Match list due soon be careful

[WilcoWorld]

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On a manual BP cuff yes. Automatic BP cuffs use oscillation to measure the MAP. Basically they occlude the artery and release pressure, as pressure in the vessel increases (with decreased occlusion) there are pressure oscillations against the arterial wall which increase in amplitude up to a maximum point and then decrease again. The maximal point of oscillatory amplitude is the MAP. Then the BP cuff will derive systolic and diastolic from that depending on how the manufacturer sets its algorithm. Only MAP is measured on an automatic BP cuff.

in practice we still use cuff SBP/DBP as cutoffs for PRNs, but in truth it's inaccurate.

That's really interesting, thanks.

 

[gro2001]

Really? I'm willing to be convinced by evidence, so please educate me.

I'm thinking of my most recent case where we had a patient with MAPs in the mid to high 50's with consistent readings on serial measurements. Placed a CVL and started levophed and then had MAPS in the high 60s to low 70's with consistent readings on serial measurements. So I didn't feel a need for an art line.

Tell me what I'm missing, I'm genuinely open to learning.

I wouldn't go as far as to claim evidence beyond anecdotal.

But I see this phenomenon fairly commonly in the ICU: someone has both a blood pressure cuff (reading an OKish BP) and an arterial line with a decent waveform (reading a crappy BP). Patient is sick, with obvious hypo perfusion (some combination of bad mental status, low urine output, high/rising lactate). Even in the ICU everyone wants to believe the better number. I start treating the A-line as real, push up the pressure, markers of shock resolve. Ironically, then the numbers start correlating.

Basically when the blood pressure is abnormal, non-invasive blood pressure measurement is not reliable.

 

[MechEDoc]

Learn something new every day

On a manual BP cuff yes. Automatic BP cuffs use oscillation to measure the MAP. Basically they occlude the artery and release pressure, as pressure in the vessel increases (with decreased occlusion) there are pressure oscillations against the arterial wall which increase in amplitude up to a maximum point and then decrease again. The maximal point of oscillatory amplitude is the MAP. Then the BP cuff will derive systolic and diastolic from that depending on how the manufacturer sets its algorithm. Only MAP is measured on an automatic BP cuff.

in practice we still use cuff SBP/DBP as cutoffs for PRNs, but in truth it's inaccurate.

I guess that screws those carefully derived screening guidelines for preeclampsia?

 

[BoardingDoc]

I guess that screws those carefully derived screening guidelines for preeclampsia?

The calculated values are probably fairly accurate when not way outside normal range. As other posters above have said, they get an art line reading that's super low and a cuff reading that's ok, then they give fluids/pressors and when the art line reading comes up to a more normal range, the cuff reading starts to match.

Long story short, I think if your cuff tells you that your systolic is > 160, it's likely accurate enough that you should follow the guidelines and go get checked. They can always do a manual pressure in the office/ER.

 

[xaelia]

Haven't done a central line in ... 7 years?

The rise of peripheral pressors and the fall of CVO2 has made the requirement for central lines a rarity.

The rarity ensured all the ED docs effectively became (relatively) deskilled compared to the intensivists.

It was decided the best thing for patients was to have the most practiced hands performing the procedure (not to mention cutting down on CLABSI).

It's definitely important to know how to do one and be trained on them – but it's entirely possible you could go out and practice and almost never do one again.

Same with thoracostomies – management of many small to medium pneumothoraces has moved to observational, again making this a potentially very rare procedure depending on practice setting.

Don't get me started on (non-therapeutic) arterial lines ...

 

[Rekt]

Haven't done a central line in ... 7 years?

The rise of peripheral pressors and the fall of CVO2 has made the requirement for central lines a rarity.

The rarity ensured all the ED docs effectively became (relatively) deskilled compared to the intensivists.

It was decided the best thing for patients was to have the most practiced hands performing the procedure (not to mention cutting down on CLABSI).

It's definitely important to know how to do one and be trained on them – but it's entirely possible you could go out and practice and almost never do one again.

Same with thoracostomies – management of many small to medium pneumothoraces has moved to observational, again making this a potentially very rare procedure depending on practice setting.

Don't get me started on (non-therapeutic) arterial lines ...

Strong disagree. You just work somewhere with very low acuity. The dichotomy between mild peripheral pressors such as a sprinkle of Levo at 4mcg and ending up four pressors is pretty small. There’s rarely an inbetween. If you’re sending a patient up on multiple pressors through a peripheral line that’s piss poor lazy medicine.

And deskilled? I did around 200-215 central lines and dialysis lines in my residency of 3yr. I do about one week or so depending right now. I can drop a USCVL IJ in about 5 minutes. Not even counting how much it helps nursing staff with access and not losing peripheral lines etc

 

[xaelia]

Strong disagree. You just work somewhere with very low acuity. The dichotomy between mild peripheral pressors such as a sprinkle of Levo at 4mcg and ending up four pressors is pretty small. There’s rarely an inbetween. If you’re sending a patient up on multiple pressors through a peripheral line that’s piss poor lazy medicine.

And deskilled? I did around 200-215 central lines and dialysis lines in my residency of 3yr. I do about one week or so depending right now. I can drop a USCVL IJ in about 5 minutes. Not even counting how much it helps nursing staff with access and not losing peripheral lines etc

I've no argument against an acuity difference – and that's emblematic of the scope of EM.

I'd actually argue you have the *high* acuity, rather than the opposite:

​

"Over 12 months, 182 emergency physicians performed 1582 of 2805 procedures (56%) and supervised (resident, nurse practitioner or physician assistant) an additional 1223 of the procedures they did not perform (43%). Median (interquartile range) physician performance for each procedure was CVC 0 [0, 2], tube thoracostomy 0 [0, 0], tracheal intubation 3 [0.25, 8], and LP 0 [0, 2]."​

​

https://onlinelibrary.wiley.com/doi/full/10.1002/emp2.12238

 

[thegenius]

@xaelia you work in New Zealand, right? if I recall? Just curious. probably explains the difference in opinion over your most recent post between you and others who frequent this forum.

 

[xaelia]

@xaelia you work in New Zealand, right? if I recall? Just curious. probably explains the difference in opinion over your most recent post between you and others who frequent this forum.

For the past 2.5 years.

The previous 5 were at Kaiser.

UTHouston before that (and we definitely put lines in people there - because usually we had as much or more expertise than the IM residents or CC fellows in the ICU).

 

[lucid_leprechaun]

For the past 2.5 years.

The previous 5 were at Kaiser.

UTHouston before that (and we definitely put lines in people there - because usually we had as much or more expertise than the IM residents or CC fellows in the ICU).

This is wild to me. I didn’t realize there were such drastic differences in acuity at different locations. I’ve always worked at city hospitals so I put a line in just about every shift. Intubate every two or three shifts. Probably a chest tube a month although I agree most are being managed expectantly.

 

[WilcoWorld]

Haven't done a central line in ... 7 years?

The rise of peripheral pressors and the fall of CVO2 has made the requirement for central lines a rarity.

The rarity ensured all the ED docs effectively became (relatively) deskilled compared to the intensivists.

It was decided the best thing for patients was to have the most practiced hands performing the procedure (not to mention cutting down on CLABSI).

It's definitely important to know how to do one and be trained on them – but it's entirely possible you could go out and practice and almost never do one again.

Same with thoracostomies – management of many small to medium pneumothoraces has moved to observational, again making this a potentially very rare procedure depending on practice setting.

Don't get me started on (non-therapeutic) arterial lines ...

Maybe if you don't see trauma patients? But if you take care of traumas, I think you need to know how to do a thoracostomy.

 

[xaelia]

This is wild to me. I didn’t realize there were such drastic differences in acuity at different locations. I’ve always worked at city hospitals so I put a line in just about every shift. Intubate every two or three shifts. Probably a chest tube a month although I agree most are being managed expectantly.

Maybe if you don't see trauma patients? But if you take care of traumas, I think you need to know how to do a thoracostomy.

Intubations were quite frequent at UT Houston, obviously.

The Kaiser NW locations are not trauma centers; intubate occasionally, rarely have a pigtail catheter to insert for spontaneous PTX. The scenario above of the medical patient requiring multiple, escalating vasopressors just simply didn't happen – we never had to worry about boarding ICU patients.

Here in NZ we're the only major trauma location on the South Island with 120,000 visits a year. The same level of acuity, but I suspect a significant chunk of the super-sick medical patients requiring lines and multiple pressors are deemed not appropriate for ICU level care, here. Most of our trauma is blunt – like most countries outside the U.S. – which rarely requires a thoracostomy (although I have done one here for GSW).

We've obviously strayed far from the "Don't rank an HCA residency" point, of course!

 

[Tipsy McStagger]

a significant chunk of the super-sick medical patients requiring lines and multiple pressors are deemed not appropriate for ICU level care, here.

Will you expand on this please? If you’re saying what I think you’re saying, we need this cultural shift here as well.

 

[RustedFox]

Will you expand on this please? If you’re saying what I think you’re saying, we need this cultural shift here as well.

Kiwiland has people with reasonable expectations regarding end of life care.

 

[Dr Mantis Toboggan]

Kiwiland has people with reasonable expectations regarding end of life care.

I wonder too if folks also look after themselves better and their diabetics aren’t in florid DKA 5 times a year etc.

 

[Tipsy McStagger]

Kiwiland has people with reasonable expectations regarding end of life care.

Hey man, this is America. People shouldn't have to die if they don't want to. In this land we get what we want, when we want it. If I wanted it some other way I'd go live in North Korea.

 

[TooMuchResearch]

Intubations were quite frequent at UT Houston, obviously.

The Kaiser NW locations are not trauma centers; intubate occasionally, rarely have a pigtail catheter to insert for spontaneous PTX. The scenario above of the medical patient requiring multiple, escalating vasopressors just simply didn't happen – we never had to worry about boarding ICU patients.

Here in NZ we're the only major trauma location on the South Island with 120,000 visits a year. The same level of acuity, but I suspect a significant chunk of the super-sick medical patients requiring lines and multiple pressors are deemed not appropriate for ICU level care, here. Most of our trauma is blunt – like most countries outside the U.S. – which rarely requires a thoracostomy (although I have done one here for GSW).

We've obviously strayed far from the "Don't rank an HCA residency" point, of course!

I think every trauma chest tube I've placed since residency has been for blunt trauma. Kicked by an animal, run over by a tractor, fell off a ladder, slipped on ice probably covers every one of them.

 

[RustedFox]

I think every trauma chest tube I've placed since residency has been for blunt trauma. Kicked by an animal, run over by a tractor, fell off a ladder, slipped on ice probably covers every one of them.

I've placed exactly two for a GSW since residency.

All others, blunt trauma or spontaneous pneumothorax.

 

[xaelia]

I suppose it's just a matter of institutional practice in the sense I think most of our traumatic pneumothoraces are managed conservatively – blunt or otherwise. I can recall plenty of instances from residency and Houston a decade ago where any pneumothorax would have been an indication for thoracostomy, but now it seems the vast minority.

 

[TooMuchResearch]

I suppose it's just a matter of institutional practice in the sense I think most of our traumatic pneumothoraces are managed conservatively – blunt or otherwise. I can recall plenty of instances from residency and Houston a decade ago where any pneumothorax would have been an indication for thoracostomy, but now it seems the vast minority.

I've aspirated a couple of spontaneous ones and watched a few, but most of the spontaneous ones I've seen have been big enough to need something, and basically every blunt trauma tube I've placed has probably actually needed it done. I haven't had anyone tell me to not place them.

 

[WilcoWorld]

It's really funny how quickly the threads in the EM forum go off topic. It's as if there's some...oh look - A squirrel!

 

[TooMuchResearch]

Every reader finds a key phrase or maybe just a single word that stands out to them and that's what the next post is about. Just like a shift in the ED.

 

[cyanide12345678]

Would you avoid all of these newly accredited programs?
Lakeland Regional Health Program Initial Accreditation 08/25/2022 Emergency medicine
NYU Long Island School of Medicine Program Initial Accreditation 08/25/2022 Emergency medicine
Geisinger Health System (Wilkes Barre) Program Initial Accreditation 08/25/2022 Emergency medicine
University of Texas Medical Branch Hospitals Program Initial Accreditation 01/12/2023 Emergency medicine

UT Galveston technically wouldn’t be new. They just shut down after ike and i guess finally re-opened their program.

UT Galveston is a real medical school With quality education.

 

[xaelia]

Would you avoid all of these newly accredited programs?
Lakeland Regional Health Program Initial Accreditation 08/25/2022 Emergency medicine
NYU Long Island School of Medicine Program Initial Accreditation 08/25/2022 Emergency medicine
Geisinger Health System (Wilkes Barre) Program Initial Accreditation 08/25/2022 Emergency medicine
University of Texas Medical Branch Hospitals Program Initial Accreditation 01/12/2023 Emergency medicine

I suppose the question circles back to what we think the point of an EM residency might be?

Does every program need to churn out leaders with SAEM, ultrasound podcasters, AHRQ grant chasers, etc.? Or is it simply to see sufficient volume of pathology to be able to recognise and manage it appropriately up to the expected standard of care – so the graduates pass their boards, do the procedures, and are qualified to move the meat around in any one of hundreds of community hospitals across the country?

You could argue in some respects that HCA-type hospitals are the best preparation for the corporate futures into which they are birthed. 🙃

(I obviously don't think we ought to aspire to mediocrity, either, but that doesn't mean the graduates from these programs won't know what they're doing when they finish).

 

[Tipsy McStagger]

You could argue in some respects that HCA-type hospitals are the best preparation for the corporate futures into which they are birthed. 🙃

I dunno, the quality I've seen out of new grads lately has me thinking that the newest metric is door to consult time. From that metric's standpoint they're crushing it.

 

[RustedFox]

I dunno, the quality I've seen out of new grads lately has me thinking that the newest metric is door to consult time. From that metric's standpoint they're crushing it.

We hired an HCA grad last year sometime. He didn't last long at all.

Unmanageably bad. Like, whoa.

 

[thegenius]

I've placed exactly two for a GSW since residency.

All others, blunt trauma or spontaneous pneumothorax.

Most of my traumatic chest tubes (about 5/year) are penetrating. I don't go nuts over spontaneous pneumothorax, they are all quasi stable and you can take your time

 

[southerndoc]

Most of my traumatic chest tubes (about 5/year) are penetrating. I don't go nuts over spontaneous pneumothorax, they are all quasi stable and you can take your time

I vision a traumatic chest tube as being a traumatic insertion as opposed to a chest tube in trauma patients. 🤣

 

[Mount Asclepius]

I vision a traumatic chest tube as being a traumatic insertion as opposed to a chest tube in trauma patients. 🤣

Haha. A penetrating traumatic chest tube at least seems more straight forward than a blunt force traumatic chest tube. I just can’t see @thegenius hitting someone in the chest repeatedly with a flimsy rubber tube. Unless of course if working for USACS and the patient is Dominic.

 

[BoardingDoc]

Haha. A penetrating traumatic chest tube at least seems more straight forward than a blunt force traumatic chest tube. I just can’t see @thegenius hitting someone in the chest repeatedly with a flimsy rubber tube. Unless of course if working for USACS and the patient is Dominic.

If Dom came in as a trauma, just let the NP take care of him and go see some waiting room patients to keep that door to doc time down. He might die, but I'm sure he'd do so happy in the knowledge that his vision was fully realized before he went.

 

[xaelia]

If Dom came in as a trauma, just let the NP take care of him and go see some waiting room patients to keep that door to doc time down. He might die, but I'm sure he'd do so happy in the knowledge that his vision was fully realized before he went.

1) Trauma alert – $$$
2) ED NP sees patient along with CRNA, cardiothoracics NP, trauma NP, ICU NP, and orthopedics PA.
3) Everyone stands around furiously documenting to the maximum level of service while the patient deteriorates.
4) High fives, pizza.

 

[wareagle726]

1) Trauma alert – $$$
2) ED NP sees patient along with CRNA, cardiothoracics NP, trauma NP, ICU NP, and orthopedics PA.
3) Everyone stands around furiously documenting to the maximum level of service while the patient deteriorates.
4) High fives, pizza.

5) Send chart to liability sponge...errr...supervising MD

 

[collegestud2013]

For the medical students on this board. Do yourselves a favor and avoid any hca program. Similarly avoid any new program at this point. Anything with less than a 3 year track record is proof that this residency exists solely to enrich the hospital.

If you want to be a lemming go and work at an hca site as a trainee.

This is your PSA from EF.

Most USMDs might have that option, but there's always a flood of marginally qualified Caribbean IMGs and FMGs, and those with major red flags in med school (eg failing Step 1, having to repeat a year) who won't otherwise have much options. These programs will still eventually fill if they lower their standards enough.

 

[EctopicFetus]

Most USMDs might have that option, but there's always a flood of marginally qualified Caribbean IMGs and FMGs, and those with major red flags in med school (eg failing Step 1, having to repeat a year) who won't otherwise have much options. These programs will still eventually fill if they lower their standards enough.

Yep. But at some point jobs won’t be an option. Then what.