Rosen on EM

I saw him speak several years ago on a roundtable discussion about ED sedation. We were talking about the management of a drunk trauma pt

Rosen : I would give Haldol 10 mg IV push at this point

Pharmacy Geek: Dr Rosen, are you aware that Haldol is not FDA approved for IV use?

Rosen: Ive been using IV Haldol for over 25 years. Fuc% the FDA.

The only sound in the room was several sphincters tightening.

Priceless!

 

Although Dr Rosen's optimism is encouraging, the reality behind "politics" will continue on, EM into critical care has yet to be approved because of the IM dinosaurs...can you imagine what Surgeons would do to suggest a non surgically trained person to enter the OR? The cardiologist? I mean it takes practically 7 years after med school to get the privilege of interventional cards i highly doubt EM guys will get any where near there as well. Then again this is just one dude's opinion...

 

I am writing a paper with him and one of the great parts of my residency is that he is here for 3 months out of the yr or so and takes us to dinner every week (as long as he isnt traveling) on his dime. The guy is wicked smart (still).

FYI, I had the same talk with him about national HC and he has lots of international exp and thinks EM sucks across the world esp in Australia and Italy (where he has a project rolling right now). He thinks national HC just wont work and brought up the military as an example and how working less is better than working more as pay is similar. I could go on but I wont.

 

haha -- Save it for the G-damn socialized medicine thread EF.

 

YEP! CS dont tell me you are with the dark side?

 

FYI, there are two cardiology EM fellowships in the country one in California & one in Virginia. Very competitive. Also trauma/critical care is available as a EM fellowship Info is available on the SAEM website

 

I think doing a cardiology RESEARCH fellowship is a little different than doing an interventional fellowship that will allow one to cath. Maybe Rosen is right, but I just don't see it happening.

 

Agreed. I dont think that we should be cathing people, it takes too long and it not just some simple quick thing to do. Also special equipment will be needed etc. I also agree I cant see the cards guys allowing this to happen.

 

While I agree that some of those fellowship ideas seem pretty optomistic, I imagine Dr. Rosen is slightly more informed in the world of EM than me.

Trauma surgery? Really? Man I don't know, I'm of the mind that if you want to operate you need to do a surgical residency.

I guess the other question I have about the world of fellowships is one of coverage. I mean if you have the EM/Cardio trained guy working in a small community where he is the only one in the group who can cath, how does that work? Is he "on call" for urgent procedures? Does he work ED shifts and other shifts in the cath lab? Can he walk out of the ED and leave single coverage to go do a cath?

Any ideas?

 

Of course the fellows are not trained to do caths. (neither are just IM cardiology fellows, you have to do an additional IM interventional cardiology fellowship after a regular/general cardiology fellwoship). My significant other is an IM cards fellow-interventional. However, you are trained during the EM cardiology fellowship to do cardiac stress test in cardiac centers. A friend of mine is doing the fellowship now. For more info, you can contact the individual programs.Unfortuantely, there are only two in the country.

Let me reiterate you can not do caths as an EM cardiology fellow trained. Also, as a trauma/ICU fellow traimed you are not doing surgery. I think you can work as at trauma ICU attending. There numerous Trauma/ICU fellowships in the country. One of the most well known is at University of MAryland.

MAybe one of the PD or attendings can give us more detailed info abt this topic.

 

Hey, I just think something needs fixed. I don't claim to have the answers though.

 

Things need to be fixed but socialized med is not it. Agreed I dont have the answers but the way things are going (socialization) is the wrong way

 

I hope he is right about all the things mentioned above. I would definitely support training in critical care as well as trauma surgery, however with great certainty, I can gurantee surgeons won't stand for that.

JJ

 

Without getting too much into it (cause I think we've had this discussion before) -- I think the larger problem is access to health care. And I think the employment tied health insurance will be obsolete in 10 years. Somehow the system needs to be opened up. Doesn't necessarily have to be socialized, but access needs changed.

 

seems to me that EM docs would be very comparably prepared to enter a cardio/interventional cardio fellowship track after EM res. don't know if i see that happening either though. trauma surgery fellowship seems much less likely.
i met Rosen at my iview at BIDMC and he was a trip. what a character he is. that was quite a highlight of the iview season.

 

Hi, just curious: Beaudubbs & amoryblaine are u guys medical students. Because trauma/icu is a very popular EM fellowship. If you are medical students going into EM. (By the way, when I was a 4th yr student I did not know abt different EM fellowships). Emergency Medicine offers alot of fellowship opportunities (some accredited, some not). You can do fellowships in international medicine, sports medicine, hyperbaric medicine, pediatric/em, toxicology, ultrasound, etc. If you go to the SAEM.org website there is a long list of fellowships. Hope that site gives you some more info into Emergency Medicine.

EM rocks. So many opportunities

I love my job.

 

But I think they should understand the trauma/icu fellowship doesn't entail any surgery / OR time whatsoever. Purely resus in the bays and ton of icu time which may be fine for some.

The impression I got from the OP was that Rosen was implying the future of EM holds opportunities to partake in fellowships that will allow the ER doc to cath someone, allow the ER doc to go into the OR and take out a spleen....etc...

I think we can all agree that those respective specialties won't be allowing that anytime soon...plus my personal opinion is that we would be overstepping our boundaries. Everyone has their role in the world of medicine/surgery. Our role in EM is to hold down the ER not the OR or the cath lab.

 

love EM and can't wait to start my residency, but i think i'll pass on the idea of an emergency physician doing MY ex-lap

 

ohh, that's scary EM physician in the OR & doing caths.
My significant other is doing 5 years of cardiology fellowship to do interventional cardiology (cath's, etc). ANd he is not happy with EM cardiology trained doc doing stress test, and he definitely would be pissed if we could do caths. Definitely stepping on other speciality toes.

Call me old fashion, but I don't think I'm ready for EM in the OR.

 

Word...

 

I think what many of you may be hinting towards is the future EM subspecialty of observational medicine.

Obs medicine is interesting. You are treating patients in limbo between admission and acutual ED care. This is where pressure to alleviate the system may fall. We could take many soft admits and throw them here. Patient ED waits would be cut, more beds would be available in the ED, more patients would be seen. The obs unit would be run by EM physicians. We take away simple admissions hospitalist always whine about and keep the money for ourselves. In turn, we turn over sicker patients to the hospitalists.

We have a Obs unit established at my residency. As of now we only have certain categories of patients that are put there. Ex/ asthmatics, vomiting and diarrhea, chest pain R/O, allergic rxn, etc. But the possibilities are endless. Consider for example simple pain issues, cellulitis, IV abx treatment, monitoring situations, alcohol intoxication. etc. PAs and NP run the unit under supervision of a EP.

Think of the potential an Obs unit will have and the impact the subspecialty will have. For example, all chest pains R/O pt. will have treadmill stress tests supervised by us, the EM doc, not the cardiologist. I'm not sure about nuclear tests, but they are certainly much eaisier to perform than catherizations. I think I was ready to supervise a treadmill stress test in my 4th year of medical school. The possiblities are realistic and logical.

 

If EM grads are allowed into cardiology fellowships, then what's stopping family medicine from entering them?

 

which hospital is this?

i spent some time in an academic ED (A&E) in hong kong and the setup there is a 50ish bed ED with a 15-20 bed observation ward staffed by the EPs. sounds similar to what you described. i could definitely see the benefits of this type of model, but didn't know they existed in american EDs.

the patient census at this particular A&E was pretty large (400/day, ~150k/year) so i imagine that wait times would be even more horrendous without the o-ward.

 

Speaking of stepping on the toes of other specialties, the cardiology folks are one of the biggest poachers of radiology. I'm of course speaking of echo's, doppler studies, stress imaging, and especially cardiac cath. Cardiology was able to incorporate these procedures as part of what they do because they could control where the patient went. "Hey, we don't need to refer you to the radiology group, we learned how to do x, y, z and can do it here (and bill you for it)." Other than politics, I really don't see any reason why EP's should be forbidden to get trained in doing cardiac cath (or relevant surgeries). The procedure would have real meaning in emergency medicine.

 

Where I trained, it was the "CEU" - "Clinical Evaluation Unit". Where I'm at now, it used to be the "CDU" - "Clinical Decision Unit" a/k/a "Can't Decide Unit". Now it's strictly "Chest Pain Center" - but no stress and D/C, because there are 3 private cardiology groups, and who would read the results? When I was a resident, there was one cardiology "group", which were all hospital employees (er, part of the huge, multispecialty group that all attendings belonged to, that provided exclusive care to the hospital, that were paid by the hospital through the group).

 

Medicine is always evolving. Cardiology stepped all over radiology for things like nuclear stress tests, cardiovascular CT. Radiology stepped all over surgery when they started doing interventional procedures. I don't know what all the future holds for EM, but what i do believe is that there is huge group of highly motivated, very hard working people going into EM and if crossing the bounds turns out to be beneficial, practical, and god-forbid profitable, then it will happen.

 

The problem with all these sub-specialties is that they are not consistent with the nature of emergency medicine. EM is designed for fast paced evaluation, management and disposition into the appropriate area, whether that be home or cardiology. If an EM doc was doing caths they would no longer function in the above capacity, because they are taking an ED patient and spending upwards of an 1 hour (set up, tear down, paperwork) solid on one patient. I know that there are times that we may spend nearly an hour with a patient but those cases are few and far between, whereas the number of patients needing caths would overwhelm an ED quickly if they were not only doing initial evaluation, treatment, and disposition, but also the definitive therapy which is quick from a medicine standpoint, but very time consuming from an EM standpoint. That said, alot of subspecialties don't really fit, so maybe this could happen. I guess you would have to take call or something (which would send chills up my spine to see good EM doctors tied to a pager!!!) on special cath shifts, because I can in no way see them occuring in the flow of a normal shift.

 

Indeed...ElZorro raises a germane point: how do you define an Emergency Medicine practitioner? Experts in the rapid recognition of sickness and health, and experts at resuscitation and airway management.

Now, as to the first part, I don't think we'll get any (honest, non-snarky) disagreement. As to the second, again, honestly, there is room at the table for EM and anesthesiology. Beyond the gas folks, the subset goes to IM, cards, and surgery - each can do part, but none can do all.

 

Here's some rebuttal to the above.

1. EM docs will most likely not do catherizations. I agree that would be tough.
2. We probably won't do trauma surgery either.
3. We can do stress tests! - Have you seen how long it takes to do one. Literally, for an exercise stress - probably about 10 min average, unless you get a marathon runner. Do we not read our own EKGs already? Really only a few basic things to look for - arrythmia, depression, elevation, and chest pain.
Regarding myoview portions, it easily goes to the radiologist.
4. Specialists always complain we are creating issues and messes. I say we start with cardiology and clean up our messes by taking away all the simple stress tests (The bread and butter) from them. Of course, all high risk patients get admitted to cards.
5. An obs unit by definition is only a period less than 24 hours, anything loonger turns into an admission. Ex, rash not improving, abd pain - not improving, CP - ruling in.
6. The care of the patient is the issue. We become the ultimate triager intrinsic to the call of our specialty. We clean up the ED faster allowing for more to be seen, save the specialists and internist from overload, discharge people more efficiently and faster, and keep the money for ourselves.

 

After "recognition of sickness" I would add "with implementation of timely, appropriate treatment." And, in the case described by the OP, (no interventional cards w/in 100 miles) I would think that preforming a diagnostic/ potentially therapeutic heart cath would be an appropriate measure in this (rural) setting. Shipping a patient even 30 miles for a heart cath is going to screw up your 90 minute door to PCI timeframe. After all, a heart cath doesn't take that long, usually 15-20 minutes. As mentioned before it's the set up and clean up that is time consuming. However, that's done by the cath team. (RN and Rad tech)
I've wasted more than 20mins before just trying to obtain some hx's!

 

Actually, here at Mayo (and at several of the places I interviewed for a job - MetroHealth springs to mind) the EP does order the stress test and does act on the results. Here the technician's raw report is used, cardiology doesn't overread the results until the next day, so functionally we (emergency medicine) oversee the test.

- H

 

Same here in Az. We order the stresses ourselves..

 

where I work we have a 24 hr ed obs/ cdu model where we (pa's) do treadmills which are overread by the em docs. all the providers in the group( pa's and md's) had to get credentialed to perform and interpret treadmills. the vast majority are negative as you would expect because to get to the cdu treamill a pt needs 2 nl ekg's 6 hrs apart and 2 nl sets of enzymes 6 hrs apart as well as no "worrisome" hx factors or comorbidities. still we are catching some folks who go on to cath who a few yrs ago would have been sent home with outpt f/u so I think this is a good idea if the unit is used appropriately and not as a dumping ground.
we also have cellulitis, asthma, tia, trauma obs, hydration, intractable pain or n/v, insert vague dx here, workup pts

 

Thanks for the resources. all of a sudden i feel acutely aware at how newbie my posts must come across sometimes. i am a 4th year hoping to match into EM in a few days and have visited the references you cite many times. sure there are many fellowships from em. no dispute there. trauma/icu is one of them. this doesn't include operative/surgical training (at least not in the OR sense). my post merely reflects my doubt that surgeons - no matter how much demand there may be for trauma surgeons - would allow anyone to enter a true surgical fellowship without surgical residency training. i would never say never though. hell, i even hope so. sounds like fun.

 

Ah, there are probably many things stopping EM grads from entering cards, and family medicine too. the question is, are they really meaningful things? to be sure, IM is not going to open its doors to one of its most competitive fellowships, potentially at the expense of IM applicants. however, is the training after 3 years of IM preparing you so much more for cards that the training in EM or family, i would say not.

 

IM may not open its door to and EP but how about those trained in EM/IM? Theoretically, once EM/IM's start doing cards fellowship, the door could open to where EM-related cardiology/cath programs can be developed specifically for EM trained physicians.

 

well IM/EM goes without saying because they are actually IM grads. no loophole there, that's 2 extra years of residency. you may be right though that the EM/IM people may help pave the way for the rest.

 

agree- em docs could easily be taught to do caths in a yr. there is currently a fellowship at duke that teaches pa's to do diagnostic caths in a yr. if we can do it you guys certainly could as well.....

 

Why do we stop internists and family practitioners from becoming board certified after a fellowship? Should we allow them to do fellowships to gain certification, much like we are thinking we can do cardiology fellowships?

The cardiologists of the world would never allow emergency physicians to perform interventional cardiology procedures. Why? The interventional cardiologists I know make upwards of 600-1 mil per year (yes, 1 mil per year). Do you think they will let some of that money slip them by? No. The ones I know are workers to the extreme. There at 5 am, home at 10 pm. They do this by choice. They could always bring others into the group, but they don't want to.

Secondly, it is highly doubtful that emergency physicians with interventional training would get enough cases per year to maintain proficiency. If they are at a large academic center, then the case load would be enough. However, it's likely that cardiology fellows are already present at such a large institution. Rural centers won't have enough volume to maintain competency with the procedure. What then? Do we allow emergency physicians trained in interventional techniques to perform elective catheterizations as well just to maintain their skills?

If only one person in an emergency physician group is trained in interventional techniques, then will that person staff the ED 24/7? No. It would resort to the same situation we have now: somebody would take call from home and come in for an emergency. I don't know about you, but not taking call for the rest of my life was a major impetus for my choosing emergency medicine as a career.

EDIT: Regarding stress tests, it is not hard to read an exercise stress test. The real issue is whether that is the best test for your patient. We do nuclear imaging stress tests and even PET scan stress tests on some patients. I'm comfortable reading an EKG stress test, but I would be a little intimidated reading nuclear imaging stress tests at this point in my career. Maybe I'll get more comfortable with them as I deal with them routinely while our seniors manage our chest pain center, but it's doubtful.

 

Future?

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17325576&query_hl=1&itool=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17320744&query_hl=1&itool=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17267528&query_hl=1&itool=pubmed_docsum


Let the interventionalists intervene while we diagnose----cut out the cards middleman (just as they did to the CV surgeons)! In time............

 

There are quite a few ED groups that read and bill for their ECGs and xrays - for at least the last 10 years

 

Perhaps with some restructuring some of these ideas could work, and work very much for our favor. The less we are reliant on consultants to help us move the meat the better off our patients, our departments, and our paychecks will be. Less time in department = more empty beds = more patients = $$$ and happier better cared for patients. What would have to happen though (IMHO) would be a restructure of personal in the department. Instead of a bunch of docs all running for the next chart in the rack, there would have to be some form of labor division. I envision something like this....first 2 hrs are spent on major trauma, next 2 on major medicine, and the next 2 on fast track. That way you trickle down from most time per patient to the least time per patient, leaving time in between encounters to tie up loose ends, labs, consults, etc. Then, the next 2 hours or so just run the stress test lab, or cath lab, or whatever the subspecilization we are talking about, this would be done at some hourly rate comprable to the time lost seeing patients, or perhaps at a higher reimbursement if you are busy enough that you get a bunch of procedures. That way you don't pull a doc to just do a whole day of subspecialization stuff or be on call (which would make me cry as a future EM doctor). Ultimately, this would greaty increase the autonomy of the ED, and facilitate faster patient disposition in many cases, and freeing up the coveted beds.

 

If you can just raise the standard of care to the point that they it is no longer feasible for them to take care of these patients you have won a lot of turf battles. Show the hospital and the powers that be that getting an in-ED stress test decreases patient mortality and annual cost (on both counts due to no over night hospital stays which really aren't good for healthy people) and then you have some very confused cardiologists....do they want to be on call and actually see every r/o CP in a timely fashion? Gone would be the days of "admit and we'll stress them in the morning, just order serial enzymes."