Scopes

[AlienHand]

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Recently I've been reading about GI emergencies, and I've noticed, not surprisingly, that various GI scopes are often required for diagnosis and/or treatment. For instance, esophagoscopy for esophageal foreign body, sigmoidoscopy for large bowel obstruction, EGD for upper GI bleed, etc. My question is, are any of these procedures performed in the ED (rather than the endoscopy suite), and if so, are any of them within the scope of practice for emergency physicians?

 

[docB]

Scope of practice is a funny term. Does it mean the material in a typical EM residency or what any given doc does or what a doc is priveledged for at a given hospital? All of my deliniation of priviledges allow me to do any procedure I deem necessary in an emergency so does my "scope of practice" include everything? I promise I'm not picking on the OP. He asked a great question and I'm just fleshing it out a little.

In answer to your actual question more EM programs are teaching with bronchoscopes for intubation and NP scopes for proximal FB removal. I could be wrong on this because I've been out for a few years but I don't know of any EPs trying to do lower FB removals (the risk of perf goes up) and no one is scoping for GI bleeds because the treatment modalities, banding, sclerosis, cautery, etc. really require advanced training. I don't know of anyone doing or teaching rigid sigs in the ED. The proctoscope is as far as I'll venture up that direction.

 

[AlienHand]

docB, Thanks for your reply. I'm a 4th year student, soon to be an intern. When I use the phrase "scope of practice" in this context, I mean:

- Can I expect to become proficient in the procedure during my residency training? (Obviously this depends on my residency program, but I'm wondering what other residency programs across the country do.)

- Can I expect to become credentialed to perform the procedure by the hospital where I eventually practice?

- Closely related to the preceding questions: Do I run an unusually high risk of being successfully sued when a complication occurs? By this, I mean a significantly higher risk than a gastroenterologist or general surgeon doing the same procedure in an emergent situation.

Regarding sigmoidoscopy, I've heard of FP's performing flex sig's for colon cancer screening. Personally, if I needed the procedure, I'd probably go to a gastroenterologist for colonoscopy, but flex sig is an acceptable alternative according to the USPSTF. Anyway, it seems like an EP should be able to do just about any procedure an FP can do since generally speaking EM is a more procedure-intensive specialty.

 

[nuke laloosh]

Occasionally, in a young pt with hematemesis and no other comorbidities who presents during the day, GI will come down to r/o badness via EGD and save an admission.

As of today, putting a scope anywhere in the gi tract is not within the scope of an EP's practice. (except an anoscope)

EM pgy-3

 

[beyond all hope]

I've NEVER had a serious GI bleed during the day. They always present at 11p-4a. It's hell trying to get GI down to scope them. Might as well start transfusing and admit to the ICU. Placed a Blakemore tube once: didn't save the patient.

No, there are no EM docs I know that do any scopes other than proctoscope.

 

[BKN]

The proctoscope is as far as I'll venture up that direction.

docB,

I'm pretty sure that you wre just typing fast (just like me). But for the benefit of the newbies:

proctoscope = rigid sigmoidoscope, it's capable of getting in about 25 cm.

flex sig same distance

anoscope is rigid and goes in about 6 cm

No, there are no EM docs I know that do any scopes other than proctoscope.

Well you can do anything you think is needed in an emergency as has been said. And you may have had other training or taken short courses. I did 100 proctoscopies as a surg intern and would be comfortable doing one.

But, you're the EP. Other problems may come in that need your immediate attention and you don't need to be tied up in an unfamiliar procedure.

Finally about GI scopes. There's almost nobody bleeding fast enough that they can't wait for the GI guy to come in. And if they were,
1. you would be busy doing the resuscitation.
2. You would be unlikely to succeed withthe scope.

 

[docB]

Yeah, I did mean anoscope. I've never done a rigid sig with a proctoscope. Don't wanna either. BKN makes a really good point about procedures taking away from the flow of the ED. Just doing the bread and butter stuff will keep you busy.