Proceduralist gun for hire

[EctopicFetus]

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...

First.. I will follow Lexdiamondz advice after this.

Let me fix this part of your statement

And you want to rename EDs into urgent care? So somewhere that sees mismanages trauma patients, does a crappy job at complex reduction with sedation, does airways poorly 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...

My edits made it better. To answer your question most medics have more experience and training than an FM doc. Dont believe me? Do your research bud about RRC requirements for FP docs to finish residency regarding tubes and compare it to your EMT-P. LOL. I want them renamed urgent cares cause thats what they become when you have a non EM doc there. If you cant fly cause the seats are sold out and you hop on a greyhound it doesnt make the bus an airplane you follow? LOL

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[EctopicFetus]

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

Yes THE Peter Rosen passed. he had numerous health issues and finally succumbed to them.

 

[MedicineZ0Z]

First.. I will follow Lexdiamondz advice after this.

Let me fix this part of your statement

And you want to rename EDs into urgent care? So somewhere that sees mismanages trauma patients, does a crappy job at complex reduction with sedation, does airways poorly 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...

My edits made it better. To answer your question most medics have more experience and training than an FM doc. Dont believe me? Do your research bud about RRC requirements for FP docs to finish residency regarding tubes and compare it to your EMT-P. LOL. I want them renamed urgent cares cause thats what they become when you have a non EM doc there. If you cant fly cause the seats are sold out and you hop on a greyhound it doesnt make the bus an airplane you follow? LOL

Again, your level of insight just seems to be incredibly poor. FMs who go work in EDs will have done >100 tubes during training, among other things. Paramedics get 5-10 cherry picked easy ones in the OR and are good to go as far as "training" goes. RTs who also intubate in many settings will have done 5-10 as well. Ya'll also "train" your midlevels to do it among other procedures and are fine with them doing it unsupervised.

Like are you seriously comparing the average FM's training credentials, who has 0 interest in EM and will never try to work in an ED, to paramedics and board certified EM? The FMs I know working in these places and busier community settings were incredibly proficient with ED procedures and took numerous courses to supplement their training.

I get that you're fixating on rare and unusual anecdotes and ignoring the other 90%. But that's not a sane or rational argument. It's just being out of touch with reality. Anyway this is all assuming that you're not just a premed troll.

 

[TooMuchResearch]

Our group replaced FP docs at rural hospitals. Those FP docs routinely called in CRNAs to intubate, transferred anyone that needed sedation, and under treated the **** out of sick patients as a rule.

Happy to trade more anecdotes if you want.

Again, your level of insight just seems to be incredibly poor. FMs who go work in EDs will have done >100 tubes during training, among other things. Paramedics get 5-10 cherry picked easy ones in the OR and are good to go as far as "training" goes. RTs who also intubate in many settings will have done 5-10 as well. Ya'll also "train" your midlevels to do it among other procedures and are fine with them doing it unsupervised.

Like are you seriously comparing the average FM's training credentials, who has 0 interest in EM and will never try to work in an ED, to paramedics and board certified EM? The FMs I know working in these places and busier community settings were incredibly proficient with ED procedures and took numerous courses to supplement their training.

I get that you're fixating on rare and unusual anecdotes and ignoring the other 90%. But that's not a sane or rational argument. It's just being out of touch with reality. Anyway this is all assuming that you're not just a premed troll.

 

[TooMuchResearch]

Oh and would routinely have the medics bypass the hospital for bigger centers.

 

[Apollyon]

Yes THE Peter Rosen passed. he had numerous health issues and finally succumbed to them.

When was this? How come no publicity, anywhere?

 

[MedicineZ0Z]

Our group replaced FP docs at rural hospitals. Those FP docs routinely called in CRNAs to intubate, transferred anyone that needed sedation, and under treated the **** out of sick patients as a rule.

Happy to trade more anecdotes if you want.

I had the complete opposite experience rotating rurally. And now at an academic center, we get trauma transfers where the FP has tubed the patient and placed a line/chest tube etc. I've heard the exact same everywhere except this forum. CRNAs were always a theoretical back up but never a first-line like you suggest.
But btw we have had transfers for simple reductions and the like by places where the only in-house staff is an NP

 

[EctopicFetus]

Our group replaced FP docs at rural hospitals. Those FP docs routinely called in CRNAs to intubate, transferred anyone that needed sedation, and under treated the **** out of sick patients as a rule.

Happy to trade more anecdotes if you want.

We had a similar issue. In one of the local papers the ems Director was quoted as saying they routinely get called by the docs to incubate patients. Now those FP docs will be out of jobs. I don’t blame FP docs for being bad at em. I would be bad at 10-15% of FP cases. They are bad at 10-15% of cases they see in the ed. No training = poor performance.
while the glut of em residencies is bad it will put better trained docs at more rural sites since people need to work.

 

[jw3600]

Again, your level of insight just seems to be incredibly poor. FMs who go work in EDs will have done >100 tubes during training, among other things. Paramedics get 5-10 cherry picked easy ones in the OR and are good to go as far as "training" goes. RTs who also intubate in many settings will have done 5-10 as well. Ya'll also "train" your midlevels to do it among other procedures and are fine with them doing it unsupervised.

Like are you seriously comparing the average FM's training credentials, who has 0 interest in EM and will never try to work in an ED, to paramedics and board certified EM? The FMs I know working in these places and busier community settings were incredibly proficient with ED procedures and took numerous courses to supplement their training.

I get that you're fixating on rare and unusual anecdotes and ignoring the other 90%. But that's not a sane or rational argument. It's just being out of touch with reality. Anyway this is all assuming that you're not just a premed troll.

**** man. You were an annoying med student poster. Now you’re annoying family med intern in the EM forum? That’s a hell of a mark you’ve left on SDN.

 

[thegenius]

I had the complete opposite experience rotating rurally. And now at an academic center, we get trauma transfers where the FP has tubed the patient and placed a line/chest tube etc. I've heard the exact same everywhere except this forum. CRNAs were always a theoretical back up but never a first-line like you suggest.
But btw we have had transfers for simple reductions and the like by places where the only in-house staff is an NP

Where did you rotate rurally? Name of hospital and city/state?

 

[Lexdiamondz]

Again, your level of insight just seems to be incredibly poor. FMs who go work in EDs will have done >100 tubes during training, among other things. Paramedics get 5-10 cherry picked easy ones in the OR and are good to go as far as "training" goes. RTs who also intubate in many settings will have done 5-10 as well. Ya'll also "train" your midlevels to do it among other procedures and are fine with them doing it unsupervised.

Like are you seriously comparing the average FM's training credentials, who has 0 interest in EM and will never try to work in an ED, to paramedics and board certified EM? The FMs I know working in these places and busier community settings were incredibly proficient with ED procedures and took numerous courses to supplement their training.

I get that you're fixating on rare and unusual anecdotes and ignoring the other 90%. But that's not a sane or rational argument. It's just being out of touch with reality. Anyway this is all assuming that you're not just a premed troll.

This just isn't true.

Take a place like JPS, which is often cited as an inpatient and critical care heavy FM residency. Their "highlights" that they list for procedures among their senior residents are like 40 CVLs and 95 intubations - numbers that are utterly unremarkable for the vast majority EM programs.

If the most procedurally competent grads at some of the most procedure-heavy FM programs are merely hitting average numbers for EM, where do you think the typical FM grad is on the spectrum. This mythical FM grad who graduates with 100 tubes is false - you're describing outliers that are far from the norm. Most of you guys will be lucky to get 25 if that.

Stop coming to our forum spewing half truths and nonsense.

 

[MedicineZ0Z]

This just isn't true.

Take a place like JPS, which is often cited as an inpatient and critical care heavy FM residency. Their "highlights" that they list for procedures among their senior residents are like 40 CVLs and 95 intubations - numbers that are utterly unremarkable for the vast majority EM programs.

If the most procedurally competent grads at some of the most procedure-heavy FM programs are merely hitting average numbers for EM, where do you think the typical FM grad is on the spectrum. This mythical FM grad who graduates with 100 tubes is false - you're describing outliers that are far from the norm. Most of you guys will be lucky to get 25 if that.

Stop coming to our forum spewing half truths and nonsense.

Typical grads aren't working at ERs. And many of those people who are, weren't chasing numbers necessarily. You can easily get 50-60+ on an anesthesia month as well. Plus pre-residency numbers count, even though they don't on paper.
People working at these places also often take additional courses too which ABEM folks repeatedly endorse.

 

[EctopicFetus]

as any em doc knows. A tube during an anesthesia rotation is a joke. A medically optimized non critically ill patient is not the same as a septic hypotensive hypoxic patient. I tell my residents that the only useful tubes they get during anesthesia are the peds under 8. Everything else is fairly meaningless. Once you do 25 standard tubes anything above that is meaningless and doesn’t teach much. You need the tubes on the sick patients.

 

[MedicineZ0Z]

as any em doc knows. A tube during an anesthesia rotation is a joke. A medically optimized non critically ill patient is not the same as a septic hypotensive hypoxic patient. I tell my residents that the only useful tubes they get during anesthesia are the peds under 8. Everything else is fairly meaningless. Once you do 25 standard tubes anything above that is meaningless and doesn’t teach much. You need the tubes on the sick patients.

So why is anesthesia the backup for the ED? When the vast majority of their patients are fairly optimized. A sick patient is cognitively challenging more than anything.
Lets not ignore the fact that VL is first line in so many EDs nationwide...

Also your number of 25 contradicts literature which cites a much higher number. That's the number to become comfortable with the anatomy, not to master good technique.

 

[Groove]

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?

Dude... I just realized that you are a baby intern which explains SO much. From your posts, you were a 3rd year med student this time 2 years ago. Why on earth are you spending so much time arguing with docs who have so much more insight and experience doing EM? You seriously think that you picked up all your procedural experience as a med student...and you consider yourself experienced now as an intern? Your EM gestalt is just so firmly established at this point after all that experience during your MS3 and MS4 years? You consider yourself qualified to judge competence in an EM attending and have expert insight into the skills required? Excuse me while I LOL. Man....if there's one thing that's ubiquitous in the world of academic medicine...it's interns with a seriously overinflated sense of their own self worth, knowledge base and experience. I don't know if you're genuinely misguided in our discussion or if you're just being a troll in this forum. I have no idea. The whole EM vs FM thing seems to be a common theme with you though. Did you apply to EM, not get in and then apply to FM as backup? This broken circular argument that many of us are having with you is just getting silly at this point.

 

[thegenius]

I’ve just marked that ***** as “ignore.”

If I could ban him from this forum I would.

 

[EctopicFetus]

Dude... I just realized that you are a baby intern which explains SO much. From your posts, you were a 3rd year med student this time 2 years ago. Why on earth are you spending so much time arguing with docs who have so much more insight and experience doing EM? You seriously think that you picked up all your procedural experience as a med student...and you consider yourself experienced now as an intern? Your EM gestalt is just so firmly established at this point after all that experience during your MS3 and MS4 years? You consider yourself qualified to judge competence in an EM attending and have expert insight into the skills required? Excuse me while I LOL. Man....if there's one thing that's ubiquitous in the world of academic medicine...it's interns with a seriously overinflated sense of their own self worth, knowledge base and experience. I don't know if you're genuinely misguided in our discussion or if you're just being a troll in this forum. I have no idea. The whole EM vs FM thing seems to be a common theme with you though. Did you apply to EM, not get in and then apply to FM as backup? This broken circular argument that many of us are having with you is just getting silly at this point.

The funny thing is he wouldnt dare say this nonsense to anyones face. There isnt a thing on here I said I wouldnt say to his or any FM docs face. I have spent my whole career working with IM/FP residents rotating thru my EDs. I currently work with FP and EM residents. This dude thinks he understands competency better than I do? Better than the slew of EM attendings on this forum. Its comical. I think we should ignore him. He can go about his business and get a rural EM job somewhere with the other more than excellent FP docs that cover those places. Good luck.

 

[VA Hopeful Dr]

The funny thing is he wouldnt dare say this nonsense to anyones face. There isnt a thing on here I said I wouldnt say to his or any FM docs face. I have spent my whole career working with IM/FP residents rotating thru my EDs. I currently work with FP and EM residents. This dude thinks he understands competency better than I do? Better than the slew of EM attendings on this forum. Its comical. I think we should ignore him. He can go about his business and get a rural EM job somewhere with the other more than excellent FP docs that cover those places. Good luck.

I hope that's not true, because while I don't disagree with much of what you've said there are a few quite insulting things you have said in this thread.

 

[deleted109597]

I've been gone, but allow me to reiterate.
People from other fields can come here for advice. They can offer their perspectives.
If they continue to antagonize in the absence of good data, they will be removed from the discussion.
But collegiality goes both ways towards our other colleagues.
That is all.

 

[Lexdiamondz]

Can we just close this blight of a thread?