Proceduralist gun for hire

[deleted109597]

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lobby congress to not pay these hospitals who don't staff BC/BE EM docs? I mean what should a hospital do if they want to be a chests pain center but can't hire an interventionalist but you know some FP doc is willing to try?

My point is, there aren't enough EPs. So to get to that critical mass we would have to create more residencies.
We would also have to be willing to be an EP at a rural critical access shop where we admit patients and round on them. Maybe do colonoscopies and EGDs. (although freestanding EDs and transfers to referral centers would make, way, way more sense, CMS doesn't want to hear that)

 

[MechEDoc]

You'd never hire an FM doc to do pathology. Or a pediatrician to do colorectal surgery. But everyone thinks EM is easy and an FM, IM, XYZ specialty doc, or a brand-new FNP can do it. It's disgusting.

If your ED is that crappy, it shouldn't be open. Period. The care you're delivering to your patients is substandard.

Agree. A huge part of the problem lies with the hospitals that will credential these individuals to work in their facilities. Why there aren't more lawsuits is beyond me… I would think taking a board-certified expert witness against and NP, PA, or FM would be like shooting fish in a barrel.

 

[thegenius]

lobby congress to not pay these hospitals who don't staff BC/BE EM docs? I mean what should a hospital do if they want to be a chests pain center but can't hire an interventionalist but you know some FP doc is willing to try?

Don't be a chest pain center. Or don't call it an emergency department. Call it something else and staff it with any dick tom and harry with an MD or DO.

Saying you have an emergency department and being greeted by an OB/Gyne or ENT is just ridiculous. So don't call it an Emergency Department. Call it the "OB /Gyne Department" or the "ENT department", or call it an Urgent Care.

 

[EctopicFetus]

My point is, there aren't enough EPs. So to get to that critical mass we would have to create more residencies.
We would also have to be willing to be an EP at a rural critical access shop where we admit patients and round on them. Maybe do colonoscopies and EGDs. (although freestanding EDs and transfers to referral centers would make, way, way more sense, CMS doesn't want to hear that)

What do we do about the lack of ents and pcps? There are enough eps. The issue is these dumps of hospitals who see 1 pph. That includes FSEDs are a waste of resources.

 

[EctopicFetus]

Don't be a chest pain center. Or don't call it an emergency department. Call it something else and staff it with any dick tom and harry with an MD or DO.

Saying you have an emergency department and being greeted by an OB/Gyne or ENT is just ridiculous. So don't call it an Emergency Department. Call it the "OB /Gyne Department" or the "ENT department", or call it an Urgent Care.

That’s exactly my point. Call it an urgent care and let those people admit. I have no issue with that. Hospitals dont like it cause of $$$$. But if you can’t provide the service either spend the money to do it or don’t. But you shouldn’t be able to pretend.

 

[deleted109597]

What do we do about the lack of ents and pcps? There are enough eps. The issue is these dumps of hospitals who see 1 pph. That includes FSEDs are a waste of resources.

Disagree. There's a ton of benefit for rural critical access FSEDs. Even if they only see 1 pph. You don't want to be trying to have an appendectomy there, but emergency medicine can be important. Timely STEMI care. Timely trauma interventions. Unless we are willing to put doctors on boxes prehospital, then there needs to be a place for the ambulance to get to within 30 minutes in general. Helicopters aren't the answer either.
And you can't be there all the time or you'll have skill atrophy.

 

[gro2001]

Disagree. There's a ton of benefit for rural critical access FSEDs. Even if they only see 1 pph. You don't want to be trying to have an appendectomy there, but emergency medicine can be important. Timely STEMI care. Timely trauma interventions. Unless we are willing to put doctors on boxes prehospital, then there needs to be a place for the ambulance to get to within 30 minutes in general. Helicopters aren't the answer either.
And you can't be there all the time or you'll have skill atrophy.

What do you think about staffing those places with midlevels and having telemedicine coverage by board certified docs? You could have 24/7 EM, CC, and subspecialty coverage that way.

 

[Lexdiamondz]

Disagree. There's a ton of benefit for rural critical access FSEDs. Even if they only see 1 pph. You don't want to be trying to have an appendectomy there, but emergency medicine can be important. Timely STEMI care. Timely trauma interventions. Unless we are willing to put doctors on boxes prehospital, then there needs to be a place for the ambulance to get to within 30 minutes in general. Helicopters aren't the answer either.
And you can't be there all the time or you'll have skill atrophy.

The problem is these places are staffed by midlevels and non-EM docs who don't know anything about trauma resuscitation and can't recognise a STEMI equivalent on an EKG.

 

[deleted109597]

What do you think about staffing those places with midlevels and having telemedicine coverage by board certified docs? You could have 24/7 EM, CC, and subspecialty coverage that way.

I'm not a fan. You can't telemedicine a procedure.

The problem is these places are staffed by midlevels and non-EM docs who don't know anything about trauma resuscitation and can't recognise a STEMI equivalent on an EKG.

I'm in agreement that they shouldn't be. But Fetus wants them closed, and I want them to only have emergency docs. They don't need the upstairs portions at all.

 

[gro2001]

I'm not a fan. You can't telemedicine a procedure.

That's what the on site NPs/PAs would be for. Obviously might not be as good with airway stuff as an EP, but the FP is going to be equally bad. Most of the other procedures they can transfer in a pinch. And there are quite a few ICUs that run this way (at least at night) so might not be that much of a stretch for EDs. And this would be doable with roughly the current numbers in the ED workforce.

 

[MechEDoc]

What do you think about staffing those places with midlevels and having telemedicine coverage by board certified docs? You could have 24/7 EM, CC, and subspecialty coverage that way.

I agree that this is should be a viable approach. Lots of procedural and diagnostic complexity can be designed out of basic emergency department care or augmented by off-site assistance. A well-trained PA with well-developed protocols and additional site-specific skills could easily handle a vast range (but not the entirety of) emergency medicine, with telemedicine and well coordinated transfer approaches this could be viable for geographically limited areas.

E.g.
* suspected meningitis - antibiotics and transfer. LP is therapeutic, not diagnostic and can be deferred to after transfer.
* Airway - Look x 1 -> LMA -> transfer
* Difficult access -> IO and trasnfer.
* etc, etc.

 

[deleted109597]

That's what the on site NPs/PAs would be for.

I'm not of the opinion that there's a ready supply of midlevels qualified to do these level of procedures. Can they be trained? Absolutely. Procedures can be done by technicians. But getting them to that point is not as easy.

 

[Fox800]

I realize we don't have the capability to have an ABEM/AOBEM-boarded doc at every ED in the country. I think we probably have way too many EDs in this country, but that's another topic.

Staffing rural EDs with FPs would be the next option - one that's in existence at tons of EDs already. An FP that has taken basically every EM-oriented skills lab (FCCS, ATLS, airway courses, APLS, Mattu's ECG course) and review course (Essentials, ACEP, etc), backed up by tele-EM with ABEM/AOBEM boarded docs on the line, is probably the best option. Just say no to midlevels flying solo. Sorry, but an average-denominator PA won't cut it.

 

[VA Hopeful Dr]

I realize we don't have the capability to have an ABEM/AOBEM-boarded doc at every ED in the country. I think we probably have way too many EDs in this country, but that's another topic.

Staffing rural EDs with FPs would be the next option - one that's in existence at tons of EDs already. An FP that has taken basically every EM-oriented skills lab (FCCS, ATLS, airway courses, APLS, Mattu's ECG course) and review course (Essentials, ACEP, etc), backed up by tele-EM with ABEM/AOBEM boarded docs on the line, is probably the best option. Just say no to midlevels flying solo. Sorry, but an average-denominator PA won't cut it.

That's actually a decent idea. Lots of smaller places have tele-ICU stuff overnight, no reason small EDs couldn't do the same.

 

[EctopicFetus]

Disagree. There's a ton of benefit for rural critical access FSEDs. Even if they only see 1 pph. You don't want to be trying to have an appendectomy there, but emergency medicine can be important. Timely STEMI care. Timely trauma interventions. Unless we are willing to put doctors on boxes prehospital, then there needs to be a place for the ambulance to get to within 30 minutes in general. Helicopters aren't the answer either.
And you can't be there all the time or you'll have skill atrophy.

The issue is you have docs out there who dont know those skills. putting an FP doc out there doesn't ensure anything you are talking about. What really happens is you have the best trained docs working in places with all the resources. Meanwhile the docs who have no idea what they are doing are the ones working with no resources or support.

I have no issue with a critical access hospital seeing 1pph. But doing that and staffing it with a FP/IM/OB GYN/ Ct surgeon/ENT isn't an emergency department regardless of the name.

Do you think just having ATLS makes you good at trauma? No its a stupid ass class that at best gets you a minimal understanding of what's going on. They can stay open, change the name and reimbursement.

 

[EctopicFetus]

I'm not of the opinion that there's a ready supply of midlevels qualified to do these level of procedures. Can they be trained? Absolutely. Procedures can be done by technicians. But getting them to that point is not as easy.

There is not a ready supply of qualified physicians. IMO a MLP who wants to do EM and did some training and did some extra time at a real ED is far better than the typical FM doc who works at an Urgent care and then starts moonlighting in an ED. They have no idea what they are doing.

 

[deleted109597]

The issue is you have docs out there who dont know those skills. putting an FP doc out there doesn't ensure anything you are talking about. What really happens is you have the best trained docs working in places with all the resources. Meanwhile the docs who have no idea what they are doing are the ones working with no resources or support.

I have no issue with a critical access hospital seeing 1pph. But doing that and staffing it with a FP/IM/OB GYN/ Ct surgeon/ENT isn't an emergency department regardless of the name.

Do you think just having ATLS makes you good at trauma? No its a stupid ass class that at best gets you a minimal understanding of what's going on. They can stay open, change the name and reimbursement.

I don't think putting an FP doc out there fixes anything either. However, in the vacuum of no doc vs less qualified doc, there's a level I would want my in-laws to get.
Which is my point. Even if we convert every rural hospital to ER only, there's still not enough ER docs. So we are stuck with either fixing that a decade from now with current class sizes, or increasing them even more. And, just like NP programs, most of them want to live in the city and will open Botox clinics instead of going rural. So we also have to pay for them to go out there. There's no easy answer here. And unless you never want to venture more than 30 minutes from a trauma center, it applies to you and your family as well.

 

[MechEDoc]

Which is my point. Even if we convert every rural hospital to ER only, there's still not enough ER docs.

I am not sure that there are not enough ER docs. I work in a semi-rural area. There is a reasonable payer mix and an excess of emergency departments. Two hospital systems are competing against each other and building neighboring emergency departments (a certificate of need is not required in this state), all of these departments need to be staffed and are currently running at less than 2 patients per hour per physician. There are multiple other similar departments throughout the state. I would guess at least half the patients seen in these departments do not see a board-certified emergency medicine physician for the bulk of their care (nominal overview of "supervised mid levels" versus FP or non-boarded physicians). Among the patient's I see on a daily basis, at least 50% are clearly for non-emergent conditions. These could easily be siphoned off a FP walk-in clinic.

 

[EctopicFetus]

I think we are just talking across each other. The issue is the gaming of the finances. Yep there aren't enough ED docs to cover those places. I think the solution is to change what you pay those places. Instead of reimbursing for non-ed level care-at more for other stuff that matters. Most of the rural Eds have incredibly low acuity. There isn't a hospital in America that is seeing 8k patients a year and is "high acuity". So if you function as an urgent care you should be paid as such and not call it an emergency dept BECAUSE IT ISNT. I do a lot of QI from rural Eds and dude the care is atrocious. They take the bottom of the barrel doctor wise with some exception. Like you said ED docs and all other docs want to live in cities. Reality is people want to live in cities which is why populations of rural communities has dwindled.

I don't think putting an FP doc out there fixes anything either. However, in the vacuum of no doc vs less qualified doc, there's a level I would want my in-laws to get.
Which is my point. Even if we convert every rural hospital to ER only, there's still not enough ER docs. So we are stuck with either fixing that a decade from now with current class sizes, or increasing them even more. And, just like NP programs, most of them want to live in the city and will open Botox clinics instead of going rural. So we also have to pay for them to go out there. There's no easy answer here. And unless you never want to venture more than 30 minutes from a trauma center, it applies to you and your family as well.

 

[EctopicFetus]

My bottom line is simple. If there isn't a BC/BE ED doc then it is not an emergency department. Period. no discussion. Thats my opinion. This isn't 1987. It is irrelevant if there are or aren't enough ED docs. I can't be a chest pain center if I dont have an interventional cardiologist. I would like my family member to have access to a quick good Cath for a STEMI more than a FP doc who is gonna push lyrics and ship them off to some hospital elsewhere.

No one seems to care about that. Instead these hospitals run "Eds" with sub par docs so they can charge their facility fees. Same rule applies if there is a MLP there. you must have a EM trained person to be an ED. No further discussion in my opinion.

 

[Fox800]

Neither will an average denominator FP doc. Have you seen their USMLEs (they are only bloated by IMGs). No thanks. they can fill the PCP arena that we all whine about not being enough.

OK, do you want to work in BFE Iowa at a critical access hospital 200 miles from the closest decent airport and see 0.5 PPH for $150/hour? I didn't think so. Nor should you have to.

FM docs already staff tons of places around the US. It's not ideal, but that's the world we live in. I'd rather have a decent FM doc who can care for folks and have an idea how to treat them than a PA or NP.

 

[EctopicFetus]

OK, do you want to work in BFE Iowa at a critical access hospital 200 miles from the closest decent airport and see 0.5 PPH for $150/hour? I didn't think so. Nor should you have to.

FM docs already staff tons of places around the US. It's not ideal, but that's the world we live in. I'd rather have a decent FM doc who can care for folks and have an idea how to treat them than a PA or NP.

Again, I agree. Those places don't have interventional cards (or many don't have gen surgery). There is no guarantee of a decent FM doc. Those guys don't know the first thing about what we do. Change it to what it is which is an urgent care center with Ct capabilities. Yes im not working there. Having a well trained EM doc see 0.5 pph is a waste of resources. There was an article to this effect in one of the EM journals about FSEDs. The guy is 100% right. The issue is not about the best use of resources though. it is that our jobs think they own us (they often do) and this is our answer to that issue.

 

[deleted87051]

There is a nurse Picc team , midline IV team. I don’t know why there couldn’t be a doctor similarly doing procedures on call. Maybe you could get them to pay you a steady retainer fee or on call hourly fee so you’re not sitting around for nothing

They could but why would they if they have in house nurses for it?

 

[cyanide12345678]

Just hope they don't get obstructive angioedema, then nobody will do anything. Even the CT Surgeon. You think the CT Surgeon will know how to set up for an advanced airway and be prepared to intubate? Nah. They will call anesthesia.

At least the CT surgeon once did a general surgery residency and can probably do a trach or cric if nothing else worked out.

 

[gro2001]

I'm not of the opinion that there's a ready supply of midlevels qualified to do these level of procedures. Can they be trained? Absolutely. Procedures can be done by technicians. But getting them to that point is not as easy.

I agree with you there. But if this model became more prevalent, these would be relatively high paying jobs for the midlevels while still probably being cost saving to the hospital (might be cheaper to have a well paid midlevel than an averagely or even poorly paid doc). Maybe this would incentivize a lot of the good midlevels to take up those jobs and push for others to upskill.

Either way, the alternative of having midlevels not qualified to do the procedures is having family physicians and failed OBGYNs not qualified to do these procedures. With the midlevels we can have telemedicine oversight and a bigger say in what happens as a specialty.

 

[TooMuchResearch]

"Call me when the patient is ready for the exam."

90% they call me with the patient still sitting up in bed and speculum isn't lubed and ready.

Yea, ideally it takes 10-15 minutes. Like from the time everything is all set up, you have already found your help (if needed), you have all the tools and needles, etc. In reality is like 45 minutes. I hate doing LP's. It's such a time suck, and every now and then you just can't get it despite seemingly good odds. Or the patient starts whining and complaining and wiggling around.

Pelvic take 1 minute. Easy peasy. I want to walk into the room, I want the woman in lithotomy position and everything all set up next to me on the mayo tray and everything at the right height. I want to walk in, say hi to the patient and boom just do it. Takes literally 1 minute.

In reality it's 10!!!!

 

[TooMuchResearch]

I almost never place central lines in a rural ED. If they're sick enough to need central access, they're too sick for my rural hospital anyway. Peripheral pressors and the ICU can decide to continue that (if they anticipate coming off pressors rapidly), PICC (most likely), central line.

A- for creativity. D+ for practicality.

Hospitals without someone on staff to perform procedures are going to be rare and probably very far apart. Plus, how many rural ERs out there have docs that have no ability to place a line or LP, etc..? I've worked in some tiny ass places and have never worked with someone that was THAT incompetent for an EP. Then you have to ask yourself, what EP would actually WANT to give up all their procedures?

 

[TooMuchResearch]

At the rural places I work, once the hospitalist is considering these procedures, they're already arranging transfer to a higher level of care.

Im considering floors also. There are a ton of IM attendings that cant do an LP or place a line. Eapecially now that very few procedures are required to graduate from an IM residency.

 

[Modanq]

Imagine getting called by a PA or NP at some hospital to do a spinal to rule out infection! Lol. Are you really going to just go ahead and stick a needle into someones back because the NP ordered a spinal. Or showing up to do a central line because the patient was a "difficult access."
The indication for the procedure is more important than the actual procedure.
I covered a small hospital for surgical coverage and was called by the ED for a PTX once. I showed up, obviously noting was set up. Went and saw a patient with decreased breath sounds on the left side. CXR that was ordered and the ED PA told me its "Not read" yet. I looked at the patient who is 4'11'' with an ETT taped at 28. Mainstem Intubatation. Lol. Imagine the risk you put yourself in.

 

[Groove]

I almost never place central lines in a rural ED. If they're sick enough to need central access, they're too sick for my rural hospital anyway. Peripheral pressors and the ICU can decide to continue that (if they anticipate coming off pressors rapidly), PICC (most likely), central line.

Yeah but there's a different between "can't" and "don't know how". Even though you might not be placing them, you certainly could if requested in your rural ED. If someone requires pressers, I always place a CVL. I feel like weak sauce if I punt it to the unit. It's funny though...some places I've worked have been complete opposites in terms of CVL expectations. I worked at this one hyper busy Level 2 right out of residency that should have been a level 1. 80K/yr volume and I swear....nobody got CVLs in the ED. I'd be talking to the ICU and offer to place one and the intensivists would be like "Noway man, we got this up here! Just leave that PIV and we'll drop one in him as soon as he gets here!". After several months, I'd find myself sneaking in a CVL just to keep my skills up. I felt like an air traffic controller with all the specialists doing most of the procedures and the ABEM docs simply moving the meat. Very weird environment. I can't say that I enjoyed it. These days I work in a level 3 55K ED and place many more than I used to, but our ICU requests that we place them if needed in all critical patients requiring pressers.

 

[Hamhock]

Don't be a chest pain center. Or don't call it an emergency department. Call it something else and staff it with any dick tom and harry with an MD or DO.

They can stay open, change the name and reimbursement.

I think @EctopicFetus and @thegenius are on to something here.

Like many of the "issues in EM" that get complained about in this forum, I think this one is mostly our fault. We have not continued to develop the world of EM. We have let others take over.

We (through the dreaded ACEP [I know CMGs won't want this as it will decrease financial returns or some other organization) should be defining emergency medicine and the regulations of emergency departments (and EMS!). It's our fault that there are multiple midlevels and non-EM physicians practicing "emergency medicine". No other field would have it!

There are plenty of FM docs out there doing procedures and diagnostics that in a city would be performed by a subspecialist. They aren't calling themselves cardiologists or advertising an obstetrics-gynecology clinic. They are practicing family medicine as their skills allow and referring or transferring as needed from their clinic or urgent care center to a subspecialist or emergency department. Are they paid the same as an OB-Gyn or ENT doc? Unlikely (although some procedures are re-imbursed the same as the subspecialist).

We should be doing the same. We should not be wasting our time defining "chest pain centers" (eyeroll) or other nonsense. We should be defining Emergency Departments (which MUST be staffed with ABEM; and of course would be "chest pain centers") and developing distant urgent care and rapid stabilization or rapid evaluation transfer centers (that would be paid less and could be staffed by any "tom-dick-and harry" MD/DO +/- midlevel (to steal someone else's words), but preferably by an FM doc with extra-training (see FM "fellowships" in EM) or whatever's left (midlevel, IM, etc).

EDIT: I suspect this might solve many of our other problems in EM (or improve them): CMGs would be less interested if the financial return on these rural sites is less and EM docs would be in a better position to form SDGs. The proliferation of weak EM residencies would be even less necessary, as the CMGs would be weakened and the argument that there are not enough EM docs would fade. The "EM fellowship" for FM docs would actually be something we could support in some cases (I wonder how many FM docs would still "really love EM" and want "to help fill a void"). Etc...

HH

 

[alpinism]

I think @EctopicFetus and @thegenius are on to something here.

Like many of the "issues in EM" that get complained about in this forum, I think this one is mostly our fault. We have not continued to develop the world of EM. We have let others take over.

We (through the dreaded ACEP [I know CMGs won't want this as it will decrease financial returns or some other organization) should be defining emergency medicine and the regulations of emergency departments (and EMS!). It's our fault that there are multiple midlevels and non-EM physicians practicing "emergency medicine". No other field would have it!

There are plenty of FM docs out there doing procedures and diagnostics that in a city would be performed by a subspecialist. They aren't calling themselves cardiologists or advertising an obstetrics-gynecology clinic. They are practicing family medicine as their skills allow and referring or transferring as needed from their clinic or urgent care center to a subspecialist or emergency department. Are they paid the same as an OB-Gyn or ENT doc? Unlikely (although some procedures are re-imbursed the same as the subspecialist).

We should be doing the same. We should not be wasting our time defining "chest pain centers" (eyeroll) or other nonsense. We should be defining Emergency Departments (which MUST be staffed with ABEM; and of course would be "chest pain centers") and developing distant urgent care and rapid stabilization or rapid evaluation transfer centers (that would be paid less and could be staffed by any "tom-dick-and harry" MD/DO +/- midlevel (to steal someone else's words), but preferably by an FM doc with extra-training (see FM "fellowships" in EM) or whatever's left (midlevel, IM, etc).

EDIT: I suspect this might solve many of our other problems in EM (or improve them): CMGs would be less interested if the financial return on these rural sites is less and EM docs would be in a better position to form SDGs. The proliferation of weak EM residencies would be even less necessary, as the CMGs would be weakened and the argument that there are not enough EM docs would fade. The "EM fellowship" for FM docs would actually be something we could support in some cases (I wonder how many FM docs would still "really love EM" and want "to help fill a void"). Etc...

HH

Unfortunately I don't think this will happen for a variety of reasons. Anyone familiar with the history of EM knows that from the very beginning we've been plagued with corruption and mismanagement that rivals some third world countries. When the specialty first started it was common practice to staff ERs with the cheapest physicians possible including those with psychiatric and substance abuse problems who couldn't find regular jobs. Keeping the hospital contract and making as much money as possible has always been the #1 priority among our founding fathers. The sad truth of emergency medicine is that the current crop of CMGs are nothing more than the natural evolution of the first SDGs and their desire to satisfy administrators and maximize profits.

The current EM leadership structure loves primary care docs and midlevels because they can pay them a fraction of what an EM doctor makes while still charging EM rates to patients. That's also the reason why they've started ER advertisements and appointments which helps attract healthy patients who pay EM rates for the convenience of being seen at 10pm on a Sunday night. Any proposed solution that affects hospital reimbursement such as converting ERs to UCs would be an automatic non starter for the reasons listed above unless there was a complete dismantling of the current EM leadership structure.

 

[TooMuchResearch]

When I'm in the big center: If I can get them to the ICU, our ICU docs will place the line or get a PICC - I'll generally order the PICC and if it can get done in the next couple hours, I'm not sure a CVL has much additional benefit for the patient, so I don't do it. Again, on some of the urosepsis type patients that probably need a whiff of norepi for 12 hours then off, they might just run them on PIV.

Are my CVL skills less so than when I did a lot of them? Probably, but I'd pick it up again if needed.

Yeah but there's a different between "can't" and "don't know how". Even though you might not be placing them, you certainly could if requested in your rural ED. If someone requires pressers, I always place a CVL. I feel like weak sauce if I punt it to the unit. It's funny though...some places I've worked have been complete opposites in terms of CVL expectations. I worked at this one hyper busy Level 2 right out of residency that should have been a level 1. 80K/yr volume and I swear....nobody got CVLs in the ED. I'd be talking to the ICU and offer to place one and the intensivists would be like "Noway man, we got this up here! Just leave that PIV and we'll drop one in him as soon as he gets here!". After several months, I'd find myself sneaking in a CVL just to keep my skills up. I felt like an air traffic controller with all the specialists doing most of the procedures and the ABEM docs simply moving the meat. Very weird environment. I can't say that I enjoyed it. These days I work in a level 3 55K ED and place many more than I used to, but our ICU requests that we place them if needed in all critical patients requiring pressers.

 

[Dred Pirate]

I realize we don't have the capability to have an ABEM/AOBEM-boarded doc at every ED in the country. I think we probably have way too many EDs in this country, but that's another topic.

Staffing rural EDs with FPs would be the next option - one that's in existence at tons of EDs already. An FP that has taken basically every EM-oriented skills lab (FCCS, ATLS, airway courses, APLS, Mattu's ECG course) and review course (Essentials, ACEP, etc), backed up by tele-EM with ABEM/AOBEM boarded docs on the line, is probably the best option. Just say no to midlevels flying solo. Sorry, but an average-denominator PA won't cut it.

Curious as to how many ED's do not have an actual ED MD - I worked at one of the smallest hospitals in the country at one point - we had an average inpatient census of 6 - and we essentially had ED MD's 24/7 - albiet only one actual employed MD (others were locum's) and he lived less than a mile from the hospital and would drive in when a patient showed up.

This small rural hospital actually saw more trauma now than my 70k visit ED in a medium size city b/c - we are not a trauma center but there are two within 30 minutes in either direction. There is an argument to be made that in a place like that it is as important to have a properly trained ED MD available - we were an hour and half drive from any hospital any larger.

 

[MedicineZ0Z]

Is this like some sort of revelation to you? who staffs the rural Eds? Who used to staff urban EDs. there is a CMG run local ed with volumes of 50k with maybe 1-2 EM docs. rest were FP/IM and a gang of MLPs. Quality was as you would expect... terrible. I think they are changing now because of all the new grads willing to work a crap job at borderline pay.

What do those docs do? who knows. risk their license for a paycheck.

I would rather a CT surgeon than an FP doc. Show an FP doc an unstable patient and ill show you someone with a brown streak in their shorts. If they don't then it is even scarier. You don't know what you don't know.

Lmao your anti-FM bias is laughable and absurd. You know in many places FM residents run codes etc. right? And that a CT surgeon (assuming you aren't trolling) has next to no medical knowledge in the context of managing bread and butter ED patients.

Haters gonna hate. I think almost everyone in this forum recognizes that there are some damn good family medicine-trained doctors working in emergency departments across the United States providing quality care, especially in in rural and underserved areas. It would be nice if we could separate ourselves from every other specialty in medicine by being the one that didn't constantly badmouth the others (you'd think we of all people would know better) but specialist hegemony knows no bounds.

I would still admit that IM and certainly any other specialty has no business being in the ED simply given their lack of ability to see kids/ob gyn.
ABEM is the obvious best choice on average, kind of a no **** thing. They'd also be better at seeing kids than a pediatrician in acute settings. Obgyn complaints, which can end in litigation if things go wrong, would be the one category where a well trained FM would handle it undoubtedly better than ABEM.
But I think 5-10 years out of residency, the differences become next to minimal for generalists working in the ED.

 

[MedicineZ0Z]

lobby congress to not pay these hospitals who don't staff BC/BE EM docs? I mean what should a hospital do if they want to be a chests pain center but can't hire an interventionalist but you know some FP doc is willing to try?

Sure dude. So you can restrict care when FM staffed places largely provide adequate care?
And you're comparing interventional cardiology to bread and butter EM? You seriously are saying a cath lab is equivalent to an ER? lol.
Literally 90% of EM is well handled by any decently trained FM doc. A very well trained one could handle just about all of it. Don't let objectivity hurt your feelings.

That's what the on site NPs/PAs would be for. Obviously might not be as good with airway stuff as an EP, but the FP is going to be equally bad. Most of the other procedures they can transfer in a pinch. And there are quite a few ICUs that run this way (at least at night) so might not be that much of a stretch for EDs. And this would be doable with roughly the current numbers in the ED workforce.

Advocating to have midlevels solo staff an ED is disgusting.

I agree with you there. But if this model became more prevalent, these would be relatively high paying jobs for the midlevels while still probably being cost saving to the hospital (might be cheaper to have a well paid midlevel than an averagely or even poorly paid doc). Maybe this would incentivize a lot of the good midlevels to take up those jobs and push for others to upskill.

Either way, the alternative of having midlevels not qualified to do the procedures is having family physicians and failed OBGYNs not qualified to do these procedures. With the midlevels we can have telemedicine oversight and a bigger say in what happens as a specialty.

Read the post below. Enjoy your lawsuits.

Imagine getting called by a PA or NP at some hospital to do a spinal to rule out infection! Lol. Are you really going to just go ahead and stick a needle into someones back because the NP ordered a spinal. Or showing up to do a central line because the patient was a "difficult access."
The indication for the procedure is more important than the actual procedure.
I covered a small hospital for surgical coverage and was called by the ED for a PTX once. I showed up, obviously noting was set up. Went and saw a patient with decreased breath sounds on the left side. CXR that was ordered and the ED PA told me its "Not read" yet. I looked at the patient who is 4'11'' with an ETT taped at 28. Mainstem Intubatation. Lol. Imagine the risk you put yourself in.

 

[thegenius]

Sure dude. So you can restrict care when FM staffed places largely provide adequate care?

As ectopic fetus wrote, and me, it shouldn't be called an emergency department unless it's staffed with an ABEM boarded ER doc.

I do agree that FM can provide adequate care for most ER patients. Out of the 22-25 that I see per shift, maybe an FM can do just the same with 18 of them. But take those small differences per shift and extrapolate over a year, and there are hundreds of sick patients getting suboptimal care and some of those will suffer irreparable morbidity or even death.

 

[Lexdiamondz]

Sure dude. So you can restrict care when FM staffed places largely provide adequate care?
And you're comparing interventional cardiology to bread and butter EM? You seriously are saying a cath lab is equivalent to an ER? lol.
Literally 90% of EM is well handled by any decently trained FM doc. A very well trained one could handle just about all of it. Don't let objectivity hurt your feelings.

Except a lot of these places don't provide adequate care, because a great majority of FM grads are emphatically not adequately trained to take care of undifferentiated sick patients.

Look, emergency medicine was founded by FM and IM docs who recognised a massive gap in physician training when it comes to that particular practice environment nearly 40 years ago. These guys arguably had much more procedural experience and saw sicker patients then than most FM trained doctors do now and they recognised that their training wasn't adequate then.

I don't know why you insist on coming here rehashing this debate - it's been settled literally for four decades. Family medicine training by and large is inadequate and inappropriate for staffing an ED. We've known this for 40 years, and most of us who have worked with FM grads, FM residents or who have had to accept trainwreck transfers from FM grads in community hospitals have had this fact reaffirmed with real-life experiences many times. Just because a hospital desperate for warm bodies will hire you to staff their ED doesn't mean you have any business working there.

You're a PGY 0.4 with minimal FM experience and practically no real EM experience. Stay in your lane dude.

 

[Groove]

RRC Minimum Requirements for EM Residency:

Adult Medical Resuscitation - 45
Adult Trauma Resuscitation - 35
Cardiac Pacing - 6
Central Venous Access - 20
Chest Tubes - 10
Cricothyrotomy - 3
Dislocation Reduction - 10
ED Bedside Ultrasound - 150
Intubations - 30
Lumbar Puncture - 15
Pediatric Medical Resuscitation - 15
Pediatric Trauma Resuscitation - 10
Pericardiocentesis - 3
Procedural Sedation - 15
Vaginal Delivery - 10

Keep in mind, these are bare minimums. Most EM residents who graduate have done hundreds of many procedures listed above. For instance, I probably had done hundreds of lines and intubations and well over 1000 US scans alone along with countless medical/trauma resuscitations and fracture/dislocation reductions upon completion of residency. FM doesn't even have any procedure requirements at all for graduation. Certainly, most FM docs have never performed many of the procedures listed.

As already mentioned, FM (and most any other specialty for that matter...) can easily handle 90% of what I do all day long. I might do it with more speed and finesse but hey...I do 100% EM, so that's expected. It's the 10% that gets you in trouble. What you call a "cardiac arrest" that you pronounced after 10 mins of coding....I call a "save" because I identified a pericardial tamponade on cardiac US at the bedside and I decompressed it immediately with a spinal needle, resuscitated the pt, called CT surgery for an emergent pericardial window and admitted the pt to the ICU. You think I'm joking, but stuff like this happens all he time in the real world. The same goes for a trauma patient. There's no time to call GS to come bail you out as you're struggling with chest tubes and no time to call anesthesia to bail you out of your failed intubation on a trauma pt in a c-collar with a bloody airway.

Now, can FM pick up a lot, if not all of the skills mentioned above with enough time and experience? Of course. Experience is everything. The more you are exposed to and learn from, the better you become. That's the nature of life....and that's why I'd be proud to work with some of my experienced FM colleagues in just about any EM environment. Some of my partners have been doing this for 20 and 30 years and we both bring certain strengths to the table. However, it's always best for patients when you get the training you need during residency and not afterwards when the stakes are high.

Why does it have to be insulting to FM or IM to admit that we are better in the ER....where we were trained to excel at? I wouldn't know where to begin managing clinic patients or all the obstetric complications and subtleties. I'd be lost managing many chronic medical illnesses and have the utmost respect for IM and FM who are responsible for managing such a large breadth of pathology and are expert diagnosticians.

 

[EctopicFetus]

Sure dude. So you can restrict care when FM staffed places largely provide adequate care?
And you're comparing interventional cardiology to bread and butter EM? You seriously are saying a cath lab is equivalent to an ER? lol.
Literally 90% of EM is well handled by any decently trained FM doc. A very well trained one could handle just about all of it. Don't let objectivity hurt your feelings.



Advocating to have midlevels solo staff an ED is disgusting.



Read the post below. Enjoy your lawsuits.

Surely this is straight up naïveté or lack of experience. If you had an intubated family member who had cold would you want an intensivist caring for them? I sure as hell would. I wouldn't want an IM doc doing it. If I was truly ill I would want an EM doc in the ED caring for me. Are there some decent FP docs working in the Eds. Yes.

on another note to Medicine ZOZ, its not just FP docs working in EDs. It is IM docs. I dont know if you have kids.. but lets say you had a 14 day old with a fever at home would you trust an IM doc (who has 0 peds experience and little to no LP training) tapping your kid or knowing what to do to treat your kid? I surely would not.

Similarly I dont want an EP doing my vasectomy, managing my kids thumb fracture, managing my mother in laws A fib.

Bizarre that this is even a question/discussion. If you remotely believe the stuff you say why not just have 1 residency for all?

 

[EctopicFetus]

Many of the patients in the ED as mentioned need very little medical care/knowledge. Those people are fine to be cared for by anyone. Literally it doesn't matter what you do.

The great Peter Rosen who just passed away told me there are 3 types of patients in the ED.
1) those who no matter what you do they will be fine
2) those who no matter what you do will fare poorly
3) those where knowing what you are doing will change their outcome.

#3 is the smallest of this batch. They are also the ones we spend reading about, learning and understanding what to do for these people.

The issue is non EM docs and MLPs aren't very good at #3.

 

[MedicineZ0Z]

As ectopic fetus wrote, and me, it shouldn't be called an emergency department unless it's staffed with an ABEM boarded ER doc.

I do agree that FM can provide adequate care for most ER patients. Out of the 22-25 that I see per shift, maybe an FM can do just the same with 18 of them. But take those small differences per shift and extrapolate over a year, and there are hundreds of sick patients getting suboptimal care and some of those will suffer irreparable morbidity or even death.

You're free to try and change the legislation. Are your midlevels providing optimal care over the course of a year? 🙄 Considering you guys don't even see their patients. Or EDs that advertise ABEM only then have a ED doc at home and an NP in-house who doesn't even have relevant experience lolol. Fix the real issues at hand.

There's also a lot of self selection for the FMs who do work in EDs. Most trained in busy settings where they got a lot of high acuity experience (ED, ICU, codes on the floor etc.). It's not usually run of the mill FM grad.

RRC Minimum Requirements for EM Residency:

Adult Medical Resuscitation - 45
Adult Trauma Resuscitation - 35
Cardiac Pacing - 6
Central Venous Access - 20
Chest Tubes - 10
Cricothyrotomy - 3
Dislocation Reduction - 10
ED Bedside Ultrasound - 150
Intubations - 30
Lumbar Puncture - 15
Pediatric Medical Resuscitation - 15
Pediatric Trauma Resuscitation - 10
Pericardiocentesis - 3
Procedural Sedation - 15
Vaginal Delivery - 10

Keep in mind, these are bare minimums. Most EM residents who graduate have done hundreds of many procedures listed above. For instance, I probably had done hundreds of lines and intubations and well over 1000 US scans alone along with countless medical/trauma resuscitations and fracture/dislocation reductions upon completion of residency. FM doesn't even have any procedure requirements at all for graduation. Certainly, most FM docs have never performed many of the procedures listed.

As already mentioned, FM (and most any other specialty for that matter...) can easily handle 90% of what I do all day long. I might do it with more speed and finesse but hey...I do 100% EM, so that's expected. It's the 10% that gets you in trouble. What you call a "cardiac arrest" that you pronounced after 10 mins of coding....I call a "save" because I identified a pericardial tamponade on cardiac US at the bedside and I decompressed it immediately with a spinal needle, resuscitated the pt, called CT surgery for an emergent pericardial window and admitted the pt to the ICU. You think I'm joking, but stuff like this happens all he time in the real world. The same goes for a trauma patient. There's no time to call GS to come bail you out as you're struggling with chest tubes and no time to call anesthesia to bail you out of your failed intubation on a trauma pt in a c-collar with a bloody airway.

Now, can FM pick up a lot, if not all of the skills mentioned above with enough time and experience? Of course. Experience is everything. The more you are exposed to and learn from, the better you become. That's the nature of life....and that's why I'd be proud to work with some of my experienced FM colleagues in just about any EM environment. Some of my partners have been doing this for 20 and 30 years and we both bring certain strengths to the table. However, it's always best for patients when you get the training you need during residency and not afterwards when the stakes are high.

Why does it have to be insulting to FM or IM to admit that we are better in the ER....where we were trained to excel at? I wouldn't know where to begin managing clinic patients or all the obstetric complications and subtleties. I'd be lost managing many chronic medical illnesses and have the utmost respect for IM and FM who are responsible for managing such a large breadth of pathology and are expert diagnosticians.

The only procedure on there that is harder to get good experience at is airways. Which you need a lot more than 30 to become even minimally proficient at.
Most EM residents have never done a cric on a human. Same for pericardiocentesis. Chest tubes are easy. CVCs are not critical in many cases (cause of IOs, PIV pressors). Resus is very important and hopefully anyone working in an ED did many of those in residency. But a lot of the other procedures you named are done in sim lab since they're rare in real life and can be learned either in sim lab or courses etc.

Surely this is straight up naïveté or lack of experience. If you had an intubated family member who had cold would you want an intensivist caring for them? I sure as hell would. I wouldn't want an IM doc doing it. If I was truly ill I would want an EM doc in the ED caring for me. Are there some decent FP docs working in the Eds. Yes.

on another note to Medicine ZOZ, its not just FP docs working in EDs. It is IM docs. I dont know if you have kids.. but lets say you had a 14 day old with a fever at home would you trust an IM doc (who has 0 peds experience and little to no LP training) tapping your kid or knowing what to do to treat your kid? I surely would not.

Similarly I dont want an EP doing my vasectomy, managing my kids thumb fracture, managing my mother in laws A fib.

Bizarre that this is even a question/discussion. If you remotely believe the stuff you say why not just have 1 residency for all?

No doubt that an IM doc should not be in an ED given both Peds and ObGyn patients. But why don't you guys ban unsupervised midlevels from the ER and ensure any midlevel has strict supervision?

 

[EctopicFetus]

You're free to try and change the legislation. Are your midlevels providing optimal care over the course of a year? 🙄 Considering you guys don't even see their patients. Or EDs that advertise ABEM only then have a ED doc at home and an NP in-house who doesn't even have relevant experience lolol. Fix the real issues at hand.

There's also a lot of self selection for the FMs who do work in EDs. Most trained in busy settings where they got a lot of high acuity experience (ED, ICU, codes on the floor etc.). It's not usually run of the mill FM grad.


The only procedure on there that is harder to get good experience at is airways. Which you need a lot more than 30 to become even minimally proficient at.
Most EM residents have never done a cric on a human. Same for pericardiocentesis. Chest tubes are easy. CVCs are not critical in many cases (cause of IOs, PIV pressors). Resus is very important and hopefully anyone working in an ED did many of those in residency. But a lot of the other procedures you named are done in sim lab since they're rare in real life and can be learned either in sim lab or courses etc.


No doubt that an IM doc should not be in an ED given both Peds and ObGyn patients. But why don't you guys ban unsupervised midlevels from the ER and ensure any midlevel has strict supervision?

Yawn. its youngins like you who know nothing who are really what we worry about. Do you have any idea about my practice? no, we dont do this. Does it happen somewhere? yep. I would likely be in the minority but i would rather an MLP with an EM doc at home than a FP doc in the ED who doesnt even know what they dont know. the self selection of FM docs has to do with them realizing they dont like clinic and either couldnt match into EM or found out late in the game they want to do EM.

dude, your ignorance of working in an ED is astounding. When did the FP doc get experience with reductions? I have some amazing stories. Doing a chest tube isnt the same as doing it right. Same thing for CVC etc. again would you trust an FP doc to LP your 10 day old with a fever? Hell i wouldnt trust them to manage the patient let alone do the LP. Same thing for a bunch of these other things. FP is mostly an outpatient residency. you dont see enough sick people to be proficient.

Hell do you think most of them could pass the EM boards? NFW. thats proof enough. we can go round and round and it doesnt matter. From now on though these places will be called "glorified urgent cares" by me on here and in person. Heck most of the UC referrals we get are beyond stupid and thats both staffed by FPs and NPs.

we had a FP guy at my old job who would send people to the ED who were grossly mismanaged. He wanted bizarre tests etc. Danger Dan was his name. Be better than Danger Dan.

 

[thegenius]

I think medicineZ0Z just trolls this forum and purposely argues and argues and really doesn't contribute all that much. He's done this kind of thing before. Just being antagonizing.

 

[EctopicFetus]

I think medicineZ0Z just trolls this forum and purposely argues and argues and really doesn't contribute all that much. He's done this kind of thing before. Just being antagonizing.

And ignorant LOL

 

[MedicineZ0Z]

Yawn. its youngins like you who know nothing who are really what we worry about. Do you have any idea about my practice? no, we dont do this. Does it happen somewhere? yep. I would likely be in the minority but i would rather an MLP with an EM doc at home than a FP doc in the ED who doesnt even know what they dont know. the self selection of FM docs has to do with them realizing they dont like clinic and either couldnt match into EM or found out late in the game they want to do EM.

dude, your ignorance of working in an ED is astounding. When did the FP doc get experience with reductions? I have some amazing stories. Doing a chest tube isnt the same as doing it right. Same thing for CVC etc. again would you trust an FP doc to LP your 10 day old with a fever? Hell i wouldnt trust them to manage the patient let alone do the LP. Same thing for a bunch of these other things. FP is mostly an outpatient residency. you dont see enough sick people to be proficient.

Hell do you think most of them could pass the EM boards? NFW. thats proof enough. we can go round and round and it doesnt matter. From now on though these places will be called "glorified urgent cares" by me on here and in person. Heck most of the UC referrals we get are beyond stupid and thats both staffed by FPs and NPs.

we had a FP guy at my old job who would send people to the ED who were grossly mismanaged. He wanted bizarre tests etc. Danger Dan was his name. Be better than Danger Dan.

Your god complex is hilarious. And your NP-inhouse/ED-doc at home reference led to a dead 20 year old girl with a missed diagnosis that a 3rd year med student would have caught in their sleep. It's now turned into a big lawsuit.

All the procedures you're naming, I don't know a single person working in an ED who doesn't know how to do them efficiently. Having had rural experience in med school, it's where I got a lot of my procedural experience. A lot of the stuff that's auto-consult in the big centers was done right there.
Maybe in your area of the country things are worse. But don't assume it's nationwide. And don't use (made up) anecdotes as evidence. There would be endless litigation if even 1% of your content in this thread was remotely accurate.

I think medicineZ0Z just trolls this forum and purposely argues and argues and really doesn't contribute all that much. He's done this kind of thing before. Just being antagonizing.

Lol no I'm keeping it honest and objective. ABEM is undoubtedly the best person to work in the ED. That's not even a debate.
But the god complex is amusing when I've been taught blatantly incorrect stuff by (supposedly top notch and academic) ABEM attendings. Doesn't mean they arent extremely qualified though.
Likewise, talented FMs can provide adequate care in EDs, but this will be a small self selected minority.


And you know I have 0 vested interest or true bias since I'm not going to work in an ER. I'll be doing a mix of outpatient and hospitalist in an open ICU setting. Will be doing the procedures talked about in this thread, but again - not in an ER.

 

[EctopicFetus]

Your god complex is hilarious. And your NP-inhouse/ED-doc at home reference led to a dead 20 year old girl with a missed diagnosis that a 3rd year med student would have caught in their sleep. It's now turned into a big lawsuit.

All the procedures you're naming, I don't know a single person working in an ED who doesn't know how to do them efficiently. Having had rural experience in med school, it's where I got a lot of my procedural experience. A lot of the stuff that's auto-consult in the big centers was done right there.
Maybe in your area of the country things are worse. But don't assume it's nationwide. And don't use (made up) anecdotes as evidence. There would be endless litigation if even 1% of your content in this thread was remotely accurate.


Lol no I'm keeping it honest and objective. ABEM is undoubtedly the best person to work in the ED. That's not even a debate.
But the god complex is amusing when I've been taught blatantly incorrect stuff by (supposedly top notch and academic) ABEM attendings. Doesn't mean they arent extremely qualified though.
Likewise, talented FMs can provide adequate care in EDs, but this will be a small self selected minority.


And you know I have 0 vested interest or true bias since I'm not going to work in an ER. I'll be doing a mix of outpatient and hospitalist in an open ICU setting. Will be doing the procedures talked about in this thread, but again - not in an ER.

Ive worked in different parts of the US. i dont know what case you are referring to but again i dont know of a single hospital that uses the NP/ED doc model. Few if any ED docs would be so dumb as to sign up for that model. Also, as someone who works with med students and FP/IM residents trust me when I say you overestimate their skills/knowledge. med students lack the clinical experience to be good. They may be able to recite the krebs cycle and thats cute but they dont have the experience to differentiate a kidney stone vs GB pathology. Truly the RNs are better because it is pattern recognition. Note I didnt say NPs.. im saying RNs. take your 3rd year med student and show them a person with acute renal colic they will rarely have any idea whats going on whereas a RN or minimally experience ED doc (like an intern 2 months in) can make that diagnosis as they wheel the patient back.

FP docs can provide adequate care to 80% of patients ina normal ED. Maybe 90-95% in a rural ED (where many of them are) as there are often no UCs to skim off some of the nonsense that those places see.

FP docs working at a hospital let it function like a higher functioning urgent care. nothing else.

Also, you need to look up what a god complex is. Then you can realize it is the antithesis of being an ED doc.

 

[Lexdiamondz]

While I'm sure we all appreciate the input from docs from different specialties, this FM intern MedicineZ0Z doesn't add anything to the discussions on this forum. Let's stop entertaining this foolishness.

 

[MedicineZ0Z]

Ive worked in different parts of the US. i dont know what case you are referring to but again i dont know of a single hospital that uses the NP/ED doc model. Few if any ED docs would be so dumb as to sign up for that model. Also, as someone who works with med students and FP/IM residents trust me when I say you overestimate their skills/knowledge. med students lack the clinical experience to be good. They may be able to recite the krebs cycle and thats cute but they dont have the experience to differentiate a kidney stone vs GB pathology. Truly the RNs are better because it is pattern recognition. Note I didnt say NPs.. im saying RNs. take your 3rd year med student and show them a person with acute renal colic they will rarely have any idea whats going on whereas a RN or minimally experience ED doc (like an intern 2 months in) can make that diagnosis as they wheel the patient back.

FP docs can provide adequate care to 80% of patients ina normal ED. Maybe 90-95% in a rural ED (where many of them are) as there are often no UCs to skim off some of the nonsense that those places see.

FP docs working at a hospital let it function like a higher functioning urgent care. nothing else.

Also, you need to look up what a god complex is. Then you can realize it is the antithesis of being an ED doc.

There were 2 threads on this very forum about the case I'm talking about. Such places exist and you saying you aren't aware of them shows your true lack of insight into what happens at the national level. And yes the very good RNs who also have 30 years experience will be better at pattern recognition of their daily job vs someone who hasn't ever stepped foot in that setting. No ****.

And you want to rename EDs into urgent care? So somewhere that sees trauma patients, does complex reduction with sedation, does airways etc is now an urgent care? Or do you want all of that driven 1 hour down the road to a bigger ED? And have the paramedic (who did 5 tubes in the OR) manage the airway vs the doc who's done it for years.
You're definitely not biased or anything...

 

[Apollyon]

Many of the patients in the ED as mentioned need very little medical care/knowledge. Those people are fine to be cared for by anyone. Literally it doesn't matter what you do.

The great Peter Rosen who just passed away told me there are 3 types of patients in the ED.
1) those who no matter what you do they will be fine
2) those who no matter what you do will fare poorly
3) those where knowing what you are doing will change their outcome.

#3 is the smallest of this batch. They are also the ones we spend reading about, learning and understanding what to do for these people.

The issue is non EM docs and MLPs aren't very good at #3.

Peter Rosen is dead? I can't find anything about the EM doc. There was some physicist that died in 2006.