Resources recommended for new ER locums job?

[doctor1963]

Hello! I started a ER locums job recently and wondered what are good references and CME products to use? The ER is located in a critical care access hospital. I have been an attending since 2014 but only have done limited emergency room shifts in the past. Thank you!

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[Lexdiamondz]

Hello! I started a ER locums job recently and wondered what are good references and CME products to use? The ER is located in a critical care access hospital. I have been an attending since 2014 but only have done limited emergency room shifts in the past. Thank you!

Are you EM trained or FM/IM trained? Depending on what your basic skills are the tools required would be significantly different

 

[turkeyjerky]

I don't know what to say. Maybe do an EM residency? There's a reason why we train in this field...

Or just hope and pray that nothing serious comes in. Odds are it'll go fine, but maybe it won't and someone'll die or have another preventable bad outcome.

 

[goodoldalky]

Hello! I started a ER locums job recently and wondered what are good references and CME products to use? The ER is located in a critical care access hospital. I have been an attending since 2014 but only have done limited emergency room shifts in the past. Thank you!

Don’t take this the wrong way, but it doesn’t sound as though you are trained to do this job. Make no mistake about it, random critical access hospital ER has no qualms sitting you out on BFE Island with no backup... anything goes wrong, it’s on you. If you insist on moving forward, though, I’d recommend the following:

Do a ton of central lines
RSI hundreds of patients with varying anatomy including pediatrics, LPs and the rest of the routine procedures (corneal FB removal, priapism drainage, para, pericardiocentesis and cric)
Tons of hours managing vents
Know resuscitation of the critically ill patient inside and out, all shock states
Be sure you understand trauma well - orthopedic reductions, thoracotomy, chest tubes
Plenty of OB, takes about 30 deliveries to get (a tiny bit) comfortable
Lots of pediatric shifts, PICU if you can get some exposure
Couple hundred hours of ultrasound training
Significant experience with procedural sedation

There may be one or two things I’ve left out..

 

[Lexdiamondz]

Don’t take this the wrong way, but it doesn’t sound as though you are trained to do this job. Make no mistake about it, random critical access hospital ER has no qualms sitting you out on BFE Island with no backup... anything goes wrong, it’s on you. If you insist on moving forward, though, I’d recommend the following:

Do a ton of central lines
RSI hundreds of patients with varying anatomy including pediatrics, LPs and the rest of the routine procedures (corneal FB removal, priapism drainage, para, pericardiocentesis and cric)
Tons of hours managing vents
Know resuscitation of the critically ill patient inside and out, all shock states
Be sure you understand trauma well - orthopedic reductions, thoracotomy, chest tubes
Plenty of OB, takes about 30 deliveries to get (a tiny bit) comfortable
Lots of pediatric shifts, PICU if you can get some exposure
Couple hundred hours of ultrasound training
Significant experience with procedural sedation

There may be one or two things I’ve left out..

tl;dr do an em residency

 

[TheSingularity]

Ooooooooo so YOU'RE the one taking $150/hr in BFE, decimating the locums market for the rest of us huh?

You've done "limited" ER shifts and now you expect a bunch of EM attendings to tell you how to learn on the fly, in an environment where you will have extremely limited support. Makes sense.

I continue to be baffled by this flippant attitude so many (non-EM trained docs, midlevels) have. Can you imagine if I popped over into the Neurosurg subforum and asked the same question?

Train for the job you want, jesus H christ.

 

[doctor1963]

Thank you to the people who responded in a respectful, professional way. I have worked in IHS and VA ED's as an attending. I have been out of residency for awhile and wanted to get some insights about resources (apps, books, cme courses, etc ) to review between shifts. I wanted to see if there are any newer resources that you found helpful. First shifts in a critical care access hospital and want to keep develop my skill sets. By the way, I do not have a flippant attitude...I am asking because I respect people who have more years of experience in the field.

 

[Lexdiamondz]

Again, figuring out where you’re starting from is pretty important. Are you EM trained (not that ABPS farce)? Can you intubate? are you familiar with trauma? are you comfortable running codes? Delivering babies? managing eye complaints? ENT complaints? Reading your own studies if you can’t get rads?

Someone with robust experience will need very different supplementary materials than someone who is basically starting from scratch

 

[Rekt]

Again, figuring out where you’re starting from is pretty important. Are you EM trained (not that ABPS farce)? Can you intubate? are you familiar with trauma? are you comfortable running codes? Delivering babies? managing eye complaints? ENT complaints? Reading your own studies if you can’t get rads?

Someone with robust experience will need very different supplementary materials than someone who is basically starting from scratch

I'm guessing IM. FP is usually at least up front about their background. Good luck to those patients and God forbid a kid or obgyn problem shows up.

 

[Alvarez13]

Do a DNP. Takes like 6 mo and you only have to know how to use a web browser and enter your bank account info in. Then you apply to a Team Health site and can work any specialty if you want. Can even admit to yourself then operate on them and then follow output as far as they're concerned.

 

[Angry Birds]

Hello! I started a ER locums job recently and wondered what are good references and CME products to use? The ER is located in a critical care access hospital. I have been an attending since 2014 but only have done limited emergency room shifts in the past. Thank you!

Hey there, welcome to the board. Sorry for the rough reception... It's obviously a sensitive topic.

Most of my colleagues at one of the sites I work at are non-EM residency trained and I can confirm that their approach seems quite shotgun to me. I think it's good that you've identified the need to powerup on EM-specific knowledge and skills.

Since going back to do an EM residency is not really a viable option, might I suggest you look into the EM fellowships designed for FP or IM folks? Realistically, however, I realize that this may not be a viable option either.

I suggest you binge on the EM blogosphere, including EMCrit, EMRAP, etc. It's quite unfortunate but many of my non-EM colleagues don't even bother to do that.

Finally, from a procedural standpoint, you have to be absolutely solid at intubations and central lines. These two skills are life and death. For the former, I recommend buying a King Vision VL with channeled blades. It's cheap, like $1300 or so. An airway course is another option although I think you can quickly master the King Vision. Of course, you also need to read the above EM resources to get proficient at all the peri-intubation issues. As for central lines, you gotta know how to use the ultrasound to at least locate a vessel, and you must get proficient at these... What I notice is that many of my non-EM colleagues are so nervous about intubations and lines that they often don't do them, leaving the patient on the brink of death. Not good.

There are certainly other procedures you should know how to do, but these two are the most common and are absolutely essential.

Of course, you must be comfortable running codes. As someone who has worked at a critical access hospital, I can confirm that the coding patient was not at all rare.

Good luck!

 

[Lexdiamondz]

I agree with most of your post. To play devils advocate though I’d argue that placing a central line is pretty much never needed emergently. Peripheral pressors. IO/PIV/EJ for quick access/resuscitation. I agree you notice skill deficiencies in those that can’t place a central line quickly or actively avoid placing them. However, when have you taken care of someone actively dying where a central line was the one thing that would have saved their life (more of a general question for all)?

Generally I'd agree but most people who can't place a CVL with US guidance generally can't place an EJ using landmarks, IOs aren't great for volume resuscitation and do infiltrate, and critical access hospitals tend to be in heroin country where people's peripheral vasculature is shot to hell.

 

[Rekt]

I like how that was point taken away from Angry Birds post and not this gem. This is the reason that non-ABEM docs don't belong in an ED. Not even to mention the many HALO procedures that I bet >75% of non-ABEM docs even know exist.

....What I notice is that many of my non-EM colleagues are so nervous about intubations and lines that they often don't do them, leaving the patient on the brink of death. Not good...

(Also, why waste time with an EJ, just do a rapid IJ)

 

[Angry Birds]

I agree with most of your post. To play devils advocate though I’d argue that placing a central line is pretty much never needed emergently. Peripheral pressors. IO/PIV/EJ for quick access/resuscitation. I agree you notice skill deficiencies in those that can’t place a central line quickly or actively avoid placing them. However, when have you taken care of someone actively dying where a central line was the one thing that would have saved their life (more of a general question for all)?

I don't like IO's. I know people who swear by them, and I've heard all the hype since residency. However, for me, if I have a crashing hypotensive patient, I want IV access to push fluids. I often do find that central line access is a turning point in patient care. Now, I got three solid lines to push stuff through. For me, that's a game-changer.

As for PIV and EJ, I find these to require a higher level of skill than central line, which takes longer to do but is easier to do (or, at least, has a higher rate of success for me).
Easy-IJ is an option, but again, if you are a thousand percent comfortable doing a central line, you're good as far as access is concerned. Everything else is cherry on top. For a non-ABEM person, I'd just stress intubation and central line...

Also, the other day I had a lady who was signed out to me who had a history of mesenteric ischemia and needed a scan with contrast... Apparently, she had been poked a million times with no success. Therefore, I decided to do a central line on her. I was told by the radiology tech that EJ or easy-IJ were not an option but central line would be fine.

I ended up getting the PIV using ultrasound, but nonetheless, had this not been the case, central line was an option. A bit crazy, of course, to do a central line for contrast, which is why I got the PIV, but nonetheless...

Speaking of, the provider before me was a non-ABEM doc who did not know how to use ultrasound at all. Nice guy, though. I guess that's why I got a soft spot for them, haha.

 

[southerndoc]

EJ's are very easy for me. I've been great at them since my paramedic days. It's my go to peripheral line if I don't need a CT with contrast (our radiologists won't allow contrast through an EJ/easy IJ). If they need contrast, then it's either an ultrasound guided PIV or a CVL. If they need admission, I frequently will just place the CVL.

 

[southerndoc]

I like how that was point taken away from Angry Birds post and not this gem. This is the reason that non-ABEM docs don't belong in an ED. Not even to mention the many HALO procedures that I bet >75% of non-ABEM docs even know exist.

OK, I'm going to show my ignorance here. I've been practicing EM for 12 years plus 4 years of residency. What are HALO procedures?

I do agree with you that non-EM-trained physicians should not be staffing ED's. Some say it's OK for FM/IM etc. to staff rural ED's, but I think that's where it matters most (when you're single coverage/no backup in a place with little specialty backup).

 

[cyanide12345678]

Techs can place EJs. No physician skill necessary. IOs are great for volume resuscitation. Yes, they can infiltrate. Place another. Everywhere is IVDA country. I pretty much never receive a critically ill transfer from a critical access hospital with a central line placed. I’ve worked in critical access hospitals and placed central lines prior to transfer. The more I practice though, the fewer central lines I place. I no longer think of them as something that is typically emergent.

Agreed. I don't think of central line as emergent, mostly it's an urgent procedure. Peripheral pressors for up to 24 hours can easily buy plenty of time if good peripheral access.

I do them when i have time, I'm never in a rush to put one in. Only a couple of times have i needed to do one emergently - mostly active bleeding patients when no one else able to get access peripherally.

Airway management is the only true emergent procedure because things can go south in minutes.

 

[Fox800]

I like how that was point taken away from Angry Birds post and not this gem. This is the reason that non-ABEM docs don't belong in an ED. Not even to mention the many HALO procedures that I bet >75% of non-ABEM docs even know exist.



(Also, why waste time with an EJ, just do a rapid IJ)

Um, sticking an obvious EJ is faster than a rapid IJ.

Not that either procedure takes an especially long time.

"HALO" is something that I think you think we all know, but isn't commonplace, so please 'splain. I'm guessing "high acuity low occurrence blah blah". We don't understand local lingo here, like when someone refers to a "Code zero" as if everyone works for their hospital system and is supposed to just know what that means by heart.

 

[EM_kindaguy]

I agree with most of your post. To play devils advocate though I’d argue that placing a central line is pretty much never needed emergently. Peripheral pressors. IO/PIV/EJ for quick access/resuscitation. I agree you notice skill deficiencies in those that can’t place a central line quickly or actively avoid placing them. However, when have you taken care of someone actively dying where a central line was the one thing that would have saved their life (more of a general question for all)?

The 2 exceptions that I think of for my emergent lines are
1) Cordis for MTP w trauma/ arterial bleed. Trying to do a true massive resuscitation through an IO/ PIV/ EJ won't work for bad hemorrhagic shock
2) Dialysis cath for emergent HD (though even this can wait minutes if not hours)

 

[Groove]

Ace wrap the upper extremity and/or use Coban. Tight. You get much greater venodilation and can most of the time easily pop in a superficial PIV with ultrasound. It's usually cake. Don't forget to take the tourniquet off. I did one of these PIVs during my last shift and as I'm cleaning the ultrasound transducer, wishing them good luck on their admission and walking out the door, the pt goes "Thanks doc...but uh...whatcha gonna do about this tourniquet on my arm?" Doh!

Otherwise, I place EJ though my pt's tend to have blubber neck syndrome and popping in an easy IJ is just as fast. I don't drop CVLs unless they warrant the benefits of one...pressors, multiple drugs, etc..

 

[Rekt]

I still disagree for those scenarios, which I posted somewhat about in a different thread (see posts below). I can also count on one amputated finger the number of times I've had Nephrology take a patient from the ED for emergent HD.

I think putting in central lines has great appeal to medical students and residents as it is one of the more fun procedures we do. Over time though once you have done countless, the novelty wears off, it can slow down the ED briefly for you to place, and they really aren't emergent.

Going to depend on where you work. So I'll have to disagree. I've done almost double digit trialysis lines for emergent HD from the ED since starting training. Most consultants at my hospital are lazy as humanly possible so no one's about to come in a do them for us.

 

[Brigade4Radiant]

If a Dialysis catheter needs to be placed vascular can come in and do a tunneled one. Procedures which I used to love take up a lot of time especially if you are in the dept by yourself

 

[NITRAS]

I like how that was point taken away from Angry Birds post and not this gem. This is the reason that non-ABEM docs don't belong in an ED. Not even to mention the many HALO procedures that I bet >75% of non-ABEM docs even know exist.



(Also, why waste time with an EJ, just do a rapid IJ)

Out of curiosity, how many of these ”HALO” procedures get done in BFE EDs? How many EM docs who have been practicing in critical access ED’s/hospitals for a few years can still do these “HALO” procedures when any kind of competence?

These small places are always going to have a hard time filling bodies because physicals like to live in big cities, on average. If there were enough EM docs to fill these places, your job market would be way worse than it is right now.

And these small EDs and hospitals largely funnel truly sick people to higher acuity places.

I’m not an EM doc, nor do I play one. I have a lot of respect for you guys, as I think your job sucks way more than mine.

 

[Angry Birds]

Out of curiosity, how many of these ”HALO” procedures get done in BFE EDs? How many EM docs who have been practicing in critical access ED’s/hospitals for a few years can still do these “HALO” procedures when any kind of competence?

These small places are always going to have a hard time filling bodies because physicals like to live in big cities, on average. If there were enough EM docs to fill these places, your job market would be way worse than it is right now.

And these small EDs and hospitals largely funnel truly sick people to higher acuity places.

I’m not an EM doc, nor do I play one. I have a lot of respect for you guys, as I think your job sucks way more than mine.

I agree with you on all counts. This is why I do not think FP/IM folks doing rural EM are the enemy. They are forced to practice in places where it is hard to recruit ABEM folks. This is a win-win situation and much better than pumping out a ton of ABEM grads, who actually compete with older ABEM grads and saturate the field.

As much as I'd like the comparison to neurosurgery, the reality is that no non-surgeons were ever doing neurosurgery. On the other hand, FP/IM folks were working in the ER long before our field was established. So, it is not apples to apples.

Additionally, I'd point out that the volume is way lower in most critical access ERs. It's honestly a cakewalk for the most part. Finally -- aside from a handful of procedures, a critical access doc should be shipping sicker patients out in an expeditious manner. You often won't have the proper equipment or nursing staff to do fancy procedures. Therefore, all that is necessary is to be proficient in the key procedures and knowledge of how to run an effective code. Then, ship ship ship.

 

[Groove]

The birth of our specialty envisioned a future where we were empowered critical care physicians working in the ED with enhanced procedural skills assuming that immediate interventions and accelerated management in the ED would significantly improve the course of the pt. What ended up happening is a result of metric based performance incentives that have taken us 2 steps back to the 1 step forward. In order to justify our speedy dispositions... no end of literature has been pumped out encouraging us to do less, treat less, hand off sooner, admit sooner, discharge sooner, intubate less frequently, CVL can be skipped, clinical decision rule and algorithm for everything and low and behold we are now back to being the triage doctors of old. You know the ones, the interns from various specialties that picked up a few skills, crash studied an EM book over the weekend and then worked shifts in the ED. Yet, here we are continuing to argue how nobody else is qualified to do our job. Talk about history having an ironic sense of humor...

I'm exaggerating of course...or am I?

 

[Brigade4Radiant]

The thing is valuable is valualbe. Objectively what is valued at your job and as an ABEM doc you can show objectively that your patients have better outcomes you see more people and bill more. Ultimatlely it means that you are a very efficent cog in the machine

 

[Apollyon]

Again, I'll ask the question that @Fox800 did - what is "HALO", in this case? I'm confident not "High Altitude Low Opening". Is it "High Acuity Low Occurrence"? @Rekt

 

[DeadCactus]

Rural patients deserve top tier emergency care but only if I can make $350/hr an hour flying to their ****hole community to work for a weekend while living, investing, and paying taxes in a major city.

 

[clibby]

Again, I'll ask the question that @Fox800 did - what is "HALO", in this case? I'm confident not "High Altitude Low Opening". Is it "High Acuity Low Occurrence"? @Rekt

High Acuity, Low Opportunity.

Basically your thoracotomies, crics, lateral canthotomies, perimortem c-sections, emergent peds intubations, etc. The things you do once or twice in residency that are critical to know how to do, but not a ton of opportunities to become truly comfortable. You may even consider pacing, CVLs, trialysis lines, LPs in the modern era, chest tubes, etc. though I would argue these should be practiced enough to be comfortable in any EM residency worthy of staying open. HALO procedures are the procedures that are less likely for a non-EM residency trained doc to have trained in and is part of the concern around the quality of training associated with hospitals opening residencies who don't have the volume/acuity; HCA or not.

 

[Lexdiamondz]

Rural patients deserve top tier emergency care but only if I can make $350/hr an hour flying to their ****hole community to work for a weekend while living, investing, and paying taxes in a major city.

Every other aspect of our daily work lives is governed by economics - why shouldn't this be?

You want me to uproot myself and bring my immigrant arse to Trump country with 1 diner in town and no movie theatre you need to give incentives to do so.

 

[DeadCactus]

Every other aspect of our daily work lives is governed by economics - why shouldn't this be?

It should be. That's why they hired someone other than an emergency medicine physician for half the cost and why those physicians and mid-levels can't find positions in major cities where they won't work cheap enough to be an attractive alternative to emergency medicine physicians. Everyone cheers the free market until the free market invents a cheaper widget, then suddenly everyone cares about safety and ethics and wants some sort of outside intervention.

Want rural emergency physicians in a free market? Then churn them out until they are cheap enough for rural sites to afford them. Which is exactly what's happening. Want well paid emergency physicians in a free market? Then limit supply and accept they are a specialty resource best utilized in large hospitals. The rural hospitals will have to do the best they can and transfer rapidly like they do for every other medical sub-specialty and citizens there will have to accept fewer resources like they do in every other aspect of their health and life.

You can't have it both ways. Either 1) our specialty is mostly a first-line field that should be in every community like pediatrics, internal medicine, and family medicine and it will see a growth in training positions and a decrease in salaries to make that happen or 2) it is a tertiary level subspecialty field which means fewer of us demanding higher salaries.

 

[alpinism]

The problem with the argument that other specialties used to work in the ER is that it completely ignores the reason why emergency medicine was created as a specialty in the first place. Those early ER docs realized that patents were receiving substandard care leading to preventable deaths and started the specialty of emergency medicine to improve the quality of care. I'd also like to remind people that if you go back far enough every specialty was previously done by other specialties. Neurosurgery used to be performed by general surgery for hundreds of years prior to it finally becoming its own specialty in the twenties. I'm sure no one here thinks that general surgeons should work as neurosurgeons because the critical access hospitals can't afford to pay a neurosurgeon and everyone needs access to neurosurgical care.

 

[Brigade4Radiant]

Also ER is pretty disrespected in academic communities. Rotating in other services ortho, medicine, cardiothoracic residents would all hate on the ER.

In the community though I say that’s where emergency medicine shines more which justifies the higher pay you get in the community.

 

[DeadCactus]

The problem with the argument that other specialties used to work in the ER is that it completely ignores the reason why emergency medicine was created as a specialty in the first place. Those early ER docs realized that patents were receiving substandard care leading to preventable deaths and started the specialty of emergency medicine to improve the quality of care. I'd also like to remind people that if you go back far enough every specialty was previously done by other specialties. Neurosurgery used to be performed by general surgery for hundreds of years prior to it finally becoming its own specialty in the twenties. I'm sure no one here thinks that general surgeons should work as neurosurgeons because the critical access hospitals can't afford to pay a neurosurgeon and everyone needs access to neurosurgical care.

No, we think neurosurgical patients should be transferred to an appropriate referral hospital to get subspecialty care because we realize it's a waste of resources to put a neurosurgeon in every hospital. No one here thinks we should put emergency physicians on every ambulance either though.

If we think every ED in the country deserves an emergency physician, that's fine. But that means mass production and lower salaries. If that's the philosophy we are going to pursue, expect EM to pay $150/hr and less in desirable locations. At $1 million a year working 48 weeks and 60 hours/wk, a neurosurgeon is $350/hr. No healthcare system is going to pay neurosurgeon prices at every rural hospital in country to put graduates from a 3 year residency to work. It's nonsense in terms of the free market, it's nonsense in terms of designing a healthcare system.

I think it's a fair argument to say that putting a board certified emergency physician to work in every sleepy rural emergency department is a waste of training and resources just like it would be a waste to put them in every ambulance. In which case, we should be limiting training positions, accept a role in the healthcare system closer to subspecialists, and focus an expectation of staffing emergency departments in major trauma and medical centers where skills and expertise can be maintained and best utilized. Urgent care, fast track, and slow rural departments would then be the purview of non emergency medicine physicians with oversight from emergency physicians.

I don't think either model is inherently better but this idea that every ED in the country is going to have 24/7 EM physician staffing at $300+/hr (or even $200+/hr if we're being honest) is a nonsensical pipedream. Bottom line, either emergency medicine is a specialist field or a generalist field. Specialists aren't found on every street corner and generalists are too abundant to demand specialist salaries. Ultimately, corporate medicine chose for us and we seem to be well down the path to becoming generalists. The decision to be a 3 year specialty was probably the first step to take us down that road, it's hard to be a specialist when you minimize the barrier to entry.

 

[goodoldalky]

No, we think neurosurgical patients should be transferred to an appropriate referral hospital to get subspecialty care because we realize it's a waste of resources to put a neurosurgeon in every hospital. No one here thinks we should put emergency physicians on every ambulance either though.

A better analogy would be the rural hospital letting a general surgeon to do neurosurgery because they are rural, and calling themselves a trauma center. You're not a trauma center, the general surgeon is not a neurosurgeon, you're claiming to provide a certain level of care, but are incapable of doing so.

If you're going to have some place where patients go for unscheduled care out in the sticks, that's fine. But it really shouldn't be called an emergency department if it is staffed by an internist, resident, or obstetrician.

Either have a standard and follow it, or don't.

 

[DeadCactus]

A better analogy would be the rural hospital letting a general surgeon to do neurosurgery because they are rural, and calling themselves a trauma center. You're not a trauma center, the general surgeon is not a neurosurgeon, you're claiming to provide a certain level of care, but are incapable of doing so.

If you're going to have some place where patients go for unscheduled care out in the sticks, that's fine. But it really shouldn't be called an emergency department if it is staffed by an internist, resident, or obstetrician.

Either have a standard and follow it, or don't.

By that same logic, all these emergency departments with emergency physicians that have to transfer patients for subspecialty care are frauds too. Better have a pediatric hospital attached if you’re going to be an emergency department, it would be a lie to tell parents you can handle emergencies but have to transfer any actually sick children. Actually, why are you even treating kids if you’re not fellowship trained? Better put an asterisk on that emergency department sign.

Emergency departments are part of a system. That doesn’t mean every part of the system has to offer the same standard of care. They don’t now and they never would and to pretend putting an emergency physician in a limited resource setting magically makes it comprable to a major medical center is unrealistic. The emergency departments is the place you go for the highest level of acute care in that area, if you need more then you get transferred.

 

[alpinism]

No, we think neurosurgical patients should be transferred to an appropriate referral hospital to get subspecialty care because we realize it's a waste of resources to put a neurosurgeon in every hospital. No one here thinks we should put emergency physicians on every ambulance either though.

If we think every ED in the country deserves an emergency physician, that's fine. But that means mass production and lower salaries. If that's the philosophy we are going to pursue, expect EM to pay $150/hr and less in desirable locations. At $1 million a year working 48 weeks and 60 hours/wk, a neurosurgeon is $350/hr. No healthcare system is going to pay neurosurgeon prices at every rural hospital in country to put graduates from a 3 year residency to work. It's nonsense in terms of the free market, it's nonsense in terms of designing a healthcare system.

I think it's a fair argument to say that putting a board certified emergency physician to work in every sleepy rural emergency department is a waste of training and resources just like it would be a waste to put them in every ambulance. In which case, we should be limiting training positions, accept a role in the healthcare system closer to subspecialists, and focus an expectation of staffing emergency departments in major trauma and medical centers where skills and expertise can be maintained and best utilized. Urgent care, fast track, and slow rural departments would then be the purview of non emergency medicine physicians with oversight from emergency physicians.

I don't think either model is inherently better but this idea that every ED in the country is going to have 24/7 EM physician staffing at $300+/hr (or even $200+/hr if we're being honest) is a nonsensical pipedream. Bottom line, either emergency medicine is a specialist field or a generalist field. Specialists aren't found on every street corner and generalists are too abundant to demand specialist salaries. Ultimately, corporate medicine chose for us and we seem to be well down the path to becoming generalists. The decision to be a 3 year specialty was probably the first step to take us down that road, it's hard to be a specialist when you minimize the barrier to entry.

I completely agree that it's a waste of resources but I don't think the right answer is to let non emergency physicians care for rural emergency patients for the exact same reasons I don't think the right answer is to let non neurosurgeons care for rural neurosurgical patients. If a critical access hospital lacks the volume to have trained emergency physicians they shouldn't be providing any emergency services just like if they lack the volume to have trained neurosurgeons they shouldn't providing any neurosurgical services.

 

[Brigade4Radiant]

The neurosurgeon example isn’t applicable because even neurosurgeon some cells don’t take care of patients directly. They need Neuro critical care or an ICU doctor. Also neurosurgery patients end up with neurosurgeons. A more apt example is saying a general surgeon should I do an emergent laparotomy for a gunshot wound in a rural area.

Also most of these rural places are just like a urgent care I a lot of aspects they can’t even admit sick patients these hospitals serve to feed other major hospitals

 

[alpinism]

Rural critical access hospitals that function like urgent cares should be called urgent cares.

The few truly sick patients that need actual emergency services can go to emergency departments.

 

[Apollyon]

Rural critical access hospitals that function like urgent cares should be called urgent cares.

The few truly sick patients that need actual emergency services can go to emergency departments.

But, they're RURAL. There aren't two in town. To be "critical access", I believe there has to be 25 miles between hospitals. And, as we all know, patients don't know if they are "truly sick" - the indigestion that feels just a little different - they don't know if it is GERD or MI. Your kid gets bitten on the face by the dog - it's your kid, so, you might be a bit amped up, and, then, how do you calculate "urgent care, or, drive 30 miles to the emergency department?"

So, for your idea - okay? It just can't be done effectively. All politics is local.

 

[emergentmd]

Cactus's best point is barrier of entry. You make radiology 3 yrs and you will see them go down the same path. Its just tooooo easy to create an EM residency b/c there are thousands of hospitals wanting cheap EM labor so they pay someone 100K to be residency directory.

 

[alpinism]

But, they're RURAL. There aren't two in town. To be "critical access", I believe there has to be 25 miles between hospitals. And, as we all know, patients don't know if they are "truly sick" - the indigestion that feels just a little different - they don't know if it is GERD or MI. Your kid gets bitten on the face by the dog - it's your kid, so, you might be a bit amped up, and, then, how do you calculate "urgent care, or, drive 30 miles to the emergency department?"

So, for your idea - okay? It just can't be done effectively. All politics is local.

Patients with chest pain already show up to urgent cares all the time and get transported to hospitals with real emergency physicians.

The main difference would be that patents with chest pain would stop being treated at hospitals with fake emergency physicians.

 

[VA Hopeful Dr]

Patients with chest pain already show up to urgent cares all the time and get transported to hospitals with real emergency physicians.

The main difference would be that patents with chest pain would stop being treated at hospitals with fake emergency physicians.

Not at 2am they don't

 

[Apollyon]

Patients with chest pain already show up to urgent cares all the time and get transported to hospitals with real emergency physicians.

The main difference would be that patents with chest pain would stop being treated at hospitals with fake emergency physicians.

You need to research critical access hospitals. I worked at one. The closest urgent care was 45 or so miles away. I don't get your point. When you're the only game in town, you get it all. There's nowhere else to go. Most is BS, but, you're the knot on the end of the rope. I am not a "fake emergency physician". My closest interventional cards were 100 miles away. I did what I had to - whether call for a helicopter, or give TNKase.

Chest painers will go to the closest. Period. They're not going to go somewhere further away.

 

[Angry Birds]

You need to research critical access hospitals. I worked at one. The closest urgent care was 45 or so miles away. I don't get your point. When you're the only game in town, you get it all. There's nowhere else to go. Most is BS, but, you're the knot on the end of the rope. I am not a "fake emergency physician". My closest interventional cards were 100 miles away. I did what I had to - whether call for a helicopter, or give TNKase.

Chest painers will go to the closest. Period. They're not going to go somewhere further away.

I agree with you. Having worked at a rural critical access hospital before, I can confirm your experience. Yes, it's true that the volume of patients is often lower in such settings... But, this doesn't mean that sicker patients don't come. In fact, it was almost every shift that I would have someone come in the middle of the night knocking on death's door.

Working in a resource-limited environment has its own set of challenges, and I don't think it's right to look down on critical access ER doctors. There is nothing fake about it. Additionally, if they can be criticized for shipping all sick patients out, then what about ER doctors at tertiary care centers who consult all the specialists for anything complicated?
Not that I actually agree with putting down tertiary care ER docs in this way, but I'm just sayin'...

 

[alpinism]

You need to research critical access hospitals. I worked at one. The closest urgent care was 45 or so miles away. I don't get your point. When you're the only game in town, you get it all. There's nowhere else to go. Most is BS, but, you're the knot on the end of the rope. I am not a "fake emergency physician". My closest interventional cards were 100 miles away. I did what I had to - whether call for a helicopter, or give TNKase.

Chest painers will go to the closest. Period. They're not going to go somewhere further away.

My point is simple:

Rural hospitals should not call it an emergency department unless its staffed with residency trained emergency physicians.

 

[alpinism]

I agree with you. Having worked at a rural critical access hospital before, I can confirm your experience. Yes, it's true that the volume of patients is often lower in such settings... But, this doesn't mean that sicker patients don't come. In fact, it was almost every shift that I would have someone come in the middle of the night knocking on death's door.

Working in a resource-limited environment has its own set of challenges, and I don't think it's right to look down on critical access ER doctors. There is nothing fake about it. Additionally, if they can be criticized for shipping all sick patients out, then what about ER doctors at tertiary care centers who consult all the specialists for anything complicated?
Not that I actually agree with putting down tertiary care ER docs in this way, but I'm just sayin'...

That sounds like a rural hospital that should have an emergency department staffed with residency trained emergency physicians.

 

[Vandalia]

That sounds like a rural hospital that should have an emergency department staffed with residency trained emergency physicians.

Are you willing to take the job for collections, which would work out to about $100/hour? On a good day?

Or to put it more precisely, you agree that we should triple the number of EM residencies?

The one thing some physicians do not realize is that it is like Lucy on the chocolate factory line: The patients keep coming and have to be seen.

You have one of three options:

1) Dramatically increase the number of EM residencies.
2) Have ED's staffed in some places with non-EM physicians.
3) Avoid #1 or #2 and have them staffed with non-physician "mid-level" providers.

The car crash victim or heart attack can't reschedule those events so they can see their primary care provider during working hours.

 

[Brigade4Radiant]

Also the hospital would say sure if you give us the money then fine.

Also they would say if that’s the case you have to be an hospital employee like a surgeon. So no more locums

HCA has expanded and they would sue if you tried to. Lose those residencies down.

Keep in mind most people do not want to live full time in critical access areas they go to Colorado New York and Cali.

I don’t want any more residency expansion also NPs and PAs used the we will practice in rural but that turns out that’s not true.

 

[Rekt]

The reality that I'm seeing already is that we're already pushing out FPs/IMs because of the huge oversupply of EM docs so it's kind of a moot argument.