Job Set Up

[DOnut]

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Hey everyone,

I've recently started looking into jobs and I've noticed that many ED's are set up where the BC EM physicians only see "sick" (meaning complex medical cases) or trauma. Everyone else is deligated to fast track where it is run by a family practice doc, or NP.

Now I love this, but it also scares the mess out of me. In my residency, there is no true fast track, so we see everyone, including the BS. Seeing only the "sick" would be very draining durin a 12 hour shift.

Now I'm writing this saying "boo hoo get over yourself and work", but there is something good about the mental break you get seeing an ankle sprain sometimes.

What do you guys think? How are your ED's set up, and do you think it's too much to see complex only everyday?

 

[southerndoc]

Many ED's are set up that way? While many ED's have fast tracks, I'm not so sure that many utilize FP's for fast tracks. Most ED's I know of will use either a PA/NP or an EP to staff fast track (we primarily staff with EP's most of the time).

At any rate, you can see some really high acuity when other people are handling the routine stuff. I can easily get 30-35% admission rates during some of my shifts, with 15-20% of those admissions going to an ICU. I'm not lacking in the number of 99284's and 99285's I'm seeing by any means.

You will likely get used to it. I actually prefer it. I love seeing sick people instead of routine URI's.

 

[GeneralVeers]

Most use a PA or NP in the fast track, even in the academic setting. I've never heard of them relegating the non-boarded FP docs there.

I love the Fast Track, because it weeds out the vast majority of complete BS and low acuity, and allows us to focus on what we trained to do.....take care of actual emergencies.

 

[bartleby]

The fast track situation is very variable from job to job. Some places still have board certified emergency physicians staffing these areas as a proportion of their shift total (one in eight shifts, for example). These days, it seems to be mostly nurse practitioners and PAs.

One other thing for you to consider if you find yourself uncomfortable with sicker patients is that a large part of this is normal for a new graduate. Getting used to "doing things on your own" is part of the seasoning process of a new attending, which in many ways is as important as your growth in residency.

if you are truly uninterested in taking care of critically ill patients, perhaps you should look for a job that sees a lower acuity of patient in general.

 

[DOnut]

Don't get me wrong. I LOVE sick patients. I love procedures, I hate the BS in the ED, I was just nervous about carring all sick people at once. For example. On any typical day I may carry 9 patients at once. 3-4 of them my actually be really sick (2-3 admits, 1 ICU).

Maybe it's just a matter of getting used to it, but can one really carry 9 truely sick patients at once? Is it just a matter of getting used to it as a new attending, or will I have to slow down? Maybe it's just an adjustment period.
Probably.

Anyway, no thoughts of ever switching fields....I was born for this. Thanks for the reply peeps.

L

The fast track situation is very variable from job to job. Some places still have board certified emergency physicians staffing these areas as a proportion of their shift total (one in eight shifts, for example). These days, it seems to be mostly nurse practitioners and PAs.

One other thing for you to consider if you find yourself uncomfortable with sicker patients is that a large part of this is normal for a new graduate. Getting used to "doing things on your own" is part of the seasoning process of a new attending, which in many ways is as important as your growth in residency.

if you are truly uninterested in taking care of critically ill patients, perhaps you should look for a job that sees a lower acuity of patient in general.

 

[Aloha Kid]

This is the tough part about gauging ER work. At best, we are told to look at the # of patients/hour as the best indicator of how busy you are going to be. Our program tells us anything over 3 pt/hour is not a good job. The other telling measurement is provider coverage hours.

Factors that cannot tell you how busy you will be are ED pt/year census and even admission percentages. For example, you could only have a yearly census of 18,000 but only 24 hours of physician coverage which means 1 doc seeing all those people at a time. You could have an admission rate of 35% but an average pt load of 1 patient/hour which makes this very doable.

On average
pgy-1 see 1pt/hour
pgy-2 see 1.5pt/hour
pgy-3 see 1.8pt/hour
pgy-4 see 2+pt/hour

The average EPs speed peaks at about 2 years out.

If you are seeing more, then ask yourself if the acuity at your hospital is different? Are you including fast track patients? Is the way you practice open to liability?

 

[docB]

Most use a PA or NP in the fast track, even in the academic setting. I've never heard of them relegating the non-boarded FP docs there.

I know that some of the Kaisers in CA would staff their fast tracks with IM or FM docs and use EPs in the main EDs.

 

[bartleby]

Part of your concern is quite justified and is an excellent example of why it is often less stressful to work in a place that has double or triple physician coverage during the busiest times of the day. If you're by yourself and have a sickie who needs a central line and an hour of bird-dogging and someone who needs an LP, you're going to get pretty jammed up if people keep on showing up.

Maybe it's just a matter of getting used to it, but can one really carry 9 truely sick patients at once? Is it just a matter of getting used to it as a new attending, or will I have to slow down? Maybe it's just an adjustment period.

 

[macdaddy23]

You're not going to see as many per hour at a place like that as compared to a place where you see everything. The ankle sprains, runny noses, minor abscesses are quick and allow you to see more patients.
The place I work at is how you describe where all(most) of the BS goes to the FastTrack. Some BS does slip by triage.
When all you are seeing is the more acute stuff most don't see more than 2/hour. People will talk about seeing 3-4 really sick an hour even at our place but when the numbers come out everyone is around 2 patients/hour.
It just feels like more when they are all sick.

 

[GeneralVeers]

Most of the old people get triaged to the ED rather than fast track. They typically take twice as long to see because they like to tell long stories, and need prodding to get to the point. Also they have 500,000 things wrong with each of them.

 

[WilcoWorld]

Most of the old people get triaged to the ED rather than fast track. They typically take twice as long to see because they like to tell long stories, and need prodding to get to the point. Also they have 500,000 things wrong with each of them.

I nominate this GV's best quotable ever.

 

[deleted65604]

Where I did residency, there was a fast track 12-12, and as a result, your patient acuity would go up over that time. Most shifts during that time, I would be admitting around 40 % of patients. It was really draining. The waiting room was always dozens deep and people were getting more and more antsy. One of my attendings volunteered to work the 5-2 shift consistently so that he didn't have to do full nights. He got really burnt out because 5 O'clock is peak time for patients to come in and for the department to really start to get either gridlocked or insanely busy as the nurses filled up the rooms like crazy. He got sick of seeing 12 chest pains and 10 abdominal pains per shift with a mix of strokes, immunosuppressed transplant patients and a mix of various complaints with abnormal vital signs that couldn't make the fast track.

I think it becomes easy as an attending to just admit all chest pains, and CT all abdominal pains and see the patient 5 minutes before their disposition, when all of their labs are back and you have the results of all of their imaging. He was one of our favorite attendings, very laid back, insanely funny at times, but after 2 years of working that schedule, he became a very grumpy bear. He decided that he needed a change of scenery and asked to have a mix of shifts so that he could experience the 3-7 lull in the middle of the night on occasion (although the busiest times can be that 3-7 AM period for staffing reasons), and the 7-12 coughs and colds, and fast track peds. I think that working in a place where you see no fast track patients and simple lacs could get really old.

My chairman as a resident said that administration should look to start adding shifts whenever the patient load went above 2.3-2.5/hour as that was getting dangerous. I agree with the above poster, that people tend to exaggerate their numbers (especially those SDN members that tend to post a lot in an effort to convince people that their program is the best there is). Some residents will count patients that a junior resident have presented to them, or that a student presented to them, and that they saw for 2 minutes, and then presented to an attending. They count it as one full patient when they did no documentation, no counseling to the patient and never answered a single question that the patient had.

If you are seeing lots of fast-track patients, and lots of junior resident's patients, then your numbers are going to look really good. However, if you are admitting 30% of your patients, some to the ICU, there is no way that you can see much more than 2 patients per hour and keep up on documentation without residents or midlevels helping you out.

 

[Aloha Kid]

Jarabacoa,

Well said. I concur whole heartedly. I love to see attendings scrambling on shifts when they are alone. Keeps them honest.

 

[GeneralVeers]

Jarabacoa,

Well said. I concur whole heartedly. I love to see attendings scrambling on shifts when they are alone. Keeps them honest.

I saw 20 patients (by myself) on shift the other night, and admitted 18 of them. I felt like I got my ass kicked.

On the other hand 18 level 5 visits = mucho RVO.