What’s working at a critical access ED like?

[plick]

For those with long experience working these shops... What’s a typical shift like? How good are your nursing staff? Do you manage/round on admitted floor patients as well? Can you actually get some sleep on overnights? Do you have access to CT scanners? And as an aside, what rate did you get as locums/traveler?

The place I’ll start working at sees about 1.4 patients per hour. Pretty good pay. The closest large hospital is actually only about 1.5 hour car ride, so not too bad distance wise.

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[betamale]

Depends, if u have a helipad nearby and a receiving hospital within 1 hr of driving distance, not too bad.

I've worked PRN at 3 critical access EDs (single coverage), once, I had 2 NSTEMIs and a really bad stroke (tPA candidate) show up all at once and another shift where a preterm delivery, brain bleed, and STEMI showed up within 2 hrs with a full waiting room, another shift where I had several sick asthmatic/croup, bronchiolitis kids show up... Very scary but you can become very confident with your skills quickly once you go through that...no back up...thank God I did not have a difficult airway or bad trauma...the transfer process were easy

Nurses were great. We had US, CT (24 hrs in house), and MRI. No floor rounding. I got to admit whoever I wanted except ICU ... I had to cover in-house emergencies, codes, transfers of crashing pts...

 

[Apollyon]

My nurses suck. There was a long while with a totally useless, ****ty director of nursing, who drove away more than 20 RNs. As such, they would hire ANYONE who had a license. Since the best ED nurse was promoted, now, every shift has at least one nurse who doesn't have any nursing skills (and this is before ****ty personalities). Our closest receiving hospital is ~100 miles away.

And covering transfers of crashing pts? TO you? If you are critical access, that doesn't even make sense.

 

[betamale]

I can transfer sick pts out like floor STEMI, strokes, kids that need tele... to higher level of care...

 

[TheComebacKid]

We rotate at one critical access hospital as residents. Take my n=1 with a grain of salt.

I would wager that no two critical access hospitals are alike. Our critical access hospital is within the network of our university/academic affiliate, making transfers for higher level of care very straight forward.

The nurses, are clearly inferior in their skills compared to those at the academic center. They get bogged down with simple tasks such as checking a blood sugar on a patient who is post ictal. "I'll do it as soon as I finish charting doc." To which I respond, "no please do it now." Fingerstick blood sugar reading: undetectably low. They really lack certain skills.

That being said, probably because I take none of the financial liability, I love working in that particular ED. The sick patients are fun to stabilize and ship off, many of the patients who have other complaints have primary physicians. The ED attending at this site is really universally the strongest and most experienced physician in the entire hospital. I know why that may make people feel uncomfortable i.e. having to leave the ED to respond to a code on the floor, but regardless, depending on what you are looking for, it might be a good gig.

It is most definitely single coverage. While I've never really seen any of the attendings sleep overnight, you may end up seeing 6 or 7 patients on some night shifts depending on how busy it is.

 

[scummie]

I rotated at a hospital like this in residency. The patients are still sick AF but you don’t have as many resources. It also depends on how brave your inpatient team is. There was no ICU, BIPAP patients were almost “too sick”. Fine line between sick enough to get admitted versus transferred out for being too complicated. Anything Peds, Ob, Trauma, psych, bye! They wouldn’t be rerouted, but still show up. You’re welcome!

I’d take a good look at your transferring process, especially if you aren’t affiliated with a bigger or tertiary system. That can be a huge pain. Sometimes I felt like I spent more time transferring people than taking care of patients. Nursing probably varies depending on your region. You might be the only doc at night. That could mean you have to go to codes, intubate or place lines.

I would say it was nice for some things, like knowing the only two GS on call and that they were very proactive. I have a buddy who signed with this hospital and he loves it. Not for me. Whatever floats your boat.

 

[Tenk]

I work primarily at a critical access hospital that has around a 23,000 volume. I also work at an academic site and did residency at a place with 100,000+ so I’ve seen a lot. I personally really enjoy working in the small places. It has more of a small town feel, everyone knows everyone and usually get along great because the people who don’t usually don’t last. I know the ceo of the hospital and he occasionally comes by and chats. I feel a lot more support than I do when I work in a bigger center and am just another worker bee.

In terms of medicine it can actually be pretty fun. You are basically it. I can call in a surgeon and OB if I need it but everything else I pretty much have to take care of. I think it makes you a better doc because you can’t just call someone and have a resident come down to take care of it.

To answers your questions: shifts vary just like any other place. There are some shifts I just sit around a few hours and watch movies though. Nursing staff vary. I’d say they are a lot nicer and follow your orders better than a busier place but at the same time some may not be as independent and forward thinking. Pluses and minuses I guess. I do not round on admitted patients. I used to get sleep most overnights, now not so much ever. We have 24 hr ct and us. Dunno about locums.

 

[88222]

I work primarily at a critical access hospital that has around a 23,000 volume. I also work at an academic site and did residency at a place with 100,000+ so I’ve seen a lot. I personally really enjoy working in the small places. It has more of a small town feel, everyone knows everyone and usually get along great because the people who don’t usually don’t last. I know the ceo of the hospital and he occasionally comes by and chats. I feel a lot more support than I do when I work in a bigger center and am just another worker bee.

In terms of medicine it can actually be pretty fun. You are basically it. I can call in a surgeon and OB if I need it but everything else I pretty much have to take care of. I think it makes you a better doc because you can’t just call someone and have a resident come down to take care of it.

To answers your questions: shifts vary just like any other place. There are some shifts I just sit around a few hours and watch movies though. Nursing staff vary. I’d say they are a lot nicer and follow your orders better than a busier place but at the same time some may not be as independent and forward thinking. Pluses and minuses I guess. I do not round on admitted patients. I used to get sleep most overnights, now not so much ever. We have 24 hr ct and us. Dunno about locums.

What skills/knowledge did you have to pick up on the job that you weren't exposed to in residency, if any? I feel like being critical access means you're responsible for a tad bit more than better resourced places, where they are more accustomed to punting certain patient care stuff to other services. Maybe I'm off the mark?

 

[Tenk]

What skills/knowledge did you have to pick up on the job that you weren't exposed to in residency, if any? I feel like being critical access means you're responsible for a tad bit more than better resourced places, where they are more accustomed to punting certain patient care stuff to other services. Maybe I'm off the mark?

I think you'll get enough intubations, central lines, chest tubes, LPs, paracentesis, and other basic procedures in an EM residency that those all become bread and butter that I still use on the regular and don't feel any lacking in skill when push comes to shove.

The things I didn't expect as much:
I've done a lot of dental trauma that I think many attendings I trained under would have punted for sure.
I've had to stabilize bleeding/reduce some pretty crazy open fractures before I can ship them.
I don't have neurosurgery, cardiology, GI, crit care/pulm, ortho, so any emergent condition (ie ICH, STEMI, massive GI bleed, etc) I have to manage and control much longer than in residency until they get shipped. Luckily I did a lot of this moonlighting so it's fine.
We don't have dialysis so sometimes I have to stabilize dialysis patient's longer than I would like.
I do a ton more non-code cardioversions than I did in residency but I don't know if that is just because I am comfortable with them or not.
I am glad I did a lot of slit lamping during residency because I need it a lot out here because a lot of guys do metal working.
I occasionally do stuff like pull out ureteral stents, pull out IUDs, and other lines and stuff that the specialists don't want to be bothered with. It's not hard or anything but I know a lot of ED attendings would never do that for whatever reason. You just need a higher comfort level with whatever you are doing is all.
If I think of anything else I'll mention it but can't really atm.

 

[Apollyon]

I work primarily at a critical access hospital that has around a 23,000 volume. I also work at an academic site and did residency at a place with 100,000+ so I’ve seen a lot. I personally really enjoy working in the small places. It has more of a small town feel, everyone knows everyone and usually get along great because the people who don’t usually don’t last. I know the ceo of the hospital and he occasionally comes by and chats. I feel a lot more support than I do when I work in a bigger center and am just another worker bee.

In terms of medicine it can actually be pretty fun. You are basically it. I can call in a surgeon and OB if I need it but everything else I pretty much have to take care of. I think it makes you a better doc because you can’t just call someone and have a resident come down to take care of it.

To answers your questions: shifts vary just like any other place. There are some shifts I just sit around a few hours and watch movies though. Nursing staff vary. I’d say they are a lot nicer and follow your orders better than a busier place but at the same time some may not be as independent and forward thinking. Pluses and minuses I guess. I do not round on admitted patients. I used to get sleep most overnights, now not so much ever. We have 24 hr ct and us. Dunno about locums.

Are you actually "critical access", or just rural? If you have 23K volume, you should be making money, which means that you are not "critical access". Critical access gets money from the state to help stay open, due to low, low volumes, but being somewhere that, if they closed, would put undue stress on the population, who would have to travel at least 25 miles to get to a hospital.

We're at about 7500, and we are not critical access. There is talk of going there, but zero progress.

 

[carbonizedeyesockets]

And to be critical access, you can’t have more than 25 inpatient beds. With a volume of 23000, I can’t see having 25 or less beds. One hospital I work at Has a volume of 19000. We have around 50-60 beds total.

 

[Tenk]

Are you actually "critical access", or just rural? If you have 23K volume, you should be making money, which means that you are not "critical access". Critical access gets money from the state to help stay open, due to low, low volumes, but being somewhere that, if they closed, would put undue stress on the population, who would have to travel at least 25 miles to get to a hospital.

We're at about 7500, and we are not critical access. There is talk of going there, but zero progress.

We are actually a critical access hospital. We have 25 inpatient beds and 21 ED beds. Crazy eh? We reside in a rural area with multiple neighboring towns that have no local hospital and tons of nursing homes. This shoots our ED census to the moon.

 

[RoyBasch]

Do you manage/round on admitted floor patients as well? Can you actually get some sleep on overnights? Do you have access to CT scanners? And as an aside, what rate did you get as locums/traveler?

Not all of these hospitals are created equal. Any ER without access to CT cannot provide the standard of care. I don't think you want to work at a hospital where you have to round on admitted patients. This isn't Somalia, you are not trained and certified to provide ongoing inpatient care. If they ask you to do this, look away.

I think the most important thing I would want to know about a small/critical access hospital is that they have pre-negotiated transfer agreements with bigger hospitals for common emergencies like stroke, STEMI, peds, etc. You want to make sure these processes have been worked out with the receiving hospitals in advance so that when the time comes to initiate the transfer it goes quickly and smoothly with minimal push back. I have had colleagues who have had to call 5+ hospitals to transfer a type A dissection from a critical access hospital with weak relationships with the bigger centers. That is not a fun situation to sit on while all the hospitals you try to call say "lol nope."

Its your life and your license, nobody is holding a gun to your head and saying you have to practice at one of these places. So do your research and make sure it's a reasonable place to work. There are solid rewarding critical access hospitals out there, I am not ****ting on them across the board.

It has been discussed ad nauseum on this board, but many of the highest paying locums shops are deeply dysfunctional and they might pay you in high dollars but they will get their pound of flesh out of you in exchange. Most residencies are at flagship academic hospitals and ER where things run very well with deep resources. The pain of working in a dysfunctional shop may not be readily apparent to you if you haven't experienced it yet, which is why the staffing companies deliberately prey on new grads with huge hourly wages.

 

[carbonizedeyesockets]

Not all of these hospitals are created equal. Any ER without access to CT cannot provide the standard of care. I don't think you want to work at a hospital where you have to round on admitted patients. This isn't Somalia, you are not trained and certified to provide ongoing inpatient care. If they ask you to do this, look away.

I think the most important thing I would want to know about a small/critical access hospital is that they have pre-negotiated transfer agreements with bigger hospitals for common emergencies like stroke, STEMI, peds, etc. You want to make sure these processes have been worked out with the receiving hospitals in advance so that when the time comes to initiate the transfer it goes quickly and smoothly with minimal push back. I have had colleagues who have had to call 5+ hospitals to transfer a type A dissection from a critical access hospital with weak relationships with the bigger centers. That is not a fun situation to sit on while all the hospitals you try to call say "lol nope."

Its your life and your license, nobody is holding a gun to your head and saying you have to practice at one of these places. So do your research and make sure it's a reasonable place to work. There are solid rewarding critical access hospitals out there, I am not ****ting on them across the board.

It has been discussed ad nauseum on this board, but many of the highest paying locums shops are deeply dysfunctional and they might pay you in high dollars but they will get their pound of flesh out of you in exchange. Most residencies are at flagship academic hospitals and ER where things run very well with deep resources. The pain of working in a dysfunctional shop may not be readily apparent to you if you haven't experienced it yet, which is why the staffing companies deliberately prey on new grads with huge hourly wages.

I imagine that actual EDs without any access to CT are pretty rare even for critical access. Do you have to call someone in from home? Sure, but I have to do that at my low volume ED on the weekends. And I would imagine that rounding on inpatients is especially rare, at least I hope so. In no way would I ever accept that.

Your second paragraph is clutch, though. There needs to be a process hammered out for transfers. One should not ever have to part the sea to get a pt transferred. No specialists in house? Fine. But, no transfer agreements? F’ that.

 

[TooMuchResearch]

Agreed, easy transfer is key.

Of course, when the usual transfer centers are closed, it helps to keep a mental (or department) list of other options.

 

[RustedFox]

+1 for the sentiments regarding transfer arrangements.
But this shouldn't be your problem.
This is a great way to wake up an admin and have them do their job.
I'm just there to do the medicine. YOU need to find me a place to put the patient, if I can't care for them here.
Wakey-wakey, DeekheadCMO.

 

[s109442]

For those with long experience working these shops... What’s a typical shift like? How good are your nursing staff? Do you manage/round on admitted floor patients as well? Can you actually get some sleep on overnights? Do you have access to CT scanners? And as an aside, what rate did you get as locums/traveler?

The place I’ll start working at sees about 1.4 patients per hour. Pretty good pay. The closest large hospital is actually only about 1.5 hour car ride, so not too bad distance wise.

I have been working in a critical care hospital for 6 years. I am 39 years young. Volume is 11K. 24 hr shifts. Transfer agreements are excellent, as are my personal relationships with cardiology, orthopedics and general surgery. Nursing is good enough. There is 24/hr coverage by general surgery and ortho. CRNA only shop. Looking back at last years logs I had 23 intubations. I am responsible for floor patients from 11pm to 7am and write admission orders during those times. I sometimes sleep 6 hrs straight. usually it’s 2-3 hrs sleep, then pt or 3 then back to sleep. $170/hr plus a quarterly bonus. Multiple times a year 2x pay shifts are available and 1-3x a year I am offered 3x pay to cover a 24/hr shift. I am happy because this structure allows me to travel with 22-23 days off per month. Married with one English setter named Marley. Please PM with any questions

 

[TooMuchResearch]

That seems like a lot of intubations for the setting. What is your pathology...or lack of traffic control like in the area?

I'm surprised you get that much sleep at an 11k location.

 

[TXEMC344]

That seems like a lot of intubations for the setting. What is your pathology...or lack of traffic control like in the area?

I'm surprised you get that much sleep at an 11k location.


Not all "Critical Access" hospitals are "Critical Access".

 

[Apollyon]

That seems like a lot of intubations for the setting. What is your pathology...or lack of traffic control like in the area?

I'm surprised you get that much sleep at an 11k location.


Not all "Critical Access" hospitals are "Critical Access".

Considering I'm at a rural hospital that is not critical access, you have to expand on this.

11k volume, 23 tubes by one doc in a year? That is quite an outlier, sure, but you need more meat on that.

And, it seems like you took a harder way to quote that, than just clicking "reply".

 

[miacomet]

I've worked at a bunch and really enjoyed them, for the most part. I found the nurses to be great and rural patients tended to be nice. Lots of transfers, for sure, but also easy to get follow-up. One had an awesome cafeteria with all local food.

 

[turkeyjerky]

I'm sitting here halfway through a 48 hr shift. 5 bed ED, volume is about 3k per year. Saw 7 or 8 patients yesterday and slept about 6 hrs (about half the time I get an uninterrupted full night of sleep). Had 1 super sick septic shock, 1 transfer for a chest pain r/o ACS--rest were easy discharges (this place transfers everything other than mild chf/copd exacerbations or someone needing like 24 hrs of IV abx). 24 hr labs, plain films and CT. US during the day but nobody on call overnight.

I would not want to do this full time for the rest of my life, as I'd die of boredom and have serious skill atrophy but as a part time gig for a few months I'll take it.

Getting 250/hr, but I think the standard rate here is more like 140.

 

[Fox800]

I'm about to start at two places like this in a suburban-ish area. Something bigger than an FSED but not as big as most typical hospitals. 50 beds attached, 8 bed ED (single coverage). 24/7 CT and US but MR is daytime hours only. 10 minutes to STEMI/stroke, 20-30 minutes to tertiary peds/level 1 trauma with no traffic, through an urban environment. EM, hospitalist, and GS only. No pediatrics, GI, cardiology, ENT, OB, etc. It's gonna be a lot of transfers for sure.

Wish me luck.

 

[Groove]

I'm sitting here halfway through a 48 hr shift. 5 bed ED, volume is about 3k per year. Saw 7 or 8 patients yesterday and slept about 6 hrs (about half the time I get an uninterrupted full night of sleep). Had 1 super sick septic shock, 1 transfer for a chest pain r/o ACS--rest were easy discharges (this place transfers everything other than mild chf/copd exacerbations or someone needing like 24 hrs of IV abx). 24 hr labs, plain films and CT. US during the day but nobody on call overnight.

I would not want to do this full time for the rest of my life, as I'd die of boredom and have serious skill atrophy but as a part time gig for a few months I'll take it.

Getting 250/hr, but I think the standard rate here is more like 140.

48h shifts at that rate? Nice. Is this a locums gig requiring air travel? If that's within driving distance to wherever you live, then I'd ride that one out as long as you can, especially if it's part time, low stress and as slow as it sounds. Milk it.

 

[plick]

I'm sitting here halfway through a 48 hr shift. 5 bed ED, volume is about 3k per year. Saw 7 or 8 patients yesterday and slept about 6 hrs (about half the time I get an uninterrupted full night of sleep). Had 1 super sick septic shock, 1 transfer for a chest pain r/o ACS--rest were easy discharges (this place transfers everything other than mild chf/copd exacerbations or someone needing like 24 hrs of IV abx). 24 hr labs, plain films and CT. US during the day but nobody on call overnight.

I would not want to do this full time for the rest of my life, as I'd die of boredom and have serious skill atrophy but as a part time gig for a few months I'll take it.

Getting 250/hr, but I think the standard rate here is more like 140.

8 pts a day at $250/hr? That’s 0.33 pph! When you’re bored of that gig PM me, I will happily take over. Just kidding... kind of.

I find that some of these critical access sites actually can pay locums pretty well, surprisingly. I don’t know if the state subsidy is responsible, but I was able to negotiate $265/hr for the 1.4pph place mentioned above.