Starting a New Job

[ERNerd]

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I recently graduated from residency and started a new job in a small rural hospital near my home. I'm generally quite happy with the job so far. I was able to set my own schedule, the pay is good, and I find the working conditions much less "painful" than residency (i.e., it's easier to get workups done and get patients dispositioned).

However, some minor annoyances are starting to crop up:

- It's nearly impossible to get Propofol in the ED for procedural sedation (not in the Pixis and Pharmacy is an obstacle). It's felt to be the purview of anesthesiologists or critical care docs. This feels like a setback, as Propofol was my first-line drug for procedural sedations during residency. (Etomidate and Ketamine are available though.)

- I had my first intubation a few shifts ago and found out that they don't have rocuronium in the ED. They have succinylcholine and vecuronium. I almost always used sux during residency, and I think there are fewer contraindications than some people think (not generally contraindicated for renal failure or head bleeds); however, I would rather see roc as a second line choice for RSI.

- They don't have ED US. Fortunately, they are able to get techs in for certain indications. I've actually discussed this with the medical director, and he seems to be on board, but getting funding for a machine may take some time.

- Too many labs are ordered from triage; I've sometimes even seen them order CT's. I appreciate the attempt at efficiency but sometimes unnecessary labs box me in to workups or dispositions I don't like. I don't want to discourage this practice completely, but I'd like to have some control over what gets ordered.

These are just minor annoyances, and I haven't raised any concerns yet. I don't want to become known as a prima donna or squeaky wheel. However, I'm really curious about whether anyone else encountered these sorts of frustrations when starting a new jow and how others have handled the situation.

 

[DocZ]

The last hospital (small pretty busty private hosp) I worked at had almost the exact same anoyances:
-Propofol only used in ICU or by anesthesia. I even saw anesthesia come down after mult failed attempts to put a hip back in, so the orthopod could do the reduction w/ propofol.
-I've been at 2 places with Sux + Vec and no Roc in the ED
-They had an ED u/s but none of the ED docs were allowed to be credentialed, so couldn't bill for it and for clinical descion making had to get an official, which meant on off hrs, call tech in from home
-Tons of labs ordered from triage, it felt like everyone got a BNP, lots of D-dimers, and the occasional Ur HCG on male pt's.

These are pretty common problems, I'm sure we could make a list thousands of items long.

 

[Arcan57]

In another thread I had someone ask me if I practiced in America, secondary to not having access to roc. We also don't have US, aren't allowed to use propofol, etomidate, or ketamine for sedation, and have protocols that lead to a URI pt. receiving a head CT, serial POC cardiac markers, CXR, and baseline labs. Oh, that was a 19yo female.

 

[DrQuinn]

I don't think you'll come across as a primadonna... you are the newest grad there, you may be more up to date with your practice than your colleagues. I would talk with your group/med director about it and get those changes instituted, atleast with propofol. Except for the recent blip with Michael Jackson (Anesthesiologists have been on the news saying it should be regulated and only given in the OR by anesthesiologists, not by anyone else anymore), most EDs can get it approved, but you just need to bring it up in a committee and get the proper procedures done for it.

In re: to labs/CTs ordered in triage, why are they being ordered if you are at a slow rural hospital? I would just tell the triage nurse "hey, except for pee, can I just see them real quick?" I think they might actually prefer this. And many times I see a patient and DC them and the RN had already drawn labs and started an IV and they weren't even necessary.

Good luck. You are already past the hardest part of starting as a new grad, you first few shifts. Congrats!
Q

 

[Hawkeye Kid]

Also a new grad, but I have some advice that was given to us at the end of residency specifically about this sort of thing:

With the exception of things that are clearly detremental to patient care, you should wait a few months before trying to change things. In addition to the concerns that you have, it's also possible that the reasoning will become more apparent the longer you're there (though maybe not for these examples). Also, you need to make sure that you're not only willing to be part of fixing the problem, but also open to the possibility that they've tried it "your way" in the past and it didn't work out for whatever reason. Our program director cautioned that "if it seems to you that there's an obviously better way to do things, it's probably occurred to them at some point as well and they do it the way they do for a reason." 3-6 months of working there might help to figure some of that out. Or, like Quinn suggests, they may just be a bit behind the times and some fresh ideas may be appreciated (though they may be more well-received if you've already established yourself a bit).

Good luck--it seems like you'll have a great gig if you can get a few basics ironed out.

 

[docB]

-Propofol is an issue in lots of places. I can get it easily but I have to document that I pushed it due to some odd nursing scope issue. You should assemble some of the relevent articles and push them up the chain. The fact is that the current literature is all about Propofol and is down on etomidate. Don't use Propofol to treat insomnia though.

-In trying to get an US machine you'll be in for a fight. Capital budgeting is a nightmare, especially with the current economy. Remember you will also have all the fights with rads over billing. And most hospitals are very apathetic about US in the ED until you can show them the codes they can use to bill for the studies.

-I've gotten used to the stuff that gets protocoled. Remember that you can always explain it away (it's not always effective but it is a viable strategy). E.g. "I wouldn't have ordered cardiac enzymes on this patient as his symptoms don't fit with ACS and his risk is very low but they were ordered in triage and they're normal so we're done." If they're abnormal you should be glad it got caught. You can even do the same thing with D Dimer: "this was ordered as a protocol but the patient is very low risk by clinical exam and Wells criteria so no CT."

 

[Hercules]

As a quick question: for those of you practicing in places without propofol/roc/ultrasound/etc, are all of your colleagues EM residency trained and/or board certified? I just started my new job too, but I am in a SDG that's been at the hospital ~30 years with all EM residency trained guys and I haven't had these problems. We're not super busy (community, 30-35K volume) but we have ultrasound, whatever sedation drug we need, and great hospital support. Just interested to see if lack of EM trained colleagues contributes to those annoyances you listed.

 

[ERNerd]

Thanks for all of the responses. The main reason these things annoy me is pride. I don't really mind using ketamine, etomidate, or versed for sedations, but it really ticks me off to be told, in effect, that I'm not qualified to use a drug like propofol safely when I used it so much during residency without issue. Anesethesiology doesn't own propofol, nor does radiology own ultrasound. EPs can use these tools safely and effectively.

Some of the docs in my group are EM-trained, others are EM-grandfathered, and probably half are FP or IM trained and have a lot of experience but no particular EM credentials. I think the group is somewhat behind the times not just because of a lack of formal EM training, but a lack of recent training. The second-youngest doc in the group is more than 10 years older than me, and I was a nontraditional myself and so a little older.

As Hawkeye Kid suggested, I've pretty much decided to lay low for a few months. I think it's important to pick one's battles carefully. Right now, my focus is on speed, efficiency, and good documentation. Once I've established myself, I may take on some of these battles selectively.

As far as the shotgun labs out of triage issue, I need to figure out how they're deciding what to order. I'm not sure yet if they're following a protocol or just using their own experience. I'll be doing quite a few overnight shifts (by choice) and when I'm in a single coverage situation, I may ask triage to just send patients back without ordering labs. Honestly, the main thing that's annoyed me so far is ordering a full panel of cardiac enzymes; where I trained troponin was the standard and CK and CK-MB were almost never ordered. I guess I'm going to have to figure out what to do with discordant values.

Hamhock, I imagine the comment about the literature being down on etomidate referred to the use of etomidate for intubating septic patients (transient adrenal suppression of dubious clinical significance). I actually think it's a pretty good drug for procedural sedation, but I have seen some bad myoclonus when the drug was used several times in a row for a chronic shoulder dislocator.