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Because it usually means nurse. Either nursing doesn't want the patient upstairs or house supervisor staffed upstairs too thin.
Necessity of Lactate for every person with a potential infection
- Thread starter thegenius
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deleted547339
Oh. Where I work it’s beds. We need to double our icu capacity....
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deleted109597
You might. But you also have lower nursing ratios, better trained nurses, and most of those patients are already on a plan. You're right that it's the volume of new patients, so I'll correct it as "the pt to physician ratio of new patients is immense"
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Right. It's this continual creep in scope of practice, and hospitals are willing to take advantage of us.
"We don't need a 24 hour anesthesiologist on-call because the ER can just do emergent intubations"
"We don't need a dedicated code physician because there's always an ER doc who can do it"
"Why wake up the intensivist at home to come place a central line? The ER doc can just place it. After all they are worthless and just wasting time anyway".
The House Supervisors ask me to treat all sorts of stuff on inpatients. When I decline, they always say "It's in the best interest of the patient". Sure it is. It's also in the best interest for all the patients if I'm managing them personally at night rather than nurses waking up a sleepy hospitalist. That doesn't mean I'm going to do it.
Honestly it's getting ridiculous. My main site near my home is a 350 bed level 3 trauma center in a very affluent community with a great call panel. They have around 60 ICU beds. Why am I still having to go upstairs and intubate and do codes? This happens because our CMGs allow this to happen and don't refuse to allow us to do this insane nonsense.
Yet all I hear here is that emergency physicians are masters at resuscitation. You seem to state that their job is to sort patients to a disposition. What's "to sort" in French again?
I'm not saying it isn't a hard job to sort in a quick, safe, accurate, and efficient manner, but if you're going to take the mantel of being the best in a resuscitation, then own it... all of it.
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deleted547339
Oh yea, a busy ICU shift is every bit, if not more, draining than an ED shift. But the vast majority of days are more difficult in the ER. It’s way easier to have a nurse titrate a levo drip on 15 patients that are already intubated and lined up than it is to have to manage a busy waiting room, have ekgs pushed in your face, head that traumas are coming in and have 10 active ED patients.
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deleted109597
I have no problem saying I'm not the best at resuscitation. I'm the best at recognizing, sure. And even then, we generally suck.
I spend a significant amount of time with real resuscitationists. The ones who do REBOA roadside. The ones who initiate ECMO at the Louvre (not a fan, honestly). It's not my job. My job is damage control resuscitation. And I might be the best at that, but I can't say that for sure. Some of those out there are way better than me. I have no trouble saying that.
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Bollocks. We are certified to work in an emergency department. Nowhere else in the hospital. We are not credentialed to do ICU work. Inpatient work. ER docs have been successfully sued doing this kind of stuff elsewhere other than an ER.
I agree it’s scope creep and we are taken advantage of. I was asked by a Hospitalist the other day to leave the ER and place a EJ on a patient on the floor. There is no one else in the hospital who can place an EJ?!?!?!?!
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This "mantle" is not born nor claimed by all emergency physicians, only a select few. Most have no interest in treating refractory shock beyond the initial resuscitation, and that's fine. The standard emergency physician should be expected to recognize shock, identify the likely etiology, and begin appropriate treatment.
I will say the "job" of ER physicians does depend a little bit on the nature of their practice environment. This is similar to other specialties as well where the smaller and more remote the hospital gets, the wider the scope of practice. For example, I know family practice docs doing full OB services, C sections, general surgery, endoscopy, etc. In small communities. However, in large cities as part of large health care systems they mostly only do adult out patient chronic disease management.
Similarly, ER physicians in remote hospitals may do more care for inpatients, ICU patients, etc.
However, in large, urban, multispecialty care hospitals, the ER physician's role is triage. It makes no sense for me to leave patients in the waiting room with undifferentiated, possibly lethal undiagnosed pathologies so that I can perform procedures or further resuscitate patients that have already been identified as requiring inpatient care in the highest levels of care in the hospital (OR, ICU, cath lab, etc.)
The patient needs inpatient care, they are at a hospital that has multiple inpatient specialists. In this environment. Our job is to bring these populations of patients and physicians together. Once this match is established, the ER physician is on to the next case.
I will concede there is a fundamental misunderstanding which is rampant throughout the medical system including other physicians about what ER physicians "do."
All I can say is:
"They don't think it be like it is, but it do."
Similarly, ER physicians in remote hospitals may do more care for inpatients, ICU patients, etc.
However, in large, urban, multispecialty care hospitals, the ER physician's role is triage. It makes no sense for me to leave patients in the waiting room with undifferentiated, possibly lethal undiagnosed pathologies so that I can perform procedures or further resuscitate patients that have already been identified as requiring inpatient care in the highest levels of care in the hospital (OR, ICU, cath lab, etc.)
The patient needs inpatient care, they are at a hospital that has multiple inpatient specialists. In this environment. Our job is to bring these populations of patients and physicians together. Once this match is established, the ER physician is on to the next case.
I will concede there is a fundamental misunderstanding which is rampant throughout the medical system including other physicians about what ER physicians "do."
All I can say is:
"They don't think it be like it is, but it do."
Yet you can't swing a stick in here without people talking about EM being the masters of resuscitation or bristling at the term "triage." I can post links to thread after thread if you like. It can't be resuscitationists only when it suits you (generalized "you"), and sorting (triage) when it suits your needs. If your job is resuscitationist, then I expect, within reason of course, that the patient is resuscitated prior to coming up. If your job is to triage patients, then I'll adjust my expectations... and not expect much.
I don't disagree. However, when a patient is having an emergency in the emergency department surrounded by emergency physicians, why is it so hard to obtain secure and safe central access for the medication that, if extravasates, is dangerous to the patient? When did it become acceptable to resuscitated a GI bleed with a 22 in the hand? These aren't patients coming from the floor to the unit... these are patients coming from an emergency department seen by a board certified emergency physician.
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That's ridiculous man. Not having to run codes in the ICU or intubate on the floor at my current gig was a huge selling point to me. Please tell me they are paying you enough to make this worthwhile. With a hospital and ICU that big, you guys must be running upstairs every shift. Is this only at night or daytime too?
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PulmCrit- Do phenylephrine and epinephrine require central access?
Until recently I believed that prolonged vasopressor administration requires a central line, to avoid extravasation. I lumped together all vasopressors, treating them all as equal. I used the occurrence of an extravasation reaction from one vasopressor as evidence that all vasopressors could...
Peripheral Vasopressor Infusions and Vasopressor Extravasation
Can we give vasopressors peripherally? And if we do, what if they leak?
Safety of peripheral intravenous administration of vasoactive medication - PubMed
Administration of norepinephrine, dopamine, or phenylephrine by peripheral intravenous access was feasible and safe in this single-center medical intensive care unit. Extravasation from the peripheral intravenous line was uncommon, and phentolamine with nitroglycerin paste were effective in...
www.ncbi.nlm.nih.gov
Safety of peripheral administration of phenylephrine in a neurologic intensive care unit: A pilot study - PubMed
Integral to the management of the neurocritically injured patient are the prevention and treatment of hypotension, maintenance of cerebral perfusion pressure, and occasionally blood pressure augmentation. When adequate volume resuscitation fails to meet perfusion needs, vasopressors are often...
www.ncbi.nlm.nih.gov
Adverse events associated with the use of intravenous epinephrine in emergency department patients presenting with severe asthma - PubMed
IV epinephrine is associated with a low rate of major and a moderate rate of minor adverse events in patients with severe asthma; however, a causal relationship has not been established. Further research investigating effectiveness, as well as safety, is warranted.
www.ncbi.nlm.nih.gov
Safety of the Peripheral Administration of Vasopressor Agents - PubMed
Vasopressors are an integral component of the management of septic shock and are traditionally given via a central venous catheter (CVC) due to the risk of tissue injury and necrosis if extravasated. However, the need for a CVC for the management of septic shock has been questioned, and the risk...
www.ncbi.nlm.nih.gov
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The pay is quite good, which is the only selling point of the job. Typically there are at least 2-3 code blues per shift I work. Fortunately most of the day we have double or even triple doc coverage until 2AM so we can at least split up the codes.
I don't understand how a hospital can have 30+ ICU beds and not have at LEAST an ICU-trained NP in house 24 hours who can intubate and do lines. It's crazy to me that we accept this crappy level of care in our ICUs.
Blog:Safety of peripheral intravenous administration of vasoactive medication - PubMed
Administration of norepinephrine, dopamine, or phenylephrine by peripheral intravenous access was feasible and safe in this single-center medical intensive care unit. Extravasation from the peripheral intravenous line was uncommon, and phentolamine with nitroglycerin paste were effective in...Safety of peripheral administration of phenylephrine in a neurologic intensive care unit: A pilot study - PubMed
Integral to the management of the neurocritically injured patient are the prevention and treatment of hypotension, maintenance of cerebral perfusion pressure, and occasionally blood pressure augmentation. When adequate volume resuscitation fails to meet perfusion needs, vasopressors are often...Adverse events associated with the use of intravenous epinephrine in emergency department patients presenting with severe asthma - PubMed
IV epinephrine is associated with a low rate of major and a moderate rate of minor adverse events in patients with severe asthma; however, a causal relationship has not been established. Further research investigating effectiveness, as well as safety, is warranted.Safety of the Peripheral Administration of Vasopressor Agents - PubMed
Vasopressors are an integral component of the management of septic shock and are traditionally given via a central venous catheter (CVC) due to the risk of tissue injury and necrosis if extravasated. However, the need for a CVC for the management of septic shock has been questioned, and the risk...
1. Even that one limits it to epi or neo. How often are you starting your septic shock patients on epi or neo?
2. "But vasopressors can cause problems in Extravasation
I'm not going to bother to list the data on norepi, b/c everyone is already familiar and fearful with that drug peripherally."
Studies:
1. I've yet to see neo started by the ED. It's normally levophed.
2. It's basically a midline they're using. Are you placing an 18 or 20 gauge IV in the arm outside of the hand, wrist, or AC and then using US to confirm placement prior to use? No? Then it wasn't what the study used as a PIV.
3. I don't have access to the full text. Was this one time pushes or epi infusion?
4. "The use of a PVL for administration of vasopressors can be considered in patients with a contraindication to a CVC." I mean... I can use the same argument against ETTs in cardiac arrest patients, but I doubt that you've surrendered the laryngoscope blade (nor do I expect you to).
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My point isn't to argue over the individual merits of each study or article. I'm playing a little bit of devil's advocate here, but my point is to show you that there is more than a small amount of literature pointing to the safety of vasopressors through a PIV, at least for a short while. For myself, I'm a little old school and old habits are hard to shake, so in general if I'm starting pressers, I'm placing a CVL before ICU placement or at the very least (assuming I've got multiple fires to put out in the ED) having a discussion with the NP or MD upstairs and affirming their ability to place a line on arrival if I can't get to it. Luckily, they understand our environment and don't mind. That may have something to do with the fact that they are private practice and the physicians are RVU based therefore they get to bill for the line. The APCs also earn extra RVUs for any procedures that they perform, so there's extra incentive all around.
I'm a firm believer that any delay with line placement in the ED should never delay a pt requiring ICU level care from physically going to the unit assuming they already have a bed assignment and are hemodynamically stable. If there are multiple code strokes and STEMIs and traumas in the ED, code coming in 5 mins out, etc.. and I'm being stretched thin...there is absolutely nothing wrong with running vasopressors through an antecubital PIV until you can place a line up in the ICU. Especially if I've already got good access on them with multiple IVs.
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It's not acceptable to resuscitate a GI bleed with a 22 in the hand. You know this, we know this. Quit displacing your bad experiences with either a solitary or multiple ED docs onto the rest of us as a whole. If you want to facilitate change, especially when it's in a patient's best interest, bring up the issue with the ED medical director or have your director broach the topic with him/her so they can evaluate the case and have a discussion with the physician at question. If you're really feeling malignant, generate a peer review but keep in mind that it's not hard to figure out who initiated it and will burn bridges with your ED docs.
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In a big center, are we the best adult resuscitationists in the hospital? Probably not. The best peds resuscitationists in the hospital? Probably not. The best at trauma in the hospital? Probably not. The best at Opthalmology? Probably not. The best at ENT complaints? Probably not.
Our field is defined not by being the expert in any one thing, but being the next best thing in just about every subspecialty. So yeah, I'm not going to be as good as an intensivist in my resuscitation knowledge, but I'm a hell of a lot better than any other field other than them. I may not have the skills of an Ophthalmologist, but when an eye complaint comes in, I'm better than any other field to deal with that other than them. We aren't the best at almost anything, there's always going to be someone more subspecialized than us. What we are the BEST at is being the next best thing in just about everything, and being amazing multitaskers.
Our field is defined not by being the expert in any one thing, but being the next best thing in just about every subspecialty. So yeah, I'm not going to be as good as an intensivist in my resuscitation knowledge, but I'm a hell of a lot better than any other field other than them. I may not have the skills of an Ophthalmologist, but when an eye complaint comes in, I'm better than any other field to deal with that other than them. We aren't the best at almost anything, there's always going to be someone more subspecialized than us. What we are the BEST at is being the next best thing in just about everything, and being amazing multitaskers.
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It's obvious you have an axe to grind here, but you're painting unfairly broad strokes against all of us. File a complaint/talk to the medical director of the ED. It's been pretty definitively demonstrated that peripherally-administered vasopressors are safe through a reliable IV for a short period (my ICU will allow it for up to ~24 hours). By your logic we should be starting central lines on every patient that we give dextrose to because they might infiltrate...
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"Three miles wide, and one inch deep. No matter who we call, they are one inch wide, and 3 miles deep."
Or, alternately, we are the first chapter in the book, or first 20 minutes of the movie. (Best first 20 minutes of any movie, IMO? "Saving Private Ryan")
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I usually put the PICC order in and have the RN call to see how soon they can do it. The answer is usually fast enough it might get done before the patient goes upstairs. The ICU doc likes this, the patient probably appreciates having the line in the arm, I keep the department flowing.
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Lucky. Our PICC team refuses to place lines in the ED. If I place the order, they won't even evaluate the pt for PICC until the pt is physically outside of the ED. I have no idea how or why this policy got implemented.
That's rich, considering this entire line got started with a broad brush about lazy intensivists.
Oh, and we're never busy with crashing patients, floor codes, rapid responses, or consults. We've got a plethora of resources to throw at anything (actually, we just lack the ability to punt to anyone else)
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Oh..you're an ICU fellow, LOL. Everything makes sense now.
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Probably because they expect you to place a line.
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Cant @southerndoc comment on several cases of successful litigation against EP's doing things outside of the ED?
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Getting a PICC placed in a septic patient or anyone who has pending blood cultures... would be near impossible in any of the hospitals I have worked at. There is usually a "policy" of not placing them in anyone who has recently drawn blood cultures.
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Yes, ton of stuff in the legal literature. Actually some recent cases of ED physicians getting sued for managing admitted patients that are boarding in the ER too.
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You are correct. Why take extra liability when you don't need to? In general if it's a patient I've cared for, and is admitted but still in the ED I'll intervene and help if something needs to be urgently done. If it's an admitted patient I've never seen before, then I always politely tell the nurse to page the admitting doc for orders.
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Why doesn't your CMG refuse the insanity? Only thing I can think of is that they believe that the contract is tenuous and are afraid that they would lose the contract if they did? Well, if you refuse, we'll just bring a new group in...
