working in EDs without the latest gadgets

[GTP]

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Hey guys. I'm an intern working at a pretty busy level 1 trauma center and we have really good ancillary staff here. It is not uncommon for RTs to see patients and administer treatments before I walk into the room and nurses know to get EKG's and have blood drawn for older chest pain patients. At this point in my residency, I still find the RT's very useful in helping me understand certain vent modes and settings. I haven't done a trauma or ICU rotation yet. In addition, we have glidescopes and ED bedside ultrasound readily available. I just recently got engaged (I'm in a long distance relationship) and have decided to move back to where my fiancé lives after graduation. It's a very affordable city of 15 k people, and we only want to stay there for about a year or two depending on the shortest contract. Our plan is to move to a mid-sized city somewhere warm after the contract. My fiancé and I see this as a nice way to save money, and it would be a huge weight off my back in terms of moving because I would simply sell all my things and move back into his apartment with my one or two suitcases. There are 2 hospitals in the city, and another one 30 minutes away. I rotated at the former 2 briefly as a 3rd yr medical student, and I don't remember seeing ultrasound, glidescopes or anything. I don't even remember ever seeing an RT at bedside during an intubation (or maybe I just didn't notice). At my current shop, RT is glued to me during RSI, asking what I need and getting it ready even before I can think to ask for it.

My question is directed at people who work at these EDs with limited resources. I'm wondering if it is a bad idea to "downgrade" from what I'm used to. I really can't imagine having to use indirect laryngoscopy for a >2/3 mallampati airway, or not having an ultrasound with me for my abd pain patients. I walk in with it during my initial eval of the patient. I know it's still early in my career and there is still time to gain confidence, but I don't want to put patients' lives at risk because of not having resources that I consider standard of care. I'd love to hear your two cents.

Thanks

 

[deleted547339]

Hey guys. I'm an intern working at a pretty busy level 1 trauma center and we have really good ancillary staff here. It is not uncommon for RTs to see patients and administer treatments before I walk into the room and nurses know to get EKG's and have blood drawn for older chest pain patients. At this point in my residency, I still find the RT's very useful in helping me understand certain vent modes and settings. I haven't done a trauma or ICU rotation yet. In addition, we have glidescopes and ED bedside ultrasound readily available. I just recently got engaged (I'm in a long distance relationship) and have decided to move back to where my fiancé lives after graduation. It's a very affordable city of 15 k people, and we only want to stay there for about a year or two depending on the shortest contract. Our plan is to move to a mid-sized city somewhere warm after the contract. My fiancé and I see this as a nice way to save money, and it would be a huge weight off my back in terms of moving because I would simply sell all my things and move back into his apartment with my one or two suitcases. There are 2 hospitals in the city, and another one 30 minutes away. I rotated at the former 2 briefly as a 3rd yr medical student, and I don't remember seeing ultrasound, glidescopes or anything. I don't even remember ever seeing an RT at bedside during an intubation (or maybe I just didn't notice). At my current shop, RT is glued to me during RSI, asking what I need and getting it ready even before I can think to ask for it.

My question is directed at people who work at these EDs with limited resources. I'm wondering if it is a bad idea to "downgrade" from what I'm used to. I really can't imagine having to use indirect laryngoscopy for a >2/3 mallampati airway, or not having an ultrasound with me for my abd pain patients. I walk in with it during my initial eval of the patient. I know it's still early in my career and there is still time to gain confidence, but I don't want to put patients' lives at risk because of not having resources that I consider standard of care. I'd love to hear your two cents.

Thanks

Eh, the US for abd pain is kind of overrated....and I don't like the glidescope, much more of a C-MAC guy. Besides, I think a bougie is the best airway backup you can have. Also, there is probably more there than you noticed, but you probably weren't looking for it at the time. The place I moonlight at (small, community ED), has an US, but I'm the only one that knows how to use it.

You need to be somewhere that you feel comfortable. I wouldn't feel comfortable working somewhere without US. I feel that US guided CVL is now standard of care and I wouldn't want to work somewhere that I couldn't meet standard of care <cue shouts from older EM guys>

 

[Daiphon]

Eh, the US for abd pain is kind of overrated....and I don't like the glidescope, much more of a C-MAC guy. Besides, I think a bougie is the best airway backup you can have. Also, there is probably more there than you noticed, but you probably weren't looking for it at the time. The place I moonlight at (small, community ED), has an US, but I'm the only one that knows how to use it.

You need to be somewhere that you feel comfortable. I wouldn't feel comfortable working somewhere without US. I feel that US guided CVL is now standard of care and I wouldn't want to work somewhere that I couldn't meet standard of care <cue shouts from older EM guys>

No shouting. Everyone has their own level of comfort.

I will say to the OP, however, that one should learn to do these things sans fancy toys. Even in a well-equipped shop, stuff breaks or goes missing or is being used by another practitioner.

For me, VL is my backup; and I agree with TNR that the bougie is really all you'll need. I prefer US lines, but if they're that sick & I don't have US, IO or landmark CVL's are where it's at... remember, too, that a CVL isn't best in a code - you want short & fat (PIV or IO) and can run pressors peripherally until they're stabilized & shipped.

Cheers!
-d

 

[Daedalus]

I will say to the OP, however, that one should learn to do these things sans fancy toys. Even in a well-equipped shop, stuff breaks or goes missing or is being used by another practitioner.

Just a resident here myself, but I completely agree with this sentiment. I also use VL as my backup - never use it unless I have to. I think every EM doc needs to be proficient and comfortable with DL and at least one type of landmark-based central line. Personally, I love subclavian lines. Go-to is still U/S-guided IJ of course, but in certain patients subclavians are ideal, and I find them easy and quick.

 

[namethatsmell]

Don't be afraid to work somewhere with fewer bells and whistles. It will make you more resilient and a better doc.

The one adjunct I encourage you to learn now is the bougie. As the above posters mention it really is that clutch.

IMHO, short version of toy wish list at a smaller site = Bougie>IOs>Ultrasound with working vascular and cardiac probes (abdominal probe a plus)>>>>>>>>>Glidescope. Of course, if there's a SW or somebody similar to handle pysch transfers that could be a trump card for all of these.

 

[deleted77919]

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[RustedFox]

I would not work at a hospital without an US. I like being able to do a FAST or quick look at the aorta (especially if I'm somewhere where those issues will require transfer). More importantly I feel that US guided central lines are standard of care. (Yes you can always place an IO. Yes you can very temporarily run through a peripheral.) Especially for a patient I have to transfer, I prefer providing as much of their definitive care as I can. Much better than letting them sit with levophed infusing through a peripheral while they wait 2 hours for transport and then another hour before they get to the receiving hospital.

If the hospital can't justify $50k for an US machine what else are they skimping on?

50k for an ultrasound machine? In what (currency)... Coins from Super Mario Brothers?

EDIT: [KingKoopa likes this.]

 

[GeneralVeers]

I would have no problem working in a place with few resources......as long as it pays well. No US? Great I'm not doing any lines except for emergent femoral. FAST is highly overrated, and haven't done one in the last year, despite working at two places with US. I'd rather just get the patient to CT quickly, which I can usually do in 5-10 minutes if I push hard enough. In a L3 trauma center, my surgeon isn't going to come in from home and operate rapidly enough for a FAST to change the outcome.

If there's a bad outcome become the hospital doesn't have US or some other tech gadget, I don't think the ED physician could be held liable.

 

[Janders]

(1) You need to be proficient without gadgets. Even if you think you'll never work in a community hospital without bedside U/S and a glidescope, one day your glidescope will break during an intubation (seen that!) or your U/S will short circuit and fry your partner during a code (that one was great!). Most hospitals don't have multiple U/S machines and glidescopes waiting in reserve on immediate notice. You'll work during a 48 hour blizzard with limited access to transfers due to the state highways being shut down. You'll work during a hurricane and 4/5 back generators at the hospital will die, killing your CT and formal U/S. Your CT machine will go down for 72 hours, repeatedly. You'll be called to a dark corner of the hospital to code a floor patient with only what you can carry up 4 flights of stairs. These are just a couple things I've seen the past few years... you have to be ready to rely on your training, physical exam, and DL. But don't worry, as you progress through training you'll grow more confident with only these things!

(2) DL and glidescope are DIFFERENT. Even though glidescope is typically EASIER then DL, there are patients whom you will fail with the glidescope and rescue yourself with DL. Massive upper GI bleed is one classic example, as the blood is going to block your video camera...
I make it a point to use DL on at least every-other patient just to keep myself proficient in both.

(3) Things are getting CHEAP. It would NOT be ridiculous for you to purchase a hand-held U/S and a small CMAC or similar videoscope to keep in your work bag if you are going to be occasionally working in small hospitals without these toys. Ask whitecoatinvestor about potential tax write off situations 😉

 

[The White Coat Investor]

I agree and didn't take a job that didn't have an US machine and a glidescope. Not that hard to find, even in community hospitals. Everyone else coming out of training for the last 10 years feels the same way you do.

 

[Arcan57]

I agree and didn't take a job that didn't have an US machine and a glidescope. Not that hard to find, even in community hospitals. Everyone else coming out of training for the last 10 years feels the same way you do.

If it's that much of an issue for you then it's probably worth buying your own.

 

[The White Coat Investor]

If it's that much of an issue for you then it's probably worth buying your own.

Nonsense. It isn't that the US is an issue. It's the fact that the administration/hospital is not responsive to your needs. That's a much bigger issue. The lack of an US/glidescope is just a symptom of the disease. You don't want to work in an ED where the hospital doesn't provide the stuff you need to do your job. It might be the US today, it'll be suture tomorrow, and next year it'll be orthopedists on the call list or an inadequate number of nurses.

You going to buy all that yourself too?

 

[Janders]

Agree with whitecoat when you're looking at a permanent / semi-permanent job, but if you are moonlighting / locums / traveling / firefighting there could be a role for having your own pocket U/S...

 

[Angry Birds]

I work at a critical access hospital. I bought a King Vision VL for only $1500. I like it better than the glidescope since it has a guided channel. Issue with the glidescope is passing the tube.

As an aside, anyone else like the King Vision VL? Did I waste my money? :'(

 

[EMIM2011]

I work at a critical access hospital. I bought a King Vision VL for only $1500. I like it better than the glidescope since it has a guided channel. Issue with the glidescope is passing the tube.

As an aside, anyone else like the King Vision VL? Did I waste my money? :'(

I use it too, mostly when working internationally. I prefer the Glidescope, but the King was what I could reasonably afford. I have had issues with not being able to advance the ETT through the channel, particularly when working in a >100F environment, the tube becomes really boggy. And the non-channeled blade somewhat negates the benefits of the hyperangulated approach for anterior airways. So, what I started doing is that I will just advance a bougie through the channel, and then railroad the ETT over it. Makes it much easier to advance it.

 

[Angry Birds]

I use it too, mostly when working internationally. I prefer the Glidescope, but the King was what I could reasonably afford. I have had issues with not being able to advance the ETT through the channel, particularly when working in a >100F environment, the tube becomes really boggy. And the non-channeled blade somewhat negates the benefits of the hyperangulated approach for anterior airways. So, what I started doing is that I will just advance a bougie through the channel, and then railroad the ETT over it. Makes it much easier to advance it.

Out of curiosity, what do you prefer the GL over the King? Just overall quality?

 

[deleted547339]

You like the C-MAC? Can't stand that thing. The clear blade is just awful. The whole point of it is to be able to perform DL as learning technique while everyone else can watch and see what you see - but DL with the C-MAC is just so much worse than regular good old steel DL. Plus, GS's are just so intuitive, like playing a video game that you can always win.

I LOVE the C-MAC. We don't have disposable blades. We have standard geometry steel blades.

 

[EMIM2011]

Out of curiosity, what do you prefer the GL over the King? Just overall quality?

Yes, a little sturdier, bigger screen, overall quality. None of these are true game changers, I think the King will save you as well as the GL will in difficult airway situations.

 

[GTP]

Thanks you guys I appreciate all the good feedback. However, it seems like alot of these things are not under my control. I ran my first code in the ED recently and the attending demanded I used the glidescope from the get go. As a 4 month intern, I can't really say no to an attending in situations like that. I have seen senior residents do blind central lines and direct laryngoscopy when they respond to hospital codes. I don't usually see attendings there. So maybe I need to go to more codes

 

[engineeredout]

Thanks you guys I appreciate all the good feedback. However, it seems like alot of these things are not under my control. I ran my first code in the ED recently and the attending demanded I used the glidescope from the get go. As a 4 month intern, I can't really say no to an attending in situations like that. I have seen senior residents do blind central lines and direct laryngoscopy when they respond to hospital codes. I don't usually see attendings there. So maybe I need to go to more codes

Maybe mid code isn't the best time to ask, but in other intubation situations why not just ask your attendings if video laryngoscopy is your shop standard "Hey do you mind if I do DL for practice?" Can't imagine too many would mind letting you have your shot at it.

For me it's MAC blade DL primarily and glide scope as a second line, but I've asked to do blind boogie intubations or miller blade intubations just to get the experience (on appropriate patients) and don't usually get turned down. If the patient is more critical and there isn't the time to mess around, I go with what I'm comfortable with.

Same with central lines for that matter. I have some attendings who insist I do blind CVCs because they know I know how to put one in with US but they want me to have the experience.