Long procedures in a non-academic setting

[whatisstudying]

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Since I'm still in training, I have no experience with small ERs (1-2 docs, no residents or students). Recently we had a suicide attempt pt that required significant laceration suturing (complex 6 cm wrist closure, simple 7 cm wrist closure). The procedure itself is simple, and the student did it. The resident also could have.

How would this work in a smaller, non-teaching ED? It bills well enough that it would still be worth doing, but it ties up the physician for a significant amount of time, effectively shutting down the ED. What if it were a much longer laceration? How do you handle things like that?

 

[goodoldalky]

Either do it in 5-10 minute blocks taking a break when you need to tend to someone else or save it for the end of your shift.

 

[inspirationmd]

Either do it in 5-10 minute blocks taking a break when you need to tend to someone else or save it for the end of your shift.

This.

Also, one of the smaller EDs I work where it's solo coverage with a PA there are a couple RNs who are signed off to do them and really enjoy it. I let them have at it once they tell me the plan. I have a look afterwards, they dress it and then to the house. My workflow never slows down.

 

[Birdstrike]

Since I'm still in training, I have no experience with small ERs (1-2 docs, no residents or students). Recently we had a suicide attempt pt that required significant laceration suturing (complex 6 cm wrist closure, simple 7 cm wrist closure). The procedure itself is simple, and the student did it. The resident also could have.

How would this work in a smaller, non-teaching ED? It bills well enough that it would still be worth doing, but it ties up the physician for a significant amount of time, effectively shutting down the ED. What if it were a much longer laceration? How do you handle things like that?

13 cm of lacs on the arm of a suicide attempt patient should not shut any department down. Get very fast, and good with a stapler. Use a nylon stitch for corners. This converts a complex lac into multiple small, simple linear ones. Then "chunk chunk chunk" away, stapling the rest. Anything that truly is complex enough (flexor tendon lacs, median/ulnar/radial nerve or arterial injury) to shut a community ED down can be fixed with one technique:

The punt.

Punt to someone on the call schedule that gets paid to do complex surgical repairs, sew nerves together, and tease glass shards out of nerve bundles. If it's not complex enough to invoke a punt, it's probably not truly complex enough to shut your department down.

 

[gman33]

Saw a patient with a complex facial lac the other day.
At the academic center, so we just called OMFS.
It took them a couple hours to get this done.

In small community without the proper coverage, would this be a transfer?
Maybe transfer to a trauma center?

No way would I have had time to deal with this situation.

 

[e30ftw]

Run it.

 

[WilcoWorld]

Saw a patient with a complex facial lac the other day.
At the academic center, so we just called OMFS.
It took them a couple hours to get this done.

In small community without the proper coverage, would this be a transfer?
Maybe transfer to a trauma center?

No way would I have had time to deal with this situation.

This stuff gets transferred every day. In fact, I often get transferred much less-warranted stuff. Examples include concussions with negative head CT's and non-focal exams, intractable back pain without caudal equina (even with a negative MRI) and chronic dementia needing placement. When it's a particularly obvious dump, the hardest I'm willing to push back is to ask "Do you think this warrants the risks of transfer?" and that's yet to change anyone's mind. On the other hand, I think refusing transfer is generally a bad idea - if someone calls to say "I need help" how can I say that they don't? If I doubt their judgement that much, shouldn't I recognize that they might be missing something, and thus giving me an incomplete or erroneous report? I've had plenty of experiences where a patient was transferred for some total BS related to one organ system, but ended up having something that really needed transfer involving another organ system that was completely missed.

 

[Old_Mil]

Long procedures are a problem. When in doubt, punt.

 

[WilcoWorld]

Just to clarify - my above post isn't meant to rag on transferring docs. Rather, it's meant to say that if you decide to transfer someone in good faith, you shouldn't meet resistance.

 

[Tiger26]

1) I do more running sutures. For those who say that "if you lose 1 stitch, you'll lose them all"--the data is the same on wound dehiscence between running and simple interupted

2) Use bupivicaine more so that you can step out if needed and still have the wound anesthestized

 

[docB]

2) Use bupivicaine more so that you can step out if needed and still have the wound anesthestized

👍👍👍
Agree with this.

I don't think a transfer is warranted just because a procedure will be inconvenient. I know I'm really irritated when I receive those. In my area such a transfer will result in an EMTALA complaint. No question. I am aware of cases where patients were transferred because the sending facility felt they needed specialty care, the specialist at the receiving facility declined to see it and the EP at the receiving facility was stuck with it and that resulted in an EMTALA complaint that was upheld.

I have been forced to make a complex lac or other long procedure wait until after my shift so I could deal with it.

 

[GeneralVeers]

For the cutters I definitely agree with staples. It's not worth my time to make it look all pretty when it's self-inflicted. Just approximate with staples to speed up healing and reduce infection.

Complex facial lacs in a single coverage setting need either the specialist or a transfer. You simply cannot spend 3 hours repairing a lac when you are the only one there. I also would not stay past my shift to do this, unless they would pay for the extra hours.

 

[link2swim06]

I feel like 40-60% of the time I spend suturing is just getting supplies, setting up, and cleaning up. I'd imagine if you were an attending and had all of this done for you it would be much faster.

And I have a feeling the attending is going to suture a lot faster than the med student. Especially if you they run the stitch.

 

[Boatswain2PA]

This stuff gets transferred every day. In fact, I often get transferred much less-warranted stuff. Examples include concussions with negative head CT's and non-focal exams, intractable back pain without caudal equina (even with a negative MRI) and chronic dementia needing placement. When it's a particularly obvious dump, the hardest I'm willing to push back is to ask "Do you think this warrants the risks of transfer?" and that's yet to change anyone's mind. On the other hand, I think refusing transfer is generally a bad idea - if someone calls to say "I need help" how can I say that they don't? If I doubt their judgement that much, shouldn't I recognize that they might be missing something, and thus giving me an incomplete or erroneous report? I've had plenty of experiences where a patient was transferred for some total BS related to one organ system, but ended up having something that really needed transfer involving another organ system that was completely missed.

I appreciate working with/for docs like you. I do a lot of locum work, sometimes in VERY rural areas. Seems like anytime I want to transfer someone for tertiary EM care, the EM physicians always have the same ideology as you (ie: they may not necessarily see the need, but they will accept.

Meanwhile, at another very rural hospital (4 hours from tertiary care) I have been stuck in limbo trying to transfer a pt to a closer secondary hospital. ICU doc there said pt wasnt sick enough to require ICU, but hospitalist said pt was too sick for the floor. Neither would accept. After an hour on the phone I say to the hospitalist "So you're saying I need to send this patient TWO hours the other way to a different hospital?" He says "yup."

I was floored.

So, on behalf of all of the rural guys who ship you patients, THANKS for accepting them, especially the "soft" ones.

 

[gman33]

Note to self, don't work at a hospital without an ICU.