May I pick your brain?

[jbod34]

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I'm still struggling with which programs I want to apply for in July when ERAS opens up. I heard from a D.O. today something I hadn't thought of before. He said that at some of the bigger programs that have every residency under the sun, the ED residents become glorified triage nurses b/c everybody gets a consult. Is this true? Am I better off looking at some of the rural programs where the ED residents have to tx everything b/c they don't have a choice? I want the experience of being able to work up and tx a wide variety of problems from vag bleed to reducing fx. Will I miss out if I'm constantly calling for a consult?
Thanks so much!!

 

[SoCuteMD]

I think southerndoc made a good point about this a few months ago. He said that calling consults gives him the opportunity to learn a procedure from the expert, someone who does the procedure every day (or quite frequently) rather than learning it from another EP, who does the procedure a couple times a month/year.

I thought it was an interesting take on the issue.

 

[suckstobeme]

I dont think it really matters. Yeah, if you have tons of consult services, you'll end up using them, but you still see the pt first, and you can decide whether to call ortho to reduce that joint or if you're gonna try it yourself first. But I think there are some advantages to having a bunch of consult services. First off, there are gonna be a bunch of problems that you're just not gonna be able to handle and its nice to have the service's residents in house to take care of the problem rather than calling up a private attending. Also, I think its a great opportunity to learn. You can ask the residents what they thought and if there's anything else that could/should be done before calling the consult, if the pt could have followed up in a specialist clinic instead of being treated in the ED, etc etc. Bottom line is this: I think you should train in the environment you want to end up in. If you want to end up rural, do rural. If you like big academic centers, do that instead.

Secondly, I dunno about the whole "glorified traige nurse" thing. I mean, basically, all the ENTs say that b/c they only see all the pts that need ENT consults, medicine only sees the pts that need medicine consults, surgery for surgery consults, etc etc. So all these services think that the ED is just consulting everyone. Nobody sees ALL the pts that the EP sees, treats and sends home except the people in the ED. Does that make sense?

 

[southerndoc]

Just because you have a consult service doesn't mean you call them for everything. You call them for things you would be calling them for in the private community. A dislocated hip that can't be reduced, a dislocated knee that needs to go for angio, that Danis-Weber Class C fracture that needs to go for ORIF, etc.

Don't expect them to be called just to place a splint on your Gamekeeper's thumb or for every dislocation in the department.

As suckstobeme pointed out, all patients are initially evaluated and managed by ED residents, no matter what the problem. Even though we have neurology in house, it is us -- the ED residents -- who does the NIH score for our stroke alerts.

 

[JackBauERfan]

Just because you have a consult service doesn't mean you call them for everything. You call them for things you would be calling them for in the private community. A dislocated hip that can't be reduced, a dislocated knee that needs to go for angio, that Danis-Weber Class C fracture that needs to go for ORIF, etc.

Don't expect them to be called just to place a splint on your Gamekeeper's thumb or for every dislocation in the department.

As suckstobeme pointed out, all patients are initially evaluated and managed by ED residents, no matter what the problem. Even though we have neurology in house, it is us -- the ED residents -- who does the NIH score for our stroke alerts.

Not in residency yet, but I agree with this from doing my home and away rotations. We did consult a lot when you have the services available but you do see the patient first and most of the time the procedure is EM's first as long as the resident is confident with it. If not, like socute said you can learn from either a resident or fellow that does more than a few a year haha. I think you can't go wrong either way, and most of the EM programs are not in rural areas (even though most will have month rotations throughout the residency where you do go to other areas besides the main teaching hospital).

 

[southerndoc]

Not in residency yet, but I agree with this from doing my home and away rotations. We did consult a lot when you have the services available but you do see the patient first and most of the time the procedure is EM's first as long as the resident is confident with it. If not, like socute said you can learn from either a resident or fellow that does more than a few a year haha. I think you can't go wrong either way, and most of the EM programs are not in rural areas (even though most will have month rotations throughout the residency where you do go to other areas besides the main teaching hospital).

Consult neurology in our ED, and if they want an LP, guess who does it? The EM resident.

 

[JackBauERfan]

Consult neurology in our ED, and if they want an LP, guess who does it? The EM resident.

yeah I mean for sure the ED should get priority haha. One time I was there and we had pericardial effusion that needed to be tapped, and the pulm fellow was getting the med intern ready to do it. Too bad the ED resident was all about it and pretty much took it over (and it was his patient); so I don't even know what the fellow was thinking without asking the ED folks ahah. But I mean this is the training program, so if there is anything in the ED, the ED residents are first shot at it, since ultimately they may be in a rural area and have to do it themself someday.

 

[jbod34]

Everyone is always so helpful. Thanks so much!!!!! You guys are great.

 

[BKN]

Everyone is always so helpful. Thanks so much!!!!! You guys are great.

I trained in the biggest centers and I've been teaching at a small county/university hospital for 20+ years. It's all good and you can learn anywhere. Overall though, I'd vote for a place where you have more control over your patients and the procedures. You learn more about reading the images and ECGs., doing the bedside sonos, and making the decisions yourselves. All things you will be doing in the middle of the night at community hospitals or as attendings in teaching intstitutions.

I guess I'm just cranky when some fresh-faced whippersnapper senior resident or fellow tries to educate me.

 

[roja]

The question you really want to ask is not do you have consults readily available (believe it or not, this is a really good thing and you want them there) but who gets priority over procedures and patient management.


For example: in our institution, patients are under ED control until they are admitted to a service. Up until that point, consults are exactly that: consults. Procedures, plans, etc are under my discretion.

Naturally, if its a procedure that is uncommon in the ED (say injection of the corpus cavernosum in priapism) naturally, I want an appropriate consult there the first time...


So, its not are consults available or not, but what is the culture of consults in the institute you are interviewing at.