Low Volume Rural ED Survival Guide?

[theWUbear]

I've been interviewed for and hired (onboarding to come) for a low volume rural ED to do a few moonlighting shift in the last few months of residency. I'm excited. I asked my PD what questions to ask the medical director for a low volume ED and the answers were as expected

• No cath lab, yes STEMI cardiologist on call to guide me with respect to tPA/no tPA and where to ship
• Tele-neurologist to 'share' my liability and decision making for stroke
• Radiology reads CT's 24/7, but there are some times (will seek clarification) that radiology may not read an XR and patient is sent home after ER doc wet reads film, nursing protocol exists for calling patient back in AM if there is a fracture/other concerning finding
• I don't believe there's MRI - forgot to ask this one

Is there a survival guide out there for this kind of practice? Or, would you guys be able to tell me what I can't miss? For instance, everyone coming in with traumatic hand pain, I'm going to seriously consider scaphoid fx and other subtle pathology, I'm going to splint everyone, give everyone ortho follow-up. I'm terrified (but excited) about this part of practice - I need to know what I need to not miss from a "nobody else is reading your plain films" perspective. I also need to learn when to initiate emergency transfer in a "my hospital system does not have MRI" situation

Any advice from you sage attendings out there is greatly appreciated

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[gamerEMdoc]

but there are some times (will seek clarification) that radiology may not read an XR and patient is sent home after ER doc wet reads film

This has never occurred to me that people work in a setting where radiologists actually do read xrays 24/7. I trained in a place where ED read plain films after business hours. It was that way at every hospital I was at in the when I was in the Navy. And the hospital system I work for now is the same. I have always assumed that outside of maybe big university hospitals, this was totally the norm in EM, that EM reads their own plain films at night.

 

[gamerEMdoc]

I've been interviewed for and hired (onboarding to come) for a low volume rural ED to do a few moonlighting shift in the last few months of residency. I'm excited. I asked my PD what questions to ask the medical director for a low volume ED and the answers were as expected

• No cath lab, yes STEMI cardiologist on call to guide me with respect to tPA/no tPA and where to ship
• Tele-neurologist to 'share' my liability and decision making for stroke
• Radiology reads CT's 24/7, but there are some times (will seek clarification) that radiology may not read an XR and patient is sent home after ER doc wet reads film, nursing protocol exists for calling patient back in AM if there is a fracture/other concerning finding
• I don't believe there's MRI - forgot to ask this one

Is there a survival guide out there for this kind of practice? Or, would you guys be able to tell me what I can't miss? For instance, everyone coming in with traumatic hand pain, I'm going to seriously consider scaphoid fx and other subtle pathology, I'm going to splint everyone, give everyone ortho follow-up. I'm terrified (but excited) about this part of practice - I need to know what I need to not miss from a "nobody else is reading your plain films" perspective. I also need to learn when to initiate emergency transfer in a "my hospital system does not have MRI" situation

Any advice from you sage attendings out there is greatly appreciated

Also this is why moonlighting or a few community EM months are so important as a resident if you train somewhere with 24/7 resources. CT 24/7 is pretty standard, but most jobs wont have xray reads at night, MRI at night (unless its basically cauda equina), some dont have US at night, etc. Plenty of places will expect you to reset fractures, use telestroke instead of having a neurologist at the bedside, etc etc. This is the community reality outside of academia.

Congrats on starting moonlighting. A ton of growth happens when most residents do.

 

[BoardingDoc]

This has never occurred to me that people work in a setting where radiologists actually do read xrays 24/7. I trained in a place where ED read plain films after business hours. It was that way at every hospital I was at in the when I was in the Navy. And the hospital system I work for now is the same. I have always assumed that outside of maybe big university hospitals, this was totally the norm in EM, that EM reads their own plain films at night.

Agreed, I trained in a tertiary care center and our locally accepted standard of care was that the ED would read the x-rays regardless of time of day and not wait for a formal read. You could call radiology during daytime hours if there was some ambiguity to it but at night you were very much on your own.

 

[deleted1027621]

Some random questions I didn't think to ask:

What types of blood products do you have? How many? I work at a place that has 2 units of trauma blood, no platelets and 2 of FFP. And we do get trauma.

If there is a surgeon on call, what is the policy for anesthesia services? I had a surgeon at on of my sites who actually stayed inhouse, but anesthesia took call from... 2.5 hours away.

How do patients get transferred? Is there EMS services available? How does it work for critical cases vs non-emergent transfers? It is common at one of my shops to have a 6-8 hour wait for transportation if not emergent.

Do they have a transfer agreement with a larger healthcare system? Having one sure does make transferring less painful.

Hope this helps!

 

[TheSingularity]

Moonlighting isn't "practice." It's just moving up the attending clock. It's the real deal. If residency programs / hospitals are going to allow residents to externally moonlight, they are basically certifying them as ready for independent practice and should either graduate them or increase their pay to what they're paying the attendings.

To the OP, be very conservative. Don't be afraid to call in the ultrasound tech or MRI if you need these things. Don't be afraid to transfer You need to do the right thing for you and your patients, not to be concerned about making the hospital money

Also this is why moonlighting or a few community EM months are so important as a resident if you train somewhere with 24/7 resources. CT 24/7 is pretty standard, but most jobs wont have xray reads at night, MRI at night (unless its basically cauda equina), some dont have US at night, etc. Plenty of places will expect you to reset fractures, use telestroke instead of having a neurologist at the bedside, etc etc. This is the community reality outside of academia.

Congrats on starting moonlighting. A ton of growth happens when most residents do.

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[gamerEMdoc]

If residency programs / hospitals are going to allow residents to externally moonlight, they are basically certifying them as ready for independent practice and should either graduate them or increase their pay to what they're paying the attendings.

They shouldn't be paid the same during their resident hours because they aren't the attendings on the case. They aren't billing for care under their license, making the final decisions, and legally generally get dropped from the case if something goes bad. Why would they be paid like an attending on shifts while they are working under an attending? And Independent moonlighting at a site when you get your independent license doesn't make you a board certified attending anymore than working in an ED as an FP doc is.

The ACGME dictates how long the minimal training is. You can't graduate in 2 years according to the ACGME even if you are ready. There are some residents that are ready to graduate in 2 years. I've worked with some outstanding residents who were way ahead of their peers. But the ACGME doesn't let you just graduate them. You also can't pay residents based on their skill, their salary is tied to their GME year. You can't just pay the best ones higher than the rest of their class.

There are also some jobs you may be ready to practice at as a resident, and some you aren't ready for. I guess it depends on where you are moonlighting. When I was a 3rd year resident, I wouldn't have wanted to go moonlight in a place that was super busy with high acquity, regardless of the money. I wanted a little independence, but time to grow into that without getting my face kicked in before I was ready.

We keep all our moonlighting within our system at our critical access hospitals, that way residents can call us for advice, we can look at their films if needed, etc. Volumes are much lower there. They can transfer anything to us. Its a good stepping stone to get over in their career. We've never had a resident EVER give us anything but positive feedback about moonlighting opportunities and how that helped them grow when they finished. That being said, its totally optional. We've had some residents choose not to. We've had residents we didn't feel were ready and didn't allow it.

 

[RoyBasch]

Do they have a transfer agreement with a larger healthcare system? Having one sure does make transferring less painful.

This is a key question.

 

[deleted109597]

Know what you've got. I work a place where the transferring services don't have functioning BiPAP. Like many places, there's not such thing as ground critical care transport, only via air. If the weather is bad, you simply hang on to the patient until the weather is better.

Be conservative on xray reads. But realized that transferring everything, especially if tertiary care is >1 hour away, really starts to annoy patients if they're discharged home from that place. Really especially if they go there by ambulance, and have to figure out how to get home.

Don't be Dr. Feelgood. Small rural places often use the ER as their candy shop. Avoid this if at all possible. Treat all acute pain, but chronic pain is better served by someone else.

Be prepared to do a lot of things on your own. The staff at these shops aren't used to critical care. They may not know how to appropriately do modern medicine, especially if their docs are practicing medicine from 30 years ago. Show them the way.

 

[TooMuchResearch]

We have 24/7 x-ray reads everywhere, even rural (same radiologists too). I don't think our group would accept a contract with anything else.

This has never occurred to me that people work in a setting where radiologists actually do read xrays 24/7. I trained in a place where ED read plain films after business hours. It was that way at every hospital I was at in the when I was in the Navy. And the hospital system I work for now is the same. I have always assumed that outside of maybe big university hospitals, this was totally the norm in EM, that EM reads their own plain films at night.

 

[TooMuchResearch]

We have an expected turnaround time from submitting images to report (for everything) of under 30 minutes. If they go beyond 45 minutes, it's generally because the tech forgot to send the pictures. In that case, a phone call to radiology after transmission of pictures generally gets a live read from the rad with us on the phone. They're a service line too and happy to provide a quality product.

Agreed, I trained in a tertiary care center and our locally accepted standard of care was that the ED would read the x-rays regardless of time of day and not wait for a formal read. You could call radiology during daytime hours if there was some ambiguity to it but at night you were very much on your own.