switch from academic to community?

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kat82

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Hi friends

3 years ago I posted here asking about the benefits of academics vs community, as I was considering leaving my academic job. I decided to stay in academics- took a large paycut when I moved to the new institution. However- I now find myself in the situation again of potentially relocating and finding a new job.

I am AGAIN considering leaving academics to work in the community. My pay currently sucks and I'm getting a little sick of teaching to be honest. I feel blah about research, publishing, etc, so I'm thinking maybe I don't belong in academics anymore. I feel like a little bit of a fraud- now when I see a med student, I get a little annoyed (sorry!) bc it just slows. me. down.

I am confident in my abilities to be efficient and move the meat. But I worry about my lack of procedural skills. I have had the luxury of having various consultants, residents and PA's do my dirty work. I'm not worried about intubation, central lines, chest tubes, LPs, etc. But I do worry about complicated hand stuff, ortho reductions, nasty complex lacerations- things I am used to plastics/ortho helping me out with.

In the community, can you share how it works with consultants? Are they still generally helpful even if over the phone? Do they see the patient urgently in their office (I work in an urban environment where again, the resident sees the patient and arranges clinic follow up for these people if needed) I'm worried about having to perform procedures outside of my comfort zone and also worried about how much it would slow me down. Is it the same across the board or are there some community places with a higher level of support?

Also- there are so many HEADACHES in an academic ED (not as a chief complaint, but headaches for me) fighting with consultants, waiting 6 hours for a CT scan, always having 40 people in the waiting room, nonstop trauma. (Edited to add, this is in an urban ED, and where we may move to the academic institution is also urban) Its just not feeling as cush as I want it to. Does this exist in the community too? Guys, I'll cut to the chase- I want a cush job. Help me!! Thanks in advance
 
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You dont have the right academic job. Haha. Makes my academic job sound like a dream. Not all academic gigs are created equal, same goes with non-academic jobs. Im not gonna refer to those as community jobs, because Some are both as a large number of EM residencies are in community (non-university) based EDs. I for one love the community residency model. Less consultants to steal the procedures I like. Still have to focus on productivity, theoughput, billing, etc. Best of both worlds IMO. My residents graduate and can move patients and document their charts to capture their rvus with the best of them, and their productivity bonuses as new attendings are often right near the top of their new group when they leave. Maybe a hybrid job in academics would be more to your liking. Maybe not, and you want to get fully out of teaching.

When you’re out there in the community you may have to do ortho stuff, you may not. If that’s your concern, thats what you need to ask your future employers when you are job searching.
 
gamerEMdoc said:
You dont have the right academic job. Haha. Makes my academic job sound like a dream. Not all academic gigs are created equal, same goes with non-academic jobs. Im not gonna refer to those as community jobs, because Some are both as a large number of EM residencies are in community (non-university) based EDs. I for one love the community residency model. Less consultants to steal the procedures I like. Still have to focus on productivity, theoughput, billing, etc. Best of both worlds IMO. My residents graduate and can move patients and document their charts to capture their rvus with the best of them, and their productivity bonuses as new attendings are often right near the top of their new group when they leave. Maybe a hybrid job in academics would be more to your liking. Maybe not, and you want to get fully out of teaching.

When you’re out there in the community you may have to do ortho stuff, you may not. If that’s your concern, thats what you need to ask your future employers when you are job searching.
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Thanks for the response. I do love working with residents. Thats the main thing I enjoy about academics. But I am over the other stuff. Maybe a community job with EM resident rotators would be good. I actually enjoy the basics of seeing patients and moving the meat. But not sure if I can cut it in the community. I feel like I've been spoiled in academics and worry I don't have the efficiency or procedural skills needed. Such a dilemma!
 
kat82 said:
Thanks for the response. I do love working with residents. Thats the main thing I enjoy about academics. But I am over the other stuff. Maybe a community job with EM resident rotators would be good. I actually enjoy the basics of seeing patients and moving the meat. But not sure if I can cut it in the community. I feel like I've been spoiled in academics and worry I don't have the efficiency or procedural skills needed. Such a dilemma!
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Have you considered a clinical (not core) faculty position at a residency? Core faculty get paid academic time but have all the academic responsibility. Clinical faculty just shows up and works their shifts with no other requirements. No publishing, conference, lectures, etc required. But you still get the benefit of working with residents and teaching clinically on your shifts. Best of both worlds for those that dont like the non-clinical aspect of academics IMO.
 
gamerEMdoc said:
Have you considered a clinical (not core) faculty position at a residency? Core faculty get paid academic time but have all the academic responsibility. Clinical faculty just shows up and works their shifts with no other requirements. No publishing, conference, lectures, etc required. But you still get the benefit of working with residents and teaching clinically on your shifts. Best of both worlds for those that dont like the non-clinical aspect of academics IMO.
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That sounds nice actually- but I worry how that looks- interviewing at an academic place, coming from an academic place, saying I don't want to be too academic. I feel like I should be selling myself as an academic....
 
Not at all. Just say you love clinical teaching, just not the other aspects of teaching. Clinical faculty are highly valuable. Think like a bussinessman. Who is more valuable to a community hospital with an EM program, the clinical faculty member who works 16 nine hour shifts, or the core faculty member that works 12, but gets paid 4 academic days a month for conference, research, meetings, etc. All stuff that makes zero dollars. They get paid for the same number of days, but the clinical faculty member is generating money during those extra four days, while the core faculty doc is getting paid not to see patients. Believe me, no well run hospital in their right mind that is hiring would turn down someone who just wants a clinical faculty position from a business standpoint.
 
gamerEMdoc said:
Not at all. Just say you love clinical teaching, just not the other aspects of teaching. Clinical faculty are highly valuable. Think like a bussinessman. Who is more valuable to a community hospital with an EM program, the clinical faculty member who works 16 nine hour shifts, or the core faculty member that works 12, but gets paid 4 academic days a month for conference, research, meetings, etc. All stuff that makes zero dollars. They get paid for the same number of days, but the clinical faculty member is generating money during those extra four days, while the core faculty doc is getting paid not to see patients. Believe me, no well run hospital in their right mind that is hiring would turn down someone who just wants a clinical faculty position from a business standpoint.
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The place we are looking the EM residency is based out of an urban hospital, not quite "community" unless I work at one of their affiliates...
 
kat82 said:
That sounds nice actually- but I worry how that looks- interviewing at an academic place, coming from an academic place, saying I don't want to be too academic. I feel like I should be selling myself as an academic....
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Your reasons are legit -- wanting to experience something a bit different and see if the grass really is greener on the other side. Not hard to explain moving to, and also on the move back if it turns out you were wrong. You've been wondering this for a while. Why not give it a shot?
 
kat82 said:
Can you share why? I want to be sold on it!
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PGY3 here.. just started moonlighting in the community a bunch after a long time in academia (med school + prior). I love community so far. I think your cases can be a lot more diverse; there's no fast track in lots of places I moonlight. I was worried about consults too at first, but at least at my hospital system this didn't turn out to be a problem... we can just call any subspecialty at our academic mothership and transfer if there's any concern for badness or need help w/ procedures.

Maybe try per diems if you aren't already.
 
gamerEMdoc said:
Not at all. Just say you love clinical teaching, just not the other aspects of teaching. Clinical faculty are highly valuable. Think like a bussinessman. Who is more valuable to a community hospital with an EM program, the clinical faculty member who works 16 nine hour shifts, or the core faculty member that works 12, but gets paid 4 academic days a month for conference, research, meetings, etc. All stuff that makes zero dollars. They get paid for the same number of days, but the clinical faculty member is generating money during those extra four days, while the core faculty doc is getting paid not to see patients. Believe me, no well run hospital in their right mind that is hiring would turn down someone who just wants a clinical faculty position from a business standpoint.
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Would that be twelve 8-hour shifts?
 
kat82 said:
Hi friends
I am confident in my abilities to be efficient and move the meat. But I worry about my lack of procedural skills. I have had the luxury of having various consultants, residents and PA's do my dirty work. I'm not worried about intubation, central lines, chest tubes, LPs, etc. But I do worry about complicated hand stuff, ortho reductions, nasty complex lacerations- things I am used to plastics/ortho helping me out with.
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Stuff that needs to get dealt with by a specialist must get dealt with by a specialist. As an ED physician, nasty complicated hand stuff that you screw up = lawsuit, ortho reductions that you screw up = lawsuit, and nasty complex lacerations that get infected = lawsuit. The particular setting only determines if you have a specialist resident who is going to come down to see the case before talking to his attending or if you call the community attending directly. Speaking of lawsuits, if you move from a academic facility to a community one you may be sacrificing some degree of sovereign immunity protection. Other things you will probably end up sacrificing: benefits/retirement because a lot of community jobs are 1099, a hosptial code team (you'll be leaving the department to go to the floor to run codes), no responsibility for procedures on admitted patients in the ICU.

In the community, can you share how it works with consultants? Are they still generally helpful even if over the phone? Do they see the patient urgently in their office (I work in an urban environment where again, the resident sees the patient and arranges clinic follow up for these people if needed) I'm worried about having to perform procedures outside of my comfort zone and also worried about how much it would slow me down. Is it the same across the board or are there some community places with a higher level of support?
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It depends on your shop I think. I've worked at a community shop where the consulting support was excellent (had an urologist come in to see a clinically dx torsion while the young man was still undergoing ultrasound) and one where it was absurd (had to fly out a STEMI because cards wouldn't come in, and in that hospital urology wouldn't come see a suspected torsion without a positive U/S). In general, I think admitting and consulting in an academic setting is easier than in a community setting.

Also- there are so many HEADACHES in an academic ED (not as a chief complaint, but headaches for me) fighting with consultants, waiting 6 hours for a CT scan, always having 40 people in the waiting room, nonstop trauma. (Edited to add, this is in an urban ED, and where we may move to the academic institution is also urban) Its just not feeling as cush as I want it to. Does this exist in the community too? Guys, I'll cut to the chase- I want a cush job. Help me!! Thanks in advance
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Crowded waiting rooms and increased volumes are a result of the ACA. The only way you are going to escape that is to go to a shop where (1) the medicaid patient population is significantly lower than average, (2) go to a geographical area where the total population is very, very low, (3) practice in a military/VA/foreign country facility that hasn't been affected by the ACA. You will probably see less trauma in a community setting only because you don't have a fleet of helicopters and ambulances concentrating that pathology at your doorstep and artificially raising its incidence. However, you're going to be the tip of the spear to deal with what comes through the door with no help from surgery residents. If you'e on a single coverage night shift, with no help from anyone at all.

The only cush job in emergency medicine is...owning a CMG or being a hospital administrator.

My advice to you, if I'm hearing what I'm hearing in your question, is to stay put (or maybe look for another academic job) and start working on your golf game and knocking out that MBA so you can transition into that magical unicorn filled world where you're pulling a six figure income without being involved in direct patient care.

Alternatively, if you really want to give community EM a try, stay at your current job and pick up 3 locums shifts a month at a community department you think you might enjoy working in. After a year or so you will be better positioned to figure out what to do.

Good luck.
 
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kat82 said:
Can you share why? I want to be sold on it!
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All the good stuff about an academic practice you don't care about any more and all the bad stuff about community practice doesn't bother you and all the stuff you're worried about are non-issues. I had a few similar worries coming out of the military that turned out to not be worth the time and effort to worry about.

I was in academics 3/4 time my first three years and have been in community practice since. It's not too hard to transition in that direction. Just don't expect any one to actually come to your ED like they do in an academic center unless you insist on it. 95% of my consultations occur over the phone, including admissions.
 
gamerEMdoc said:
Core faculty work 12 9 hr shifts, get paid four 8 hr academic days at my program.
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So, to be clear, they get paid as if they were working 16 shifts / month?
Got it, thanks. That's a pretty sweet deal.
 
Angry Birds said:
So, to be clear, they get paid as if they were working 16 shifts / month?
Got it, thanks. That's a pretty sweet deal.
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Yeah. We get payed pretty well as academics. Could certainly make more money out there on my own, but I'm just more at peace with my job working with residents. I like the constant lifelong learning, teaching, discussion of great cases, etc. Brought a whole different level of career fulfillment for me when I left the military and went into civilian practice.
 
The only things I find different between academic institutions and community hospitals are consultations everything else is site dependent (I.e. waiting room and CT times, which specialties you have available, etc. ). Agree with above that most consultations are over the phone only. If it’s within your ability to do consultants expect you to do something. I repair most multilayer and dirty lace for instance but if it’s really bad or does deserve plastics I’ll still call them. (Like large multilayer facial lac from mvc with shattered glass in wound) but that 3cm facial lac that has a muscle lac underneath expect to close it with a call to plastics who will probably say “see me in the office tomorrow” or the tendon hand lac expect hand consult to request you tack it closed, splint, and follow up outpatient for definitive repair later.
 
Rendar5 said:
The only things I find different between academic institutions and community hospitals are consultations everything else is site dependent (I.e. waiting room and CT times, which specialties you have available, etc. ). Agree with above that most consultations are over the phone only. If it’s within your ability to do consultants expect you to do something. I repair most multilayer and dirty lace for instance but if it’s really bad or does deserve plastics I’ll still call them. (Like large multilayer facial lac from mvc with shattered glass in wound) but that 3cm facial lac that has a muscle lac underneath expect to close it with a call to plastics who will probably say “see me in the office tomorrow” or the tendon hand lac expect hand consult to request you tack it closed, splint, and follow up outpatient for definitive repair later.
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Exactly. You learn that most things can be fixed temporarily or just wait until the next day. There is nothing emergent about a colles fracture reduction with normal pulses. I do them more for patient satisfaction (people hate the site of an angulated bone and expect it to be fixed NOW) than because its medically necessary.
 
gamerEMdoc said:
Exactly. You learn that most things can be fixed temporarily or just wait until the next day. There is nothing emergent about a colles fracture reduction with normal pulses. I do them more for patient satisfaction (people hate the site of an angulated bone and expect it to be fixed NOW) than because its medically necessary.
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This is all so helpful thanks!
Can you share more examples of things in the community you "temporize" until they can be seen outpatient? What if the patient is uninsured?
I'm spoiled bc I can get my consults in the ED mostly when I want.
 
kat82 said:
This is all so helpful thanks!
Can you share more examples of things in the community you "temporize" until they can be seen outpatient? What if the patient is uninsured?
I'm spoiled bc I can get my consults in the ED mostly when I want.
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- Corneal foreign bodies and other eye complaints. I do my best to get them out, but I'm not going to go crazy either. If I can easily get them out, I do. If not, ophtho followup next day. You should hopefully know how to use a slit lamp and evaluate eye complaints
- We do almost all our own ortho reductions. All dislocations and most fracture reductions. Ortho doesn't come in to do a routine reduction unless there is neurovascular compromise or its open.
- Bedside US. You may not have the luxury of calling someone in for a "Formal US" where you work depending on where you go. So its good to know how to do basic US stuff, but also things like DVT US to triage some complaints until the patient can get a formal US the next day.
- You need to learn to decide when to give TPA without having a neurologist at the bedside. And if you are in a hospital without a cath lab there or right down the road, you need to start learning about giving TPA for STEMIs.
- You need to be able to decide which psych patients need admitted and which psych patients don't need inpatient resources without having a psych consult making this decision for you.
- You better be able to put in a chest tube comfortably because traumas will come to you even if you aren't a trauma center
- You should probably know how to practice medicine without being able to order an MRI "emergently" for just about anything that isn't "rule out cauda equina or spinal abscess" after hours
- You should know how to read your own films. Chances are, you will only get radiology plain film reads up until the evening. Overnight, all plain films will be read by you and you alone.

Those are just some of the things off the top of my head. I'm sure there's more. Practicing in a University based environment with every subspecialty consultant is very convenient but a very artificial environment. If you are in that environment during your training, I highly recommend you moonlight somewhere out in the community to get experience practicing without the luxury of all of the consultants. My personal bias is that community EM programs train people in a more realistic environment as to what to actually expect out in the community, but even then, many of these programs can be resource heavy compared to some jobs out there.
 
gamerEMdoc said:
- Corneal foreign bodies and other eye complaints. I do my best to get them out, but I'm not going to go crazy either. If I can easily get them out, I do. If not, ophtho followup next day. You should hopefully know how to use a slit lamp and evaluate eye complaints
- We do almost all our own ortho reductions. All dislocations and most fracture reductions. Ortho doesn't come in to do a routine reduction unless there is neurovascular compromise or its open.
- Bedside US. You may not have the luxury of calling someone in for a "Formal US" where you work depending on where you go. So its good to know how to do basic US stuff, but also things like DVT US to triage some complaints until the patient can get a formal US the next day.
- You need to learn to decide when to give TPA without having a neurologist at the bedside. And if you are in a hospital without a cath lab there or right down the road, you need to start learning about giving TPA for STEMIs.
- You need to be able to decide which psych patients need admitted and which psych patients don't need inpatient resources without having a psych consult making this decision for you.
- You better be able to put in a chest tube comfortably because traumas will come to you even if you aren't a trauma center
- You should probably know how to practice medicine without being able to order an MRI "emergently" for just about anything that isn't "rule out cauda equina or spinal abscess" after hours
- You should know how to read your own films. Chances are, you will only get radiology plain film reads up until the evening. Overnight, all plain films will be read by you and you alone.

Those are just some of the things off the top of my head. I'm sure there's more. Practicing in a University based environment with every subspecialty consultant is very convenient but a very artificial environment. If you are in that environment during your training, I highly recommend you moonlight somewhere out in the community to get experience practicing without the luxury of all of the consultants. My personal bias is that community EM programs train people in a more realistic environment as to what to actually expect out in the community, but even then, many of these programs can be resource heavy compared to some jobs out there.
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I trained at the Mother Ship (Level 1 trauma center) and then worked at a critical access hospital. On one of my first shifts, I said about a very difficult airway, "Let's give a heads up to anesthesia in case we need them to come in." The nurse turned to me and said, "you're anesthesia."
 
One of our former residents, now attendings, was moonlighting at a small hospital without OB anywhere closeby. Someone came in with active labor who had no prenatal and she delivered the baby. Was warming the baby when the nurse said doctor we need you, she's having another baby. Delivered the twin, and it was breech. Hahahaha. It's a scary world out there.
 
gamerEMdoc said:
- Corneal foreign bodies and other eye complaints. I do my best to get them out, but I'm not going to go crazy either. If I can easily get them out, I do. If not, ophtho followup next day. You should hopefully know how to use a slit lamp and evaluate eye complaints
- We do almost all our own ortho reductions. All dislocations and most fracture reductions. Ortho doesn't come in to do a routine reduction unless there is neurovascular compromise or its open.
- Bedside US. You may not have the luxury of calling someone in for a "Formal US" where you work depending on where you go. So its good to know how to do basic US stuff, but also things like DVT US to triage some complaints until the patient can get a formal US the next day.
- You need to learn to decide when to give TPA without having a neurologist at the bedside. And if you are in a hospital without a cath lab there or right down the road, you need to start learning about giving TPA for STEMIs.
- You need to be able to decide which psych patients need admitted and which psych patients don't need inpatient resources without having a psych consult making this decision for you.
- You better be able to put in a chest tube comfortably because traumas will come to you even if you aren't a trauma center
- You should probably know how to practice medicine without being able to order an MRI "emergently" for just about anything that isn't "rule out cauda equina or spinal abscess" after hours
- You should know how to read your own films. Chances are, you will only get radiology plain film reads up until the evening. Overnight, all plain films will be read by you and you alone.

Those are just some of the things off the top of my head. I'm sure there's more. Practicing in a University based environment with every subspecialty consultant is very convenient but a very artificial environment. If you are in that environment during your training, I highly recommend you moonlight somewhere out in the community to get experience practicing without the luxury of all of the consultants. My personal bias is that community EM programs train people in a more realistic environment as to what to actually expect out in the community, but even then, many of these programs can be resource heavy compared to some jobs out there.
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This is very interesting to me, I split my practice between a level 1 academic mothership and a more typical community hospital; although that being said, I think even my community job has better resources/consultants than most. What are some other examples of things that you guys note to be different in terms of what the ER physician has to manage compared to consultants/specialists in your community shops vs. academics? I think this is a very useful list for residents reaching the end of their training. Might give them some idea of things they should focus on in the last 6-12 mos of their training if they are planning on going to the community to practice.

I agree with GamerEMDoc that orthopedists are quite scarce in the community ER and unless the fracture or dislocation needs to go to the OR (open, multiply comminuted and unreducible, etc.) it falls on the ER to do the reduction.

Another one I note that is quite different is various finger/hand injuries (partial amps, exposed bone, complicated nail beds, open fractures of fingers) the plastic surgeons either want the ER physician to repair primarily or close skin/dress and then have go to their clinic (sometimes that day) or the next.
 
gamerEMdoc said:
Exactly. You learn that most things can be fixed temporarily or just wait until the next day. There is nothing emergent about a colles fracture reduction with normal pulses. I do them more for patient satisfaction (people hate the site of an angulated bone and expect it to be fixed NOW) than because its medically necessary.
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Plus that pays MUCHO RVUs - like more than almost any other procedure, so you'd be leaving money on the table if you didn't do it!
 
This is not the proper thread but I just want to formally recant my position about non-EM trained folks. I’ve realized that there is a vast difference between EM and non-EM folks, even if the non-EM folks have been working for twenty years in the ER. There seems to be no replacement for an ER residency.

I know this is obvious to others here but I ust wanted my recantation on the record, as I had posted otherwise earlier.
 
gamerEMdoc said:
I just recently started using US to guide my hematoma blocks. Way more efficacious.
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Eh it takes me longer to get and setup an ultrasound in my department than it does to stick in a needle to the deformity and get a blush of blood in the syringe on negative pressure. Still hematoma block for the win.
 
Rendar5 said:
Eh it takes me longer to get and setup an ultrasound in my department than it does to stick in a needle to the deformity and get a blush of blood in the syringe on negative pressure. Still hematoma block for the win.
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I just always had a lot of dry sticks where i didn't hit the hematoma and the analgesia wasn't good. Especially in the wrist. Ankle hematoma blocks are insanely easy. But wrists I for whatever reason never could hit the hematoma. But when I put the US on, I can see the fracture and the hematoma. Makes is real easy.
 
gamerEMdoc said:
- Corneal foreign bodies and other eye complaints. I do my best to get them out, but I'm not going to go crazy either. If I can easily get them out, I do. If not, ophtho followup next day. You should hopefully know how to use a slit lamp and evaluate eye complaints
- We do almost all our own ortho reductions. All dislocations and most fracture reductions. Ortho doesn't come in to do a routine reduction unless there is neurovascular compromise or its open.
- Bedside US. You may not have the luxury of calling someone in for a "Formal US" where you work depending on where you go. So its good to know how to do basic US stuff, but also things like DVT US to triage some complaints until the patient can get a formal US the next day.
- You need to learn to decide when to give TPA without having a neurologist at the bedside. And if you are in a hospital without a cath lab there or right down the road, you need to start learning about giving TPA for STEMIs.
- You need to be able to decide which psych patients need admitted and which psych patients don't need inpatient resources without having a psych consult making this decision for you.
- You better be able to put in a chest tube comfortably because traumas will come to you even if you aren't a trauma center
- You should probably know how to practice medicine without being able to order an MRI "emergently" for just about anything that isn't "rule out cauda equina or spinal abscess" after hours
- You should know how to read your own films. Chances are, you will only get radiology plain film reads up until the evening. Overnight, all plain films will be read by you and you alone.

Those are just some of the things off the top of my head. I'm sure there's more. Practicing in a University based environment with every subspecialty consultant is very convenient but a very artificial environment. If you are in that environment during your training, I highly recommend you moonlight somewhere out in the community to get experience practicing without the luxury of all of the consultants. My personal bias is that community EM programs train people in a more realistic environment as to what to actually expect out in the community, but even then, many of these programs can be resource heavy compared to some jobs out there.
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Great post. I might add, however, that it may be EASIER for you to get an MRI in the community than at an academic center. Hospitals actually like it when you order studies like that because they bring in a lot of money.
 
That's true, MRIs are a lot easier for me to get at my community site. It also seems I see more patients who meet criteria for them (back pain red flags). Most of these MRs are still negative so I kind of wonder if these patients (more affluent and health savvy at my community site) look up on the internet something like "what do I tell the ER to get them to do an MRI without insurance preauthorization?"
 
The White Coat Investor said:
Great post. I might add, however, that it may be EASIER for you to get an MRI in the community than at an academic center. Hospitals actually like it when you order studies like that because they bring in a lot of money.
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All depends on tech coverage I think. During the day, its easy to get an MRI. At night, well, not always so easy. Like anything in EM though, everywhere you work is going to be a little different.
 
gamerEMdoc said:
All depends on tech coverage I think. During the day, its easy to get an MRI. At night, well, not always so easy. Like anything in EM though, everywhere you work is going to be a little different.
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I know a couple of places that are running outpatient, elective, MRIs essentially 24/7. The execs have decided that the fixed costs of the machines dominate, there is demand, so why have downtime? Strangely, the person who would appreciate an 11 pm appointment so as to not miss work is probably also far more likely to actually pay his bill.
 
Vandalia said:
I know a couple of places that are running outpatient, elective, MRIs essentially 24/7. The execs have decided that the fixed costs of the machines dominate, there is demand, so why have downtime? Strangely, the person who would appreciate an 11 pm appointment so as to not miss work is probably also far more likely to actually pay his bill.
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Interesting. For once I side with the suits, the logic is sensible. If you had easier access to MRI, what would you use it for? I think most ER physicians only use it for suspected central cord or cauda equina syndrome. Rarely suspected appendicitis in pregnancy.
 
I had a weird stroke-like case today and the tele-neurologist asked if I could get an emergent MRI. I didn't really laugh, but no. No, I can't get an emergent MRI...

And I usually sedate my colles fractures. I keep thinking I'm going to try a hematoma block, but it seems like you need to have the right patient - someone who isn't going to freak out (unlike my teenage colles fx patient today, who freaked out at the thought of taking the splint off...)
I never did hematoma blocks in residency (yeah, I'm getting old...), and I reduce pretty much everything at my community shop.
 
I sedate a lot of ortho stuff too. You go in picking your battles. There are people whose shoulder dislocations I can reduce with minimal discomfort with absolutely no meds/injections. But it has to be the right person. The person who screams when they get the IV... that person isn't going to be fine with just a hematoma block for a wrist fracture.
 
I tend to do big slug of fentanyl IV + hematoma block for colles fractures as my preferred approach. Sometimes I am not able to aspirate any blood, when this happens I know the block isn't going to work very well. I tend to sedate ankles fracture/dislocation reductions.

I have lots of periods of single coverage at my community shop so I try to avoid sedations if I can.

That being said, I agree that patient selection is key. I have had some recurrent shoulder dislocators requesting sedation right out the gate. Alternatively I have reduced horrible tri-mal ankles with just 1mg dilaudid without too much problem.
 
Tri-mal's look terrible but take about 3 seconds to reduce. I generally just give them dilaudid. Inject them if they aren't willing to tough it out. But rarely do I ever sedate them. I've even had intoxicated patients let me reduce them with nothing. I'm not sure, is alcohol that's already on board considered procedural sedation?
 
Rarely sedate reductions anymore.

U/S guided radial nerve block and hematoma block will get you just as good if not better results in half the time.
 
gamerEMdoc said:
Tri-mal's look terrible but take about 3 seconds to reduce. I generally just give them dilaudid. Inject them if they aren't willing to tough it out. But rarely do I ever sedate them. I've even had intoxicated patients let me reduce them with nothing. I'm not sure, is alcohol that's already on board considered procedural sedation?
Click to expand...

Really? I feel like tri-mals never stay in....
 
TimesNewRoman said:
Really? I feel like tri-mals never stay in....
Click to expand...

After the ankle is reduced, have someone hold the foot by the big toe with the ankle slightly inverted. Keep that position during splinting. Hold compression on the ankle from the sides while putting the sugartong part of the splint on. Usually pulls everything together and holds it there quite well.
 
I mean, they still go to the OR in a day or two, but I've had some orthopedists have trimal's go home and have outpatient surgery in a few days. I've gotten very different answers on this by different orthopods. I've been told they do better if the swelling goes down. Most still recommend next day surgery when I call them. Regardless, they usually expect us to reduce it initially in the ED at night and then they will operate in the AM as an inpatient, or in a few days as an outpatient, based on their practice style.
 
gamerEMdoc said:
Exactly. You learn that most things can be fixed temporarily or just wait until the next day. There is nothing emergent about a colles fracture reduction with normal pulses. I do them more for patient satisfaction (people hate the site of an angulated bone and expect it to be fixed NOW) than because its medically necessary.
Click to expand...
EMTALA has explicitly shown failure to reduce a fracture is a violation. Local practice is not an exception. Just hope nobody every reports it.
Surgery isn't required, but the reduction is.
 
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