ER doc *scope of practice*?

[viostorm]

Last year I moved from Virginia to Texas. I noticed, as a whole, ED physician's role is much different here in Texas then Virginia.

In Virginia it seemed the ER doc was running the trauma alert, placing chest tubes, intubating the trauma alert patient, and doing other cool things like placing temporary venous pacing wires.

In Texas here the ER doc isn't even in the room on the trauma alert. The intubation et cetera is done by the trauma surgeon. It seems as though the ER docs operate as basic outpatient clinicians.

I am strongly considering EM as a specialty, and I would certainly like to be involved with trauma patients doing interesting and helpful procedures. But my experience in Texas has made me question that.

1) Can anyone offer any insight as to what the national consensus is on the role of the ER doc?

2) What is the national consensus on what procedures/therapies ER docs should do?

3) What procedures / therapies will be included for the ER doc in the future and which will be taken over by other specialties in the 10-20 year future?

(by saying *scope of practice* I understand that most physicians hold an unrestricted medical license)

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[Sessamoid]

Your experience sounds like it's with only two (or perhaps a few) institutions. I seriously doubt EM is practiced significantly differently in Texas than it is in Virginia. Any differences you see are likely normal variation between different hospitals and not geographical.

That said, I know plenty of Texas EPs that do a lot of trauma. Myself, I can do without seeing much trauma. If you're not the one taking it to the OR, it's pretty boring and routine after a relatively short while.

 

[GeneralVeers]

It depends on the institution, whether it's private or county, whether there's a good trauma service in the hospital.

In general at county hospitals you will do more chest tubes, central lines, etc.

Some hospitals have a trauma team which handles most aspects of trauma care, whereas others do not. It has nothing to do with what state you are in.

 

[docB]

I'd say the biggest differences in who handles trauma are due to interdepartmental issues at academic institutions. For example, if you are looking at a teaching hospital that has surgery residents but not EM residents you'll probably see that surgery does the trauma solo. Other places trade off on days or divide the labor. At UC Davis the surgeons run the trauma (the EM residents rotate on the trauma srevice) but EM manages the airway.

As for non teaching centers it varies. Some have the ED doc evaluate and decide if the surgeon needs to see it and some just have the surgeon respond every time.

 

[tonem]

It depends on the institution, whether it's private or county, whether there's a good trauma service in the hospital.

In general at county hospitals you will do more chest tubes, central lines, etc.

Some hospitals have a trauma team which handles most aspects of trauma care, whereas others do not. It has nothing to do with what state you are in.

I disagree...at the community hospital (even in Texas), as an EP you are the man (or woman). No surgeon is going to come down to the ED to put in a chest tube, do a cric, put in a central line etc... and after hours the EP can be the only doctor in the hospital. Most of the big county hospitals have EM/surgery residents out the yin yang so they will be doing all those things...allowing for inter-intstitutional variation of course.

 

[viostorm]

For example, if you are looking at a teaching hospital that has surgery residents but not EM residents you'll probably see that surgery does the trauma solo.

This is exactly the situation at the place I'm at in Texas. No EM residency program but there is a surgery program.

After my experience here, I guess I am concerned that choosing a career in EM might be limiting. Especially because I think there are some important interventions that can be lifesaving, and my feeling is I would like to have the opportunity to perform them, ie be part of the trauma resucitation team. I wanted people's opinion if the situation here (where EP's are not involved at all in trauma alerts) is more typical nationally or it is the other way, where EP's do quite a bit during a trauma alert.

Has ACEP or any other governing body suggested/regulated what procedures EP's should do in their practice or is it left to what you learn in residency?

 

[FoughtFyr]

This is exactly the situation at the place I'm at in Texas. No EM residency program but there is a surgery program.

After my experience here, I guess I am concerned that choosing a career in EM might be limiting. Especially because I think there are some important interventions that can be lifesaving, and my feeling is I would like to have the opportunity to perform them, ie be part of the trauma resucitation team. I wanted people's opinion if the situation here (where EP's are not involved at all in trauma alerts) is more typical nationally or it is the other way, where EP's do quite a bit during a trauma alert.

Has ACEP or any other governing body suggested/regulated what procedures EP's should do in their practice or is it left to what you learn in residency?

I strongly suggest that you do a rotation in an ED with an EM residency before you make any decision. In your neck of the woods, Scott & White has a great program and I'm sure there are others.

- H

 

[doc05]

the bottom line is that even at a major trauma center, nontraumas will account for the vast majority of what you see. You should decide whether EM in general is right for you. once you're done with residency, you can choose where to work -- at a hospital with a trauma team, or at one where you'll do everything yourself.

and most older physicians I've met -- both EM and surgery -- get tired of trauma after a few years. You'd have to be an adrenaline junky to want to do that every day.

 

[roja]

Where are you in texas? this will explain alot.

 

[Andy Kahn]

This is exactly the situation at the place I'm at in Texas. No EM residency program but there is a surgery program.

Are you at San Antonio or Baylor-Houston (or Galveston where I went to school who are trying to get an EM program soon)? Just curious where this is going on at. Feel free to IM or PM me.

After my experience here, I guess I am concerned that choosing a career in EM might be limiting. Especially because I think there are some important interventions that can be lifesaving, and my feeling is I would like to have the opportunity to perform them, ie be part of the trauma resucitation team. I wanted people's opinion if the situation here (where EP's are not involved at all in trauma alerts) is more typical nationally or it is the other way, where EP's do quite a bit during a trauma alert.

I guess one thing I like about EM is that we are a jack of all trades. We have to be able manage the airway, MI's, traumas, pregnant pts, and kids. I look forward to having the chance to maybe do a cric, give tPA, do a thoracotomy, perimortem c-sxn, interosseus/saph cutdown, etc. Now of course, some of these are very rare and so I might not do all of these, but as an Emergency Physician, I want to be prepared and ready to do each the best I can. However the best person available should help with managing the pt. If a trauma surgeon is in house (trauma teams at academic or Level 1 settings), then he/she should do the cric or thoracotomy. A cardiologist should help with ECG interpretation, lytic management, or do the cath if available. If an Ob/Gyn is there, then he/she should do the c-sxn. However, the EP is in the ED and the pt may not have time to wait for a consultant to come in. Therefore, I want to be able to do the job if I am in a position to do so. We still do plenty of procedures and have other great responsibilities. If ortho or radiology isn't available, I want to be comfortable interpreting films/reducing fractures or doing my own focused bedside ultrasound.

Has ACEP or any other governing body suggested/regulated what procedures EP's should do in their practice or is it left to what you learn in residency?

“Beginning with the fall 2002 examinations, The Model of the Clinical Practice of Emergency Medicine (EM Model) will serve as the basis for the content specifications for all ABEM examinations.”

The model of the clinical practice of emergency medicine. Hockberger RS, Binder LS, Graber MA, et al. Ann Emerg Med 2001;37:745-770.
The Model of the Clinical Practice of Emergency Medicine. Hockberger RS, Binder LS, Graber MA, et al. Acad Emerg Med 2001 8: 660-681.

PDF and Word versions of "The Model" is available at: http://www.abem.org/public/portal/alias__Rainbow/lang__en-US/tabID__3590/DesktopDefault.aspx
Look at the appendix at the end for a list of procedures.

You definitely should ask for help when u r not comfortable doing something so I want to learn as much as possible during residency so that when I am on my own, I can be as helpful as possible for a pt. There are labs, conferences, and other ways to improve after residency. In summary, I love EM and it definitely allows us to manage a variety of pts with several skills.

-Andy

 

[viostorm]

Where are you in texas? this will explain alot.

I'm starting med school Texas Tech this fall in Lubbock. I'm currently a paramedic here in town. I've also worked as a paramedic in Charlottesville, VA, Richmond, VA and a rural VA service and I've been really trying very hard to keep an eye on which doctors do what in the hospital. I probably have worked with physicians at about 18-22 hospitals during my career as a paramedic.

I was very suprised when things were SO much different here in Lubbock.

It sounds like local politics and hospital capabilities play a great deal into what EP's do and what they do not do.

I know is a little early to start stressing about residency but I want to find research opportunities early so I will be a competitive applicant. With my EMS background it was natural for me to want to be in the ER.

I should have also stated I have noticed a majority of the EP's here have not done an EM residency. We have one Level I and one Level II center and both are staffed with mostly IM or Family docs. Even the OMD for one of the services here is a family doc. There are two other hospitals here and it is pretty much the same situation.

I would hate to go have this great emergency experience during residency and then for the rest of my career be in a situation where I was very limited in my practice. With this in mind I was wondering what other people's experience was on this.

 

[Sessamoid]

I was very suprised when things were SO much different here in Lubbock.

So you're basing your opinion of medical practice on the whole state of Texas on a couple hospitals in Lubbock? Yikes.

I should have also stated I have noticed a majority of the EP's here have not done an EM residency. We have one Level I and one Level II center and both are staffed with mostly IM or Family docs.

The fact that their training was limited probably has more to do with the limited scope of their practice than politics or hospital policy.

With this in mind I was wondering what other people's experience was on this.

There are boatloads of threads here describing what we do on a daily basis. Lubbock is an aberration because it's a little dusty hole of a city that nobody wants to live in. Hard to get residency-trained grads out in the middle of nowhere.

 

[viostorm]

So you're basing your opinion of medical practice on the whole state of Texas on a couple hospitals in Lubbock? Yikes.

No way. I totally understand I have a limited perspective. Which is why I posted. I totally understand Lubbock is not necessarily representative of Texas.

However, that being said one of the professors who recently moved down from Colorado Springs, CO told me that up there ER docs are limited in what they do. He also said most of them were IM and not EM trained. He did not elaborate so please no one get all huffy. He was very suprised when I told him the VA EP's did chest tubes and intubated during trauma alerts. I only relay this conversation because it made me wonder if here is more representative of what EP's do nationally. And so I posted to SDN.

 

[fuegofrio17]

If you are at Texas Tech, go to El Paso for your 3rd and 4th year. The residency program is located there and is very good. In El Paso, the trauma team only comes down when the EP deems they are necessary and calls them. All other traumas are handled exclusively by EPs. EM is always responsible for the airway (anesthesia do not come down for traumas) and procedures are equally shared with surgery WHEN they are called down.

The program is at a county hospital with great pathology, good ancillary services, and a layed back atmospehere. If you are interested in EM and spend your 3rd and 4th years in Lubbock or Amarillo you are doing yourself a great disservice. All of the Tech students who matched into EM this year went to El Paso for their 3rd and 4th years.

 

[Andy Kahn]

I'm starting med school Texas Tech this fall in Lubbock. I'm currently a paramedic here in town. I've also worked as a paramedic in Charlottesville, VA, Richmond, VA and a rural VA service

I was very suprised when things were SO much different here in Lubbock.

Wow, you are in Lubbock! I totally overlooked my roots. I grew up in West Texas (Lamesa, TX which is 60 miles south of Lubbock). I moved to Lubbock in 8th grade, finished at Lubbock High, and did pre-med at Texas Tech in Lubbock. During my pre-med days, I actually spent a couple of weeks w/ the director of the ED at Covenant Lakeside (they closed that ED and put all their ED resources at big Covenant on 19th and Indiana). He did EM residency at Orlando I believe. I know there is another EM trained guy at Covenant but haven't met him personally.

I think Texas is behind in some aspects EM. Look at the number of residencies in Texas versus say Michigan or Ohio and compare populations. Do programs in small towns have to send residents elsewhere for certain requirements like trauma? (I know that Scott & White sends their residents to Brackenridge in Austin and also a military program for a few months. El Paso sends their residents to Phoenix for 2 months).

The state of Texas is split by I-35. Believe me, I grew up feeling the state bias towards the big cities side of TX (I did it myself by assuming you were in SA, Houston, or UTMB) so West Texas may be behind the rest of the state which itself has plenty of room for improvement in EM.

The 4 civilian EM programs in Texas are at Dallas (Parkland/Children's), Houston (Memorial Hermann), El Paso (Thomason Hospital), and Temple (Scott & White). There are military programs at Ft. Sam Houston (San Antonio) and Ft. Hood (near Temple and Killeen) also. I have heard from friends or faculty that they all are good and have different strengths.

I know is a little early to start stressing about residency but I want to find research opportunities early so I will be a competitive applicant. With my EMS background it was natural for me to want to be in the ER.

PM me and I can get you in touch with the few EM trained EP's in Lubbock that I know of. Get involved w/ EMRA, SAEM, AAEM, or what ever student interest group related to EM you can. Do well in classes and boards. Most importantly, do well on your EM rotation (at a place with a program so that you get that experience and so that you can get a SLOR)). I know students can rotate do 3rd & 4th yr at either El Paso, Lubbock, or Amarillo now so El Paso would be ideal since they have an EM program but I heard that the El Paso campus is becoming its own independent Tech med school soon so I don't know how that will effect where you do rotations. I heard that the Lubbock med school might replace the El Paso rotations with Midland/Odessa? You should still feel free to rotate at another place w/ an EM residency. Dallas is the closest one (a mere 5 or 6 hr drive from Lubbock) or you can go anywhere you can find some housing. Do you still have connections in Virginia?

I should have also stated I have noticed a majority of the EP's here have not done an EM residency. We have one Level I and one Level II center and both are staffed with mostly IM or Family docs. Even the OMD for one of the services here is a family doc. There are two other hospitals here and it is pretty much the same situation.

I am sure you will find that many places that do not have EM residencies will be like that. Galveston had zero EM trained faculty that I knew of when I was a MS3. It grew to 3 by my MS4 year and I am sure they have expanded as they are trying to start a program. When very few are EM trained, then you will definitely see a difference in how things work.

Lubbock is a great place, but it is behind in certain things. Just as many small towns do not have EM trained EP's, Lubbock is a small city that is far from EM residencies, but has great potential given that there is a major university and a med school in town. What is "OMD"?

I would hate to go have this great emergency experience during residency and then for the rest of my career be in a situation where I was very limited in my practice. With this in mind I was wondering what other people's experience was on this.

I definitely feel you should get the great EM experience during residency. If you later go to a slow, low volume place, that transition sounds better than training where you are not prepared to go into a busier place. I think I may go back to Lubbock one day (although I love the big city right now and want to practice in a similar environment for awhile after residency). Also, the ED director in Lubbock that I knew was younger than all of the other physicians in the ED who had been there awhile (who were IM or family medicine trained). I think he came in and became director early b/c he was EM trained, board certified, etc. He grew up in Lubbock and had family there so he came back and it worked out great for him. I know in Victoria, TX (between San Antonio, Houston, and Corpus Christi) where I did my outpt rotations as a MS3, their ED is run by a family medicine trained guy who had been there awhile. He lived 2.5 hrs away in Austin. A surgery resident in San Antonio (2.5 hrs away) worked there and an EM trained doc from Corpus Christi worked there, too. I wonder if an EM trained guy went into town if he would have a great position right away even if he was new and young.

I have also noticed many large cities have multiple med school and EM programs (NYC, LA, Chicago, Phily, Detroit, Bay Area, Boston, Balt/DC, etc) but Dallas and Houston only have 1 EM program each. (although seems Miami is lacking in an EM program currently. Are they getting one soon?)

Anybody with more info on Texas programs or a comparison of other programs in this state would be helpful.

-andy

 

[fuegofrio17]

The Texas Tech El Paso campus is currently scheduled to enroll its first class in 2008. The state has authorized the new school, but financing may push the 2008 date back a few years.

 

[Sessamoid]

What is "OMD"?

"Orchestral Manoeuvres in the Dark"?

 

[viostorm]

"Orchestral Manoeuvres in the Dark"?

Operational Medical Director - paramedics practice on thier license and they write/approves the protocols.

 

[Febrifuge]

In El Paso, the trauma team only comes down when the EP deems they are necessary and calls them. All other traumas are handled exclusively by EPs. EM is always responsible for the airway (anesthesia do not come down for traumas) and procedures are equally shared with surgery WHEN they are called down.

That sounds very much like Hennepin.

 

[ERMudPhud]

No way. I totally understand I have a limited perspective. Which is why I posted. I totally understand Lubbock is not necessarily representative of Texas.

However, that being said one of the professors who recently moved down from Colorado Springs, CO told me that up there ER docs are limited in what they do. He also said most of them were IM and not EM trained. He did not elaborate so please no one get all huffy. He was very suprised when I told him the VA EP's did chest tubes and intubated during trauma alerts. I only relay this conversation because it made me wonder if here is more representative of what EP's do nationally. And so I posted to SDN.

Everyone I know working in Colorado Springs is EM trained, many came from DG, and can certainly do whatever they need to in a trauma resuscitation. There may be some old IM or FP trained EP's who grandfathered in but the majority if not all the new hires are EM trained.

Don't worry. After you are done with residency if you still really like trauma there will be plenty of places where you can do all the lines, airways, and chest tubes etc... that you want.

 

[Apollyon]

"Orchestral Manoeuvres in the Dark"?

Great band...one of my favorites. Toronto Exhibition Stadium 1988, with Depeche Mode - excellent show. Strong work!

 

[DrQuinn]

"Orchestral Manoeuvres in the Dark"?

Woah I thought I was the only one that used to listen to them!

Q

 

[viostorm]

Thanks for everyone for their advice. I feel like I have a better understanding of the EP's role.