FP's in the ED

[ComicBookHero20]

I heard that FPs are allowed to work in the ED without a problem, but I also heard there was an issue that because they didn't take an EM residency that the pay scale is different (this maybe a rural vs urban thing)?

i also heard similar that if you do an EM fellowship (after an FP residency) that it's the same scenario above (I am aware that if you do those fellowships that you do not qualify for EM board certification)

I wanted to know how true all this was or if it was all lies...

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[deleted6669]

This topic has come up before (do a search) but in brief:
places that can afford residency trained/boarded em docs will hire them preferentially.
this is most major cities or desireable areas.
as you get more rural, emergency dept volumes decrease so hospitals can't afford an em doc at 200k+/yr so they are more open to hiring fp docs with em experience or em specialty pa's for 50-80 dollars/hr.
em fellowship trained fp docs would certainly have their pick of these rural slots but still couldn't work at most urban/suburban hospitals unless they were places with fp em fellowships.
the caveat to all of this is that until 1984 or so fp docs with 5 yrs em experience could challenge the em boards and get boarded in em without doing a residency in em so there are still lots of older fp docs(with em board certification) working in urban depts. there are also fp docs working in urban depts who are not boarded who have worked there forever and now can't leave because no one else will hire them and if they quit their current jobs and wanted them back they couldn't get them due to new hiring guidelines.
to make it more confusing their are several dual em/fp residencies(5 yrs long) out there as well so someone you think of as an "fp doc" because you see them in clinic all the time and every now and then in the e.d. could actually be residency trained and boarded in both.
hope that helps.

 

[iatrosB]

This topic has come up before (do a search) but in brief:
places that can afford residency trained/boarded em docs will hire them preferentially.
this is most major cities or desireable areas.
as you get more rural, emergency dept volumes decrease so hospitals can't afford an em doc at 200k+/yr so they are more open to hiring fp docs with em experience or em specialty pa's for 50-80 dollars/hr.
em fellowship trained fp docs would certainly have their pick of these rural slots but still couldn't work at most urban/suburban hospitals unless they were places with fp em fellowships.
the caveat to all of this is that until 1984 or so fp docs with 5 yrs em experience could challenge the em boards and get boarded in em without doing a residency in em so there are still lots of older fp docs(with em board certification) working in urban depts. there are also fp docs working in urban depts who are not boarded who have worked there forever and now can't leave because no one else will hire them and if they quit their current jobs and wanted them back they couldn't get them due to new hiring guidelines.
to make it more confusing their are several dual em/fp residencies(5 yrs long) out there as well so someone you think of as an "fp doc" because you see them in clinic all the time and every now and then in the e.d. could actually be residency trained and boarded in both.
hope that helps.

Good response emed...mine would have simply been:

 

[ComicBookHero20]

so whats the likelihood if i do an FP residency...live in an urban city and want to split time btwn a clinic and the ED...

according to the PD i met on my medical school rotation, doing this is incredibly do-able

 

[DrMom]

getting less and less common in an urban setting. much more common in a small town environment.

 

[deleted6669]

so whats the likelihood if i do an FP residency...live in an urban city and want to split time btwn a clinic and the ED...

according to the PD i met on my medical school rotation, doing this is incredibly do-able

in an urban environment the more common/likely split is clinic/urgent care.

 

[Noyac]

I know, here he goes again.
But I can't help thinking, if you want to do other things than FP why are you doing a FP residency. The FP-EM thing does make a lot more sense to me than the FP-OB thing though. Its all about making your life easier and loving it. Not making things harder on yourself.

 

[lowbudget]

I know, here he goes again.
But I can't help thinking, if you want to do other things than FP why are you doing a FP residency. The FP-EM thing does make a lot more sense to me than the FP-OB thing though. Its all about making your life easier and loving it. Not making things harder on yourself.

I don't know... same reason anesthesiologists have pain management clinics. Makes no sense to me either.

 

[lowbudget]

Just as an aside, as much as it's difficult to staff rural ED's, my friends who are completing EM residencies are finding it tough to find jobs in their urban geography of choice at a salary/rate that they like. There's a significant discount if they do find it. These EM groups are negotiating monsters too.

Just saying... Writing may be on the wall already. All y'all wanting to get into EM may be late...

 

[Noyac]

I don't know... same reason anesthesiologists have pain management clinics. Makes no sense to me either.

SO who is better trained to do this then? Don't tell me, FP.

Isn't this the issue?

Also, did you bother to read my last two sentences there?

 

[Noyac]

lowbudget, forgive me if I mistook your response. If it was contrite then I agree, it makes no sense. But your example of anesthesiologists opening pain clinics is not a very good one b/c as I pointed out, its about making your life easier. Which pain clinics can do for you. Also, anesthesiologists have the BEST training for this, unlike the topic at hand.

 

[lowbudget]

Truth be told, IMO, I don't think a typical FP residency prepares a typical FP resident to hold down a level 1 trauma center in a high-acuity-high-volume urban academic ED. The number of half-days in continuity clinic over 3 years just doesn't transfer to the number of shifts EM residents do in the ED. Certainly, an FP resident can acquire that experience by taking additional shifts/electives/fellowship/moonlight and work successfully in the ED. At the end of the day, and this is true for all types of privileging, it's the experience that counts, not the specialty designation (e.g. not all ID doctors are knowledgeable of HIV... can you imagine?... it all depends on their exposure during fellowship... not all ortho's can do hand or spine... etc.)

That said, while FPs may not be the "best trained" to work in the ED, don't assume that EM residents get "the best training." It's far from perfect. How can EM doctors who train in the ED, med-surg floor, and ICU make decisions on who can or cannot go home to be managed on an outpatient basis? I don't understand that. They don't spend enough time in primary care clinic, or SNF, or LTACs, or Nursing Homes, or any other setting where a CT scanner is hard to come by. And they think it's useless to them, if you ever talk to them. How often have you stood in the ED and said to yourself, if this exact patient had presented to my clinic, I would have approached it differently? Because EM residents don't follow patients onto the floor or into the outpatient setting, their training is like doing algebra without ever looking at the answers. It's not all their fault. A system that rewards docs for speed but punishes them for inaccuracies, leading to sloppy work, inappropriate treatment, and high malpractice costs, only exacerbates the problem.

So, sure, ok, maybe the typical FP's not qualified to work in an urban ED, but EM docs can learn a thing or two from FP's.

 

[Noyac]

Truth be told, IMO, I don't think a typical FP residency prepares a typical FP resident to hold down a level 1 trauma center in a high-acuity-high-volume urban academic ED. The number of half-days in continuity clinic over 3 years just doesn't transfer to the number of shifts EM residents do in the ED. Certainly, an FP resident can acquire that experience by taking additional shifts/electives/fellowship/moonlight and work successfully in the ED. At the end of the day, and this is true for all types of privileging, it's the experience that counts, not the specialty designation (e.g. not all ID doctors are knowledgeable of HIV... can you imagine?... it all depends on their exposure during fellowship... not all ortho's can do hand or spine... etc.)

That said, while FPs may not be the "best trained" to work in the ED, don't assume that EM residents get "the best training." It's far from perfect. How can EM doctors who train in the ED, med-surg floor, and ICU make decisions on who can or cannot go home to be managed on an outpatient basis? I don't understand that. They don't spend enough time in primary care clinic, or SNF, or LTACs, or Nursing Homes, or any other setting where a CT scanner is hard to come by. And they think it's useless to them, if you ever talk to them. How often have you stood in the ED and said to yourself, if this exact patient had presented to my clinic, I would have approached it differently? Because EM residents don't follow patients onto the floor or into the outpatient setting, their training is like doing algebra without ever looking at the answers. It's not all their fault. A system that rewards docs for speed but punishes them for inaccuracies, leading to sloppy work, inappropriate treatment, and high malpractice costs, only exacerbates the problem.

So, sure, ok, maybe the typical FP's not qualified to work in an urban ED, but EM docs can learn a thing or two from FP's.

Well of course FP's are not qualified for a Level 1 trauma center nobody said they were. We are talking about rural right. If you are not talking about the rural setting then you are way off base. And nobody said the EM guys were perfect, just a better option due to better training. You ust be kidding when you compare this topic to orthopods and ID guys. They don't correlate.

 

[sophiejane]

as I pointed out, its about making your life easier.

Is it really? See, I don't think that is necessarily true for everyone, and certainly not for many who rise to the challenge of family medicine and primary care.

Something I hear pretty frequently from subspecialists is that they could never handle the breadth of what we have to know and be comfortable with as FPs. Most people recognize that being a good generalist is really hard and challenging work. We are primary diagnosticians, and that means constantly keeping up with a huge amount of information.

If I had wanted an easier life, well, I would have chosen something more specialized.

I want a job that is challenging and satisfying. I could make it easy, but that's not what it's about for me. At least not right now. The great thing about FM is that if, at any point, I want to make it easier, I just say the word, and stop doing deliveries, start traveling to interesting places on locums jobs, quit inpatient, etc. No other specialty has the flexibility we have.

 

[andwhat]

yeah politics in the ED are insanely inconsistent. There are some docs making as miserable as 60 dollars per hour, and others making around $200 K annually. It really varies and fluctuates.
If an Emergency Department is well staffed, then it obviously becomes a bit more difficult for an FM doc to obtain a well paying position in the ED.
EDs have moved to 'fast track' venues, and have used FM docs there. I think that logistically this is a crime, and should be outlawed. FM docs are way overqualified to see sore throats and coughs, thats like Urgent Care. At least Urgent Care pays well at most places.

 

[lowbudget]

Well of course FP's are not qualified for a Level 1 trauma center nobody said they were. We are talking about rural right. If you are not talking about the rural setting then you are way off base. And nobody said the EM guys were perfect, just a better option due to better training. You ust be kidding when you compare this topic to orthopods and ID guys. They don't correlate.

Ok, so then where's the threshold? At what point can you say an FP is not qualified to work in an ED while an EM doc is? Level 3? Level 5? And what is meant by rural? Population of 25,000? 100,000? 1 million? I'm also having a hard time understanding what is meant by "better training" and how you define that?

At the end of the day, I don't think anyone can answer these questions because nobody knows. At *best*, it's a matter of opinion, rather than a matter of fact.

And if you're willing to accept midlevels staffing ED's across the country (rural or urban) doing a great job at it, I think you should be willing to accept FP's staffing ED's across the country (rural or urban) doing a great job at it. Or midwives and FP's doing OB. Not because it's better than nothing, but because they do a great job at it.

How about this?
Do you honestly believe that a "general" anesthesiologist (who typically does a prelim internal medicine) is "best trained", or even "adequately trained", to be taking care of children undergoing surgery at a community hospital after doing a couple of rotations in pediatric anesthesiology?

 

[sophiejane]

And if you're willing to accept midlevels staffing ED's across the country (rural or urban) doing a great job at it, I think you should be willing to accept FP's staffing ED's across the country (rural or urban) doing a great job at it. Or midwives and FP's doing OB. Not because it's better than nothing, but because they do a great job at it.

A-freakin'-men to that.

 

[8744]

Since at least fifty percent of American medicine is total bull****, and I mean completely and utterly useless and nothing but a total waste of money, and since an even greater percentage of Emergency Medicine, some say approaching seventy percent of every dollar we spend, is likewise nothing but an exercise in wasted money, on one level it doesn't really make much of a difference who works where. Your training in family medicine is good for the Emergency Department because fully 90 percent of your cases are also bull**** and you therefore have a pretty good handle on how to deal with them...not that it matters because "do nothing " as a plan, all across the medical profession, would probably lead to a statistically significant improvement in any health quality metric you care to name.

It is only because so much of American medicine is bull**** that many of you would even contemplate working in the Emergency Department without adequate training. You can indeed run a small ED as an "Urgent care" and quickly transfer all of your more difficult cases to a larger, better-staffed ED. It happens all the time where I work. We have a constellation of rural EDs all around us that punt everything but the obvious cold in young, non-pregnant patient.

 

[deleted87716]

Your training in family medicine is good for the Emergency Department because fully 90 percent of your cases are also bull**** and you therefore have a pretty good handle on how to deal with them.

Not that I doubted it, but thanks for validating my decision not to go into EM.

Glad you like it, though. After all, somebody has to work all those nights, weekends, and holidays. Better you than me.

 

[lowbudget]

Since at least fifty percent of American medicine is total bull****, and I mean completely and utterly useless and nothing but a total waste of money, and since an even greater percentage of Emergency Medicine, some say approaching seventy percent of every dollar we spend, is likewise nothing but an exercise in wasted money, on one level it doesn't really make much of a difference who works where. Your training in family medicine is good for the Emergency Department because fully 90 percent of your cases are also bull**** and you therefore have a pretty good handle on how to deal with them...not that it matters because "do nothing " as a plan, all across the medical profession, would probably lead to a statistically significant improvement in any health quality metric you care to name.

It is only because so much of American medicine is bull**** that many of you would even contemplate working in the Emergency Department without adequate training. You can indeed run a small ED as an "Urgent care" and quickly transfer all of your more difficult cases to a larger, better-staffed ED. It happens all the time where I work. We have a constellation of rural EDs all around us that punt everything but the obvious cold in young, non-pregnant patient.

HA! I was about to say the same. Considering how the majority of crap, I mean the sheer volume of it, that goes to the ED is NON-EMERGENT, it could be said that emergency physicians are actually the least qualified to be taking care of their patients.

Hilarious. Because it's true (and sad).

 

[iatrosB]

We have a constellation of rural EDs all around us that punt everything but the obvious cold in young, non-pregnant patient.

You mean they manage the cold by themselves with such poor training!

 

[8744]

HA! I was about to say the same. Considering how the majority of crap, I mean the sheer volume of it, that goes to the ED is NON-EMERGENT, it could be said that emergency physicians are actually the least qualified to be taking care of their patients.

Hilarious. Because it's true (and sad).

No. You missed my point which was that a lot of people who are unqualified for the job feel like they could do it because like most of the medical profession, Emergency Medicine suffers from a glut of bull**** patients. Not all EM patients are bull**** however. I'd say probably ten percent of mine are full-blown medical emergencies (two out of twenty I typically see in a shift) and another couple need some real medical skills. The rest are a waste of time and money for an Emergency Department (except we make money on them so I'm all for 'em).

As for taking care of them, we are not a primary care clinic so adjusting insulin, blood pressure meds, or well-child checks are not my problem. If you are too far out of whack we admit you and if not you can square it away with your PCP...which is why when I did my Family Medicine year a blood pressure of 180/95 was a big deal in the clinic but doesn't raise an eyebrow in the ED in an otherwise asymptomatic patient.

 

[secretwave101]

"do nothing " as a plan, all across the medical profession, would probably lead to a statistically significant improvement in any health quality metric you care to name.

The last time doctors in Israel went on strike, there was a sizable drop in both mortality and iatrogenic morbidity. That was a few years ago, and the result made them look so bad they haven't threatened to do it again.

Other than laughter, "do nothing" really is the best medicine much of the time.

 

[MidwestFM]

Of the two hospital systems where I admit patients, one uses FM docs in the ED and one uses only EM boarded physicians. I would rather send my patients to the FM docs every time. They do better histories, better exams, and are more thoughtful in ordering tests. The other group seems to order a CT angio of the chest on everyone with chest pain before they are seen by the physician, regardless of 100% O2 sats and lack of other symptoms. Their approach is not only more expensive, but tends to lead to further invasive and unnecessary workup for incidental findings

 

[MedicineDoc]

No. You missed my point which was that a lot of people who are unqualified for the job feel like they could do it because like most of the medical profession, Emergency Medicine suffers from a glut of bull**** patients. Not all EM patients are bull**** however. I'd say probably ten percent of mine are full-blown medical emergencies (two out of twenty I typically see in a shift) and another couple need some real medical skills. The rest are a waste of time and money for an Emergency Department (except we make money on them so I'm all for 'em).

As for taking care of them, we are not a primary care clinic so adjusting insulin, blood pressure meds, or well-child checks are not my problem. If you are too far out of whack we admit you and if not you can square it away with your PCP...which is why when I did my Family Medicine year a blood pressure of 180/95 was a big deal in the clinic but doesn't raise an eyebrow in the ED in an otherwise asymptomatic patient.

I'm kind of wondering which full blown medical emergencies you are referring to.

Do you mean coding?
A stroke?
A tension pneumo?
DKA?
A PE?
An Overdose?
A fracture?
A cricothyroidectomy?

It seems like if you are qualified to treat these on the floor it's not that far a leap to treat them in the ED.

 

[lowbudget]

I'm kind of wondering which full blown medical emergencies you are referring to.

Um... acne, hello?

 

[deleted87716]

Um... acne, hello?

 

[8744]

I'm kind of wondering which full blown medical emergencies you are referring to.

Do you mean coding?
A stroke?
A tension pneumo?
DKA?
A PE?
An Overdose?
A fracture?
A cricothyroidectomy?

It seems like if you are qualified to treat these on the floor it's not that far a leap to treat them in the ED.

How many cricothyroidectomies (as an example) does the average family practice doctor do, expect to do, or is prepared to do? How many airways? How many codes? How many of any standard Emergency Medicine procedures? How many critically ill patients are they prepared to manage for a couple of hours while an ICU bed is found? Admittedly, it's not rocket science but the skill, knowledge, and decisiveness of a well-trained Emergency Physician is not just something you casually pick up during your FP residency after a couple of months of Emergency Medicine rotations where they stuck you in fast track or assigned you the easy patients.

Additionally, we are usually practicing with a paucity of information. I get snide calls from admitting physicians every now and then asking how I could possibly have not known that their patient had lung cancer or a long history of seizures to which I reply, "My apologies, as the patient was dumped in the waiting room by his friends who then left, was unconscious at the time, and seizing so badly that we had to intubate him I didn't have time to take a good history." (Not to mention often not even knowing his name with any more specificity than his friends relating to the triage nurse that his name was "T-dog.")

What you are really pointing out is that there is overlap between generalist medical specialties which is true. If you think specialty certification is bull**** just say so. I can pass myself off as a hospitalist and the hospital wouldn't care except that they might place themselves in legal jeopardy. That doesn't mean I should take a hospitalist job if I can find one or that I would make a good hospitalist.

I might as well say that anybody can do family practice as long as thy have a few checklists and some guidelines from the AAFP. The truth is that most of American Medicine is bull**** and we are all just bouncing it around until the whole system collapses. PAs, NPs, rogue Family Medicine physicians trying to slide into higher paying specialties...doesn't matter. It's hard to screw up bull****. Mostly if you just leave it alone it will just lay there harmlessly which is why we have still not come to the point where everybody with vague abdominal pain gets a radiation intensive, contrast heavy CT scan.

 

[8744]

Um... acne, hello?

I kid you not, I actually had this as a chief complaint the other night. And I was working for an indecisive, completely out-of-control attending who sent me on a four-hour zebra hunt. It wasn't even that bad a case, the patient was teenager with no other medical problems, and charting should have taken longer than actually seeing and discharging the patient.

And the department was full. The charge nurse was pissed and rolled her eyes when I said, "We're waiting for the sed rate."

Like I said, most of American medicine is bull****.

 

[MedicineDoc]

How many cricothyroidectomies (as an example) does the average family practice doctor do, expect to do, or is prepared to do? How many airways? How many codes? How many of any standard Emergency Medicine procedures? How many critically ill patients are they prepared to manage for a couple of hours while an ICU bed is found? Admittedly, it's not rocket science but the skill, knowledge, and decisiveness of a well-trained Emergency Physician is not just something you casually pick up during your FP residency after a couple of months of Emergency Medicine rotations where they stuck you in fast track or assigned you the easy patients.

Additionally, we are usually practicing with a paucity of information. I get snide calls from admitting physicians every now and then asking how I could possibly have not known that their patient had lung cancer or a long history of seizures to which I reply, "My apologies, as the patient was dumped in the waiting room by his friends who then left, was unconscious at the time, and seizing so badly that we had to intubate him I didn't have time to take a good history." (Not to mention often not even knowing his name with any more specificity than his friends relating to the triage nurse that his name was "T-dog.")

What you are really pointing out is that there is overlap between generalist medical specialties which is true. If you think specialty certification is bull**** just say so. I can pass myself off as a hospitalist and the hospital wouldn't care except that they might place themselves in legal jeopardy. That doesn't mean I should take a hospitalist job if I can find one or that I would make a good hospitalist.

I might as well say that anybody can do family practice as long as thy have a few checklists and some guidelines from the AAFP. The truth is that most of American Medicine is bull**** and we are all just bouncing it around until the whole system collapses. PAs, NPs, rogue Family Medicine physicians trying to slide into higher paying specialties...doesn't matter. It's hard to screw up bull****. Mostly if you just leave it alone it will just lay there harmlessly which is why we have still not come to the point where everybody with vague abdominal pain gets a radiation intensive, contrast heavy CT scan.

Seriously, how hard could it be to do a cricothyroidectomy? The anatomic landmarks are incredibly easy to identify. you pretty much just have to cut away the skin and make a hole in the obvious place. As for your seizing patient did you consider giving some ativan?

 

[sophiejane]

Alright! Pass the popcorn, here we go again!!

 

[deleted87716]

I kid you not, I actually had this as a chief complaint the other night. And I was working for an indecisive, completely out-of-control attending who sent me on a for-hour zebra hunt...The charge nurse was pissed and rolled her eyes when I said, "We're waiting for the sed rate."

What, no derm consult? I'll bet that kills your Press Ganey score.

 

[8744]

Seriously, how hard could it be to do a cricothyroidectomy? The anatomic landmarks are incredibly easy to identify. you pretty much just have to cut away the skin and make a hole in the obvious place. As for your seizing patient did you consider giving some ativan?

Whoa. It's easy on a cadaver when you have plenty of time and the stakes are low but how about a 350 pound lady on coumadin with no neck to speak of and no airway? There are no landmarks and there is no "obvious place." It's not as simple as making a hole. By that criterion, putting in a temporary transvenous pacemaker is also nothing but "making a hole." Heck, almost every procedure we do (central lines, chest tubes, pleurocentesis, DPL, etc.) is just "making a hole."

I'm not saying that placing a surgical airway is arcane magic but it does take some skill and, more importantly, the decisiveness to know when to do one.

Ativan? Really. I had no idea. Dude. Airway, Breathing, Circulation. You can load your apneic patient up with all the ativan in the world but if you ain't got breathing, you ain't got nothing. Do you want to wait a minute or two for the ativan to take effect while the patient chokes and aspirates his vomit? The safest thing to do for any patient who arrives in status is to secure the airway.

Come on. Like I said, it's not rocket science but you have to know a little bit.

 

[8744]

What, no derm consult? I'll bet that kills your Press Ganey score.

The attending wanted me to consult the on-call dermatologist for outpatient follow-up but she finally decided against it because it was 3AM. But I had to spend fifteen minutes looking up the number, faxing the patient's information, and writing instructions on how to find the clinic. In our irresponsible age, it is not enough to tell the patient, "Follow up with a dermatologist of your choice. Look in the phone book."

 

[MedicineDoc]

Whoa. It's easy on a cadaver when you have plenty of time and the stakes are low but how about a 350 pound lady on coumadin with no neck to speak of and no airway? There are no landmarks and there is no "obvious place." It's not as simple as making a hole. By that criterion, putting in a temporary transvenous pacemaker is also nothing but "making a hole." Heck, almost every procedure we do (central lines, chest tubes, pleurocentesis, DPL, etc.) is just "making a hole."

I'm not saying that placing a surgical airway is arcane magic but it does take some skill and, more importantly, the decisiveness to know when to do one.

Ativan? Really. I had no idea. Dude. Airway, Breathing, Circulation. You can load your apneic patient up with all the ativan in the world but if you ain't got breathing, you ain't got nothing. Do you want to wait a minute or two for the ativan to take effect while the patient chokes and aspirates his vomit? The safest thing to do for any patient who arrives in status is to secure the airway.

Come on. Like I said, it's not rocket science but you have to know a little bit.

Intubation is not always the first indication in SE. Many times ativan comes first depending on the respiratory status. I have a problem with the idea that family medicine physicians can't perform simple procedures like a cricothyroidectomy. Soon there will be some tech somewhere who only does central lines and cricothyroidectomies saying hey only me the tech of central lines and cricothyroidectomies should do this not stupid EM docs who mostly just prescribe antibiotics for viral illnesses. When you say "we" put in central lines are you trying to imply that only EM docs and surgeons can put in a central line? Those are routine procedures performed by FM and IM docs. I have anastomosed the femoral artery in a rat as well as made end to side anastomoses in tiny rat vessels I'm pretty damn sure that I or any medical school graduate can make a hole in the cricothyroid membrane . In fact I think I could train an eight year old to not just do it but do it well. Are you trying to tell me that the "adams" apple (thyroid cartilage) isn't a major landmark and that somehow it is difficult to find the cricothyroid membrane?! I didn't specialize because I would become bored doing the same damn things every day. I am not prepared to accept limiting my practice because somebody thinks I'm stepping on their turf without a fight.

This idea that there should be a specialist for every little thing is a relatively recent idea. My grandfather, a Generalist, performed amputations in WWI on the front lines in England, delivered babies, and performed minor surgeries. What have we got for all the specialists? According to the Darthmouth study we have gotten worse outcomes and greater costs in areas with more specialists.

 

[MOHS_01]

Intubation is not always the first indication in SE. Many times ativan comes first depending on the respiratory status. I have a problem with the idea that family medicine physicians can't perform simple procedures like a cricothyroidectomy. Soon there will be some tech somewhere who only does central lines and cricothyroidectomies saying hey only me the tech of central lines and cricothyroidectomies should do this not stupid EM docs who mostly just prescribe antibiotics for viral illnesses. When you say "we" put in central lines are you trying to imply that only EM docs and surgeons can put in a central line? Those are routine procedures performed by FM and IM docs. I have anastomosed the femoral artery in a rat as well as made end to side anastomoses in tiny rat vessels I'm pretty damn sure that I or any medical school graduate can make a hole in the cricothyroid membrane . In fact I think I could train an eight year old to not just do it but do it well. Are you trying to tell me that the "adams" apple (thyroid cartilage) isn't a major landmark and that somehow it is difficult to find the cricothyroid membrane?! I didn't specialize because I would become bored doing the same damn things every day. I am not prepared to accept limiting my practice because somebody thinks I'm stepping on their turf without a fight.

This idea that there should be a specialist for every little thing is a relatively recent idea. My grandfather, a Generalist, performed amputations in WWI on the front lines in England, delivered babies, and performed minor surgeries. What have we got for all the specialists? According to the Darthmouth study we have gotten worse outcomes and greater costs in areas with more specialists.

WHOAAAA... easy big fella.

Let me promise you that cric'ing someone is not always an easy procedure, and I have seen more than one upper level surgery resident pucker up when doing one in a controlled OR setting, much less than a trauma bedside with less than optimal lighting, facilities, and help.

The hardest part of medicine (and the least learned art) is fully understanding one's limitations. This goes for everyone in every specialty.

Oh, BTW -- it is cricothyroidotomy; you're not excising the da** thing.

 

[8744]

Intubation is not always the first indication in SE. Many times ativan comes first depending on the respiratory status. I have a problem with the idea that family medicine physicians can't perform simple procedures like a cricothyroidectomy. Soon there will be some tech somewhere who only does central lines and cricothyroidectomies saying hey only me the tech of central lines and cricothyroidectomies should do this not stupid EM docs who mostly just prescribe antibiotics for viral illnesses. When you say "we" put in central lines are you trying to imply that only EM docs and surgeons can put in a central line? Those are routine procedures performed by FM and IM docs. I have anastomosed the femoral artery in a rat as well as made end to side anastomoses in tiny rat vessels I'm pretty damn sure that I or any medical school graduate can make a hole in the cricothyroid membrane . In fact I think I could train an eight year old to not just do it but do it well. Are you trying to tell me that the "adams" apple (thyroid cartilage) isn't a major landmark and that somehow it is difficult to find the cricothyroid membrane?! I didn't specialize because I would become bored doing the same damn things every day. I am not prepared to accept limiting my practice because somebody thinks I'm stepping on their turf without a fight.

This idea that there should be a specialist for every little thing is a relatively recent idea. My grandfather, a Generalist, performed amputations in WWI on the front lines in England, delivered babies, and performed minor surgeries. What have we got for all the specialists? According to the Darthmouth study we have gotten worse outcomes and greater costs in areas with more specialists.

I'm telling you just that. You may not get out much but many of our sickest patients look like Jabba the Hut. It is impossible to palpate anything through 4 inches of fat. You have to sort of guess, make a generous incision, and quickly blunt dissect.

And then you can hit an artery and get all kinds of blood in your field, completely obscuring your field of view. Then you have to hook the trachea which they tell me can retract way down into the neck in which case you are screwed.

On the other hand, if you're too timid to intubate for status epilepticus, you will probably not be decisive enough to say, "**** it, we're going for a cric," in time to save your apneic, airwayless patient.

I repeat, Emergency Medicine is not rocket science and our "signature procedures" are not brain surgery. But putting it all together when required is the thing and your ability to dick around with rat arteries has nothing to do with the ability to stick a finder needle into the internal jugular vein in a crashing patient using nothing but his carotid arterial pulse as a guide while everybody and his brother is either sticking something in or on the patient or watching you screw it up.

Rat dies? No big deal. Stick a carotid and tear it or drop a lung? Big deal.

 

[deleted87716]

many of our sickest patients look like Jabba the Hut.

Bummer, that. Too bad they don't look like Princess Leia in her gold bikini. Hell, I'd probably work for free.

 

[lowbudget]

I'm telling you just that. You may not get out much but many of our sickest patients look like Jabba the Hut. It is impossible to palpate anything through 4 inches of fat. You have to sort of guess, make a generous incision, and quickly blunt dissect.

And then you can hit an artery and get all kinds of blood in your field, completely obscuring your field of view. Then you have to hook the trachea which they tell me can retract way down into the neck in which case you are screwed.

On the other hand, if you're too timid to intubate for status epilepticus, you will probably not be decisive enough to say, "**** it, we're going for a cric," in time to save your apneic, airwayless patient.

I repeat, Emergency Medicine is not rocket science and our "signature procedures" are not brain surgery. But putting it all together when required is the thing and your ability to dick around with rat arteries has nothing to do with the ability to stick a finder needle into the internal jugular vein in a crashing patient using nothing but his carotid arterial pulse as a guide while everybody and his brother is either sticking something in or on the patient or watching you screw it up.

Rat dies? No big deal. Stick a carotid and tear it or drop a lung? Big deal.

Man, you're right... sounds complicated.

When I hit your ER, make sure you have already called Anesthesia to do my airway (I want fiberoptic) if I'm in SE, and I want ENT at the bedside ready to do my cric. And I want a Cardiovascular Surgeon at the bedside just in case I need a chest tube and/or an arterial anastamosis, with rat sutures. And my ventilator better be made of gold and diamonds with my name engraved at Tiffany's ready to go.

And make sure you have already asked Neurology for permission to give me Ativan. I don't care if it's 3 am. If Derm can be woken up for some low budget sed rate rash, so should Neuro. And I swear I will sue the crap out of you if you don't do any of these things. Because I will ask you for your PROCEDURE LOG in COURT and ask you how many you've done compared to these SPECIALISTS. "Dr. ER, how many crics, as you call them, have you performed during residency. Hmm... well that's funny, because an ENT 1st year resident has done much more while doing a triple axel on a pommel horse. Isn't it true that you are indeed unqualified and practicing outside your scope?"

And these guys (not women, because they may get pregnant and ask for time off) better be AOA from USNews Top 5 (at least Top 10) Research (not Primary Care) Medical Schools, not D.O.'s, not FMG's. They better be the Chairman of those Departments too with current CME's.

I want SPECIALISTS taking care of me, damnit. Not no general doctor or no "emergent practitioner" in no emergency room.

 

[MOHS_01]

Thanks for your post. Very informative and contributed greatly to the discussion.

 

[MedicineDoc]

On the other hand, if you're too timid to intubate for status epilepticus, you will probably not be decisive enough to say, "**** it, we're going for a cric," in time to save your apneic, airwayless patient.
.

Who said anything about an apneic airwayless patient? Isnt it true that EMT-B and army personnel and are trained to do a cricothyroidotomy with a piece of glass or a pocket knife if neccessary? I think there is a merit badge for boy scouts although it might be a little advanced for brownies.

 

[8744]

Who said anything about an apneic airwayless patient? Isnt it true that EMT-B and army personnel and are trained to do a cricothyroidotomy with a piece of glass or a pocket knife if neccessary? I think there is a merit badge for boy scouts although it might be a little advanced for brownies.

Again, you can train someone to do it but doing it is the thing. I've done two on people...and six on dogs in animal lab. It's not as easy as you think even on an anesthetized dog. Additionally, making the decisions to do it is, so to speak, most of the fun. And I reiterate: it is not rocket science. Being an infantryman, as an example, isn't rocket science either and is simply the ability to execute a number of fairly simple tasks. And yet nobody would say that a National Guard Bulk Fuel Specialist who has had some basic infantry training is the equivalent of an Army Ranger, a fellow who is perhaps the premier infantryman in the world.

 

[8744]

Man, you're right... sounds complicated.

When I hit your ER, make sure you have already called Anesthesia to do my airway (I want fiberoptic) if I'm in SE, and I want ENT at the bedside ready to do my cric. And I want a Cardiovascular Surgeon at the bedside just in case I need a chest tube and/or an arterial anastamosis, with rat sutures. And my ventilator better be made of gold and diamonds with my name engraved at Tiffany's ready to go.

And make sure you have already asked Neurology for permission to give me Ativan. I don't care if it's 3 am. If Derm can be woken up for some low budget sed rate rash, so should Neuro. And I swear I will sue the crap out of you if you don't do any of these things. Because I will ask you for your PROCEDURE LOG in COURT and ask you how many you've done compared to these SPECIALISTS. "Dr. ER, how many crics, as you call them, have you performed during residency. Hmm... well that's funny, because an ENT 1st year resident has done much more while doing a triple axel on a pommel horse. Isn't it true that you are indeed unqualified and practicing outside your scope?"

And these guys (not women, because they may get pregnant and ask for time off) better be AOA from USNews Top 5 (at least Top 10) Research (not Primary Care) Medical Schools, not D.O.'s, not FMG's. They better be the Chairman of those Departments too with current CME's.

I want SPECIALISTS taking care of me, damnit. Not no general doctor or no "emergent practitioner" in no emergency room.

I agree that American medicine is too specialized. Did you all know, for example, that pediatricians and internists used to be considered specialists, consultants who were called in when your regular doctor was in over his head, and not primary care as they are today? Certainly medicine has grown more complex but it is primarily for legal and economic reasons that we consult so many specialists nowadays. Legally because consulting a cardiologist or a nephrologist for routine medical problems has become the de facto standard of care and economically because generalists no longer have the time in a standard clinic visit to address the multiple problems of their increasingly comorbid patients.

This is all, however, just another manifestation of how out-of-control our medical system has become, burdened as it is with insanity, perverse incentives, and a complete disregard for common sense that borders on psychosis. Take my specialty, for example. The problem with it (and the rest of the medical profession) is that everything is a goddamn emergency, even things that are not, and most busy Emergency Departments run in a crisis mode most of the time because of an inability to to say, "Go home, come back in the morning if you don't feel better, you probably don't have anything wrong with you and if you do, another eight hours isn't going to make much of a difference."

Take for example my number one favorite complaint of "spotting" and mild pelvic pain in an otherwise asymptomatic, healthy, and hemodynamically stable newly pregnant patient.

Could it be an ectopic pregnancy? A molar pregnancy? A cyst? An early ovarian torsion? Any of many gynecological pathologies? Sure it could. But the money we spend on the work up, as it costs four times what it would cost at the lady's OB/Gyn (with whom she often has an appointment only days away), to find out a few day early is part of the expense that is going to bankrupt our nation. In other words, in a perfect world she'd get a "quant" beta-HCG and a set of vitals which, if consistent with her dates would lead to a discharge and instructions to keep her scheduled pre-natal visit at the (free) OB clinic to which she had been assigned. Instead, she gets the works including an emergent and therefore expensive ultrasound (even if I do a bedside el-cheapo non-billable one that "doesn't count).

Insanity.

 

[sophiejane]

Man, you're right... sounds complicated.

When I hit your ER, make sure you have already called Anesthesia to do my airway (I want fiberoptic) if I'm in SE, and I want ENT at the bedside ready to do my cric. And I want a Cardiovascular Surgeon at the bedside just in case I need a chest tube and/or an arterial anastamosis, with rat sutures. And my ventilator better be made of gold and diamonds with my name engraved at Tiffany's ready to go.

And make sure you have already asked Neurology for permission to give me Ativan. I don't care if it's 3 am. If Derm can be woken up for some low budget sed rate rash, so should Neuro. And I swear I will sue the crap out of you if you don't do any of these things. Because I will ask you for your PROCEDURE LOG in COURT and ask you how many you've done compared to these SPECIALISTS. "Dr. ER, how many crics, as you call them, have you performed during residency. Hmm... well that's funny, because an ENT 1st year resident has done much more while doing a triple axel on a pommel horse. Isn't it true that you are indeed unqualified and practicing outside your scope?"

And these guys (not women, because they may get pregnant and ask for time off) better be AOA from USNews Top 5 (at least Top 10) Research (not Primary Care) Medical Schools, not D.O.'s, not FMG's. They better be the Chairman of those Departments too with current CME's.

I want SPECIALISTS taking care of me, damnit. Not no general doctor or no "emergent practitioner" in no emergency room.

I don't care if it wasn't informative, it was great!