Emergency Physician Procedures

[joeDO2]

I've been noticing a lot of older physicians commenting that many of the procedures they used to do themselves are now being consulted out to specialty services. Thought it would be interesting to see what procedures you all are doing out there and which you typically consult out. I got this list from the ACEP credentialing recommendations but left out the ones that are obviously essential in every department. Might be beneficial to list community vs academic and urban vs rural.

Procedural sedation
Neuromuscular blockade
Regional intravenous block
Regional nerve block
Open cardiac massage
Transvenous pacing
Arthrocentesis
Lumbar puncture
Peritoneal lavage
Proctoscopy
Slit lamp exam
Thoracentesis
Tonometry
Suprapubic catheterization
Naso/pharyngeal endoscopy
Central venous access- Jugular, Subclavian, Femoral
Intraosseous infusion
Swan-ganz catherterization
Venous cutdown
Intrauterine fetal monitoring
Injection of bursa/joint
Trephination nail
Pericardiocentesis
Tube thoracostomy
Gastric lavage
Repair of extensor tendon
Repair of flexor tendon
Ultrasound- FAST
Ultrasound- gynecologic
Ultrasound- Abdominal aorta
Ultrasound- Biliary
Ultrasound- Renal
Ultrasound guided procedures

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[pianoman511]

DPL (peritoneal lavage) is pretty much never done due to CT and FAST exams. Swans are also not done routinely any more.

Suprapubic caths I did in cadaver lab but are not commonly done (usually urology will perform if truly needed). Flexor tendon repairs, as far as I know, are not in the scope for EM physicians although extensor repairs are. Ortho would likely handle those. Venous cutdowns are not difficult according to vascular surgeons but they would be the ones doing those although with ultrasound and IO you would probably not need to do a cutdown to get access.

The other procedures would probably be location dependent, but I have done most (if not all) of the remaining procedures between actual patients, simulation, and cadaveric training.

 

[DrQuinn]

been out 7 years.
at our setting (250k city, nonacademics but good tertiary care center), I can tell you i'll do everything except its our "custom" to not do the following:
PTAs
paracentesis
thoracentesis

we'll do everything else. in fact the ICU docs would prefer we do the lines down int he ED, though I can get anyone up to the unit within 30 minutes of bed request (usually).

ah the joys of being in a community setting.
Q

 

[EM_Rebuilder]

Another thing is pay... Especially if there is an RVU component.

I have to single out LPs on this one, I like this procedure, but most people hopefully agree it either goes very smooth and you can be in and out in 5 mins, or its a total cluster and 30 mins later you are still trying.

I can have IR do it, and me see a stubbed toe, and make more money.

I still do the LPs on occasion, but I am very choosey on them.

For better or worse, we are driven in part by the almighty dollar...

 

[RPedigo]

My residency program, county, southern California.

Procedural sedation - EM
Neuromuscular blockade - EM
Regional intravenous block - EM
Regional nerve block - EM
Open cardiac massage - EM in conjunction with trauma surgery. On all traumatic full arrests where there is a thoracotomy, the trauma surgery team is there. We had multiple thoracotomies this week and they were shared between the two services.
Transvenous pacing - EM in conjunction with cardiology. If the patient is stable-ish and requires transvenous pacing urgently, it will be done in the cath lab. If they need it emergently (or urgently and it is not cath lab hours), we will do it.
Arthrocentesis - EM, but ortho typically does hips or prosthetic joints.
Lumbar puncture - EM
Peritoneal lavage - EM
Proctoscopy - So anoscopy of course we do, but proctosigmoidoscopy or more invasive scoping is typically done by someone else.
Slit lamp exam - EM
Thoracentesis - EM
Tonometry - EM
Suprapubic catheterization - EM (occasionally urology).
Naso/pharyngeal endoscopy - Depends on the attending and the indication. We do have a fiberoptic scope and we do use it, but often times if the patient requires ENT consultation anyway we will do it in conjunction with them since they'll want to see it anyway and scoping the patient twice is poor form in my opinion.
Central venous access- Jugular, Subclavian, Femoral - EM
Intraosseous infusion - EM
Swan-ganz catherterization - Cardiology. I'll put in the introducer catheter if I have time and they want to float the Swan, but it would be incredibly incredibly rare for someone to float a Swan in the ED here. If they are getting a Swan they have declared themselves as requiring disposition to the ICU and should go there.
Venous cutdown - EM
Intrauterine fetal monitoring - EM initially, we have our own fetal monitoring machine. If it requires prolonged monitoring one of the OB nurses will come down and set everything up as well and sit with the patient and watch the strip. We have OB in-house 24/7 (as with almost all specialty/subspecialty) and they are involved in their care early. Also, anyone over 20 weeks pregnant can go straight up to Labor and Delivery and be triaged by the OB/GYN team and bypass the Emergency Department (which is nice).
Injection of bursa/joint - EM
Trephination nail - EM
Pericardiocentesis - EM
Tube thoracostomy - Traumatic chest tubes are split 50/50 with the trauma service, but there are more than enough to go around. Medical chest tubes (e.g., an atraumatic pneumothorax, empyema, etc.) are all EM.
Gastric lavage - People do this? (Kidding. Kind of.)
Repair of extensor tendon - Depends on where the injury is, but some can be repaired by us. That said, if it doesn't look like a very straight-forward repair or is not in a zone amenable to ED repair, see below...
Repair of flexor tendon - Are you crazy? Emergency Physicians do this? (If they do, they definitely shouldn't, because flexor tendons pretty much require a hand specialist because they are complex and dysfunction is crippling.) Hand surgery is in-house at our institution 24/7.
Ultrasound- FAST - EM
Ultrasound- gynecologic - EM
Ultrasound- Abdominal aorta - EM
Ultrasound- Biliary - EM
Ultrasound- Renal - EM
Ultrasound guided procedures - EM

 

[deleted109597]

It's funny, because my community experience is the opposite. A lot of the old guard doesn't (and never did) any of those procedures. The old guys probably couldn't turn on the US.
The guys with EM training can do almost all of those procedures, as others have noted.
I get PTAs transferred almost daily because I have ENT on the call schedule that I end up letting the medical student, or janitor, or whomever else wants to do it.

 

[Bostonredsox]

Another thing is pay... Especially if there is an RVU component.

I have to single out LPs on this one, I like this procedure, but most people hopefully agree it either goes very smooth and you can be in and out in 5 mins, or its a total cluster and 30 mins later you are still trying.

I can have IR do it, and me see a stubbed toe, and make more money.

I still do the LPs on occasion, but I am very choosey on them.

For better or worse, we are driven in part by the almighty dollar...

I think this is important. My shops Ed (community shop) has a mix of old time FPs and some younger EM guys. I know for a fact the younger guys can do most everything on that list. But the reality is it takes 15 minutes to do a thoracentesis, and there are 15 patients waiting to be seen. It is easier to just admit them to medicine and we will do it on the floor. And sometimes if the floors are busy we send them to IR. Unless a procedure is urgent, or the ED doc has a med/fp resident on service who wants to do it, I have found they tend to defer it the admitting team or consulting physician so they can keep trying to move the meat. I am not sure if they are reimbursed for the procedures so I don't know If that is a factor or not. I know it is on the floors. The hospitalists aren't compensated for procedures so then send all the thoras and paras to IR, neuro for the LPs, ICU team for the lines, etc etc.

When your getting paid to move the meat, well, its hard to take time away to do a procedure unless it cant wait for someone else to do it.

 

[Apollyon]

Arthrocentesis - EM, but ortho typically does hips or prosthetic joints.

Typically? There is NO WAY I am EVER touching a prosthetic joint with a needle. Likewise, tapping a hip? Really? At the 4 jobs I have had since residency, I've never once even had the opportunity to be credentialed for dislocated hip replacement. Relocation and tapping are in the same yard, in my mind. And add that it's a kid to it? Umm, no thanks.

Just see what happens when you tap a prosthetic knee or hip, and score the articular surface with the needle. That's especially galling, because you can see it on plain Xray - don't need a CT or MRI or ultrasound that has to be explained to the jury.

The point of my post is twofold - first is, when you are working, you might not even have the opportunity to do the procedure (and don't EVER perform a procedure for which you are not credentialed, even if you have been trained and done it many times), and, second, part of residency isn't just learning how to do something, but when to NOT do it.

 

[BJJVP]

Its interesting how varied things can be. I feel comfortable doing hip reductions but I am fairly inexperienced and nervous about PTAs. I didnt know there were places where that was bread and butter EM. This probably has a lot to do with variations in hospital culture, different prevalence of certain conditions, and different emphasis at different training programs in different regions.

 

[joeDO2]

I guess the other question would be with all the variability, what is sufficient to credential someone in a particular procedure. How many times observing, how many times performing under supervision?

 

[Rendar5]

depends on the procedure.

 

[BJJVP]

I guess the other question would be with all the variability, what is sufficient to credential someone in a particular procedure. How many times observing, how many times performing under supervision?

Everytime Ive been credentialed, it seemed as if the application for procedures was some generic list that includes everything within the scope of EM. The only exception was getting credentialed for sedations required a special reading assignement followed by a quiz with a minimum passing score (this was in every small hospital I worked at)

 

[Apollyon]

Everytime Ive been credentialed, it seemed as if the application for procedures was some generic list that includes everything within the scope of EM. The only exception was getting credentialed for sedations required a special reading assignement followed by a quiz with a minimum passing score (this was in every small hospital I worked at)

That was my point about dislocated hip relocation, though - from large uni system to tiny rural hospital, nowhere I've been has it been on the list. And that is the 4 page list like you mention of seemingly almost everything from Roberts and Hedges.

 

[dotcb]

Things I haven't done but would do:

Suprapubic catheterization - this looks pretty easy. If I was working rurally - I'd try this. At my center, urology would do it.

Pericardiocentesis

Things I wouldn't do.

Peritoneal lavage - never done one, surgery would do it if it needed to be done.

Proctoscopy - I don't even know what that is. Anoscopy - do regularly.

Intrauterine fetal monitoring - never worked anywhere where EM was remotely responsible for this. Ob does it.

Repair of flexor or extensor tendon - never done it. Not gonna do it now.

 

[BJJVP]

That was my point about dislocated hip relocation, though - from large uni system to tiny rural hospital, nowhere I've been has it been on the list. And that is the 4 page list like you mention of seemingly almost everything from Roberts and Hedges.

OK, I see your point now. I'd better check if I'm even credentialed for the procedure then! I always just assumed that I was.

 

[Janders]

I've reduced a couple hips by myself in tiny / small community hospitals. If it is a native hip, it is emergent. I don't see it as all that different than shoulder, elbow, ankle, etc relocations. Need some sedation certainly!

Tapping a hip is a whole different animal.

 

[Hercules]

Just to clarify: are some of you saying you actually don't do hip reductions? I haven't been anywhere where hip, shoulder, ankle, elbow, etc reductions were not considered standard EM procedures. Whether it's a native or artificial hip, I've always reduced them in the ED. Are your orthopedists saying they want to be called for hip reductions?

 

[bougiecric]

I think one person said they don't do hip reductions.

It reminds me of an attending I had in residency. He said, "I don't do distal radius fracture reductions -- I'm not credentialed. They can be splinted and followed up by ortho the next day." Technically, he's probably right, but come on. Strong words in a department where the ortho resident comes down to do all the reductions.

Now that I'm on my own, I couldn't in my wildest dreams imagine telling parents, "Sorry, I know your kid's arm is all kinds of jacked up, but I'm not credentialed to fix that. I'm going put a splint on it and you can give the orthopedist a call in the morning."

At some point I think you have to trust your training and take pride in what you do. I don't care if the hip or distal radius isn't on a formal credentialing list. I do closed reductions all the times -- probably more often than many orthopedists. It is part of my expertise. I'm very skeptical that this would come back on me if there was a poor outcome -- I'm a board certified emergency physician and I have numerous organizations to fall back on if I were ever questioned. As well, it is standard of care in my location for the EP to do all reductions.

I'd love to be shown one concrete example where a board certified EP was hung out to dry because they did a procedure they weren't "credentialed" for.

 

[Apollyon]

Just to clarify: are some of you saying you actually don't do hip reductions? I haven't been anywhere where hip, shoulder, ankle, elbow, etc reductions were not considered standard EM procedures. Whether it's a native or artificial hip, I've always reduced them in the ED. Are your orthopedists saying they want to be called for hip reductions?

I think one person said they don't do hip reductions.

It reminds me of an attending I had in residency. He said, "I don't do distal radius fracture reductions -- I'm not credentialed. They can be splinted and followed up by ortho the next day." Technically, he's probably right, but come on. Strong words in a department where the ortho resident comes down to do all the reductions.

Now that I'm on my own, I couldn't in my wildest dreams imagine telling parents, "Sorry, I know your kid's arm is all kinds of jacked up, but I'm not credentialed to fix that. I'm going put a splint on it and you can give the orthopedist a call in the morning."

At some point I think you have to trust your training and take pride in what you do. I don't care if the hip or distal radius isn't on a formal credentialing list. I do closed reductions all the times -- probably more often than many orthopedists. It is part of my expertise. I'm very skeptical that this would come back on me if there was a poor outcome -- I'm a board certified emergency physician and I have numerous organizations to fall back on if I were ever questioned. As well, it is standard of care in my location for the EP to do all reductions.

I'd love to be shown one concrete example where a board certified EP was hung out to dry because they did a procedure they weren't "credentialed" for.

I was the one person who said it. What do you want me to say? Should I challenge the status quo as a new hire, to rock the boat for something that I have never done, and I suspect has a reason why it is not offered as a procedure?

To the first person, a hip is a different deal than a shoulder or elbow. What about a knee? Do you 1. relocate it 2. order the angiogram and then 3. call ortho/3a. call vascular? I don't know about you guys, but, at my last hospital, the vascular surgeon could, most times, only be reached by one nurse who knew his home phone number (seriously). And, for a hemi, don't you worry about grinding the cartilaginous surface off of the acetabulum?

As to the second, welcome to litigious America. Just like the lady just recently fired by Lowe's for chasing a shoplifter, sure, do something for which you are not credentialed. Then, when the medical staff committee calls you in, no matter how right you were, there's at LEAST a slap on the hand, if not censure, or being booted off the medical staff.

But, whatever. Say I have no pride, call me a loser, call me a weak EP, call me dumb, call me whatever you want. Insult the hell out of me, curse me, whatever makes you feel good. I've never done it, and I've never been credentialed for it, or had the option. What can I say?

 

[dotcb]

There shouldn't be a lot of gray area within a group about who does what. An organized ED, hospital, and subspecialty cadre should have agreed upon pathways for who does what and who handles X problem.

 

[joeDO2]

not sure if it happens in EM as much but i've seen in other specialties certain docs within the same group have different credentialing and therefore the pathways change regarding who happens to be on at the time

 

[namethatsmell]

Just to clarify: are some of you saying you actually don't do hip reductions? I haven't been anywhere where hip, shoulder, ankle, elbow, etc reductions were not considered standard EM procedures. Whether it's a native or artificial hip, I've always reduced them in the ED. Are your orthopedists saying they want to be called for hip reductions?

I interviewed at a ton of programs last year and can tell you that MANY residencies --especially very academic programs or those with a "name" attached-- lose lots of reductions to ortho. The most common excuse I heard from residents at these places was: "well, ortho won't see the patient at clinic unless they do the reduction...but it's OK because we get reductions at our community site." Of course, many of these programs only have 1-4 months at a "community site" during the entire residency.

Now more directly to the question's point: At my program's main shop we generally own all our reductions. But an artificial hip? We're probably going to call ortho for that if they can come down in a reasonable time frame.

 

[Hercules]

I was the one person who said it. What do you want me to say? Should I challenge the status quo as a new hire, to rock the boat for something that I have never done, and I suspect has a reason why it is not offered as a procedure?

To the first person, a hip is a different deal than a shoulder or elbow. What about a knee? Do you 1. relocate it 2. order the angiogram and then 3. call ortho/3a. call vascular? I don't know about you guys, but, at my last hospital, the vascular surgeon could, most times, only be reached by one nurse who knew his home phone number (seriously). And, for a hemi, don't you worry about grinding the cartilaginous surface off of the acetabulum?

But, whatever. Say I have no pride, call me a loser, call me a weak EP, call me dumb, call me whatever you want. Insult the hell out of me, curse me, whatever makes you feel good. I've never done it, and I've never been credentialed for it, or had the option. What can I say?

Apollyon-- not calling you out at all; just surprised by the variation both in training and in community jobs. I completely understand each ED is a different environment and you don't want to be the outlier in your group in most cases. I was trained to do pediatric distal forearm fracture reductions, so I did them when I got to my community job. A few months later I learned that none of my partners did them and that ortho wanted to be call in to do these reductions, so I changed my practice and call them in now.

Our ortho guys are more than happy though for us to do the hip (native and artificial) and knee reductions. No, I don't worry about the cartilaginous surface. I don't call them about their artificial hip reductions unless I've attempted it and can't reduce it. I reduce the hip the same way they would and if I can't get it they just take it to the OR. I still call ortho and get the ct angio after knee reductions.

 

[The White Coat Investor]

Procedural sedation Frequent
Neuromuscular blockade With intubation, frequent
Regional intravenous block No
Regional nerve block Rare except digital
Open cardiac massage No
Transvenous pacing No, but we have the equipment. Just never had to.
Arthrocentesis Yes
Lumbar puncture Yes
Peritoneal lavage Uhhh....not in this century
Proctoscopy If anoscopy counts
Slit lamp exam Frequent
Thoracentesis Rarely
Tonometry Frequent
Suprapubic catheterization Not yet, but I'd do it with an US
Naso/pharyngeal endoscopy Rarely, I usually call ENT because I'm not good at it
Central venous access- Jugular, Subclavian, Femoral Frequent
Intraosseous infusion Rarely, but very comfortable
Swan-ganz catherterization Haven't done one since residency
Venous cutdown Never done one outside of ATLS
Intrauterine fetal monitoring No
Injection of bursa/joint Generally leave to ortho in clinic
Trephination nail Frequent
Pericardiocentesis Willing, but haven't had to
Tube thoracostomy Yes
Gastric lavage Never had much need, but no problem
Repair of extensor tendon No
Repair of flexor tendon No
Ultrasound- FAST Yes
Ultrasound- gynecologic Yes
Ultrasound- Abdominal aorta Yes
Ultrasound- Biliary Yes
Ultrasound- Renal Yes
Ultrasound guided procedures Yes

Hope that helps. I called plastics to help with a lateral canthotomy (which I never did in residency) but I'll do the next one myself.

 

[namethatsmell]

Actually, since we're on the subject of procedures here's something the OP and current applicants might consider: you want to be at a program where you get first dibs on as many procedures as possible. Even nicer is the ability to call a specialist if you're crazy busy, have already done tons of the given procedure, and you think there's better learning to be had with other patients.

This may seem obvious, but you won't actually know how a program handles procedures unless you ASK residents about stuff like this on the interview trail. Most residents are honest about this kind of thing as long as you're somewhat discreet. You may be surprised by what you hear (good or bad)--I certainly was. For example, one program bragged that their residents usually graduate with 3x more than the required number of intubations (about 100)...turned out 40-60 usually came from their awesome anesthesia month. Other places don't really let interns (or even pgy2s) intubate in the ED. Maybe you're OK with that but you should know it up front. Could go on but you get the picture.

Procedures aren't the only thing to look for in a program and you shouldn't expect to do lat canth's all the live long day (surprised that wasn't on your list btw). But you want to actually feel comfortable with that list at the top of the thread when you're an attending? Best train someplace you may actually get to do them.

 

[joeDO2]

good point. i'll keep that in mind when looking at programs.

 

[dchristismi]

I put in hips, both native and prosthetic. Big fan of the Captain Morgan technique (just up, not torqued, please!), and it works quite well for this petite female.
The vast majority of these are total hips have dislocated in the past, and it's not the patient's first rodeo. (And not a dislocated fracture or acetabular fx - Ortho gets to deal with those when I have ortho, or they get shipped.) But a straightforward "I stood up, turned, and my hip popped out again" and I am more than happy to slip em some propofol and pop 'er back. Maybe it's my patient population, or that the local orthos installed joke hips for a few years...

I do not, however, tap them. Never tap a joint with hardware in place, either.

We have a clause in our credentialling that basically gives us leeway in emergencies.
Am I credentialled to do a perimortem c-section? No.
Would I be excused that in a true crisis? Yes. (And this came up last year, and thankfully the OB hit the door 30 seconds before the patient did, but that was the outcome of the discussion.)

So for my community shop:

Procedural sedation: all the time
Neuromuscular blockade: sure
Regional intravenous block: nope
Regional nerve block: I suppose if you wanted to, but not generally, aside from fingers
Open cardiac massage: While I technically have cardiothoracic surgeons who drive lamborghinis, they live just too far away to even bother. So no. Don't do thoracotomies either, although we do have the fancy surgical tray.
Transvenous pacing: Interventional cards
Arthrocentesis: knees, sure.
Lumbar puncture: All the time. IR if I can't get it.
Peritoneal lavage: Huh?
Proctoscopy: Nope
Slit lamp exam: So, our slit lamp lens walked off about 2 months ago... so at the moment, no. Send to ortho's office.
Thoracentesis: Could, but IR can do it.
Tonometry: Hell, my nurses do this.
Suprapubic catheterization: Uro
Naso/pharyngeal endoscopy: Doesn't happen. We have no ENT, and I can't.
Central venous access- Jugular, Subclavian, Femoral: Us, although the intensivists just replace them.
Intraosseous infusion: us
Swan-ganz catherterization: snort. Was this a joke?
Venous cutdown: IO FTW
Intrauterine fetal monitoring: Nope
Injection of bursa/joint: I suppose if you wanted, but not really.
Trephination nail: Midlevels do most of these
Pericardiocentesis: In a code situation, sure. Otherwise, someone else.
Tube thoracostomy: That would be us
Gastric lavage: Sure, although doesn't usually help
Repair of extensor tendon: Nope
Repair of flexor tendon: Nope
Ultrasounds in general- we have 24/7 US so while we have a machine, most of us just order the comprehensive study and have the rad tell us.
Ultrasound guided procedures: Central lines, sure. Check abscess pockets? I suppose. Paracentesis, etc? That's why IR gets paid the big bucks.

And I'd be willing to bet that if I called optho for a lat canth, I'd get "but I'm a retina guy!" That was the cry of the 2 opthos my partner called for a lid laceration involving the tear duct. (Who got shipped to oculoplastics at one of the surrounding meccas)

 

[deleted109597]

Since delay in reduction is associated with worsening AVN, I would argue you'd be more "on the hook" for not doing it than doing it. Not to say it is not entirely shop dependent, but I reduce all of them. Fractures or not. If you've got someone at your shop that can take them to that OR, you aren't changing managment. If you've got to ship them, transporting a dislocated hip is very unfair to the patient.

 

[The White Coat Investor]

Slit lamp exam: So, our slit lamp lens walked off about 2 months ago... so at the moment, no. Send to ortho's office.

I bet that makes for an interesting appointment.

 

[cyclohexanol]

I'll bite. Academic community program, level 1 trauma center.

Similar to above posters, we reduce all joints prosthetic or native. We do not tap prosthetic joints.

Procedural sedation - EM, very frequent
Neuromuscular blockade - EM, very frequent
Regional intravenous block - never done one
Regional nerve block - I do this, not infrequently
Open cardiac massage - EM+trauma, maybe once a month?
Transvenous pacing - our group is mixed. I'm very comfortable with them and do them when needed. others send to cath lab for interventional cards to do
Arthrocentesis - EM, frequently.
Lumbar puncture - EM, frequently
Peritoneal lavage - nope
Proctoscopy - nope, although we will do anoscopy when indicated
Slit lamp exam - EM, all the time
Thoracentesis - again our group is mixed. I will do these when needed
Tonometry - EM, frequently
Suprapubic catheterization - I've done one of these as a med student. Can't really think of a time I would have to do one, although I could
Naso/pharyngeal endoscopy - not yet
Central venous access- Jugular, Subclavian, Femoral - EM, frequently
Intraosseous infusion - EM, frequently
Swan-ganz catherterization - have done many in the ICU but no need in the ED
Venous cutdown - EM. I'm credentialed but have never done one aside from ATLS
Intrauterine fetal monitoring - no. OB comes down, or we send pt up to L&D
Injection of bursa/joint - EM, infrequently. Although I typically inject some bupivicaine into any joint i tap anyway so I guess that counts.
Trephination nail - EM, frequently
Pericardiocentesis - EM if urgent, otherwise send to cards/CT surgery
Tube thoracostomy - EM, frequently
Gastric lavage - EM, infrequently
Repair of extensor tendon - nope - splint, refer to hand
Repair of flexor tendon - nope - splint, refer to hand
Ultrasound- FAST, gyn, aorta, biliary, renal, procedures - EM, multiple times a day

 

[Arcan57]

Community shop -

Reductions are us unless we can't get them then ortho gets involved, usually by telling us to do it again with more sedation

Procedural sedation - Us
Neuromuscular blockade - Us
Regional intravenous block - no, never did one in residency either
Regional nerve block - depends, I do face and distal extremity, have learned but don't do prox ext.
Open cardiac massage - never
Transvenous pacing - I'll place transducer, usually go to lab since our interventionalist responds in similar time frame as STEMI
Arthrocentesis - yes
Lumbar puncture - yes
Peritoneal lavage - low-frequency probe just broke so maybe, but otherwise no
Proctoscopy - no
Slit lamp exam - yes
Thoracentesis - not usually, would do if pt is extremely symptomatic but in those cases usually a tube is indicated
Tonometry - yes
Suprapubic catheterization - urology
Naso/pharyngeal endoscopy - uncommon but yes ENT isn't on call panel that day
Central venous access- Jugular, Subclavian, Femoral - yes except we don't do subclavians due to mandate to use U/S on every line
Intraosseous infusion - yes
Swan-ganz catherterization - while I enjoy rupturing pulmonary arteries for no detectable clinic benefit, sadly no
Venous cutdown - that's why God invented the IO
Intrauterine fetal monitoring - no.
Injection of bursa/joint - after discussion regarding risk of introducing infection, occasionally
Trephination nail - yes
Pericardiocentesis - if hemodynamically unstable tamponade then yes
Tube thoracostomy - yes
Gastric lavage - nursing function
Repair of extensor tendon - nope - splint, refer to hand
Repair of flexor tendon - nope - splint, refer to hand
Ultrasound- FAST, gyn, aorta, biliary, renal, procedures -yes,no (except for advanced 1st trimester I can see with low frequency probe),sometimes,no,no,yes

 

[dchristismi]

I bet that makes for an interesting appointment.

Ha! That's what posting on little sleep gets me!

Although I did learn the other night that we have a new, portable slit lamp... that is older than the optho who came in to see my patient with an exceptionally weird exam. (he was stumped, iritis vs uveitis with an 8mm nonreactive pupil but no APD)

 

[neusu]

I'll offer to walk ED residents through burr holes for EVD or subdural drain placement. Is this worthwhile or more of a boondoggle for them?

 

[Arcan57]

I'll offer to walk ED residents through burr holes for EVD or subdural drain placement. Is this worthwhile or more of a boondoggle for them?

It's never something we'd get proficient at, but it's nice to have in the toolbox when a patient is herniating and the OR is an hour away. I know there was a move towards cross-training G-surgs to do this and place ex-fixes to become a one-stop shop for stabilizing trauma patients.

 

[MediCane2006]

Plastics/hand fellow here.

I need you guys to come teach our (large university hospital) ED to reduce finger dislocations....

 

[Rendar5]

Hahahaha, that's silly. The only time I can't reduce a finger dislocation it's because there's a major rupture that requires surgery. (only had that issue once)

 

[Hercules]

Hahahaha, that's silly. The only time I can't reduce a finger dislocation it's because there's a major rupture that requires surgery. (only had that issue once)

The other times you'll have this happen is when there is a fracture dislocation and the fragment is actually stuck in the tendon. Had this happen twice (one of them being my own finger as an intern).