Is the ER doc I want to be a fantasy?

[acadianvoyager]

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Current resident at a busy community hospital with every specialist at my fingertips...a little too much at my fingertips! I often feel like a triage PA instead of the bad-ass ER doc of my dreams.

Calling ortho for distal radius reductions. Calling cardiology to ask if it's okay to give adenosine to determine whether this narrow-complex tachycardia is AFib vs SVT. Watching the general surgeons do chest tubes. I feel emasculated and useless as I rely so heavily on specialists that I'm acquiring no real skills of my own.

I know ER is not non-stop critical patients. I'm fine with treating the SI patients and the chest pains and the functional abdominal pain. But sometimes, I'd also like to be the smart, capable ER doc that I dream of being. How can I get the training to do my own reductions, thoracotomies, etc., without necessarily switching programs? Would working in a county setting after residency build my skill set up?

 

[namethatsmell]

Almost every community shop out there will have you consulting less and doing more of your own procedures.

If you're weak in an area after residency you can always do CME courses, watch videos, read, talk with specialists at your shop if they are cool, etc. You'll keep learning, like the rest of us.

By the time you finish residency you'll be more capable than you realize. If you came out of residency feeling you knew everything and had done/seen everything you would have far bigger problems than being humble and eager to learn more.

 

[RuralEDDoc]

Current resident at a busy community hospital with every specialist at my fingertips...a little too much at my fingertips! I often feel like a triage PA instead of the bad-ass ER doc of my dreams.

Calling ortho for distal radius reductions. Calling cardiology to ask if it's okay to give adenosine to determine whether this narrow-complex tachycardia is AFib vs SVT. Watching the general surgeons do chest tubes. I feel emasculated and useless as I rely so heavily on specialists that I'm acquiring no real skills of my own.

I know ER is not non-stop critical patients. I'm fine with treating the SI patients and the chest pains and the functional abdominal pain. But sometimes, I'd also like to be the smart, capable ER doc that I dream of being. How can I get the training to do my own reductions, thoracotomies, etc., without necessarily switching programs? Would working in a county setting after residency build my skill set up?

I hear you - that does not sound like an ideal training setting. Sounds more like an academic shop with residents galore than a community site.
Get a busy rural job with little backup as your first job. You will find that you have enough training to know what to do, now you just have to do it - there’s no one else around to do it for you!

 

[emergentmd]

I am a big proponent of training in a County Hospital just for this reason. You will be confident in almost all procedures.

If I were you, I would ask the specialists to let you do the procedures which I think many would do even if they supervise you. I would moonlight so you will be the only one to do these procedures.

Once you are out at a community hospital, you will never see a Pulmonologist coming to do a chest tube. Ortho will never come to reduce.

 

[gamerEMdoc]

Current resident at a busy community hospital with every specialist at my fingertips...a little too much at my fingertips! I often feel like a triage PA instead of the bad-ass ER doc of my dreams.

Calling ortho for distal radius reductions. Calling cardiology to ask if it's okay to give adenosine to determine whether this narrow-complex tachycardia is AFib vs SVT. Watching the general surgeons do chest tubes. I feel emasculated and useless as I rely so heavily on specialists that I'm acquiring no real skills of my own.

I know ER is not non-stop critical patients. I'm fine with treating the SI patients and the chest pains and the functional abdominal pain. But sometimes, I'd also like to be the smart, capable ER doc that I dream of being. How can I get the training to do my own reductions, thoracotomies, etc., without necessarily switching programs? Would working in a county setting after residency build my skill set up?

Particularly why avoided big university based sites when I chose my residency, and Im still happy with that choice years later. And why I chose to work in a community EM residency when it came time to finding an academic job.

 

[southerndoc]

acadianvoyager, like you I work in a place where every available specialty is available for consultation. However, we do our own reductions, we don't need cardiology's blessing to administer adenosine or cardiovert, and we don't have thoracic surgery place our chest tubes.

Have you considered talking to the specialties? I was told 20-30 years ago, the neurologist's used to come here to do LP's and ortho did reductions. Not sure when it changed, but obviously there was a discussion with the consultants and "power" was transferred from them to us.

I once had the best friend of an orthopedic surgeon come in with a shoulder dislocation. He said he was going to be seeing him in the ER. I called him and he said "put me on speakerphone so I can talk to him." Then he told him "the ER doc does 1,000 times more reductions than I do; you're in better hands than what I can do. Let him reduce it and I'll see you in the office tomorrow."

Try to change the culture. If that's not successful and you want to be autonomous, then you may want to look for another place.

 

[link2swim06]

Take a job in a busy, community hospital without any residents when you are done.

Unless there is some complication or other issue, I never am calling for:
distal radius reductions
adenosine for SVT
cardioversion for new onset a fib
intubations
procedural sedation
etc, etc.

I don't need "permission" to do those procedures. I am credentialed to do those and it's within our scope of practice. I do the procedure if it is clinically indicated and I have the expertise to perform the procedure.

Some procedures I almost never seen done in the community (i.e. thoracotomy) and I would expect to be doing many in your career.

 

[GonnaBeADoc2222]

OP, how is your program meeting RRC requirements for certain procedures for graduation? Are you truly doing no chest tubes? Is the program massaging the numbers by relying heavily on sim?

 

[engineeredout]

That's why I'm glad to be training where I am - the subspecialists don't have residents/fellows

Current resident at a busy community hospital with every specialist at my fingertips...a little too much at my fingertips! I often feel like a triage PA instead of the bad-ass ER doc of my dreams.

Calling ortho for distal radius reductions. Calling cardiology to ask if it's okay to give adenosine to determine whether this narrow-complex tachycardia is AFib vs SVT. Watching the general surgeons do chest tubes. I feel emasculated and useless as I rely so heavily on specialists that I'm acquiring no real skills of my own.

I know ER is not non-stop critical patients. I'm fine with treating the SI patients and the chest pains and the functional abdominal pain. But sometimes, I'd also like to be the smart, capable ER doc that I dream of being. How can I get the training to do my own reductions, thoracotomies, etc., without necessarily switching programs? Would working in a county setting after residency build my skill set up?

How about you just do the procedures, then tell your attending afterwards? Not gonna call gen surg if the chest tube is already in

 

[Angry Birds]

How to be an ER doctor:

Problem in the head? CT scan and consult Neuro.
Problem in eyes? Consult Ophthalmology.
Problem from nose to the clavicle? Consult ENT.
Problem in chest? labs/EKG, Admit to Medicine, and consult Cardiology.
Problem in abdomen? CT scan and Surgery consult.
Problem in extremities? X-ray and Ortho consult.
Problem on skin? Steroid cream and outpatient Derm consult.

(This is nowhere true, but this is what many think of our specialty unfortunately. Don't be that doc and feed into the stereotype!)

 

[RoyBasch]

I can tell you the type of ER physician you want to be is the norm at community hospitals. That job definitely exists and I would say is typical. In the community I can tell you most consultants are fairly absent from ERs. You will continue to learn and get more independent in your first several years of practice. This is true even for the residents who trained at one of the big scary county programs (believe me, I trained at one). Even those residents don't realize how heavily they were leaning on their attendings...until they're gone.

The second question is will you be ready for this type of job based on your current training. I would encourage you when consulting residents come to your department to see if they will supervise you. I.e. surgery senior supervise you do the chest tube, or ortho resident supervise you do the reduction.

That being said, the "hard" part of emergency medicine is the cognitive decision making and not the procedures which for the most part are not too technically challenging. I would argue the hardest part of a chest tube is knowing when to do one. Otherwise in the words of Billy Mallon "the only thing standing between you and the chest tube are the ribs." (Ok that might be an over simplification, but most ER procedures are not technically challenging).

My point is you can learn the cognitive decision making from these consultants. Which is really the important thing. Example: You see a patient in SVT and you think: "this person needs adenosine." But your ivory tower attending insists on running by that decision by cardiology. You run it by cardiology and they say "given the adenosine." I would say you still have learned what you need to as an ER resident, and when you see this patient again in the future as an attending you will know what to do.

 

[TheComebacKid]

OP I am training at an an academic site, and honestly, sometimes I wish I trained at a community site because my impression was that it was less consultant heavy. Your experience sounds atypical.

We also end up consulting on way too many distal radius fractures instead of just reducing on our own. I agree with you, it's really difficult to be an ED doc and have to stand aside and watch a consultant put in a chest tube. It's happened to me a few times and then they come and get you when they want you to order a CXR. It's the absolute worst.

People will tell you all sorts of advice on how to handle this issue, and I can tell you for a fact that most of it is incorrect. Asking a consultant if they will let you do the procedure NEVER works. Even if they agree to it, they will inevitably end up taking over the procedure. Them "showing you" ends in always in them actually doing it. And honestly, I don't blame them. If you are consulting a service, especially if it's another resident, they are going to do the procedure. They are the ones who are going to be held accountable for the outcome. It's very rare for a ortho resident to let me do a reduction and "teach me" when they are going to get chewed out by their attending if it's not perfect.

The solutions:
1) You need to get support from your attendings. If you aren't getting it, you NEED to tell your PD and raise hell about it. If there is a procedure I want, I will tell my attending and most of the time they will fight for me to get it. If you don't have your attending on your side, it won't fly.
2) Try to convince your attendings not to consult. This is hard to do, and many of them are stubborn, and they don't want to deal with a complicated reduction, lac repair etc. I tell them that I want to do the procedure, I ask them to teach me how to do it so we don't have to consult in the first place. If they aren't going to do it, again, raise hell with your PD
3) Do the procedure, then consult the specialist. This one has gotten me into trouble a bunch of times, but sometimes it's how it needs to be. For instance, I got pissed that I wasn't getting enough distal radius fracture reductions. So I did a hematoma block and reduced it. My attending being lazy and overly conservative felt uncomfortable with that, and requested I consulted ortho. I consulted ortho and they were really upset that I had done a hematoma block (couldn't get an exam) and did a reduction already. It's poor form honestly and I don't think this is the best way to do it, but I made it very clear with them: if you don't want me doing the reduction before calling you, then you need to teach me how to do these so I am ready when I go into community practice and you aren't there. Ever since then I have been getting more procedures.

To be honest, things like ortho reductions are bread and butter and we need to be good at them. But you HAVE to get your airways, chest tubes, central lines etc because those are critical life saving procedures and your program should not be letting people take them from you.

You have to advocate for yourself and be aggressive about it. But you also need some buy in from your attendings and residency leadership. If you aren't getting it, be vocal about it. Ask your co-residents what experiences they are having. If they are having similar issues, again, bring it up with your PD, you guys will have more power in numbers. When you fill out your ACGME surveys, dock your program points in these issues, they will be forced to address it otherwise they will go on probation.

Good luck

edit: regarding your question about county programs... I don't think county programs are having residents just getting all these thoracotomies and chest tubes. county programs offer great training, and sometimes they have very sick patients, but sometimes they have very low acuity patients who are just looking for a bed to sleep in. Community places I would argue are a great place to train because you get a good combination of high acuity patients, less consultants. You are probably at a good program with a lot of good pieces in place but you need to make your voice heard with your residency leadership that you need their support.

edit2: MOONLIGHT. MOONLIGHT. MOONLIGHT. Take every opportunity to do this if you can. Don't waste your time being chief resident and getting caught up in other BS, moonlight for the experience in these procedures, not even the money.

 

[Angry Birds]

My point is you can learn the cognitive decision making from these consultants. Which is really the important thing. Example: You see a patient in SVT and you think: "this person needs adenosine." But your ivory tower attending insists on running by that decision by cardiology. You run it by cardiology and they say "given the adenosine." I would say you still have learned what you need to as an ER resident, and when you see this patient again in the future as an attending you will know what to do.

That's a very strange situation. I've given Adenosine a million times, and never asked anyone about it. There isn't even time to wait for the cardiologist, and also you'll sound so stupid with the cardiologist. Also, as a resident, I had given Adenosine without asking the EM attending... It's so cookie cutter, straightforward (as long as you make sure it ain't Vtach etc.).

"Excuse me, ma'am... I know you feel like dying due to your heart rate being in the 180's, but I'm waiting on my cardiologist to call me back. He's in the pooper right now."

Unacceptable.

 

[southerndoc]

I tried giving adenosine while in the trauma bay dealing with a cardiac arrest. The nurse wouldn't give it unless I was present. Thankfully one of my colleagues popped his head in the room while they pushed the adenosine and then left.

Not sure why it's our culture not to give adenosine without the doc in the room. ******ed. Our nurses won't give adenosine unless the patient is on the defib pads. Even more ******ed. We have some really awesome nurses, but some of their "policies" (more like hand me down culture) baffles me.

 

[Angry Birds]

I tried giving adenosine while in the trauma bay dealing with a cardiac arrest. The nurse wouldn't give it unless I was present. Thankfully one of my colleagues popped his head in the room while they pushed the adenosine and then left.

Not sure why it's our culture not to give adenosine without the doc in the room. ******ed. Our nurses won't give adenosine unless the patient is on the defib pads. Even more ******ed. We have some really awesome nurses, but some of their "policies" (more like hand me down culture) baffles me.

I dunno, I disagree... I think the doctor *should* be in the room for Adenosine. Adenosine has all sorts of risks, especially when there is always a chance that it is given for the wrong rhythm.

Adenosine can cause (prolonged) asystole, seizures, bronchospasm, etc. This is especially true for older patients. I remember during my intern year, the attending gave Adenosine and told me to prepare for intubation. I was confused, but lo and behold, the patient went into asystole and required intubation.

 

[southerndoc]

I dunno, I disagree... I think the doctor *should* be in the room for Adenosine. Adenosine has all sorts of risks, especially when there is always a chance that it is given for the wrong rhythm.

Adenosine can cause (prolonged) asystole, seizures, bronchospasm, etc. This is especially true for older patients. I remember during my intern year, the attending gave Adenosine and told me to prepare for intubation. I was confused, but lo and behold, the patient went into asystole and required intubation.

I've given adenosine more than 200 times if not even more during my time as a paramedic, resident, and attending. I've only experienced one side effect: prolonged asystole (30 seconds) in a dialysis patient.

 

[Tenk]

I've given adenosine more than 200 times if not even more during my time as a paramedic, resident, and attending. I've only experienced one side effect: prolonged asystole (30 seconds) in a dialysis patient.

Haha I had that happen once. Wasn’t 30 seconds but in my head I was like: WAKE UP MOTHER ****ER!!!

 

[Birdstrike]

Current resident at a busy community hospital with every specialist at my fingertips...a little too much at my fingertips! I often feel like a triage PA instead of the bad-ass ER doc of my dreams.

Calling ortho for distal radius reductions. Calling cardiology to ask if it's okay to give adenosine to determine whether this narrow-complex tachycardia is AFib vs SVT. Watching the general surgeons do chest tubes. I feel emasculated and useless as I rely so heavily on specialists that I'm acquiring no real skills of my own.

I know ER is not non-stop critical patients. I'm fine with treating the SI patients and the chest pains and the functional abdominal pain. But sometimes, I'd also like to be the smart, capable ER doc that I dream of being. How can I get the training to do my own reductions, thoracotomies, etc., without necessarily switching programs? Would working in a county setting after residency build my skill set up?

Wait. Aren't you rotating on these services?
Ortho, surgery, ICU. You should be rotating through these. If so, you would likely do all that on those rotations, even if you don't in the ED>

 

[dchristismi]

Modified valsalva is even faster than adenosine, and NNT is low enough that I try it on pretty much everyone before the nurse even gets a line.

 

[Psai]

I've given adenosine more than 200 times if not even more during my time as a paramedic, resident, and attending. I've only experienced one side effect: prolonged asystole (30 seconds) in a dialysis patient.

That doesn't mean that the nurse has your experience. I think it's totally reasonable to have the doctor in there to push adenosine and watch the patient.

 

[Pigg-O-Stat]

What you're describing is really unacceptable. I've worked in Level 1 trauma, and I've worked in tiny low volume FED's - and even in the FED's I've placed CTs and pushed adenosine. You will need these skills on day 1 as an attending, no matter where you end up. My advice is to find a way to get experience with these things while in residency, whatever it takes.. And I agree you should always be in the room when adenosine is pushed.

 

[alpinism]

OP, how is your program meeting RRC requirements for certain procedures for graduation? Are you truly doing no chest tubes? Is the program massaging the numbers by relying heavily on sim?

Its more common than you think.

Plenty of programs nowadays are using SIM and cadaver labs just to get minimum numbers.

I'd estimate that probably 50% if not more of EM residencies would not be able to get their required chest tube numbers (10) without using SIM or cadaver labs.

 

[alpinism]

How to be an ER doctor:

Problem in the head? CT scan and consult Neuro.
Problem in eyes? Consult Ophthalmology.
Problem from nose to the clavicle? Consult ENT.
Problem in chest? labs/EKG, Admit to Medicine, and consult Cardiology.
Problem in abdomen? CT scan and Surgery consult.
Problem in extremities? X-ray and Ortho consult.
Problem on skin? Steroid cream and outpatient Derm consult.

(This is nowhere true, but this is what many think of our specialty unfortunately. Don't be that doc and feed into the stereotype!)

Go to any big name well known academic hospital and that's essentially how they train their EM residents.

 

[Spindrift11B4]

This whole thread has made me seriously rethink my rank list...oh well, too late for that!

 

[Fox800]

Consulting to push adenosine? You do realize your paramedics are pushing this in the field off of standing orders...

 

[southerndoc]

Go to any big name well known academic hospital and that's essentially how they train their EM residents.

I trained a big name academic hospital and didn't need to call cards to push adenosine.

 

[Angry Birds]

I trained a big name academic hospital and didn't need to call cards to push adenosine.

Me too.

 

[GonnaBeADoc2222]

I trained at the ivory tower as well.

My orthopedics experience was similarly INCREDIBLY weak. Almost no fracture reduction training at all. We had the obligate ortho rotation but the ortho resident never let us do anything because the reductions had to be pristine and they were afraid of their attendings.

Luckily these aren't hard procedures really. Nor are they life saving. Just try to align as best you can and they will be seen in clinic anyway that day or the next.

That being said, your experience with things like chest tubes and adenosine for SVT is just bizarro world. A BC EM doc can't make the decision for adenosine without cards? That's kinda pathetic. Also, you need experience in chest tubes because one day you're going to have to throw one in on an unstable patient. Maybe you can try to see of thoracic surgery will let you come to the OR with them for more practice?

 

[s109442]

Family medicine trained at a hospital with no other residents. Was not hard to get chest tubes, lines and intubation, heavy ICU experience. How is it even remotely possible as an ER resident not to get 10x times as many procedures as I did. I work in Rural ER no specialty back up been doing it since day 1 out of residency. Am I missing something here. Fracture reductions are a sense of stress for an ER trainee resident, ah what’s up wit dat.

 

[gamerEMdoc]

Family medicine trained at a hospital with no other residents. Was not hard to get chest tubes, lines and intubation, heavy ICU experience. How is it even remotely possible as an ER resident not to get 10x times as many procedures as I did. I work in Rural ER no specialty back up been doing it since day 1 out of residency. Am I missing something here. Fracture reductions are a sense of stress for an ER trainee resident, ah what’s up wit dat.

You answered your own question. The fact is, there's only so many patients to go around. If you work in a program that sees 70K patients a year and has only a few other residency services, there's going to be a lot more procedures to go around than a giant University based place that sees 50k, has the same number of ED residents, and has a residency and fellowship for everything under the sun.

 

[acadianvoyager]

Hey thanks guys for your thoughts. It's really good to hear that my hospital is probably at a more extreme end of calling specialists. It's difficult for me to judge that spectrum as a resident, so really appreciate external input. Gives me hope that I'll be able to practice a little more independently when I'm out in the community.

 

[acadianvoyager]

Its more common than you think.

Plenty of programs nowadays are using SIM and cadaver labs just to get minimum numbers.

I'd estimate that probably 50% if not more of EM residencies would not be able to get their required chest tube numbers (10) without using SIM or cadaver labs.

I'm interested to hear that. I would say that we rely strongly on SIM to get our required numbers.

 

[acadianvoyager]

I can tell you the type of ER physician you want to be is the norm at community hospitals. That job definitely exists and I would say is typical. In the community I can tell you most consultants are fairly absent from ERs. You will continue to learn and get more independent in your first several years of practice. This is true even for the residents who trained at one of the big scary county programs (believe me, I trained at one). Even those residents don't realize how heavily they were leaning on their attendings...until they're gone.

The second question is will you be ready for this type of job based on your current training. I would encourage you when consulting residents come to your department to see if they will supervise you. I.e. surgery senior supervise you do the chest tube, or ortho resident supervise you do the reduction.

That being said, the "hard" part of emergency medicine is the cognitive decision making and not the procedures which for the most part are not too technically challenging. I would argue the hardest part of a chest tube is knowing when to do one. Otherwise in the words of Billy Mallon "the only thing standing between you and the chest tube are the ribs." (Ok that might be an over simplification, but most ER procedures are not technically challenging).

My point is you can learn the cognitive decision making from these consultants. Which is really the important thing. Example: You see a patient in SVT and you think: "this person needs adenosine." But your ivory tower attending insists on running by that decision by cardiology. You run it by cardiology and they say "given the adenosine." I would say you still have learned what you need to as an ER resident, and when you see this patient again in the future as an attending you will know what to do.

Very good advice, thank you.

 

[WilcoWorld]

Hey thanks guys for your thoughts. It's really good to hear that my hospital is probably at a more extreme end of calling specialists. It's difficult for me to judge that spectrum as a resident, so really appreciate external input. Gives me hope that I'll be able to practice a little more independently when I'm out in the community.

As an academic attending, I suggest that you respectfully push your faculty on these issues. On your next edge case with a faculty member that you have a good rapport with, come up with your plan and suggest doing it without a consult. By edge case, I mean something on the border - reducing a shoulder dislocation or tapping a knee, for instance. Don't use the next periprosthetic hip dislocation to push the envelope.

You might be pleasantly surprised how your faculty respond.

 

[BoardingDoc]

Don't use the next periprosthetic hip dislocation to push the envelope.

But those are so much easier than native hip reductions.

That said, I agree. If you're honestly calling ortho to put back in a shoulder or tap a knee, you need to talk to someone about it. That's completely absurd.

 

[The White Coat Investor]

Its more common than you think.

Plenty of programs nowadays are using SIM and cadaver labs just to get minimum numbers.

I'd estimate that probably 50% if not more of EM residencies would not be able to get their required chest tube numbers (10) without using SIM or cadaver labs.

Agreed. Chest tubes aren't that common. I'm in a Level III right now and it's been quite a while since I did one. That said, I did enough in residency and its not that hard that I think I could do one a decade and be competent at it.

 

[gamerEMdoc]

As an academic attending, I suggest that you respectfully push your faculty on these issues. On your next edge case with a faculty member that you have a good rapport with, come up with your plan and suggest doing it without a consult. By edge case, I mean something on the border - reducing a shoulder dislocation or tapping a knee, for instance. Don't use the next periprosthetic hip dislocation to push the envelope.

You might be pleasantly surprised how your faculty respond.

I mean no disrespect as a fellow academician, but is reducing a shoulder or tapping a knee really something on the edge of whether you consult ortho? I've never consulted ortho for either of these procedures in my life, not in residency, out on my own, nor in an academic setting now. I can't imagine orthopedics every coming in for a knee aspiration. And I wouldn't consider reducing a periprosthetic hip dislocation as "pushing the envelope". This is just all part of normal EM to me.

 

[WilcoWorld]

I mean no disrespect as a fellow academician, but is reducing a shoulder or tapping a knee really something on the edge of whether you consult ortho? I've never consulted ortho for either of these procedures in my life, not in residency, out on my own, nor in an academic setting now. I can't imagine orthopedics every coming in for a knee aspiration. And I wouldn't consider reducing a periprosthetic hip dislocation as "pushing the envelope". This is just all part of normal EM to me.

I think I've been unclear/misunderstood.

I do not think that the procedures I listed warrant consultation - that's why I suggested that the OP use such cases to push their faculty to act without first asking permission of a consultant: because they're so obviously within our scope. However, the OP said they consult Cards before pushing adenosine - something I'd never dream of consulting Cards for. So it sounds like this is an exceptionally consult-heavy department. I was trying to suggest a path forward that I see as likely to work given the environment that was described.

 

[gamerEMdoc]

I think I've been unclear/misunderstood.

I do not think that the procedures I listed warrant consultation - that's why I suggested that the OP use such cases to push their faculty to act without asking permission: because they're so obviously within our scope. However, the OP said they consult Cards before pushing adenosine - something I'd never dream of consulting Cards for. So it sounds like this is an exceptionally consult-heavy department. I was trying to suggest a path forward that I see as likely to work given the environment that was described.

Oh ok, makes sense!

 

[wareagle726]

I'd estimate that probably 50% if not more of EM residencies would not be able to get their required chest tube numbers (10) without using SIM or cadaver labs.

Is this really the case? I did't realize there was that much discrepancy between programs actually performing procedures in "real life" vs. SIM.

 

[Hercules]

That % seems pretty crazy to me too. I trained at a big academic tertiary care center with way too many consultants back when we didn’t even count sim lab procedures, and even then no one had any trouble logging procedures. Has he cultural climate changed that much?


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[DrYoda]

But those are so much easier than native hip reductions.

That said, I agree. If you're honestly calling ortho to put back in a shoulder or tap a knee, you need to talk to someone about it. That's completely absurd.

Agreed. If you're calling ortho for run of the mill reductions and knee taps there is a problem. I would (politely) speak to the program director or a core faculty member you get along with well.

 

[PlutoBoy]

That's a very strange situation. I've given Adenosine a million times, and never asked anyone about it. There isn't even time to wait for the cardiologist, and also you'll sound so stupid with the cardiologist. Also, as a resident, I had given Adenosine without asking the EM attending... It's so cookie cutter, straightforward (as long as you make sure it ain't Vtach etc.).

"Excuse me, ma'am... I know you feel like dying due to your heart rate being in the 180's, but I'm waiting on my cardiologist to call me back. He's in the pooper right now."

Unacceptable.

Haha. Yeah, I used to do this routinely during my residency and then as a hospitalist (IM).

OP, sometimes you just have to be a little assertive and take ownership of the patient and show that you are ready to do the procedure.

For example, when I wanted to do central lines I used to prepare the patient and scrub and have everything ready and then have a nurse call the attending or my superiors when I was already at the head of the bed, scrubbed in, patient prepped. When they showed up I simply said "this patient needs a line." Worked every time. Maybe a similar approach would work in the ED? For example, call ortho or your attending but have everything ready for you to do the reduction?

(Of course now I hate doing lines.)

 

[Trail Blazer]

I'd say the only procedure we consistently need to complete through sim and not on living patients are the 3 pericardiocenteses needed to graduate. Outside luck, I'm not sure if any resident in a 3/4 year program will have 3 patients requiring an emergent pericardiocentisis.

Sent from my SAMSUNG-SM-G928A using Tapatalk

 

[slatermd]

OP, I’m training in a somewhat similar environment (lots of consultants available at all times, even for trivial stuff we should be doing without calling them), and I’ve developed two behaviors that have helped me a lot.

Whenever your attending consults on something you haven’t done before, or aren’t comfortable doing yourself yet, go in with the consultant and “assist with the procedure,” ie make them teach you how to do it. In my first week of intern year I saw my first case of priapism...attending hadn’t drained one in years so she told me to consult Uro, have them walk me through it, then come back and re-teach her. I did this and now I would only consult on priapism if I attempted and failed, or if there was some bizarre high-flow anatomy/penile implant/other tertiary care situation I’d rather turf. I ended up having to take the same approach with my first PTA, pigtail catheter, and Colles’ fracture.

You can do this with the majority of procedures your attendings are consulting out. It’s an especially valuable approach for things that are difficult to simulate, but anytime you’re on the phone calling in a consultant for something you feel you should be able to do as an ED doc, tell them you’ll be there to assist and would love it if they could walk you through it.

Having a lot of consultants doesn’t mean it’s impossible to pick up the skills you need; learning from them can be as good as or better than learning from ED attendings (but don’t tell mine I said that 😉

The other thing you can do for things like central lines, LPs, and chest tubes, is simulate them (if your program has the right sim materials) as much as needed to feel like you could comfortably do the procedure on a patient without supervision. If you don’t have good sim resources, find the best YouTube videos you can and watch them 5 or so times for each procedure, until you can mentally rehearse the steps in order without missing one. Another big hangup is not knowing where to find the supplies you need (CVC/LP/Chest tube kit), and not knowing what is and is not in your kits (for example, for central lines I need to grab the ultrasound probe cover, sterile flushes, biopatch, and tegaderm that are not in the kit). If an attending has to walk you through all of this, it’s going to make them wish they weren’t letting you do the procedure. But if you know what and where everything is, and you have rehearsed enough that you feel you could do the procedure autonomously, then the attending can truly just be “present for the key portions of the procedure.” They’ll spend basically no more time than they would have if they farmed it out, and they’ll capture the RVUs.

 

[TheComebacKid]

Whenever your attending consults on something you haven’t done before, or aren’t comfortable doing yourself yet, go in with the consultant and “assist with the procedure,” ie make them teach you how to do it. In my first week of intern year I saw my first case of priapism...attending hadn’t drained one in years so she told me to consult Uro, have them walk me through it, then come back and re-teach her. I did this and now I would only consult on priapism if I attempted and failed, or if there was some bizarre high-flow anatomy/penile implant/other tertiary care situation I’d rather turf. I ended up having to take the same approach with my first PTA, pigtail catheter, and Colles’ fracture.

The problem with this approach is that you don't always have a consultant who is amenable to teaching you. If you work at an academic center, as a PGY-2 EM resident, your consultant is a PGY-2 ortho resident. Many of them are still figuring stuff out and aren't the most qualified to teach. In addition, many of them are getting so many consults a night that they can't take the time to do it. And lastly, at least at my shop, if we are consulting them, then they are the ones who are going to be held responsible for the outcome of the patient. Why would they let some EM resident do a reduction when their attending will chew them out if it isn't perfect when the patient follows up in clinic?

Consultant teaching skills, availability and willingness to teach is very variable.

On the other hand, YOUR attendings in the ED have a personal obligation to teach you this stuff. That is their effing job. If they don't feel comfortable doing a procedure, then they should get comfortable with it otherwise work elsewhere. Your program leadership should make this very clear with all of the clinical faculty you work with.

The sad to honest truth is that many ED attendings know how to do most procedures, but they are too lazy to do it or rather, they would rather just see more patients. It's too time intensive and it's sometimes easier to just have a consultant do it. You also shift a great degree of the liability off your shoulders once the consultant is involved. That is frankly, unacceptable. If you don't want to take the time to teach your own resident a procedure (that someone else taught you how to do in residency), then you should gtfo of a teaching hospital with an EM residency and work somewhere else.

/rant

 

[Zarika]

I'm a PGY4 general surgery resident at an academic program with an ED residency that seems very consult heavy. I'm sure there are tons of patients they send home that we never see, but it's fairly routine to be consulted for several procedures per 24 hour period. (abscess I&D, chest tubes and pigtails, thrombosed hemorrhoids- all stuff the ED would take care of in a place without in house consults). I can echo what someone else said above about getting all the stuff ready. If I have to spend 20 minutes running around the ED to print a consent, get all the supplies (bc they're never where they are supposed to be and all the supplies for one procedure aren't usually in the same location, local is in the Pyxis so we need a nurse to get it for us), etc and then the ED resident walks in and wants to do the pigtail - unlikely to happen. On the other hand, if the supplies are ready, it's not a big deal to let the ED resident do it. He or she already did all the work- they should get to do the "fun" part too.

 

[TooMuchResearch]

I mean no disrespect as a fellow academician, but is reducing a shoulder or tapping a knee really something on the edge of whether you consult ortho? I've never consulted ortho for either of these procedures in my life, not in residency, out on my own, nor in an academic setting now. I can't imagine orthopedics every coming in for a knee aspiration. And I wouldn't consider reducing a periprosthetic hip dislocation as "pushing the envelope". This is just all part of normal EM to me.

We called Ortho for periprosthetic hope dislocations and periprosthetic knee arthrocentesis and sometimes they did them. Out in the community now, the specialists are happy to have us do everything.