The lack of control of Emergency medicine

[turkeyjerky]

You know, I've worked with a couple of FM or IM trained ED docs who are decent resuscitationists, as well as some Emergency Physicians who are decidedly not. However, neither is the norm. I think that's the point.

(Also, for the record I learned about warfarin reversal in med school, okay it's not some secret. I also had a hematologist chew me out one time after the fact for giving vitamin k to a GI bleed--he told me that they would prefer to ride it out w/ FFP for a few days. F'ing joker)

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[namethatsmell]

Except you don't. I'm FM and haven't set foot in an ED or hospital professionally speaking since residency and I know that.

I once interviewed for a swanky outpatient job in a very niche field. The physician owner of the practice insisted that since I was base trained in EM I could handle some primary care needs for the practice. After I explained in a few different ways why I wasn’t qualified for that the owner finally laughed and said “primary care is easy enough that even an NP can do it, so give yourself some credit.” That was my cue to smile, nod, and ride away into the sunset. M*rons who can’t appreciate what they don’t know abound in medicine.

 

[Franzd'Epinay]

I'll add "other factors beyond your control" to the list.

- nurse "can't get a line"
- laboratory can't laboratory.
- patient refuses blood/CT/leaving until their demands are met.

Etc.

Don't forget the longest diagnostic procedure of all: obtaining and sending a urine sample.

I'm mostly kidding, but one time I did an LP and got back the results before the urine was sent...

 

[GeneralVeers]

Don't forget the longest diagnostic procedure of all: obtaining and sending a urine sample.

I'm mostly kidding, but one time I did an LP and got back the results before the urine was sent...

A UA should almost never hold up the disposition. If it's been hours and I have a weak/dizzy old lady or a septic person being admitted, I start the appropriate therapy and call the hospitalist.

 

[Franzd'Epinay]

A UA should almost never hold up the disposition. If it's been hours and I have a weak/dizzy old lady or a septic person being admitted, I start the appropriate therapy and call the hospitalist.

Oh yeah, this person had like 17 different reasons to be admitted, but it's still one of those "you've gotta be kidding me" moments when a UA isn't done.

 

[namethatsmell]

Don't forget the longest diagnostic procedure of all: obtaining and sending a urine sample.

I'm mostly kidding, but one time I did an LP and got back the results before the urine was sent...

I used to work with a guy who'd bring a bell to work. It had one purpose: to announce to all the techs and nurses that he was still waiting on a patient's UA.

Apparently he'd gotten tired of bugging staff to get a sample for a patient so instead he just rang a bell. It got to the point where whenever it rang everybody ran the board to see if there were any UA's outstanding.

Saved a ton of repetitive conversations and seemed to improve dispo times. And it was amusing to see pavlov in action. He was otherwise very nice to staff and didn't overuse the bell. Dude was pretty much a genius.

 

[pkwraith]

If it takes too long, I just order a straight cath. I usually find that provides enough incentive that I get a clean catch urine in 30 minutes.

 

[The Knife & Gun Club]

I'll add "other factors beyond your control" to the list.

- nurse "can't get a line"
- laboratory can't laboratory.
- patient refuses blood/CT/leaving until their demands are met.

Etc.

Recently had a lady tell me she would only consent for a left sided femoral central line. Because she’a had them at ever other site and it hurts too much.

And she wants a sandwich first, and not one of the cheap ones - one with lettuce.

 

[Siggy]

You know, I've worked with a couple of FM or IM trained ED docs who are decent resuscitationists, as well as some Emergency Physicians who are decidedly not. However, neither is the norm. I think that's the point.

(Also, for the record I learned about warfarin reversal in med school, okay it's not some secret. I also had a hematologist chew me out one time after the fact for giving vitamin k to a GI bleed--he told me that they would prefer to ride it out w/ FFP for a few days. F'ing joker)

From an inpatient management standpoint, I almost never give vit K. It's either takes too long to do anything helpful (i.e. acute bleeds), or if the patient's not bleeding then you bottom out the INR and it's a pain to get it back to therapeutic and you're normally fine just watching it slowly float back down.

 

[RustedFox]

Recently had a lady tell me she would only consent for a left sided femoral central line. Because she’a had them at ever other site and it hurts too much.

And she wants a sandwich first, and not one of the cheap ones - one with lettuce.

See; its this nonsense that makes it "just too much" for me.

 

[The Knife & Gun Club]

See; its this nonsense that makes it "just too much" for me.

I call it Florida-retirement-home syndrome.

 

[MedicineZ0Z]

Well apparently you do. Any EM / critical care training teaches this (and perhaps even IM)...but why would an FM doc know this?

Residency dependent. All of my FM interns would know immediately how to dispo the disaster scenes mentioned in the OP. If your patient population and training settings (and self interest) facilitate that learning, then it is actually expected.

You know there are open ICUs with FM hospitalists who do every code/intubation/line etc.

My wife pgy3 FM resident spends 2 months in adult ER and 1 month in peds ER in her entire residency. And then 1 month in ICU. That's about the critical care training they have. And that too as off service residents, they are never pushed like a EM resident will be, they likely won't have the sickest patients.

She cannot manage critical patients, just like i can't manage clinical patients because i have little to no chronic disease management training.

Your wife is probably at a crappy program. It happens. Plenty of them in every specialty.

 

[JacobMcCandles]

Residency dependent. All of my FM interns would know immediately how to dispo the disaster scenes mentioned in the OP. If your patient population and training settings (and self interest) facilitate that learning, then it is actually expected.

You know there are open ICUs with FM hospitalists who do every code/intubation/line etc..

And you know that these are the exceptions and not the rules. Most FM residents couldn’t care less about those kind of patients because they’re not your typical FM patients. If they did they probably would be doing a specialty that sees/manages those patients frequently.

 

[cyanide12345678]

Residency dependent. All of my FM interns would know immediately how to dispo the disaster scenes mentioned in the OP. If your patient population and training settings (and self interest) facilitate that learning, then it is actually expected.

You know there are open ICUs with FM hospitalists who do every code/intubation/line etc.

Your wife is probably at a crappy program. It happens. Plenty of them in every specialty.

It's a decent program that is teaching her family medicine - clinical management, outpatient procedures, and hospitalist medicine - NOT critical care medicine or emergency medicine. Because that's not what these FM grads do when they grow up and enter the real world.

3 or so months in the ER, which is the requirement for FM training, does not teach them the nuances of emergency medicine. It just doesn't. I did 5 months as pgy1, 7-8 as pgy2, and 9-10 as pgy3. All i know is emergency medicine, that's my mindset and my training. If I've spent 6 or so months in ICUs, doesn't make me a critical care ICU doc.

Be humble in medicine. You don't know what you don't know. If you think you can practice in a setting where you've spent 3-4 months in training, then your weaknesses will be exposed.

 

[Lexdiamondz]

Residency dependent. All of my FM interns would know immediately how to dispo the disaster scenes mentioned in the OP. If your patient population and training settings (and self interest) facilitate that learning, then it is actually expected.

You know there are open ICUs with FM hospitalists who do every code/intubation/line etc.

Your wife is probably at a crappy program. It happens. Plenty of them in every specialty.

if self interest and acuity was enough then why can't these FM guys do a half-decent job if they chose to earn a living working in the ED for years?

Obviously self interest isn't a replacement for actual dedicated training.

 

[Leonthemedico]

In my opinion the true emergencies require EM doc. Examples of true emergencies are Vtach, tamponade, trauma, poisoning, Boerhaave etc.
On the other hand a competent FM doctor can safely manage most minor emergencies or acute diseases like constipation, vomiting, back pain, knee pain, or any other type of pain. It's what we as FM doctors see in our office every day especially in the rural setting.
Maybe in the urban setting there is less of those acute conditions but the rural doctors must have a solid knowledge.

 

[southerndoc]

In my opinion the true emergencies require EM doc. Examples of true emergencies are Vtach, tamponade, trauma, poisoning, Boerhaave etc.
On the other hand a competent FM doctor can safely manage most minor emergencies or acute diseases like constipation, vomiting, back pain, knee pain, or any other type of pain. It's what we as FM doctors see in our office every day especially in the rural setting.
Maybe in the urban setting there is less of those acute conditions but the rural doctors must have a solid knowledge.

So are you advocating that they treat all the non-acute/non-emergent patients and just let the rare near-death ones languish?

 

[cyanide12345678]

In my opinion the true emergencies require EM doc. Examples of true emergencies are Vtach, tamponade, trauma, poisoning, Boerhaave etc.
On the other hand a competent FM doctor can safely manage most minor emergencies or acute diseases like constipation, vomiting, back pain, knee pain, or any other type of pain. It's what we as FM doctors see in our office every day especially in the rural setting.
Maybe in the urban setting there is less of those acute conditions but the rural doctors must have a solid knowledge.

I can also probably do 80-90 percent of hospitalist medicine, doesn't mean i should do it

 

[turkeyjerky]

From an inpatient management standpoint, I almost never give vit K. It's either takes too long to do anything helpful (i.e. acute bleeds), or if the patient's not bleeding then you bottom out the INR and it's a pain to get it back to therapeutic and you're normally fine just watching it slowly float back down.

So for head bleeds you just give them Kcentra every day til discharge?

Absent the odd case of a minor but potentially significant bleed in a patient w/ a mechanical mitral valve or something, I just don't get it. Am I missing something?

 

[MedicineZ0Z]

It's a decent program that is teaching her family medicine - clinical management, outpatient procedures, and hospitalist medicine - NOT critical care medicine or emergency medicine. Because that's not what these FM grads do when they grow up and enter the real world.

3 or so months in the ER, which is the requirement for FM training, does not teach them the nuances of emergency medicine. It just doesn't. I did 5 months as pgy1, 7-8 as pgy2, and 9-10 as pgy3. All i know is emergency medicine, that's my mindset and my training. If I've spent 6 or so months in ICUs, doesn't make me a critical care ICU doc.

Be humble in medicine. You don't know what you don't know. If you think you can practice in a setting where you've spent 3-4 months in training, then your weaknesses will be exposed.

We routinely admit to the ICU routinely where I am, as do many FM programs. Whether or not you become competent at taking care of a portion of critical patients is program dependent. Like I said, vast majority of open ICU hospitalist jobs with limited intensivist support will hire FM docs. Or you can hire a midlevel.

if self interest and acuity was enough then why can't these FM guys do a half-decent job if they chose to earn a living working in the ED for years?

Obviously self interest isn't a replacement for actual dedicated training.

There are plenty of older docs who are not good. But you know there are faculty at some EM programs who were FM and got grandfathered in.
But there's no excuse for not knowing how to handle the cognitive side of EM.

 

[Lexdiamondz]

There are plenty of older docs who are not good. But you know there are faculty at some EM programs who were FM and got grandfathered in.
But there's no excuse for not knowing how to handle the cognitive side of EM.

I know them. Some of them trained me.

100% of them would say to you that in 2021, FM or IM training overall is not sufficient to competently, safely and efficiently practice the full spectrum of Emergency Medicine.

 

[MedicineZ0Z]

I can also probably do 80-90 percent of hospitalist medicine, doesn't mean i should do it

I know them. Some of them trained me.

100% of them would say to you that in 2021, FM or IM training overall is not sufficient to competently, safely and efficiently practice the full spectrum of Emergency Medicine.

Of course. Over 90 percent of programs will not prepare you. But the issue in the OP is almost entirely due to being an old timer and outdated. I've gotten ridiculous recs from older cardios and nephros and other specialists. There are gen surgs who cant operate a laparoscopic well.

Plenty of outdated docs out there. It's not exclusive to the ED by one bit. Every specialty has them and that's the entire issue here rather than being fm In an ed.

And I think this whole discussion was about icu work initially.
There is a PA I know who is in her 20s and runs an icu overnight solo. She also solo staffs a rural ED. Now she wants to leave the icu to do primary care with ed. She initially did derm out of school and was interested in nephro during school.
Sounds ridiculous except everyone reading this knows midlevels like this or similar.

Yet you're telling me I cant admit patients to the icu after doing it longitudinally for 3 years on top of dedicated time?

 

[Lexdiamondz]

Of course. Over 90 percent of programs will not prepare you. But the issue in the OP is almost entirely due to being an old timer and outdated. I've gotten ridiculous recs from older cardios and nephros and other specialists. There are gen surgs who cant operate a laparoscopic well.

Plenty of outdated docs out there. It's not exclusive to the ED by one bit. Every specialty has them and that's the entire issue here rather than being fm In an ed.

And I think this whole discussion was about icu work initially.
There is a PA I know who is in her 20s and runs an icu overnight solo. She also solo staffs a rural ED. Now she wants to leave the icu to do primary care with ed. She initially did derm out of school and was interested in nephro during school.
Sounds ridiculous except everyone reading this knows midlevels like this or similar.

Yet you're telling me I cant admit patients to the icu after doing it longitudinally for 3 years on top of dedicated time?

Dude there was a guy who posted here as a newish FM grad a couple weeks back that couldn't manage bread & butter sepsis.

Last year I recall an FM grad who posted on the forums trying to figure out how to get procedural experience after working for 18 mos and nearly killing someone.

Being an old timer had nothing to do with it.

Nobody is telling you you can't practice whatever field of medicine you want to. You can do anything that an institution will credential you to do.

You just probably won't be very good at it, and next to people who actually trained for the job you probably would look substandard by comparison.

It's your license.

 

[Siggy]

So for head bleeds you just give them Kcentra every day til discharge?

Absent the odd case of a minor but potentially significant bleed in a patient w/ a mechanical mitral valve or something, I just don't get it. Am I missing something?

How often do you give kcentra and see a significant rebound in the INR days later?

 

[MedicineZ0Z]

Dude there was a guy who posted here as a newish FM grad a couple weeks back that couldn't manage bread & butter sepsis.

Last year I recall an FM grad who posted on the forums trying to figure out how to get procedural experience after working for 18 mos and nearly killing someone.

Being an old timer had nothing to do with it.

Nobody is telling you you can't practice whatever field of medicine you want to. You can do anything that an institution will credential you to do.

You just probably won't be very good at it, and next to people who actually trained for the job you probably would look substandard by comparison.

It's your license.

Isolated examples. Excluding old docs, almost everyone taking a job is well prepared it. I already said vast majority of FM is not prepared at all for full spectrum ed work.

I responded in regards to critical patients, which are 100% in FM scope. And crit care (to the level done by IM docs without fellowship) = / = em work. And scope of practice includes c sections for those who have fellowship training or (screening) colonoscopies or many other things shared by specialists and primarycare.


Btw I can also make a list of life threatening things that newly minted boarded ed docs missed too, only to be picked up on admission. Sky high d dimers without a CTA. Pain control admit that's actually a dissection. Hypotensive septic being ignored for an hour after 1L of saline. Trust me, this stuff is done by board certified docs too.

 

[cyanide12345678]

Of course. Over 90 percent of programs will not prepare you. But the issue in the OP is almost entirely due to being an old timer and outdated. I've gotten ridiculous recs from older cardios and nephros and other specialists. There are gen surgs who cant operate a laparoscopic well.

Plenty of outdated docs out there. It's not exclusive to the ED by one bit. Every specialty has them and that's the entire issue here rather than being fm In an ed.

And I think this whole discussion was about icu work initially.
There is a PA I know who is in her 20s and runs an icu overnight solo. She also solo staffs a rural ED. Now she wants to leave the icu to do primary care with ed. She initially did derm out of school and was interested in nephro during school.
Sounds ridiculous except everyone reading this knows midlevels like this or similar.

Yet you're telling me I cant admit patients to the icu after doing it longitudinally for 3 years on top of dedicated time?

Are you a resident or attending? I'm going to guess pgy 1 or 2. Pgy 2s start to get really confident and cocky

I think you haven't been in the game long enough to be burned enough to know what you don't know. But correct me if I'm wrong.

It's not like those MLPs are practicing great medicine either.

 

[MedicineZ0Z]

Are you a resident or attending? I'm going to guess pgy 1 or 2. Pgy 2s start to get really confident and cocky

I think you haven't been in the game long enough to be burned enough to know what you don't know. But correct me if I'm wrong.

It's not like those MLPs are practicing great medicine either.

What's the cocky part? I said these incompetent folks exist in every single specialty, and in equal proportions. And that portions of crit care are well within FM scope. The hospital medicine boards is literally cosponsored by ABFM and ABIM. Those boards contain parts of critical care management as part of their core competency. In other words, a hospitalist absolutely needs to be comfortable with portions of critical care.
It doesn't mean every family doctor will be, just that the ones doing that sort of work are expected to be.

 

[cyanide12345678]

What's the cocky part? I said these incompetent folks exist in every single specialty, and in equal proportions. And that portions of crit care are well within FM scope. The hospital medicine boards is literally cosponsored by ABFM and ABIM. Those boards contain parts of critical care management as part of their core competency. In other words, a hospitalist absolutely needs to be comfortable with portions of critical care.
It doesn't mean every family doctor will be, just that the ones doing that sort of work are expected to be.

You didn't answer the question.

It happens early in your career when residents haven't had significant complications or if you don't do something frequently enough to know how badly things can go south. The few 1 in 100 really bad crap that happens teaches you more than the remaining 99 times when things went smoothly.

My personal humbling moment was when i missed intubation on a guy in pgy2. The moment he got succ, a fountain of vomit just kept pouring out, Through the nose, the mouth, anesthesia missed after me, guy aspirated a tonne, eventually went into ARDS and died. I have never seen this much vomit ever, suction kept getting pieces stuck and couldn't keep up. It was bad. Every intubation since then, i keep an LMA bedside, ready to go.

Run a few pediatric < 1 yo codes, have a few complications, miss a few things, have a few airway nightmares, manage 20+ patients simultaneously by yourself, go through transport delays where you can't get critical patients out who are dying, then you will get humbled. It takes time and experience.

 

[MedicineZ0Z]

You didn't answer the question.

It happens early in your career when residents haven't had significant complications or if you don't do something frequently enough to know how badly things can go south. The few 1 in 100 really bad crap that happens teaches you more than the remaining 99 times when things went smoothly.

My personal humbling moment was when i missed intubation on a guy in pgy2. The moment he got succ, a fountain of vomit just kept pouring out, Through the nose, the mouth, anesthesia missed after me, guy aspirated a tonne, eventually went into ARDS and died. I have never seen this much vomit ever, suction kept getting pieces stuck and couldn't keep up. It was bad.

Run a few pediatric < 1 yo codes, have a few complications, miss a few things, have a few airway nightmares, manage 20+ patients simultaneously by yourself, go through transport delays where you can't get critical patients out who are dying, then you will get humbled. It takes time and experience.

Ah the good ol, eat your young and flex on your trainees approach. Typical attending who will go out of their way to bark at residents, eat their young and then turn around and bow down to midlevels taking over. Not sure if you even realize it, but you literally said nothing that's even remotely related to the point.

 

[cyanide12345678]

Ah the good ol, eat your young and flex on your trainees approach. Typical attending who will go out of their way to bark at residents, eat their young and then turn around and bow down to midlevels taking over. Not sure if you even realize it, but you literally said nothing that's even remotely related to the point.

Sure. Time will teach you. Good luck.

 

[JacobMcCandles]

It’s clear they’re a resident. Everyone will have misses no matter what you do. I’ve seen patients code on their way out of the hospital after being discharged from the floor. You know what all those ‘misses’ you’ve seen have in common? They were admitted. I say ‘misses’ because I’ve seen more sky high d-dimers with negative CTAs than positive ones. The septic patient wasn’t a miss, just bad care. That patient likely didn’t need more fluid next, they likely needed early pressors but it sounds like you didn’t know that. I’d be curious what type of pain the dissection had because it’s basically standard of care to miss those atypical aortic dissections. It’s rare for intractable pain to get admitted without some kind of advanced imaging. Nonetheless, you’ll learn a lot moving forward and probably look back at these posts and cringe. We’ve all been there.

 

[MedicineZ0Z]

It’s clear they’re a resident. Everyone will have misses no matter what you do. I’ve seen patients code on their way out of the hospital after being discharged from the floor. You know what all those ‘misses’ you’ve seen have in common? They were admitted. I say ‘misses’ because I’ve seen more sky high d-dimers with negative CTAs than positive ones. The septic patient wasn’t a miss, just bad care. That patient likely didn’t need more fluid next, they likely needed early pressors but it sounds like you didn’t know that. I’d be curious what type of pain the dissection had because it’s basically standard of care to miss those atypical aortic dissections. It’s rare for intractable pain to get admitted without some kind of advanced imaging. Nonetheless, you’ll learn a lot moving forward and probably look back at these posts and cringe. We’ve all been there.

I mean that's sort of my point. That even up to date younger board certified doctors will miss classic textbook things. Just that incompetent care with large misses will typically happen with a select cohort of older docs that are out of date. It's not just FM in ED, which is what this thread was trying to sell in an echo chamber.

And the patient has a d dimer of 11. The septic guy got started on levo once I reminded the ED about him after coming down to see him. And the dissection patient was pretty textbook.

 

[JacobMcCandles]

I mean that's sort of my point. That even up to date younger board certified doctors will miss classic textbook things. Just that incompetent care with large misses will typically happen with a select cohort of older docs that are out of date. It's not just FM in ED, which is what this thread was trying to sell in an echo chamber.

And the patient has a d dimer of 11. The septic guy got started on levo once I reminded the ED about him after coming down to see him. And the dissection patient was pretty textbook.

The degree of d-dimer elevation is irrelevant. You clearly haven't seen many dissection patients because the atypical presentation is likely more common than the textbook presentation. The intractable pain dissection patient you mentioned I'm guessing had chest pain since you said it was 'textbook'. That's called a chest pain rule out admission but I digress. Did you throw in the central line or have the ED doc do it? Judging by the way you worded it I'm guessing the ED did although I've got $5 that says you'll say you did.

Your point is that misses happen and our point is that more misses happen when somebody is practicing in a suboptimal environment for their training. That would be FM in an ICU or ED just like I would do an awful job in a clinic or OR.

 

[MedicineZ0Z]

The degree of d-dimer elevation is irrelevant. You clearly haven't seen many dissection patients because the atypical presentation is likely more common than the textbook presentation. The intractable pain dissection patient you mentioned I'm guessing had chest pain since you said it was 'textbook'. That's called a chest pain rule out admission but I digress. Did you throw in the central line or have the ED doc do it? Judging by the way you worded it I'm guessing the ED did although I've got $5 that says you'll say you did.

Your point is that misses happen and our point is that more misses happen when somebody is practicing in a suboptimal environment for their training. That would be FM in an ICU or ED just like I would do an awful job in a clinic or OR.

The degree of elevation is literally what tells you whether or not a blood clot is effectively ruled out. It's also why we have age adjusted thresholds. It's not a binary tool.
And where I am, the ED infrequently does CVCs compared to most busy settings. The admitting service in the ICU does most.

I also suggest reading what I wrote about hospital medicine competencies and boards.

 

[JacobMcCandles]

The degree of elevation is literally what tells you whether or not a blood clot is effectively ruled out. It's also why we have age adjusted thresholds. It's not a binary tool.
And where I am, the ED infrequently does CVCs compared to most busy settings. The admitting service in the ICU does most.

I also suggest reading what I wrote about hospital medicine competencies and boards.

The d-dimer is either positive or negative for a particular person. A d-dimer of 0.66 in a 65 year old is the same as it being 9. Those are both positive. How 'positive' the number is irrelevant. That was my point which you missed. And it appears the ED doc did put in the central line for you or else you would have just put it in and ordered the pressors yourself.

 

[MedicineZ0Z]

The d-dimer is either positive or negative for a particular person. A d-dimer of 0.66 in a 65 year old is the same as it being 9. Those are both positive. How 'positive' the number is irrelevant. That was my point which you missed. And it appears the ED doc did put in the central line for you or else you would have just put it in and ordered the pressors yourself.

Except you're literally wrong. I don't even need the citations below. Just understanding the pathophys should tell you that degree of elevation is important in the absence of other etiologies for an elevated d dimer.

High D‐dimer levels increase the likelihood of pulmonary embolism - Tick - 2008 - Journal of Internal Medicine - Wiley Online Library
Never ignore extremely elevated D-dimer levels: they are specific for serious illness - PubMed (nih.gov)
Quantitative d-dimer levels and the extent of venous thromboembolism in CT angiography and lower limb ultrasonography - PubMed (nih.gov)

And the idea that the ED would even do an LP for us is laughable let alone putting in an IJ.

 

[sylvanthus]

No its still positive or negative. Other things matter after that fact, not the absolute number.

Id welcome you calling me for an icu consult for ekos/tpa/thrombectomy based on dimer level. Im sure youd enjoy that converation.

.....Dudes a senior or recent family med grad.....

 

[thegenius]

MedicineZOZ is a troll. I blocked him so long ago I don't even remember when I did it. I've only blocked or ignored content from two people on this site and he's one of them

 

[JacobMcCandles]

Except you're literally wrong. I don't even need the citations below. Just understanding the pathophys should tell you that degree of elevation is important in the absence of other etiologies for an elevated d dimer.

High D‐dimer levels increase the likelihood of pulmonary embolism - Tick - 2008 - Journal of Internal Medicine - Wiley Online Library
Never ignore extremely elevated D-dimer levels: they are specific for serious illness - PubMed (nih.gov)
Quantitative d-dimer levels and the extent of venous thromboembolism in CT angiography and lower limb ultrasonography - PubMed (nih.gov)

And the idea that the ED would even do an LP for us is laughable let alone putting in an IJ.

Please enlighten the class on how the absolute number (slightly positive vs. incredibly positive) dictates the changes in your clinical management? It doesn’t.

Also, who said anything about an LP? You definitely are a troll. Bye.

 

[Lexdiamondz]

Isolated examples. Excluding old docs, almost everyone taking a job is well prepared it. I already said vast majority of FM is not prepared at all for full spectrum ed work.

I responded in regards to critical patients, which are 100% in FM scope. And crit care (to the level done by IM docs without fellowship) = / = em work. And scope of practice includes c sections for those who have fellowship training or (screening) colonoscopies or many other things shared by specialists and primarycare.


Btw I can also make a list of life threatening things that newly minted boarded ed docs missed too, only to be picked up on admission. Sky high d dimers without a CTA. Pain control admit that's actually a dissection. Hypotensive septic being ignored for an hour after 1L of saline. Trust me, this stuff is done by board certified docs too.

Spoken like someone who's never had a job before

 

[d2305]

So the original FP in the ER doesn't know he's incompetent? That's hard to comprehend.

 

[VA Hopeful Dr]

So the original FP in the ER doesn't know he's incompetent? That's hard to comprehend.

No its not. We all know lots of incompetent physicians of all stripes. I doubt many of them know it either.

 

[Lexdiamondz]

So the original FP in the ER doesn't know he's incompetent? That's hard to comprehend.

Most incompetents don't know they're incompetent.


If they did, they'd try to get better.

 

[Birdstrike]

Most incompetents don't know they're incompetent.


If they did, they'd try to get better.

Incompetents are the most competent at pointing out other incompetents that don't know they're incompetent.

 

[turkeyjerky]

Why is it that every recent thread seems to get derailed by some disgruntled FM resident or MLP?

 

[Birdstrike]

Why is it that every recent thread seems to get derailed by some disgruntled FM resident or MLP?

It's the internet being the internet. There's nothing you can do.

 

[southerndoc]

It's the internet being the internet. There's nothing you can do.

I was going to move posts to the off-topic forum, but the OP started an FM vs. EM trained discussion based on his original post (complaining about workups in the ED from an FM-trained physician). Therefore, I'm considering them on-topic.

I'm being more aggressive at issuing warnings, deleting posts, moving off-topic posts to the off-topic forum, and banning trolls.

Please report posts that you think need to be moderated. Trying to keep up with things with all the COVIDness going on at the hospital. I sometimes walk away from a clinical shift or a disaster planning meeting thinking I need a nitro and a Valium. I suggested a Pez dispenser in the ER with both. I think the admins thought I was joking.

 

[Birdstrike]

I sometimes walk away from a clinical shift or a disaster planning meeting thinking I need a nitro and a Valium. I suggested a Pez dispenser in the ER with both. I think the admins thought I was joking.

I hear ya, man. The only thing I can do is put on a Grateful Dead show and run to the point of complete exhaustion. I've been doing it a lot, lately.

 

[GeneralVeers]

I hear ya, man. The only thing I can do is put on a Grateful Dead show and run to the point of complete exhaustion. I've been doing it a lot, lately.

I've just stopped worrying about COVID. Let the admins deal with the disaster stuff. I put on my surgical mask, see the patients, end my shift and go home. I've realized that overcrowding and lobby medicine aren't things I can control at this point so don't waste my time worrying about it.

 

[southerndoc]

I've just stopped worrying about COVID. Let the admins deal with the disaster stuff. I put on my surgical mask, see the patients, end my shift and go home. I've realized that overcrowding and lobby medicine aren't things I can control at this point so don't waste my time worrying about it.

I'm an admin (associate medical director, chair of ED PIC committee, EMS medical director). I also have to improve things in the ER to keep an EMS unit available for 911 calls because of extended wall times. It's hard to not get overwhelmed when your average hospital ER in metro Atlanta is consistently running with an NEDOCS score >400 on a daily basis.

We're implementing multiple plans to help. Some docs have excellent ideas, and I always welcome input from them.