complications. And you and I both know the likelihood of a midlevel being the one to place that line in the community is astronomical.

So yes, as long as it's done right, I'd actually prefer this approach for my loved one over the traditional "jump straight to an invasive procedure with potentially serious complications" approach.

 

[RustedFox]

See; it's this attitude of "it takes too much time; have someone else do it" that is poisonous to medicine at all levels.

From FM to ER.
From ER to ICU.

Everyone can do their own job.

It's the *powers that be* that need to cool their jets and let us do our jobs the right way.

 

[sylvanthus]

In a lot of cases I would actually be pretty satisfied with that as long as the IV and site were being checked frequently. If those 20 hours or so of pressors are enough to stabilize and reverse the underlying pathology and potentially be taken off pressors, then absolutely! It saves my family member a central line which carries its own lot of complications. And you and I both know the likelihood of a midlevel being the one to place that line in the community is astronomical.

So yes, as long as it's done right, I'd actually prefer this approach for my loved one over the traditional "jump straight to an invasive procedure with potentially serious complications" approach.

Im fine with someone coming to the unit with peripheral pressors running so long as its at a reasonable dose. If they are running 20 of levo and still “soft” on their bp ill be pissed. Cuz that pt will inevitably require a central line and id consider them to be underresuscitated in ED.

Otherwise, a lowish dose, cool, no worries ill order a picc to be done in the am.