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Scope of ER practice

Discussion in 'Clinical Rotations' started by Hedwig, Jan 17, 2002.

  1. Hedwig

    Hedwig Senior Member
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    In your opinion, what percentage of what patients who come through the ER doors do ER doctors treat WITHOUT consulting a specialist in another department? In light of this question, what exactly is the scope of practice of an emergency physician. "Emergency" is so vague...

    (I hope this isn't too simplistic or ignorant or anything. I'm not a medical student yet.)
     
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  3. jimjones

    jimjones Senior Member
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    Hey this is a great post. Do emrgency room docs set and cast broken bones (non-complicated)?
     
  4. Freeeedom!

    Freeeedom! Senior Member
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    Hedwig, not a stupid question.

    An EM physician, since it is a seperate specialty, can do many things. Simple things like suturing and casting, to Lumbar taps, Ultra sound, joint taps, thoracentesis, gyn exams, opthamology exams, relocating dislocated shoulders/hips/fingers, casting/splinting and treating every single abdominal pain, chest pain, dypnea, headache, syncope etc etc etc, that comes through the door. Not to mention trauma which is shared with the trauma team. Probably only 25% of what enters the hospital is admitted...but everyone that enters the ED seems an EM doc.
     
  5. DrQuinn

    DrQuinn My name is Neo
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    Good question. I'm on my EM rotation now and am applying to EM residencies this summer... so I'll give you my perspective on what I see and read... Where I am now if there's a trauma, usually the trauma surgeon sees that patient, but if they're unavailable or late, the EM physician sees the pt...
    If its an opthlamologic emergency, the EM doc will usually refer that out once a tentative diagnosis is made...
    GI-wise I've only seen an esophageal varix need an immediate GI consult.
    Primary care wise triage sometimes called the primary doc and asks if the doc wants to see the patient instead of the EM doc...
    Strokes however I think are a different issue. At the place I'm at the doc will stabilize the patient and have the neurologist come and eval the patient to confirm thrombolytics...
     
  6. droliver

    Moderator Emeritus 10+ Year Member

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    In response to the original ?:

    I think ER physicians send out 60-75% of the people that come thru without a consult @ a University ER. At private hospitals I believe this % drops considerably for a couple reasons. 1) ER doctors generally do not want to spend much time making a diagnosis because they're busy & due to their fear of malpractice. If its not straightforward & minor, they hit the phone.
    2)a lot of patients at private hospitals will have a primary physician (as opposed to a university ER)& out of a mix of politics/courtesy they call their FP/Internist to see what they want to do
     
  7. tonem

    tonem Senior Member
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    I don't agree with droliver's assessment of emergency medicine. First of all, I don't think EM physicians consult any more than anyone else does. The purpose of the emergency room is to sort out patients. Minor cases are treated for acute problems (or acute exacerbations of chronic problems) and then sent home. More serious patients are stabilized and admitted.

    As far as calling the primary care physician, It's usually done after the patient is on the way home and it is both a courtesy and a necessary part of patient care to ensure that the patient receives appropriate follow-up.

    Finally, I'd agree that there are physicians out there that are motivated by fear, or that are just plain lazy but you can't generalize that to include the entire specialty of emergency medicine.
     
  8. when i worked in a non-university er (for around 5 years) i realized that everything other than a sore throat or extremely simple problem got consults. at the very least the ER doc called the patients primary care to ask if they wanted anything else or an admission. or maybe they got a 24 hour hold...in my opinion, it seemed that the trick to ER medicine was knowing who to call, but that is just my opinion!

    i hate to say it, but if you are practicing medicine and not motivated by fear, you are ignorant. the lawyers have dictated how medicine should be practiced.

    so, my experience agrees with droliver

    although it was in the same state (kentucky) for the most part..but when i was in california it was the same, but i spent less time there.
     
  9. Freeeedom!

    Freeeedom! Senior Member
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    I agree whole heartedly with TONEM and I absolutely disagree with neilc (sorry dude).

    The scope of EM practice is EXTREMELY broad. But let me also clarify something...
    Many people, perhaps neilc, that have worked in the ED in the past, have worked with NON-EM trained physicians. These are the IM docs who now work in the ED (because they make more money in the ED) and simply never felt comfortable with treating patients WITHOUT consults...these are the people that will soon be extinct in EM practice.
    EM trained (BC/BE) physicians are taught to do things obviously without consult, it is part of the specialty! It saves time and money to do things by yourself...That is one reason EM is expanding its scope of practice to include things like Ultrasonography etc, it saves time and lives (the benefits of having only BC/BE EM trained physicians in the ED seems to make sense).

    For those of you wanting to learn more...

    <a href="http://www.saem.org" target="_blank">www.saem.org</a>
    <a href="http://www.emra.org" target="_blank">www.emra.org</a>
    <a href="http://www.aaem.org" target="_blank">www.aaem.org</a>
    <a href="http://www.acep.org" target="_blank">www.acep.org</a>


    good luck and stay correctly informed!!!
     
  10. droliver

    Moderator Emeritus 10+ Year Member

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    Freeedom,

    if I'm not mistaken you are still a medical student (no?). I work reguarly between as many as 6-8 hospitals at a time ranging from a University ER, a VA, a private pediatric hospital, and 5 busy private hospital. The practice patterns @ these ER's has nothing to do with the competence or scope of training of these doctors (many were ER residency trained). It has to do with interspecialty politics, convenience, & liability. Each specialty does this to some degree. For instance,I don't think there's a private practive surgeon I've worked with in town who doesn't turf vent management (beyond overnight cases)to pulmonary medicine guys. Is this because you don't finish general surgery with enough experience in this...no, we probably take care of more of these patients than anyone during our residency years. These consults (along with ID, cardiology, renal, etc..) have to do with the fact that @ a certain point 1) you don't want to be bothered 24 hrs a day for blood gases,accu checks 2)some people take care of certain things better than you do 3) it keeps professional relationships open with referring MD's,& 4) it can help with medical liability if you have subspecialists involved. This same calculus applies to ER physicians- liability, convenience, professional relationships, etc....
     
  11. yeah, i still stand by it also..at my er it was about 50/50 em vs primary care trained. it is not a dig on er medicine, i know these guys were great docs, fully capable of handling everything that walked through the door...but, just being capable is not what limits or determines your scope of practice. it is time, politics and malpractice, to a large degree. and, if you are a busy ER doc, calling in a consult means its someone else's problem, and you can hit the next chart in the rack...
     
  12. tonem

    tonem Senior Member
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    So droliver, would you agree that EM physicians don't consult any more than anyone else does? I still don't think calling someone's PCP is a consult. You are treating their patient on a one time basis. It doesn't make sense to jump in there and do something that might affect the patient's long term care especially if the patient is there in the evening or on a weekend because he couldn't get in to see their regular doctor. How would you feel if someone saw one of your patients once and changed the entire course of their treatment. Wouldn't you appreciate a call.
     
  13. emedpa

    emedpa GlobalDoc
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    having worked in a variety of ER settings( community, university, trauma, hmo ) over the last 16 years, I am more inclined to agree with freeeedom. newly minted residency trained/boarded EM docs have a much broader scope than the ER docs of 20 years ago who were mostly IM/FP/Surgery folks learning about EM and making it up as they went along. I still work with a few of these folks who feel the need to call ophtho for every corneal abrasion and ENT for every case of epistaxis.
    while I do agree that em folks call their colleagues more than other specialties, often these calls are courtesy calls to arrange follow up or to arrange admission after most workup and tx are complete. for instance," hi this is dr smith in the E.D., I just saw your pt mr jones for an anterior M.I., he has had asprin/beta blockers/heparin and TPA with improvement in his sx and ekg. would you like him on tele or in the ccu? anyway, just my 2 cents worth...
     
  14. UHS2002

    UHS2002 Senior Member
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  15. jimjones

    jimjones Senior Member
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    If someone comes into the ER with a broken arm, does the ER doc lood at the films and set and cast it or call the ortho surgeon?
     
  16. Mr. happy clown guy

    Mr. happy clown guy Senior Member
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    That depends from place to place...but if you have a guy with a non-deformed arm pain from a fall, ED doc will order the xray, interpret it and if it is fractured and not needing surgery, splint it and refer to Ortho. That is the typical scenerio
     
  17. emedpa

    emedpa GlobalDoc
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    in many places the ER doc will reduce most fractures that will not require ORIF and have them follow up with ortho. it varies from place to place. at 1 of the ER's I work at, ortho only wants to be called for O.R. cases or when a problem arises with a closed reduction.
     
  18. Freeeedom!

    Freeeedom! Senior Member
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    As a perfect example of referal...If I as the ED doc saw a patient with a deformity from a fracture, I would first CALL ortho, consult with them, then after such consult, would do the appropriate treatment (let ortho deal with it or I will do it). More than likely that is an ORTHO case (resident case).

    Knowing when to consult and knowing when to NOT consult is part of being a board certified EM doc!!
     
  19. droliver

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    In my experience (in a large metropolitan area with a lot of orthopedic surgeons in town), this scenario would almost always get an orthopedic surgery consult in the ER unless it was 2-3 am. The Pediatric ER is probably more conservative & less likely to do it themselves I've noticed. At the university ER I think it would depend on the mechanism of injury, but they would probably be a little more aggressive about setting it themselves. Closed hand fractures would probably be splinted by the ER physican, except for the worlds only dedicated hand emergency room which resides here & gets sent hand injuries from surrounding states
     

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