Surgical Procedures

[stud247]

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Is tendon laceration http://emrap.tv/index.php?option=com_content&view=article&id=118:EMRAPTV18-ExtensorTendon the most advanced/complicated surgical procedure that EM physicians perform? How many cases of tendon lacerations would a resident do in your EM program? What if he doesnt get many of them, does it mean he'll avoid them in his professional practice?

 

[GeneralVeers]

Is tendon laceration http://emrap.tv/index.php?option=com_content&view=article&id=118:EMRAPTV18-ExtensorTendon the most advanced/complicated surgical procedure that EM physicians perform? How many cases of tendon lacerations would a resident do in your EM program? What if he doesnt get many of them, does it mean he'll avoid them in his professional practice?

Zero.

 

[Hawkeye Kid]

Zero.

Agreed. The important thing is making the diagnosis. Then it's suture, splint and follow up.

Technically, I suppose it's within our scope of practice (it's in the books, at least) but I don't know any EPs that do it.

 

[willow18]

I watched an ortho resident do it (while teaching the off-service EM resident) in the ED. It probably is within the scope of practice, depending on its complexity of course. It honestly didn't seem that complicated or technically difficult. Having said that, I'm sure that in tertiary institutions ortho will always be consulted.

 

[GeneralVeers]

I watched an ortho resident do it (while teaching the off-service EM resident) in the ED. It probably is within the scope of practice, depending on its complexity of course. It honestly didn't seem that complicated or technically difficult. Having said that, I'm sure that in tertiary institutions ortho will always be consulted.

The hand is a high liability body part, as most people need use of their hands for employment. Any complication could thus bring a large malpractice settlement.

The evidence shows that tendons can be re-attached within 1 week without complication, so there's no need for a relatively unskilled ED physician to do the procedure when he can refer the patient to a hand specialist.

If you're in the most rural parts of the country with no hand specialist within hundreds of miles then I can see repairing one in the ED at that point.

 

[BADMD]

Is tendon laceration http://emrap.tv/index.php?option=com_content&view=article&id=118:EMRAPTV18-ExtensorTendon the most advanced/complicated surgical procedure that EM physicians perform? How many cases of tendon lacerations would a resident do in your EM program? What if he doesnt get many of them, does it mean he'll avoid them in his professional practice?

I repaired one tendon as resident during a hand rotation. It came apart before we were done with the rest of the tendons.

Tendon repair is not easy and requires more than just sewing the two ends together. Not to mention that doing it properly is going to take more time than you want to dedicate to a non-dying patient.

Clean --> close skin --> splint --> clinic

 

[stud247]

How about canicular lacerations of the eyelid? How many do you do in residency or in practice? Thanks!
http://emedicine.medscape.com/article/1212531-treatment

 

[BADMD]

Zero.

You want an operating microscope, canilicular stents, not to mention a facility with F-ing small sutures that really can't be seen without magnification. This takes significant practice and should really be done by an ENT with experience in facial plastics or an ophthomologist.

This repair shouldn't really be performed in the ED, let alone by an Emergency Physician. I know it is mentioned in procedure books, but it isn't done by EPs.

 

[tkim]

I repaired one tendon as resident during a hand rotation. It came apart before we were done with the rest of the tendons.

Tendon repair is not easy and requires more than just sewing the two ends together. Not to mention that doing it properly is going to take more time than you want to dedicate to a non-dying patient.

Clean --> close skin --> splint --> clinic

Ditto. Did one during hand. Takes a long time to do. In a community ED, everything would grind to a halt. The meat would not be moved, the meat would not be happy.

 

[Jeff698]

Ditto. Did one during hand. Takes a long time to do. In a community ED, everything would grind to a halt. The meat would not be moved, the meat would not be happy.

"Vengeance is mine" sayeth the stagnant meat upon receipt of their Press Ganey surveys.

Take care,
Jeff

 

[Old_Mil]

Is tendon laceration http://emrap.tv/index.php?option=com_content&view=article&id=118:EMRAPTV18-ExtensorTendon the most advanced/complicated surgical procedure that EM physicians perform? How many cases of tendon lacerations would a resident do in your EM program? What if he doesnt get many of them, does it mean he'll avoid them in his professional practice?

I'm not going to repair someone's lacerated tendon. I'm going to stabilize them and refer them to Ortho to fix a lacerated tendon. Surgery is best left to surgeons.

 

[droliver]

I think by most community standards of care, tendon repair would be outside the scope of practice of an EM trained physician and leave you extremely exposed med-mal wise for complications or poor outcomes (which are common).

 

[DocZ]

The big EM procedure books list a lot of very common and some very uncommon procedures. It doesn't mean that they are all w/i the scope of practice. I suppose there are ED docs credentialed to do Burr holes, I wouldn't do one.

How about these two different procedures?
1)Lateral Canthotomy - an emergent procedure, how many people have done one of these?

2)Transvenous pacers are obviously within the scope and not uncommon but I would bet many residents never float a pacer nowadays. How often do community ED docs really do this

 

[Midwest Medic]

I have done one lateral canthotomy while in residency. It was a 14 y/o who was hit in the eye by a baseball with 20/40 sight when he got to the ED. He lost sight quick and had ptosis, so we did the lateral canthotomy on him and he regained sight soon after that. Not a hard procedure, but a little nerve wracking cutting right next to someone's eye. Luckily the kid was holding still and not a 3 y/o thrashing about.

 

[EMCC]

I have done two lateral canthotomies (both during residency)...

I have 'floated' at least 10 transvenous pacers within the past year, but then again I was doing a trauma and critical care fellowship (definitely more pacers than most ED guys should do/have done)...

 

[Norman]

Is tendon laceration http://emrap.tv/index.php?option=com_content&view=article&id=118:EMRAPTV18-ExtensorTendon the most advanced/complicated surgical procedure that EM physicians perform? How many cases of tendon lacerations would a resident do in your EM program? What if he doesnt get many of them, does it mean he'll avoid them in his professional practice?

I've done tendon laceration repairs as a resident. It depends on your plastics coverage.

This is a minor procedure compared to other things you would do (i.e. thoractomy.)

 

[Norman]

I'm not going to repair someone's lacerated tendon. I'm going to stabilize them and refer them to Ortho to fix a lacerated tendon. Surgery is best left to surgeons.

IN the two states where I trained, ortho wouldn't touch hands.

 

[Jeff698]

IN the two states where I trained, ortho wouldn't touch hands.

How odd. At my residency, ortho and plastics split hand coverage on a QOD basis.

At my community gig, they all go up to "the big house" (our academic parent hospital) 'cause nobody, ortho or plastics, will touch them.

Take care,
Jeff

 

[stud247]

I've done tendon laceration repairs as a resident. It depends on your plastics coverage.

This is a minor procedure compared to other things you would do (i.e. thoractomy.)

cool. which states was it in? are you more likely to do complex lacerations at community hospitals where there is less surgical coverage?