Training in fellowship?

[lost premed]

Can someone that has done fellowships share how much additional general EM training can be obtained from a fellowship? I am at a 3 year EM program and am afraid I will feel incompetent coming out of residency. We have trouble with many procedures and see relatively low volume per shift. We are also very academic so many competing specialities for procedures. I was wondering if pursuing a fellowship can help with this. But from my understanding, the fellows in our program basically act as attendings. There isn't really any really "learning" that happens in their general EM shift and all procedures would obviously go to residents over fellow. Thoughts?

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[namethatsmell]

Don't do a fellowship for the purpose of improving your EM procedural skills.

You're going to be acting as an EM attending at any fellowship you go to...that's part of how you cover your salary.

The good news is that your humbleness is highly protective against iatrogensis. Cocky new attendings make nice 007s. You're not going to feel comfortable as a new attending no matter where you trained.

If possible take your first attending gig at a community hospital with decent acuity. Keep working hard to learn and improve and things will come together over time.

 

[alpinism]

Namethatsmell is correct. You won't be getting additional procedural training with most of the EM fellowships. If anything its usually the opposite since typically the fellows are supervising residents who perform all the procedures. If you do work alone its usually in the fast track with low acuity patients who need simple things like laceration repairs. The one exception would be CCM fellowship but I certainly wouldn't recommend doing that just to get some procedural experience. Honestly your best option would be to find a high acuity community hospital job with lots of procedures.

 

[clibby]

I agree that fellowship likely won't make you a much better EM doc (CCM and PEM withstanding). I would recommend that when you look for your first job, look for a moderate to high acuity community place (without residents as they will do most of the work) where you can hone a lot of your skills and tailor your own style of practice. It is also really helpful to work somewhere where you are not single coverage if you can help it. Every shift my colleagues and I run things by each other whether it is an odd presentation and we want to verify our plan or just something cool to share and it is very helpful as a new attending. Stay humble and don't be afraid to ask for help, that is what colleagues and consultants are for.

 

[WilcoWorld]

Experience is the cure for what ails you @lost premed - try and get it somewhere that will provide you support (double coverage shop, not running floor codes, not catching babies all the time).

 

[Birdstrike]

Can someone that has done fellowships share how much additional general EM training can be obtained from a fellowship? I am at a 3 year EM program and am afraid I will feel incompetent coming out of residency. We have trouble with many procedures and see relatively low volume per shift. We are also very academic so many competing specialities for procedures. I was wondering if pursuing a fellowship can help with this. But from my understanding, the fellows in our program basically act as attendings. There isn't really any really "learning" that happens in their general EM shift and all procedures would obviously go to residents over fellow. Thoughts?

You're still a resident, right? If you're a 3rd year resident, you still have 8 months, nearly 1/4 of your residency, left. If you're a second year, you're not even halfway done. If you're a first year, you haven't even started yet.

Despite the fact that you're having a crisis of confidence right now, you've got plenty of time to short up skills you need help on. Have confidence in your training, that after 3 years, you'll be ready. Chances are, you will.

If you're a 1st or 2nd year, chill out. You're not supposed to feel too confident, yet. You have plenty of time. If you're a third year, talk to your program director about ways you can get extra practice on specific procedures you feel you need help on. He or she might give you ways to do that. Or, they may give you some insight into how you're progressing. It's possible you're doing much better than you think you are.

 

[DeadCactus]

Fellowship is a way of adding new skills to a foundation of emergency medicine. If you don't feel secure in your foundation, then you're better off going into the community to a busy high acuity setting with double coverage. That will polish out rough spots. Going into a fellowship where you have residents to be a crutch and your educational efforts will go toward your new niche will just allow dust to collect on rough spots.

 

[TheComebacKid]

Assuming you don't go to some bottom of the barrel HCA residency, the vast majority of 3 year residencies will prepare you more than adequately for being an attending in EM. This is from someone who did a 4 year program.

I also did a fellowship, and I completely agree with what has been said already... Fellowship will give you additional skills outside of EM, it won't make you a better EM doctor. Plus as a fellow I was expected to work as an attending in the ED and see patients with residents, and I also moonlit a ton during my fellowship year. But regardless, there is nobody to supervise you, you are not a trainee any longer when you are working clinically in the department.

As someone who did a 4 year program, I STILL graduated residency lacking confidence and felt like I wasn't prepared for independent practice. Despite these feelings, you will likely surprise yourself. No matter what happens, no matter how many years of residency + fellowship you do, you will never see every single thing and you will have to improvise and sometimes make s*** up as you go.

Now as a junior attending, I can tell you that I've learned more in my first year out probably than I did in all of training. Furthermore, there are tons of things I have already done this first year out that I did for the first time and never did in residency.

 

[Rekt]

Assuming you don't go to some bottom of the barrel HCA residency, the vast majority of 3 year residencies will prepare you more than adequately for being an attending in EM. This is from someone who did a 4 year program.

I also did a fellowship, and I completely agree with what has been said already... Fellowship will give you additional skills outside of EM, it won't make you a better EM doctor. Plus as a fellow I was expected to work as an attending in the ED and see patients with residents, and I also moonlit a ton during my fellowship year. But regardless, there is nobody to supervise you, you are not a trainee any longer when you are working clinically in the department.

As someone who did a 4 year program, I STILL graduated residency lacking confidence and felt like I wasn't prepared for independent practice. Despite these feelings, you will likely surprise yourself. No matter what happens, no matter how many years of residency + fellowship you do, you will never see every single thing and you will have to improvise and sometimes make s*** up as you go.

Now as a junior attending, I can tell you that I've learned more in my first year out probably than I did in all of training. Furthermore, there are tons of things I have already done this first year out that I did for the first time and never did in residency.

Disagree. This isn't the olden' days anymore. If your programs patient volume and/or procedure volume can't cut it, then the program needs to be cut. Name and shame imo. The one thing that can be controlled for and be confident about is procedures when leaving residency. That is the last thing you should feel incompetent in.

 

[e30ftw]

OP you've received good advice in this thread.

I would agree a fellowship is unlikely to increase your confidence/competence in EM procedures especially compared to a year of community practice, and you may actually feel *less* prepared than when you graduate residency, since most fellowships are at academic departments and you may not do many procedures over that year.

The best thing you can do now is fix the issues while you are still in residency.

It may help if you state specifically how you feel unprepared. Some EM skills like ortho reductions and even LPs can be fine-tuned in clinical practice. It's embarrassing to have to transfer a difficult hip reduction or get a bloody tap during your first years but it's probably not going to get you in trouble. Last week I accepted an elbow-dislocation transfer from a doc with 20+ years of practice. Kind of embarrassing for him but I don't care because I love reductions and the patient was very grateful.

OTOH you should be able to intubate, decompress the chest, and establish venous access in essentially any patient. You will get in trouble in community practice if you are calling people in to manage pneumos or trying to transfer patients you haven't stabilized.

I would agree if this is a recurring issue at this program it is a serious failing and needs to be addressed.

 

[TheComebacKid]

Disagree. This isn't the olden' days anymore. If your programs patient volume and/or procedure volume can't cut it, then the program needs to be cut. Name and shame imo. The one thing that can be controlled for and be confident about is procedures when leaving residency. That is the last thing you should feel incompetent in.

The vast majority of "standard" 3 year programs have adequate volume/procedural experience. Again, if you go to a CMG residency in a lower volume place, this is the exception, and usually is inadequate training.

When it comes to airway, central lines, chest tubes (most of the time, not always), ultrasound, basic reductions, I&Ds, lac repairs, LPs, paracentesis, arthrocentesis etc I think most residencies can get numbers to demonstrate proficiency. If we are talking about low frequency procedures like surgical airway, pericardiocentesis, I think very few graduates feel totally competent/confident doing those at the time of graduation.

 

[Rekt]

The vast majority of "standard" 3 year programs have adequate volume/procedural experience. Again, if you go to a CMG residency in a lower volume place, this is the exception, and usually is inadequate training.

When it comes to airway, central lines, chest tubes (most of the time, not always), ultrasound, basic reductions, I&Ds, lac repairs, LPs, paracentesis, arthrocentesis etc I think most residencies can get numbers to demonstrate proficiency. If we are talking about low frequency procedures like surgical airway, pericardiocentesis, I think very few graduates feel totally competent/confident doing those at the time of graduation.

I think you'd be very shocked at the volume at some of these "big name" academic places. There's many university level places that see like 30-50k a year with 12-18 residents a year. Totally inappropriate. Not that I think the CMGs are doing anything good either, but it's not just them.

 

[alpinism]

Yeah I personally know people from big name programs who did only a small handful of fracture reductions in residency.

No way you can get competent let alone feel comfortable doing it only for a month during an orthopedics rotation.

 

[thegenius]

Yeah I personally know people from big name programs who did only a small handful of fracture reductions in residency.

No way you can get competent let alone feel comfortable doing it only for a month during an orthopedics rotation.

I'm one of those...our attendings would want us to consult Ortho for these. The reasoning was "division of labor...it is so busy down here (sic) [in the ER] that you have to see all the sickies."

 

[RustedFox]

Yeah I personally know people from big name programs who did only a small handful of fracture reductions in residency.

No way you can get competent let alone feel comfortable doing it only for a month during an orthopedics rotation.

So, this was the one "common procedure" that I felt like I could have been better at when I made the jump from resident to attending.
It wasn't a shortcoming of my program; I can tell you that. We had opportunities to reduce.
Sure, we had ortho residents to compete with for some procedures, yes.
The shortcoming was on my part, because I let my enthusiasm for the more cognitive and esoteric aspects of medicine get in my own way.
I looked at a simple Colles fracture as: "Okay, pull on it, boring. I got some really cool pathophysiology over here in the other room. I'll let the apes from ortho get excited over that."

So, when I hit the community and it was really just me reducing some fractures... yeah, I didn't feel like I was as good as I should have been.
It wasn't hard to get good, though. Really.

 

[thegenius]

So, this was the one "common procedure" that I felt like I could have been better at when I made the jump from resident to attending.
It wasn't a shortcoming of my program; I can tell you that. We had opportunities to reduce.
Sure, we had ortho residents to compete with for some procedures, yes.
The shortcoming was on my part, because I let my enthusiasm for the more cognitive and esoteric aspects of medicine get in my own way.
I looked at a simple Colles fracture as: "Okay, pull on it, boring. I got some really cool pathophysiology over here in the other room. I'll let the apes from ortho get excited over that."

So, when I hit the community and it was really just me reducing some fractures... yeah, I didn't feel like I was as good as I should have been.
It wasn't hard to get good, though. Really.

You're better for dealing with the esoteric stuff. Reductions for the most part, while plentiful, are not as critical as the really sick patient that nobody knows about. I felt my medical education out of residency was top notch and I'm better for it.

 

[Birdstrike]

Yeah I personally know people from big name programs who did only a small handful of fracture reductions in residency.

No way you can get competent let alone feel comfortable doing it only for a month during an orthopedics rotation.

It's funny. I did tons of wrist reductions in EM residency. Then, I don't think I did a single one in almost a decade in practice as an EM attending. They were all done by ortho PAs.

 

[Brigade4Radiant]

A lot of procedures can get turfed out to specialty residents at some of the big name programs

 

[dadaddadaBATMAN]

So, this was the one "common procedure" that I felt like I could have been better at when I made the jump from resident to attending.
It wasn't a shortcoming of my program; I can tell you that. We had opportunities to reduce.
Sure, we had ortho residents to compete with for some procedures, yes.
The shortcoming was on my part, because I let my enthusiasm for the more cognitive and esoteric aspects of medicine get in my own way.
I looked at a simple Colles fracture as: "Okay, pull on it, boring. I got some really cool pathophysiology over here in the other room. I'll let the apes from ortho get excited over that."

So, when I hit the community and it was really just me reducing some fractures... yeah, I didn't feel like I was as good as I should have been.
It wasn't hard to get good, though. Really.

Honestly I think this is a completely overblown problem. I’m a community doc. No residents. Went to huge academic center, could have done probably 3x as many reductions if i was aggressive.

Community approach:
Shoot xray
Pull
Shoot again
Call the ortho. Look good? Great kthx bye.
Look bad? Ok I’ll do it again.
Look good? Kthx bye
Look bad still? Like bad enough that you wanna come in? No? Ok where do they follow up. Yes? Ok come help me.

I have had to have them come in zero times in last two years, and I freely admit I “suck at ortho” as a thread from a while ago states.

This is not the thing to get knickers in a knot about. It’s high morbidity if you mess up, but as long as you have an Ortho on call and you aren’t too proud you’ll be fine and figure it out.

Go to the place with a lot of sick people.

Procedures are monkey work. They aren’t what makes me an important part of the ed. Anyone can learn them, even out in practice. You can’t learn to think out in practice.

What matters is having enough to be at least competent and to see enough to know WHEN to do them and when not to.

 

[thegenius]

“Knickers in a knot about”

Hmm!

 

[dadaddadaBATMAN]

“Knickers in a knot about”

Hmm!

I’m limited by censorship. Knickers in a twist is too britshy, I’m still an American.

 

[alpinism]

I mean sure I mostly agree with the above but to play devil's advocate why not go to a program with both thinking and doing opportunities?

It doesn't have to be this all or nothing type situation in training and you can certainly be managing sick patients while performing reductions.

Reminds me of the programs that still call anesthesia for trauma airways cause they're "experts" and they're "not for trainees". These same people then graduate having never done one and will justify it by saying its not really that important and its easy to learn as an attending out in the community. Now obviously most reductions aren't life and death but I think most people would agree its a little suboptimal to be reducing your first knee dislocation while alone at some rural critical access hospital. I guess what I'm trying to say is that we really shouldn't keep tolerating all these residency programs that clearly don't provide adequate training in performing basic procedures in emergency medicine.

 

[dadaddadaBATMAN]

I mean sure I mostly agree with the above but to play devil's advocate why not go to a program with both thinking and doing opportunities?

It doesn't have to be this all or nothing type situation in training and you can certainly be managing sick patients while performing reductions.

Reminds me of the programs that still call anesthesia for trauma airways cause they're "experts" and they're "not for trainees". These same people then graduate having never done one and will justify it by saying its not really that important and its easy to learn as an attending out in the community. Now obviously most reductions aren't life and death but I think most people would agree its a little suboptimal to be reducing your first knee dislocation while alone at some rural critical access hospital. I guess what I'm trying to say is that we really shouldn't keep tolerating all these residency programs that clearly don't provide adequate training in performing basic procedures in emergency medicine.

I think we probably agree more than disagree.

I just get annoyed by the community hospital masturbation sometimes, and the opposite is like true for folks from community residency. Academics have their disadvantages, but between first knee dislocation and having minimal exposure to transplant, lvad, sick kids, and various other things at a quartenary or tertiary place I’d rather do the one. Agree it’s not either or.

I also think academic programs need to have less tolerance for skill atrophy in Attendings and less tolerance for giving away procedures. My own residency was awful about chest tubes. I did plenty of large bore but got out of residency with only one pigtail, then promptly had to place 10 in my first year as an attending. I think I did fine despite this, but I could have had 7-8 more pigtails if my Department had fought for us.

I do question how many knee dislocations, elbow dislocations there are period. I have seen three total in 5 years of em. Judging a residency by that kind of metric seems a little odd. Judging them for giving away trauma airways is completely fair, because that’s ridiculous.

Having said that aside from the c collar I think those are some of the easier tubes I did in residency or practice. Active Gi bleeds, sick dka etc get a much higher sphincter tone from me.

 

[TheComebacKid]

As an academic attending I fight hard for residents to get procedures.

But the voice in the back of my head is always there... "Just call IR to do this large volume paracentesis. Call plastics to repair this complex facial laceration. Call ortho to reduce this joint." When you have the resources there, and more patients to see, it's very difficult to not offload these tasks and liability on someone else.

But our residents suffer for it. It's also not fair for overworked consult residents. I think academic attendings really fail their trainees in that regard when it comes to over consulting at academic centers. That being said, it's not always the attendings, there are really bad institutional and department policies that state "for X problem, must consult Y service". I know where I trained, getting outpatient follow up for a patient after an orthopedic injury was next to impossible unless the patient was seen in the ED by the consulting service. Ortho consult = 1 week follow up. ED reduction on their own = lost to follow up. It's hard to justify for patient care. And in reality, that's not how it is in the community where the vast majority of graduates will practice.

I remember ortho would get infuriated if the ED attempted the reduction before they were consulted when I was in residency. In the community, good luck getting an orthopod to come in for anything unless you've tried multiple times and failed and even then they may not come in.

We can do better. The ED is basically the most fertile ground in all of medicine for procedural experience and the consultants really take advantage of it for their training. I think we have to protect our turf a little more. Unfortunately, for the vast majority of academic EM departments, they don't hold enough rank to go up against ortho, plastics, ENT and the other more "respected" departments, which is makes it even more challenging.

 

[Tipsy McStagger]

I remember ortho would get infuriated if the ED attempted the reduction before they were consulted when I was in residency. In the community, good luck getting an orthopod to come in for anything unless you've tried multiple times and failed and even then they may not come in.

This is my one gripe about the community. By means of an example: we have 2 private GI groups that are contracted through the hospital. They share call in whatever way they agreed upon amongst their groups. Recently I had a variceal bleed come into the unit, I intubate and stabilize as best as I can and call the on-call GI physician. It's about 11pm. I hear them clicking through the chart, then they tell me "oh so this patient had a colonoscopy about 6 years ago by the other group, so you need to call them." I'm thinking, wtf?!

So I call the on-call paging service for this other group, who is not on call. Someone calls me back and is angry because it's late and they're not on call. They tell me it's absurd I'm calling them for this - and I agree. They refuse to come in. I go back and forth for longer than is reasonable between these two groups - who will of course not talk to each other, because then they'd have to do something.

Ultimately the person who was not on call ended up coming in. Very angry, and I don't disagree.

Rinse and repeat with ENT, who no matter what usually doesn't come in for anything (there are 1 or 2 who actually will come in, the rest won't). Even our trauma surgeons can't get them to come in, and they are very vocal about their feelings for our ENT groups.

In academia, it would be taken care of. That's the only good thing about academics as far as I can see. Of course that's just me, I understand people enjoy teaching etc.

 

[GassYous]

This is my one gripe about the community. By means of an example: we have 2 private GI groups that are contracted through the hospital. They share call in whatever way they agreed upon amongst their groups. Recently I had a variceal bleed come into the unit, I intubate and stabilize as best as I can and call the on-call GI physician. It's about 11pm. I hear them clicking through the chart, then they tell me "oh so this patient had a colonoscopy about 6 years ago by the other group, so you need to call them." I'm thinking, wtf?!

So I call the on-call paging service for this other group, who is not on call. Someone calls me back and is angry because it's late and they're not on call. They tell me it's absurd I'm calling them for this - and I agree. They refuse to come in. I go back and forth for longer than is reasonable between these two groups - who will of course not talk to each other, because then they'd have to do something.

Ultimately the person who was not on call ended up coming in. Very angry, and I don't disagree.

Rinse and repeat with ENT, who no matter what usually doesn't come in for anything (there are 1 or 2 who actually will come in, the rest won't). Even our trauma surgeons can't get them to come in, and they are very vocal about their feelings for our ENT groups.

In academia, it would be taken care of. That's the only good thing about academics as far as I can see. Of course that's just me, I understand people enjoy teaching etc.

Ha when I was an intern in the ED I had a patient come in with a nonfunctioning g tube that needed to be replaced that evening. I tried to flush it, use cola etc. nothing going. I saw that it was placed during a combined trach/g tube under an omfs surgeon.

So I called the omfs resident who said they don't do g tubes so try calling general surgery. I called gen surg and the consult resident said it's not the kind of g tube that they typically place. Because they didn't put it in, they don't want to be responsible for it. They suggested I talk to GI. I asked GI and same thing with a suggestion for contacting IR. I asked IR if they would replace it and it was a no go. So I called oral surgery again and told them that I thought because it was done during their procedure they should be primary and figure out the situation.

After some chart review, it turned out that the original trach/g-tube was a combined oral surgery and ent case and it was an ENT attending who actually put the g tube in while oral surgery was traching. So after several hours and many phone calls, I was able to admit this g tube patient to ENT.

 

[Tipsy McStagger]

Ha when I was an intern in the ED I had a patient come in with a nonfunctioning g tube that needed to be replaced that evening. I tried to flush it, use cola etc. nothing going. I saw that it was placed during a combined trach/g tube under an omfs surgeon.

So I called the omfs resident who said they don't do g tubes so try calling general surgery. I called gen surg and the consult resident said it's not the kind of g tube that they typically place. Because they didn't put it in, they don't want to be responsible for it. They suggested I talk to GI. I asked GI and same thing with a suggestion for contacting IR. I asked IR if they would replace it and it was a no go. So I called oral surgery again and told them that I thought because it was done during their procedure they should be primary and figure out the situation.

After some chart review, it turned out that the original trach/g-tube was a combined oral surgery and ent case and it was an ENT attending who actually put the g tube in while oral surgery was traching. So after several hours and many phone calls, I was able to admit this g tube patient to ENT.

And meanwhile 20 more people have checked into the department. Consult wars suck.

 

[southerndoc]

This is my one gripe about the community. By means of an example: we have 2 private GI groups that are contracted through the hospital. They share call in whatever way they agreed upon amongst their groups. Recently I had a variceal bleed come into the unit, I intubate and stabilize as best as I can and call the on-call GI physician. It's about 11pm. I hear them clicking through the chart, then they tell me "oh so this patient had a colonoscopy about 6 years ago by the other group, so you need to call them." I'm thinking, wtf?!

So I call the on-call paging service for this other group, who is not on call. Someone calls me back and is angry because it's late and they're not on call. They tell me it's absurd I'm calling them for this - and I agree. They refuse to come in. I go back and forth for longer than is reasonable between these two groups - who will of course not talk to each other, because then they'd have to do something.

Ultimately the person who was not on call ended up coming in. Very angry, and I don't disagree.

Rinse and repeat with ENT, who no matter what usually doesn't come in for anything (there are 1 or 2 who actually will come in, the rest won't). Even our trauma surgeons can't get them to come in, and they are very vocal about their feelings for our ENT groups.

In academia, it would be taken care of. That's the only good thing about academics as far as I can see. Of course that's just me, I understand people enjoy teaching etc.

Someone needs to talk to your consultants about the implications of EMTALA.

EMTALA requires that they come physically evaluate the patient if you request it, and the person listed as being on call for that specialty is responsible even if it's another group's patient. In your situation, the on-call gastroenterologist committed an EMTALA violation by not coming to see the patient.

 

[Rekt]

Someone needs to talk to your consultants about the implications of EMTALA.

EMTALA requires that they come physically evaluate the patient if you request it, and the person listed as being on call for that specialty is responsible even if it's another group's patient. In your situation, the on-call gastroenterologist committed an EMTALA violation by not coming to see the patient.

Yep. Drop the EMTALA violation line and it usually changes everyones tune. If they still give you crap. Tell them you're documenting a consult request for them to come in because they're on call and then tell them they can personally contact the other group on call themselves.

You're not some mediator. They aren't your mom and dad and you aren't inferior to any specialist. Put your big boy pants on and tell them professionally you don't tolerate any of this.

 

[Apollyon]

Reminds me of a case from when I was a resident. GI bleed. MICU resident says pt doesn't need the unit. The med resident (same year as the MICU resident) says he's not comfortable with the pt on the floor. Rightfully, IMO, the MICU resident impugns the floor guy.

Unfortunately, I do not recall how it resolved. I may be, in my mind, conflating another case with how it shook out.

 

[Tipsy McStagger]

I don't believe EMTALA applies to admitted patients (in this case - a transfer from another hospital). Also, I only have numbers for paging services, and I can't make them call them. It's just the culture of the groups here, they don't touch other people's patients, no matter how long ago it was.

 

[turkeyjerky]

Yep. Drop the EMTALA violation line and it usually changes everyones tune. If they still give you crap. Tell them you're documenting a consult request for them to come in because they're on call and then tell them they can personally contact the other group on call themselves.

You're not some mediator. They aren't your mom and dad and you aren't inferior to any specialist. Put your big boy pants on and tell them professionally you don't tolerate any of this.

Right. These attempted deferrals based on a prior relationship are such bull. They're appropriate for nonemergent, floor consults but completely out of bounds for an actual emergent consult. Although we do it to ourselves in many cases w/ how often we call to inform them of nonurgent crap way too often.

Imagine if an EM doc refused to see a patient b/c "they were just in another ER and should go back there".

 

[thegenius]

I don't believe EMTALA applies to admitted patients (in this case - a transfer from another hospital). Also, I only have numbers for paging services, and I can't make them call them. It's just the culture of the groups here, they don't touch other people's patients, no matter how long ago it was.

There is legal precedent that it does apply to admitted patients.

There was a hospital in Fl many years ago that would admit psych patients waiting in the ER for several days, and then discharge them hours later claiming that EMTALA no longer applies once they were admitted. They were successfully sued.

The overarching theme here is if someone has a medical, surgical, or psychiatric emergency the health care system is obligated to stabilize them before they are discharged. Doesn't matter if it's ER or inpatient.

 

[Dr Mantis Toboggan]

I don't believe EMTALA applies to admitted patients (in this case - a transfer from another hospital). Also, I only have numbers for paging services, and I can't make them call them. It's just the culture of the groups here, they don't touch other people's patients, no matter how long ago it was.

EMTALA definitely applies to admitted patients.

 

[Jabbed]

I think we probably agree more than disagree.

I just get annoyed by the community hospital masturbation sometimes, and the opposite is like true for folks from community residency. Academics have their disadvantages, but between first knee dislocation and having minimal exposure to transplant, lvad, sick kids, and various other things at a quartenary or tertiary place I’d rather do the one. Agree it’s not either or.

I also think academic programs need to have less tolerance for skill atrophy in Attendings and less tolerance for giving away procedures. My own residency was awful about chest tubes. I did plenty of large bore but got out of residency with only one pigtail, then promptly had to place 10 in my first year as an attending. I think I did fine despite this, but I could have had 7-8 more pigtails if my Department had fought for us.

I do question how many knee dislocations, elbow dislocations there are period. I have seen three total in 5 years of em. Judging a residency by that kind of metric seems a little odd. Judging them for giving away trauma airways is completely fair, because that’s ridiculous.

Having said that aside from the c collar I think those are some of the easier tubes I did in residency or practice. Active Gi bleeds, sick dka etc get a much higher sphincter tone from me.

Managing sick transplant patients involves starting antibiotics and calling the transplant team to have them grumble at you.

Managing LVAD patients involves checking wires, fluids +/- pressors, and calling the cardiac transplant team to have them grumble at you.

Managing chronically sick kids involves starting antibiotics, fluids, suctioning trachs/nebs and calling the PICU to have them grumble at you. Nobody really sees that many genetically normal sick kids during residency (myocarditis, epiglottitis, legitimately bad DKA) because there just aren't that many out there. When they do come in, PEM fellow swoops in for intubation because they've only gotten 10 tubes over 3 years.

The presence of a c-collar is the least difficult aspect of a true trauma airway. I'm referring specifically to trauma involving the airway. True trauma airways are patients that are shot in the mouth, expanding neck hematomas, Lefort fractures, inhalation burns were the epiglottis is sloughing off as you're trying to advance the tube. I wouldn't have traded those experiences for another 100 routine intubations on anesthesia or even emergent ones in the ED.

 

[southerndoc]

EMTALA definitely applies to admitted patients.

To my knowledge, and the law is complex and open to interpretation by the CMS investigator, I do not believe it applies to admitted patients who are transferred from another facility directly to an inpatient bed. I believe it applies to patients who are admitted from an ER though until their condition stabilizes.

There was a recent case where a psychiatric patient was in observation status for 2 days and then sent to a mental health facility by private vehicle 150 miles away. The patient jumped out of the moving vehicle at 65 mph and died. The court ruled that EMTALA applied even though the patient was admitted under observation status. Whether it applies to true admissions is depending on the circumstances.

GovInfo

Official Publications from the U.S. Government Publishing Office.

www.govinfo.gov

 

[MedicineZ0Z]

Why not take a course or two to address those deficiencies? Seems like the simple solution rather than a whole fellowship...

 

[Lexdiamondz]

Why not take a course or two to address those deficiencies? Seems like the simple solution rather than a whole fellowship...

Because simulations =/= real life.

Not once has **** ever been hitting the fan, where I thought to myself "I wonder what my simulation director would do right now"

 

[MedicineZ0Z]

Because simulations =/= real life.

Not once has **** ever been hitting the fan, where I thought to myself "I wonder what my simulation director would do right now"

If you want some more exposure to a couple of specific things, then courses can be a practical way to fill in that gap. Doing a fellowship just to maybe get to practice those things a few more times isn't realistic when one might also have other priorities in life

 

[Lexdiamondz]

If you want some more exposure to a couple of specific things, then courses can be a practical way to fill in that gap. Doing a fellowship just to maybe get to practice those things a few more times isn't realistic when one might also have other priorities in life

Again. Simulation =/= real life.

Tubing a mannequin at a conference center in Orlando isn't going to get you ready for when the 400 lb dope fiend decides to drink from the Purell dispenser on the wall and starts seizing. You learn emergency medicine by doing emergency medicine.

 

[RustedFox]

Again. Simulation =/= real life.

Tubing a mannequin at a conference center in Orlando isn't going to get you ready for when the 400 lb dope fiend decides to drink from the Purell dispenser on the wall and starts seizing. You learn emergency medicine by doing emergency medicine.

Oh my Lord.
I have seen that so many times.
Well; not all of them seized... but "400 lb dope fiend drinking from the Purell dispenser on the wall."

 

[dadaddadaBATMAN]

Managing sick transplant patients involves starting antibiotics and calling the transplant team to have them grumble at you.

Managing LVAD patients involves checking wires, fluids +/- pressors, and calling the cardiac transplant team to have them grumble at you.

Managing chronically sick kids involves starting antibiotics, fluids, suctioning trachs/nebs and calling the PICU to have them grumble at you. Nobody really sees that many genetically normal sick kids during residency (myocarditis, epiglottitis, legitimately bad DKA) because there just aren't that many out there. When they do come in, PEM fellow swoops in for intubation because they've only gotten 10 tubes over 3 years.

The presence of a c-collar is the least difficult aspect of a true trauma airway. I'm referring specifically to trauma involving the airway. True trauma airways are patients that are shot in the mouth, expanding neck hematomas, Lefort fractures, inhalation burns were the epiglottis is sloughing off as you're trying to advance the tube. I wouldn't have traded those experiences for another 100 routine intubations on anesthesia or even emergent ones in the ED.

I wrote out a lot of specific responses to this, but in an effort to be brief while I have a lot of respect for you jabbed (seem like a bright guy/gal from what you write) I have no respect for that post.

You should involve consultants early in complex patients. But in the community they aren’t seeing the pt, you are, and you’ll be managing stuff until they transfer since your hospitalist friends don’t do this kind of patient. Might be hours or days in current environment. Having an intelligent conversation on possibility of pump thrombosis and knowing when setting indicate distributive shock in lvad or that they get avms, bleed like stink and have weird embolus things etc. are good to know. The same could be said for transplant on other stuff (mostly just respect them, they’re sicker than they look and expect weird ****).

Sick kids are a lot more common than people who Hemingway themselves, or transect their trachea on a saw. Peds em didn’t exist where I trained. I saw plenty of these, and intubated my share of kids, ran (more than) my share of pediatric codes.

And the poster I responded to was talking about a blanket response of anesthesia to airways for trauma. I agree that is obviously unacceptable. Most trauma tubes are drunk uncooperative people in c collars that trauma wants intubated for convenience. The rare inhalation injury airway is obviously an important em experience.

 

[MedicineZ0Z]

Again. Simulation =/= real life.

Tubing a mannequin at a conference center in Orlando isn't going to get you ready for when the 400 lb dope fiend decides to drink from the Purell dispenser on the wall and starts seizing. You learn emergency medicine by doing emergency medicine.

I'm talking specifically about OP. He's doing an EM residency lol. I have found courses to be very helpful in filling in gaps (before and after - for improving patient procedure performance).