How much radiology to know if working in rural or community setting?

[MedicineZ0Z]

If there's no radio in the hospital, how much should one know in order to practice with maximal competency? Chest xray reading + fractures on xray I'm assuming is a given. CTs (stroke)? And ultrasound as a nice bonus skill?

---

Members don't see this ad.

 

[miacomet]

This is more of an issue in insane urban hospitals (I'm looking at you, HHC and other NYC hospitals that just have residents reading) than in rural hospitals. I have worked in several small, rural hospitals, and it was pretty easy to get an US tech to come in. Readings were generally done by nighthawks for everything. It's really high liability not to have radiologists reading. Most rural hospitals these days are part of a larger system, so someone on staff reads for all the hospitals.

I would NOT work anywhere where I had to read my own CTs and ultrasounds. Xrays OK as long as they are overread the next day and someone calls back. I also would not work anywhere I HAD to do US to R/O ectopic, or really for any other reason. It takes a while to do a good study, and the liability, esp for ectopic, is through the roof.

I'm assuming you meant hemorrhagic stroke on CT, but if I'm CTing for that, I want a read.

 

[miacomet]

I should add that I don't know any community shops where docs do their own ultrasounds aside from FASTs and for a few procedures. This seems to be a weird academic EM obsession that does not translate in places where you have to move patients. I don't get WHY ultrasound beyond IJs and FASTs is such a big deal in EM these days. It's a fun skill, but not really valued anywhere outside academia, I don't think. You'll get a CXR for a PTX, an official US for ectopic, RUQ pain, or R/O peds appy. Techs or nurses will do US-guided IV's.

Am I missing something? Why are residencies spending so much time on this? Do other community shops do more?

 

[TooMuchResearch]

At even our groups most rural place, imagining is all read by off-site subspecialty radiologists 24/7.

 

[Vandalia]

To add to the above, it would be very rare for a place not to have tele-radiology coverage. The limiting factor in a very rural location is often getting the imaging done, not interpreting it, since they may not have a CT tech in house.

The concern of the EM physician is what is going to kill the patient before the radiologist sees the images, but that is what you do an EM residency for.

 

[TooMuchResearch]

To add to the above, it would be very rare for a place not to have tele-radiology coverage. The limiting factor in a very rural location is often getting the imaging done, not interpreting it, since they may not have a CT tech in house.

The concern of the EM physician is what is going to kill the patient before the radiologist sees the images, but that is what you do an EM residency for.

And on nights like tonight when I just want to sneak a little nap, it's taking forever for my CT person to get here. But at least I know the emergency body radiologist is awake somewhere in the city and ready to read.

 

[TheComebacKid]

At our community site in residency the attendings have to read all the X-rays overnight (not during the day time, because you know, patients only get broken bones during daylight hours)

CT scans are read by some teleradiology person overnight thank goodness.

 

[TooMuchResearch]

And on nights like tonight when I just want to sneak a little nap, it's taking forever for my CT person to get here. But at least I know the emergency body radiologist is awake somewhere in the city and ready to read.

And the radiologist called me within 15 minutes of scan completion with actionable results!

 

[Janders]

So, yes we have nighthawk read CT and U/S.

We read our own Xrays (every type you can think of.. so know chest and your typical ortho...) and they are over-read the next day.

We have no U/S tech from 2300-0700, so it pays to be handy with the 'ol probe at least

BUT
I VERY FREQUENTLY find that nighthawk misses IMPORTANT CT findings. We have the advantage of seeing the patient, examining the patient, and knowing what we are looking for. I've found all sorts of rib fractures, spinal fractures, pelvic fractures, ischemic gut, pelvic abscess and other things NOT called on the initial nighthawk read. As well, sometimes you wait 1-2 hours for the nighthawk read-- in a critically ill patient, in a setting where you transfer out to tertiary care, it is helpful to be able to interpret your CTs at least enough to get the ball rolling on treatment. I.E. Thats a clear dissection, obvious PE, obvious SBO / appy / perforated divertic / etc.

So I strongly encourage people to learn CT reading-- its fun to correlate it to your patient, honestly.

 

[alpinism]

I should add that I don't know any community shops where docs do their own ultrasounds aside from FASTs and for a few procedures. This seems to be a weird academic EM obsession that does not translate in places where you have to move patients. I don't get WHY ultrasound beyond IJs and FASTs is such a big deal in EM these days. It's a fun skill, but not really valued anywhere outside academia, I don't think. You'll get a CXR for a PTX, an official US for ectopic, RUQ pain, or R/O peds appy. Techs or nurses will do US-guided IV's.

Am I missing something? Why are residencies spending so much time on this? Do other community shops do more?

Well for example US has higher sensitivity for PTX than CXR and also takes less than 2 min to perform at the bedside.

Ultrasound for Detection of Pneumothorax - R.E.B.E.L. EM - Emergency Medicine Blog

 

[GonnaBeADoc2222]

Well for example US has higher sensitivity for PTX than CXR and also takes less than 2 min to perform at the bedside.

Ultrasound for Detection of Pneumothorax - R.E.B.E.L. EM - Emergency Medicine Blog

Yes, assuming you have a nice ultrasound machine. Where I work, I basically have an iPad on a stick.

I trained at one of those academic powerhouses that was inappropriately giddy about ultrasound. Silly things like differentiating systolic vs diastolic heart failure or diagnosing shoulder separation.

In my community site, I have in house rads for everything during the day and nighthawk for CT/MRI/US at night. I have to read my own plain films at night, and both nighthawk and my nighttime plain film reads are over read the next day by our in house folks. I'm not the best at reading plain films or at orthopedics in general, but seriously, it isn't a big deal. If you don't see anything obvious and something just doesn't feel right (especially in a kid over a growth plate), just splint it and have them follow up.

I will agree about nighthawk being slow and missing things though. Or, equally, if not more annoying, over calling some nonsense that necessitates me having a surgeon come consult on the patient.

 

[miacomet]

Well for example US has higher sensitivity for PTX than CXR and also takes less than 2 min to perform at the bedside.

/QUOTE]

Yes, of course. But you need to know what percentage PTX, whether they need a chest tube vs a pigtail, whether they need admission vs a repeat CXR in 6 hours. So I don't see how you save time or improve care with an ultrasound??

 

[miacomet]

So, yes we have nighthawk read CT and U/S.

We read our own Xrays (every type you can think of.. so know chest and your typical ortho...) and they are over-read the next day.

We have no U/S tech from 2300-0700, so it pays to be handy with the 'ol probe at least

BUT
I VERY FREQUENTLY find that nighthawk misses IMPORTANT CT findings. We have the advantage of seeing the patient, examining the patient, and knowing what we are looking for. I've found all sorts of rib fractures, spinal fractures, pelvic fractures, ischemic gut, pelvic abscess and other things NOT called on the initial nighthawk read. As well, sometimes you wait 1-2 hours for the nighthawk read-- in a critically ill patient, in a setting where you transfer out to tertiary care, it is helpful to be able to interpret your CTs at least enough to get the ball rolling on treatment. I.E. Thats a clear dissection, obvious PE, obvious SBO / appy / perforated divertic / etc.

So I strongly encourage people to learn CT reading-- its fun to correlate it to your patient, honestly.

Do you DC possible ectopics based on your own US? Do you have a vaginal probe? Curious as to what your practice is. To me, seems like high liability.

Agreed Nighthawks misses a fair amount of stuff. We are lucky to have staff rads all night, albeit remotely, and they read within an hour or so.

 

[miacomet]

At our community site in residency the attendings have to read all the X-rays overnight (not during the day time, because you know, patients only get broken bones during daylight hours)

CT scans are read by some teleradiology person overnight thank goodness.

Aside from patient satisfaction issues, there aren't many negative consequences to most missed fractures. If you miss it, it's most likely subtle, and it can be taken care of just as well with a splint and follow up with ortho/fracture clinic/family medicine.

 

[Angry Birds]

Aside from patient satisfaction issues, there aren't many negative consequences to most missed fractures. If you miss it, it's most likely subtle, and it can be taken care of just as well with a splint and follow up with ortho/fracture clinic/family medicine.

I just tell everyone the following: “The radiologist will officially read your X-ray within 24-48 hours. I took a look at it and didn’t see anything major. However, there’s always the possibility that I missed something small. But even if I did, this means it’s so small that it won’t likely change the management. In any case, we’ll call you if I missed something, but you are your best advocate: ask your PCP to confirm that the X-ray was in fact officially read as negative. Any questions?”

 

[alpinism]

You can accurately estimate the PTX percentage based on the location of the lung point.

Some studies have even shown US to be superior to CXR in determining the percentage of lung collapse.

Semi-quantification of pneumothorax volume by lung ultrasound. - PubMed - NCBI

 

[TooMuchResearch]

You can accurately estimate the PTX percentage based on the location of the lung point.

Some studies have even shown US to be superior to CXR in determining the percentage of lung collapse.

Semi-quantification of pneumothorax volume by lung ultrasound. - PubMed - NCBI

Sure, or I can get an x-ray and see the next patient.

 

[miacomet]

Sure, or I can get an x-ray and see the next patient.

Exactly. The above article about PTX percentage is interesting and informative. But you'd have to be doing a ton of US to keep up those skills while your waiting room fills up and admin gets upset. 2 minutes on 10 traumas a day and I have to get the pt to CT within 10 minutes and transferred out by 90 mins by our criteria or risk our trauma goals, so not happening with the care and accuracy probably exhibited in the study. In my rural hospital, you are probably getting a CT anyway for traumatic PTX as we have to transfer traumas, so it's essential to R/O other injuries.

So I will do a quick E-FAST because our trauma guidelines mandate it, and then most likely off to the scanner.

 

[TooMuchResearch]

Exactly. The above article about PTX percentage is interesting and informative. But you'd have to be doing a ton of US to keep up those skills while your waiting room fills up and admin gets upset. 2 minutes on 10 traumas a day and I have to get the pt to CT within 10 minutes and transferred out by 90 mins by our criteria or risk our trauma goals, so not happening with the care and accuracy probably exhibited in the study. In my rural hospital, you are probably getting a CT anyway for traumatic PTX as we have to transfer traumas, so it's essential to R/O other injuries.

So I will do a quick E-FAST because our trauma guidelines mandate it, and then most likely off to the scanner.

Your trauma guidelines mandate you do an EFAST? Why?

When our nurses ask if I'm going to do a FAST in stable trauma activations, I tell them there is no utility in it.

 

[miacomet]

Your trauma guidelines mandate you do an EFAST? Why?

When our nurses ask if I'm going to do a FAST in stable trauma activations, I tell them there is no utility in it.

There's no good reason. It's part of the recert criteria decided by some person who is not me.

 

[deleted109597]

I should add that I don't know any community shops where docs do their own ultrasounds aside from FASTs and for a few procedures. This seems to be a weird academic EM obsession that does not translate in places where you have to move patients. I don't get WHY ultrasound beyond IJs and FASTs is such a big deal in EM these days. It's a fun skill, but not really valued anywhere outside academia, I don't think. You'll get a CXR for a PTX, an official US for ectopic, RUQ pain, or R/O peds appy.

Endorse

Techs or nurses will do US-guided IV's.

HAHAHAHAHAHAHAHAHAHAHAHAHA NO. Maybe the PICC nurse can use it. But they work banker's hours too.

 

[miacomet]

Endorse

HAHAHAHAHAHAHAHAHAHAHAHAHA NO. Maybe the PICC nurse can use it. But they work banker's hours too.

Sorry your staff isn't so skilled. Our techs and our nurses do US guided IVs all the time. It's no more dangerous than a regular PIV, so why not? I would be so annoyed in my single-coverage shop if I had to spend ages getting an IV. Lots of people would get IOs heh heh heh. The techs especially love it. More interesting than cleaning up poop.

 

[turkeyjerky]

Do you DC possible ectopics based on your own US? Do you have a vaginal probe? Curious as to what your practice is. To me, seems like high liability.

Agreed Nighthawks misses a fair amount of stuff. We are lucky to have staff rads all night, albeit remotely, and they read within an hour or so.

I discharge threatened AB's all the time based on my own bedside ultrasound, always TA, since doing a TV is too much of a hassle. If I can't see an IUP, then I get a formal one. Heterotopics are so uncommon (in the absence of fertility treatment) so as not to be worth worrying about,and I trust my ability to confirm an IUP. If it looks funn, the Iget a formal to rule out a cornual ectopic, I suppose.

As far as liability goes, the ones that get me are when rads doesn't see an ectopic and there's an adnexal mass that they read as a simple cyst, when there's a definite chance that it's an ectopic.

 

[deleted109597]

Sorry your staff isn't so skilled. Our techs and our nurses do US guided IVs all the time. It's no more dangerous than a regular PIV, so why not? I would be so annoyed in my single-coverage shop if I had to spend ages getting an IV. Lots of people would get IOs heh heh heh. The techs especially love it. More interesting than cleaning up poop.

Yeah, I've worked at 8 hospitals, and there's been a PICC nurse at 2. It's surprisingly uncommon for nurses to put US guided PIV in my experience. I'm sure it's great at your shop. It just isn't universal.

 

[miacomet]

Yeah, I've worked at 8 hospitals, and there's been a PICC nurse at 2. It's surprisingly uncommon for nurses to put US guided PIV in my experience. I'm sure it's great at your shop. It just isn't universal.

Agreed. I'm very spoiled. It's unfortunate, though, as it's a huge time saver IME.

 

[miacomet]

I discharge threatened AB's all the time based on my own bedside ultrasound, always TA, since doing a TV is too much of a hassle. If I can't see an IUP, then I get a formal one. Heterotopics are so uncommon (in the absence of fertility treatment) so as not to be worth worrying about,and I trust my ability to confirm an IUP. If it looks funn, the Iget a formal to rule out a cornual ectopic, I suppose.

As far as liability goes, the ones that get me are when rads doesn't see an ectopic and there's an adnexal mass that they read as a simple cyst, when there's a definite chance that it's an ectopic.

Reasonable approach. I don't mind transabdominal, but TV is a whole different kettle of fish clinically, radiographically, technically, and it's hard to find the probe and clean it.

 

[MechEDoc]

I should add that I don't know any community shops where docs do their own ultrasounds aside from FASTs and for a few procedures. This seems to be a weird academic EM obsession that does not translate in places where you have to move patients. I don't get WHY ultrasound beyond IJs and FASTs is such a big deal in EM these days. It's a fun skill, but not really valued anywhere outside academia, I don't think. You'll get a CXR for a PTX, an official US for ectopic, RUQ pain, or R/O peds appy. Techs or nurses will do US-guided IV's.

Am I missing something? Why are residencies spending so much time on this? Do other community shops do more?

Ha! I want to work where you are!

US techs take hours at night. They'll argue about the hCG too. I don't argue, I remind them it's an order. For select patients I'll do my own studies and then document in the chart (DVT, abdominal aorta, gallbladder, clear intrauterine pregnancy on transabdominal, pleural and pericardial effusions). Nurses generally can't do US PIV or they are terrible at it. If I don't place my own, then I'll have to do a central line. Only have had to do one central on 2 years for this indication. I have to place a PIV once every week or two when I'm on with the C team. No night reads on plain films, variable reliability in callbacks for over reads. Yes, this is super high risk and I don't like it. Night hawk sucks and misses things. On chest or abdomen CTs if I'm worried I call surgery and review the images together. Caught lots of misses. I drink (x1 beer, no more!) after shift, I makes me feel better for 30 minutes, then I fall asleep. It's not healthy.

I'm starting to think I'm working at the wrong places.

 

[miacomet]

Ha! I want to work where you are!

US techs take hours at night. They'll argue about the hCG too. I don't argue, I remind them it's an order. For select patients I'll do my own studies and then document in the chart (DVT, abdominal aorta, gallbladder, clear intrauterine pregnancy on transabdominal, pleural and pericardial effusions). Nurses generally can't do US PIV or they are terrible at it. If I don't place my own, then I'll have to do a central line. Only have had to do one central on 2 years for this indication. I have to place a PIV once every week or two when I'm on with the C team. No night reads on plain films, variable reliability in callbacks for over reads. Yes, this is super high risk and I don't like it. Night hawk sucks and misses things. On chest or abdomen CTs if I'm worried I call surgery and review the images together. Caught lots of misses. I drink (x1 beer, no more!) after shift, I makes me feel better for 30 minutes, then I fall asleep. It's not healthy.

I'm starting to think I'm working at the wrong places.

I'm spoiled at my job, and I realize most nurses and techs are not as skilled as ours, but I think it's a battle worth fighting otherwise it's too easy for the nurses to demand an US IV. OTOH, it's just me at night with no one else in the hospital. No problem with techs coming in at night.

DVT studies? You must be really fast or really good or have lots of time! Does everyone do this at your shop? Why don't you just CT for AAA etc? No CT in house?

Curious as to what kind of shop you work at, and also if you are making the big bucks.

 

[MechEDoc]

I'm spoiled at my job, and I realize most nurses and techs are not as skilled as ours, but I think it's a battle worth fighting otherwise it's too easy for the nurses to demand an US IV. OTOH, it's just me at night with no one else in the hospital. No problem with techs coming in at night.

DVT studies? You must be really fast or really good or have lots of time! Does everyone do this at your shop? Why don't you just CT for AAA etc? No CT in house?

Curious as to what kind of shop you work at, and also if you are making the big bucks.

A quick DVT study takes about 2-3 minutes a side. In a lower risk patient, way faster than waiting for a tech or playing the d-dimer game.

I only do AAA studies in screening for back pain (e.g. smoker and/or >50 years old) or unstable patients.

I'd like my nurses to be better, but they just aren't nor does administration support them in getting better or learning new tricks.

 

[miacomet]

A quick DVT study takes about 2-3 minutes a side. In a lower risk patient, way faster than waiting for a tech or playing the d-dimer game.

I only do AAA studies in screening for back pain (e.g. smoker and/or >50 years old) or unstable patients.

I'd like my nurses to be better, but they just aren't nor does administration support them in getting better or learning new tricks.

I am really impressed with your ability to do a DVT study in that short a time! What kind of shop are you at (city, town, academic, community)?

 

[MechEDoc]

Community. Dumpster fire. Travel full time for a CMG. Never know what you'll find when you get there.

One needs to take a quick look at the popliteal vein, place ultrasound gel from the inguinal crease to 20 cm distal on the medial side, visualize the common femoral and greater saphenous vein, the deep and superficial femoral vein, and then proceed distally down the leg for approximately 20 cm compressing the veins. Hand a towel to the patient and tell them to wipe themselves off.

High risk patients get a study by radiology. Shared liability and confirmed images in PACS. Low risk patients get the above and a discharge.

 

[miacomet]

Community. Dumpster fire. Travel full time for a CMG. Never know what you'll find when you get there.

One needs to take a quick look at the popliteal vein, place ultrasound gel from the inguinal crease to 20 cm distal on the medial side, visualize the common femoral and greater saphenous vein, the deep and superficial femoral vein, and then proceed distally down the leg for approximately 20 cm compressing the veins. Hand a towel to the patient and tell them to wipe themselves off.

High risk patients get a study by radiology. Shared liability and confirmed images in PACS. Low risk patients get the above and a discharge.

I hope they are paying you handsomely for this dumpster fire! Insane. It would save the hospital money to get better trained nurses and techs to help you out so you can see more patients. It may take only five minutes, but it takes me zero minutes to ask the clerk to call in the ultrasonographer.

What region of the country is said DF in? Why do you stay? Big Benjamins?

 

[Psai]

I am really impressed with your ability to do a DVT study in that short a time! What kind of shop are you at (city, town, academic, community)?

You just look for the veins and press down to see if it's compressible. It doesn't replace the formal study but it's a nice quick and dirty way to look for a clot.

 

[MechEDoc]

I hope they are paying you handsomely for this dumpster fire! Insane. It would save the hospital money to get better trained nurses and techs to help you out so you can see more patients. It may take only five minutes, but it takes me zero minutes to ask the clerk to call in the ultrasonographer.

What region of the country is said DF in? Why do you stay? Big Benjamins?

West coast. Same deal around the country. Good pay. Looking for an exit. I had a patient in status, couldn't get the nurse to increase to propofol drip (wouldn't follow orders type, does her own thing). Finally asks me if I'm going to give any antiseizure meds (this was an EtOH withdraw seizure, so no sodium channel blockers), I mention that that propofol was kind of like the nuclear option for seizures. "Oh really? I didn't know that!" 10 years ED experience in that one too. Guy spent an hour shaking. No benzo gtts available. Pharmacy wouldn't release a loading dose of phenobarbital.

I've learned tons, but it's not worth it.

You're right about the time thing, but if it lets me free up a room faster so I can start working on the waiting room, then it can be worth it at times. I've also had techs refuse to do bilateral lower extremity studies ("policy"), I'll put their name in the chart, note their refusal despite being unlicensed to do so, then perform my own study and document it. C'est la vie. I have found BLE clots

 

[Psai]

West coast. Same deal around the country. Good pay. Looking for an exit. I had a patient in status, couldn't get the nurse to increase to propofol drip (wouldn't follow orders type, does her own thing). Finally asks me if I'm going to give any antiseizure meds (this was an EtOH withdraw seizure, so no sodium channel blockers), I mention that that propofol was kind of like the nuclear option for seizures. "Oh really? I didn't know that!" 10 years ED experience in that one too. Guy spent an hour shaking. No benzo gtts available. Pharmacy wouldn't release a loading dose of phenobarbital.

I've learned tons, but it's not worth it.

Jesus christ...

 

[MechEDoc]

Jesus christ...

Yeah, the guy was an old pro at EtOH. Slow push 400 mg propofol, held the paralytics, he gagged when I put the tube in. Wow!

 

[miacomet]

West coast. Same deal around the country. Good pay. Looking for an exit. I had a patient in status, couldn't get the nurse to increase to propofol drip (wouldn't follow orders type, does her own thing). Finally asks me if I'm going to give any antiseizure meds (this was an EtOH withdraw seizure, so no sodium channel blockers), I mention that that propofol was kind of like the nuclear option for seizures. "Oh really? I didn't know that!" 10 years ED experience in that one too. Guy spent an hour shaking. No benzo gtts available. Pharmacy wouldn't release a loading dose of phenobarbital.

I've learned tons, but it's not worth it.

You're right about the time thing, but if it lets me free up a room faster so I can start working on the waiting room, then it can be worth it at times. I've also had techs refuse to do bilateral lower extremity studies ("policy"), I'll put their name in the chart, note their refusal despite being unlicensed to do so, then perform my own study and document it. C'est la vie. I have found BLE clots

Jesus Christ again. I am going to assume that the nurse in question (along with the lazy sono techs) was unionized and can't be moved from his or her perch. I thought this **** only happened in NYC. My guess is no CIWA protocol in that DF.

Quit. Now. I have worked at a dozen hospitals and none were this universally bad, even in the rural south. Awful. There is nothing worse than a hospital with lazy ancillary staff. If the nurses and techs know everything, maybe they can save money on docs.

 

[TooMuchResearch]

West coast. Same deal around the country. Good pay. Looking for an exit. I had a patient in status, couldn't get the nurse to increase to propofol drip (wouldn't follow orders type, does her own thing). Finally asks me if I'm going to give any antiseizure meds (this was an EtOH withdraw seizure, so no sodium channel blockers), I mention that that propofol was kind of like the nuclear option for seizures. "Oh really? I didn't know that!" 10 years ED experience in that one too. Guy spent an hour shaking. No benzo gtts available. Pharmacy wouldn't release a loading dose of phenobarbital.

I've learned tons, but it's not worth it.

You're right about the time thing, but if it lets me free up a room faster so I can start working on the waiting room, then it can be worth it at times. I've also had techs refuse to do bilateral lower extremity studies ("policy"), I'll put their name in the chart, note their refusal despite being unlicensed to do so, then perform my own study and document it. C'est la vie. I have found BLE clots

Holy ****.

 

[namethatsmell]

I've also had techs refuse to do bilateral lower extremity studies ("policy"), I'll put their name in the chart, note their refusal despite being unlicensed to do so, then perform my own study and document it. C'est la vie. I have found BLE clots

You're being taken advantage of, leave this gig now.

If you'd rather not leave if things could improve, then you need to have your group leadership get on this ASAP (hopefully they're already aware). Tell them you don't feel comfortable with this kind of crap and will leave immediately if it isn't fixed. Give them one week. Emphasize your concerns about the patient safety and liability issues. If (when) they do nothing (heaven forbid they risk this delightful contract) then walk. Don't give them an open-ended timeframe or you're just working against yourself.

 

[miacomet]

You're being taken advantage of, leave this gig now.

If you'd rather not leave if things could improve, then you need to have your group leadership get on this ASAP (hopefully they're already aware). Tell them you don't feel comfortable with this kind of crap and will leave immediately if it isn't fixed. Give them one week. Emphasize your concerns about the patient safety and liability issues. If (when) they do nothing (heaven forbid they risk this delightful contract) then walk. Don't give them an open-ended timeframe or you're just working against yourself.

Agreed with Smell. No money is worth this! You don't have to be mean- just explain your biggest concerns (in this case it seems the most critical issues are nursing, nursing, techs, and resources) and that you simply can't continue to practice good medicine in such an environment, and that you will be leaving in X amount of time if they can't be fixed. If you are a FF and you aren't willing to fully walk away from your income, you could offer to work at a different shop. But no amount of money is worth this. FWIW, I have worked government jobs that are better run than this place. You are doing no favors to yourself, your profession, or your patients by staying in this cluster.

 

[miacomet]

Community. Dumpster fire. Travel full time for a CMG. Never know what you'll find when you get there.

One needs to take a quick look at the popliteal vein, place ultrasound gel from the inguinal crease to 20 cm distal on the medial side, visualize the common femoral and greater saphenous vein, the deep and superficial femoral vein, and then proceed distally down the leg for approximately 20 cm compressing the veins. Hand a towel to the patient and tell them to wipe themselves off.

High risk patients get a study by radiology. Shared liability and confirmed images in PACS. Low risk patients get the above and a discharge.

If I'm doing a study, I consider them high risk, and they are going to get the right study done well. If they are low risk, no study. My techs spend 30 minutes on a DVT study. But my gig makes US easy. Having a tech on call is not pricey. I don't get it. But I am not an administrator.

 

[MechEDoc]

Finally done with that hospital. The nurse still has a job because the hospital is so desperate to keep anybody on board that hasn't yet quit. The pharmacist will have to answer at some point to his regulating board. The letter is already written…

Now headed out for greener pastures.

 

[TooMuchResearch]

Finally done with that hospital. The nurse still has a job because the hospital is so desperate to keep anybody on board that hasn't yet quit. The pharmacist will have to answer at some point to his regulating board. The letter is already written…

Now headed out for greener pastures.

Never look back.