Lopressor IV... how much I hate it.

[gasnewby]

ER doc for five years. what's that, 8 hour shift, 3x/week? hardcore man. i think that equals one surgery intern year.

---

Members don't see this ad.

 

[BADMD]

I'm actually curious what the payment structure is in these hospitals where everyone works at. At the ER I'm at, while not fee for service, the more I do, the more I make.

In the time it takes to call a central line consult, I can put it it and I get RVUs.
Lacs? Sure, the longer the better. Layered? Great, high complexity, more RVUs. I + D? Stab, cut, prob, rinse, pack, Cha-Ching! Finger fracture? Get co-attending to do sedation, reduce, splint, and RVUs abound...

Surgery gets uppity when we do chest tubes, but I'm perfectly happy putting one in.

LP, paracentesis, thoracentesis...more for the bottom line. Hell, I do anooscopy an patients with BRBPR...highest paying procedure in the ED.

Leave an ECG unread? That pays about $75 and it takes 30 seconds (if that long).

The easiest way to make money in the ED is to do stuff to patients and not think about stuff they could have. I get more "credit" if I give someone the Full Rivers (all six hours of it), complete with procedures, than for any 3 of the normal BS patients. (Although a few efficiently evaluated chest pain patients can pay fairly well).

What I'm really getting at is that there must be some economics going on that rewards patients per hour or low length of stay and does not reward efficient billing. If it was economically in their favor to take care of some of this stuff, they would.

Oh, and for Doc02: In residency, I actually put in quite a few ventrics. While I'm never going to do it again, I definitely can.

 

[Farbar]

well, kimberli cox is supposed to be an attending and a moderator. i have personally gotten e-mails from her about personally attacking other posters. all that said, she is way off base. to suggest that an er doc would consult out for an i and d, central line, chest tube, etc.. is rediculous. maybe an fp working in the ed of your backwoods hospital would do that but not a ed doc who is board certified. i realize that you think surgeons know everything but i have gotten consults when on the medicine service about treating pneumonia. i mean, really, you can't figure out how to treat a pneumonia?

the bottom line: we all need each other. if you think ed docs are so stupid than work down there yourself. otherwise, shut your pie hole.

 

[blotto geltaco]

otherwise, shut your pie hole.

whoa now settle down there young fella, you are way off base here.

 

[Winged Scapula]

well, kimberli cox is supposed to be an attending and a moderator

I have been extremely open about who I am, where I trained and where I am now. Therefore, it would be very easy for you to verify that I am indeed an attending. As for being a Moderator, yes...that is also easily verifiable. No "supposed" about it.

i have personally gotten e-mails from her about personally attacking other posters.

Which has nothing to do with this thread. I have not personally attacked anyone.

all that said, she is way off base. to suggest that an er doc would consult out for an i and d, central line, chest tube, etc.. is rediculous. maybe an fp working in the ed of your backwoods hospital would do that but not a ed doc who is board certified.

Sorry to disagree with you, but I am not SUGGESTING it happens, I am STATING it happens. Yes by both FM physicians staffing an ED (although actually they did a better job) and presumably BC EM physicians. I am simply sharing my experience, which at this point in time, is much greater than yours is, given your description of your station in life. It doesn't mean that my experience happens everywhere nor is it the norm. But your statement that these things do not occur is naive and patently incorrect. There are several others here who will agree that they also have been consulted for the very same. EM physicians are perfectly capable of doing the above, yet they choose not to in our experience in many situations.

i realize that you think surgeons know everything but i have gotten consults when on the medicine service about treating pneumonia. i mean, really, you can't figure out how to treat a pneumonia?

I have never once said that surgeons know everything; again you are making assumptions. I agree that a consult to medicine for treatment of pneumonia sounds ridiculous but it would be inappropriate for me to comment further as I do not know the particular circumstances. If you want to get into a contest, I can name just as many ridiculous consults from medicine to surgery as you can the opposite.

I am quite comfortable with accepting that surgeons make mistakes just like all other physicians do.

the bottom line: we all need each other.

Agreed...you'll get no argument from me there.

if you think ed docs are so stupid than work down there yourself.

Again, putting words into my mouth. I never said ED docs were stupid and I don't think they are. As a matter of fact, I know they aren't. That is not the issue here, nor has it been in any number of other posts about the problem. What is of issue is that EM physicians need to get a thicker skin when others vent about them. Surgeons might be arrogant but at least we don't go around crying and complaining everytime someone makes a crack or complaint about us.

otherwise, shut your pie hole.

And that my friend, because you have been warned in the past, has earned you an infraction.

Have a nice night.

 

[Farbar]

ok. i apoligize for remarks that earned an infraction. i got to excited, unprofessional i know.

either way, this forum is dominated by surgeons who constantly trash all other groups. kimberli can repremand me, although deserved, but it does not change the fact: we all work together. i get a nasty e-mail for suggesting it but it is true. we need u you guys, we need internist, we need fp's, we need pediatricians, we need radiologist, we need pathologist, we need orthopods.

this is best for PATIENTS.

i will probably get another nasty e-mail from k. cox for this but it is true. no specialty is perfect. critize the ed and your ok. critize anyone else and get reprimanded. i just don't understand it.

in the ed we work our tails off every day for our patients. we try to direct them to the best care. i guess on sdi you can trash nurses but not surgeons. get a backbone.

 

[Apollyon]

Wow, that guy is as good as a neurosurgeon and a radiologist combined. Whatever they're paying him, they'd better double it!!

I once had to place a ventriculostomy and I paged Apollyon and he came and did it. True story.

The beauty of the ER is that the more they consult, the less they can be litigated. Apollyon acts like the reverse is true, like some lawyer is going to go, "huh, you consulted Cardiology, GI, IM, Pediatrics, OB-Gyn, PM&R, Surgery, and Housekeeping? This is grounds for a lawsuit!!" Meanwhile, he's down at his ER running some PCR gels and checking out karyotypes, apparently.

Tired I get - he's a normal guy, but do you have to be so combative and offensive all the time? You berate me, yet you trot out your heroics - between all of the central lines you've put in, the orders you've made sure everyone knows about, and the nurses you've owned - and you do this idiotic stuff. You're not funny, and if you're going for sarcasm, you missed it. Whether you believe it or not, EM-trained docs look at their own films (although chest/abd CT, MRI, and u/s - beyond bedside, goal-directed - are not within my level of training), and do their own procedures. Now, you seem to have a reading comprehension problem, because I didn't say that I read the MRI - I gave the clinical. And I didn't say I operated on the MRI patient - I called the neurosurgeon, who did the surgery.

As I said, I get Tired's perspective. Yours, all I can tell you is, if you are REALLY like this, and not a "paper tiger", you have a long 4 years and 7 1/2 months ahead of you. But, then again, since you're the brilliant intern, you'll savor all of it, as you save the world.

As a coda, since you didn't nut up and name where you're at, I'll tell you - sure, there are people that are consult-happy, and ones that will freely tell you that their procedure skills are weak, but I've never seen an EM-trained doc hide from a consultant or not want to talk to them for fear of a weak consult or unfinished patient - if the chart wasn't done, the workup was, and the details were filled in. Also, I've screwed up, majorly, several times, but, knock on wood, I haven't yet killed a patient, and any patient that died on me was despite my efforts, not because of them (and that dates back to my EMS days). I am so happy that, again, the people I work with are more collegial. PCRs and karyotypes? Again, dude, you're not funny, and sarcasm rarely works online.

An open question - why is it surgery juniors and interns that raise such a ruckus on SDN? Why don't you ever see a senior or attending with complaints about everything, or thumping their chests as to their procedural skill or conquering seeming battalions of nurses?

 

[Apollyon]

What is of issue is that EM physicians need to get a thicker skin when others vent about them. Surgeons might be arrogant but at least we don't go around crying and complaining everytime someone makes a crack or complaint about us.

no specialty is perfect. criticize the ed and your ok. criticize anyone else and get reprimanded. i just don't understand it.

Kinetic (and his various incarnations) made a cottage industry of it. doc02 is picking the ball up. Various others have intermittently rung the "ding the ED" bell frequently. It's a given on SDN that it will go on unabated. I only ask for intellectual honesty, as everyone is somewhere where these ghastly things happen (or don't happen), yet no one will say where. Kim is an exception, but, then again, she's more stand-up than most (or, virtually all) of the anonymous, gutless wonders here.

Think I have a thin skin? Find a post where I berated another specialty and pumped myself up at the same time (there is one post out there somewhere among my ~9800 where I told a story where I was flabbergasted, but I can't think of it right now - when I do, I'll post it) - you can't. I don't need to say I'm good because you're bad; it's not a zero-sum game. All I know is that, 2 or three times a week, patients ask me where my office is, or if I could become their doctors.

And, as for "gasnewby", it's not 3 8hr shifts - it's 3 12s. But, then again, "Vikings" or "centurions" who think their value as doctors is measured by the blunt number of hours they put in are either neophytes or delusional.

 

[GoodMonkey]

ugh.
why does every thread have to degenerate into either an EM bashing or nurse bashing thread? it's getting pretty d@mn old.


(intern in a surgical field here, btw.)

 

[Blade28]

now, come on, i don't really believe this. gripe about the er all you want but you were actually asked to draw labs and place a central line as a consult? i cannot imagine any er ever asking a simple procedure like a central line to be done by a consulting service. if this is true, i am ashamed of that er doc, you would not be wrong to let him have it.

I was consulted by the ER to place an IJ CVL twice last year...once in a big patient, once in a patient with torticollis. In general, though, their residents have always taken care of IV access (and are even pretty damn good at peripherals!).

The best is YOU'LL be doing the actual suturing and afterwards they'll act like they could do it, too. Like, you'll be writing your note and a resident or even attending will walk over and grin and go, "so, what, a two-layer repair? You use nylons for the skin? Good choice, it's what I would have done."

While not quite to that degree, yes, I have had experiences where the attending will wander over and offer advice, criticism, etc. while I'm working. Usually this upsets me because the very reason I'm doing it is because said attending didn't feel comfortable sewing up a hand lac, or forehead lac, etc.

Nope. They call surgery or Medicine (depending on where the patient is going to).

Surgical airway? Nope. They call surgery.

Nope. They stick an 18 gauge needle into the abscess and call it a day. Or if they actually wield a scalpel, they'll make a simple incision rather than a cruciate, not break down any loculations, not pack the wound and not irrigate it with COPIOUS amounts of saline. Then when the patient comes back septic, they'll call surgery to admit him.

Medicine to place a chest tube?! Here, only surgery does them - we get consulted to place them all the time by other services who have dropped patients' lungs.

Crichs, yeah, definitely only done by surgery.

And don't get me started on I&Ds...half of our abscess consults are ones that weren't touched by anyone, the other are ones that a previous person - from either ER or IM - has simply lanced by sticking a large-bore IV needle into. Rarely will there be any kind of incision, perhaps 1 cm long at the most. Forget about opening widely, debriding, irrigating, or packing.

I didn't want to see this thread become an RN/ER-bashing thread, and I should add that from my experience and observations, Apollyon has always seemed a strong physician who exemplifies what's good about the EM field. Unfortunately many of our experiences with our respective EDs aren't like that.

 

[Winged Scapula]

ok. i apoligize for remarks that earned an infraction. i got to excited, unprofessional i know.

Thank you for the apology. It happens to all of us and the fact that you were post-call last night makes it even less suprising.

either way, this forum is dominated by surgeons who constantly trash all other groups.

The surgeons may be the most vocal but there are plenty of other specialties here; perhaps its the nature of our personalities to complain louder than anyone else when we see a problem.

Nonetheless, we have discussed these issues (of "bashing" other specialties) at the Mod and Admin level and the decision has been made that an area where SDN residents can go to vent is needed. It is not considered bashing or trashing when it occurs here. If I or anyone else were to go into the EM forums and start kicking up a fuss, THAT would be bashing. So while it may seem that EM and nursing gets all the trashing here, believe me...there are nasty anti-surgeon posts in the Anesthesiology forum, the Gastro forum, etc. Those guys just don't tend to post here and I cannot do much about getting other users over here: "hey guys, come on over to the Intern forum to bash on the surgeons! Wicked fun!!!"

kimberli can repremand me, although deserved, but it does not change the fact: we all work together.

That has never been debated. It is true but I'll remind you that this complaining goes on in every career. Administrative personnel complain about their bosses, they complain up the ladder, etc. It is human nature to vent your frustrations.

i will probably get another nasty e-mail from k. cox for this but it is true. no specialty is perfect. critize the ed and your ok. critize anyone else and get reprimanded. i just don't understand it.

In order to clarify things and my name, I have never sent out "nasty emails". As a matter of fact, I think Apollyon is the only user I've ever had a email exchange with regarding the TOS, and I would think he would agree I was never "nasty". Users who violate the SDN Terms of Service get a standard form letter via PM, with occasional alterations to fit the topic.

In addition, it is not SDN policy to reveal any action against other users. But to claim that those who bash the ER get off while those who bash surgery are reprimanded is not only false but ridiculous. I do not admit to being perfect but I do try and be fair.

in the ed we work our tails off every day for our patients. we try to direct them to the best care. i guess on sdi you can trash nurses but not surgeons. get a backbone.

Again, not true. Your infraction was not issued because you insulted a surgeon, but rather you insulted another SDN member. If it helps you sleep at night, plenty of users have been warned and infracted for their comments about nurses; a couple were even banned or post-held. We try and be fair.

I think everyone here would agree that these posts get tiresome. But frankly, when we try to close them people get upset. They want a place to vent and we are allowing it, as long as the venting stays reasonably within the TOS. Internship is an incredibly hard time for everyone and you cannot blame some surgery interns, who feel beat up by nurses and the ED, to want to dump all that frustration here, to feel validated by others who feel the same, who have had the same experience.

 

[Winged Scapula]

I
Medicine to place a chest tube?! Here, only surgery does them - we get consulted to place them all the time by other services who have dropped patients' lungs.

And this is a perfect example of how things are different at every hospital. When I rotated at the VA, even the medicine ATTENDINGS there did not have privileges for chest tubes or thoracentesis. Surgery did them all.

At the main uni hospital, everyone had privileges to do them and medicine regularly placed their own chest tubes (albeit they tended to place pigtails) except in the case of PTx after thoracentesis or in difficult patients, then they would consult CTS rather than general surgery.

 

[gasnewby]

Surgery gets uppity when we do chest tubes, but I'm perfectly happy putting one in.

Because you then demand that we follow them and manage them on the floor. Also, we get a little tired of seeing ER residents put them in the subq, in the liver, in the lung parenchyma, halfway in the pleural space, etc. At least if we put them in, we know where they are. We could write up a nice case series, in fact. "Chest tube misadventures by ER residents."

 

[gasnewby]

Find a post where I berated another specialty and pumped myself up at the same time

How about this one?

Think I have a thin skin?

Yep. Why are you lurking on intern forums, anyway? Creepy.

It's not 3 8hr shifts - it's 3 12s. But, then again, "Vikings" or "centurions" who think their value as doctors is measured by the blunt number of hours they put in are either neophytes or delusional.

. Thanks. You're right, what could anyone possibly learn from an extra 50-60 hours per week?

 

[Apollyon]

As a matter of fact, I think Apollyon is the only user I've ever had a email exchange with regarding the TOS, and I would think he would agree I was never "nasty".

Absolutely correct. Kim has only ever been professional, courteous, and a straight shooter. I find it distressing, though, that I'm one of the few that actually has read and knows the TOS (that's not admin/mod/"the man").

 

[Apollyon]

How about this one?

How so? I asked one poster - as I've said multiple times, the surgeons I work with now, and did work with at Duke, are all well above the pale, and are excellent technicians, collegial, and honest, sincere people. And, likewise, just where did I say that "EM is great because surgery sucks!"? Because that is what YOU are saying.

As for "creepy", what in the world are you talking about? There are a BUNCH of non-interns posting here. What's creepy is you thinking there's anything wrong with posting on an open internet message board.

Oh, and, by the way - that extra 50-60 hours per week...yeah, chief, you go with that. Why do you think community surgeons do lap appys in 45 minutes or less? Or even a bowel resection for perf in about 1 hour and 15 minutes? Why don't they stretch it out to make up that 90 hour week? (That's a rhetorical question for you.)

 

[Apollyon]

Medicine to place a chest tube?!

When I interviewed all those years ago now for prelim IM at Geisinger in Danville, PA, a resident told me about the ICU - it's a mixed med/surg, and the senior teaches the junior - whether it's a medicine senior and surgery junior, or the reverse. I don't know if it's still that way, but the medicine residents were procedurally strong (as they were at Mt. Sinai, but not so much at Duke).

 

[gasnewby]

It's weird that you were an intern, "all those years ago," but come onto a message board to pick fights with interns. Whatever floats your boat. No different than what ER attendings do in real life!

 

[Blade28]

I don't think Apollyon picks fights - rather, he staunchly defends his chosen field (as all of us do) in multiple forums/threads.

As a long-time poster, he's been a valuable resource to SDN and frequently provides enlightening insights into the world of ED. I love to vent about the ER as much as the next surgery resident, but he's one of the good guys, really.

 

[BADMD]

Because you then demand that we follow them and manage them on the floor.

Actually, I don't demand anything. I think medicine is perfectly capable of managing a chest tube. It isn't particularlly difficult in most cases. Usually it is the medicine team that refuses to follow them and demands surgery is on board.

Also, we get a little tired of seeing ER residents put them in the subq, in the liver, in the lung parenchyma, halfway in the pleural space, etc. At least if we put them in, we know where they are. We could write up a nice case series, in fact. "Chest tube misadventures by ER residents."

This is great example of where proper training and education comes in. Instead of moaning and creating "policies," then moaning about the results of those policies, just trying to do some teaching is the way to go. And frankly, having sat in on a few surgical M&Ms, I hardly think it is just the EM residents who have chest tube misadventures.

 

[gasnewby]

Really? I find him to be kind of...well, his name does say "Tool." Let's just say that's an appropriate moniker.

Why I'm good

I find it distressing, though, that I'm one of the few that actually has read and knows the TOS (that's not admin/mod/"the man")...

Why others are bad

Kim is an exception, but, then again, she's more stand-up than most (or, virtually all) of the anonymous, gutless wonders here.

why is it surgery juniors and interns that raise such a ruckus on SDN? Why don't you ever see a senior or attending with complaints about everything, or thumping their chests as to their procedural skill or conquering seeming battalions of nurses?

Now, you seem to have a reading comprehension problem

But, then again, since you're the brilliant intern, you'll savor all of it, as you save the world.

you do this idiotic stuff. You're not funny, and if you're going for sarcasm, you missed it.

Professional, huh? I really want to be like him when I'm an attending. He's a great role model, staunch defender or the ER and the like. I'm bored. I'm off to the ER to watch some Youtube and eat snacks.

 

[Apollyon]

Professional, huh? I really want to be like him when I'm an attending. He's a great role model, staunch defender or the ER and the like. I'm bored. I'm off to the ER to watch some Youtube and eat snacks.

You just don't get it. Individuals are not the whole. Your cut and paste job does not support your case. I mean, I could cobble together the same thing from one line here and one line there from your posts to support the same thing. You conveniently pass by my continued support of the surgeons I work with and have worked with, and highlight phrases out of context.

Not that I am, but neither are you up to professional, dispassionate discussion. I'm done with you (for the negligible input you've had).

 

[Winged Scapula]

When I interviewed all those years ago now for prelim IM at Geisinger in Danville, PA, a resident told me about the ICU - it's a mixed med/surg, and the senior teaches the junior - whether it's a medicine senior and surgery junior, or the reverse. I don't know if it's still that way, but the medicine residents were procedurally strong (as they were at Mt. Sinai, but not so much at Duke).

By reputation, its still true at Danville. Hershey had separate MICU/SICU/NICUs and the medicine residents there were procedurally strong as well, as they did their own central lines, chest tubes, etc. and only very rarely called surgery. When they did, we knew it was a tough one.

 

[Winged Scapula]

Absolutely correct. Kim has only ever been professional, courteous, and a straight shooter. I find it distressing, though, that I'm one of the few that actually has read and knows the TOS (that's not admin/mod/"the man").

What?!? You mean people aren't reading it when they first register?

(which reminds me, I was registering at some other site recently, and just clicked on "Agree" without scrolling through the TOS. I actually got a pop-up which said "You must first read the Terms of Service before clicking on Agree"!. Maybe SDN needs to add that feature.)

 

[Winged Scapula]

Actually, I don't demand anything. I think medicine is perfectly capable of managing a chest tube. It isn't particularlly difficult in most cases. Usually it is the medicine team that refuses to follow them and demands surgery is on board.

While that can seem frustrating, especially to some of the younger members here, frankly it is my opinion that YOU (whomever that refers to...surgeons, EM docs, internists, etc.) should follow a patient that you performed a procedure on.

Therefore, if I placed a chest tube, I should be following the patient and I should be deciding when it comes out. The biggest beef I've had with medicine is when I place the chest tube and they decide when it can come out...sometimes to disastrous results. It takes little time (ie, you don't have to be managing anything else, just checking on the tube) and goes a long way toward preventing having the tube come out too early, nurses dislodging it (they don't seem to be as careful on medicine floors where they aren't used to the patients having a tube), etc.

Of course my tune is different now as an attending...as an intern your goal is to block as many admissions, consults, patients to round on as possible!

 

[Winged Scapula]

It is not fair to Apollyon (or anyone else) to cut and paste comments made over the course of the last 24 hours to depict who he is or what contributions he's made to SDN. For that matter, you could do the same for me and come up with a picture of someone who is less than courteous or professional (given my response to farbar).

As Blade notes, Apollyon has been a long-time member of SDN and is well-respected here. That absolutely does not mean that I agree with everything he says, nor he I. We have had our disagreements here before but his input is valuable and I welcome it.

Non-interns are welcome to post in the Intern forum (if only because I like posting here ) and actually can provide some assistance and insight to those suffering through internship.

So on that note, let's try and be civil to each other, while respecting the right to disagree. All of us have had bad experiences with each other's colleagues and sometimes we just want to vent about it.

 

[Faebinder]

Well it's time for another Lopressor IV story and this time it involves the ER. They called us for a consult on a patient we operated on 2 weeks ago for rectal cancer. She has a well known documented gastroparesis (ostomy functioning so there is no reason for them to call colorectal for a stomach problem).... and not only does the ER want us to admit her for gastroparesis, they want us to give orders for lopressor IV (she has high blood pressure and high heart rate and my guess is that she doesnt take her blood pressure meds). This is at 3 am in the morning. All I could think is... why can't an ER attending write for lopressor and then attempt to bug us (wrongfully mind you) about it in the morning.

Sorry, I side with the others in that the ER sucks. Maybe if they get rid of EMTALA we'd start seeing more professionalism from ER staff.

Apo, you might be a nice guy but you aint in the ER here (and yes we do have an ER residency here).

and of course... lopressor IV sucks ass.

 

[Apollyon]

Apo, you might be a nice guy but you aint in the ER here (and yes we do have an ER residency here).

and of course... lopressor IV sucks ass.

As you are GI/CR, I gotta chuckle at 1. "sucks ass" and 2. just want to say (with a little irony with my word choice) that that is a 'bummer' story.

 

[Observer]

The policy at my hospital is that if the IV Metoprolol is a replacement for a pre-existing prescription, then the patient may have it pushed by any RN on Med/Surg. If it's a new med, then they go to a hardwire room and have it pushed by an ICU nurse. It sounds irresponsible to wait until the patient goes into RVR.

 

[doc02]

I was going to reply, but once I read that some EM "Fellow" (wonder what the fellowship is in, advanced phone transfers?) places ventriculostomies, performs anoscopies, and inserts chest tubes (actually our EM residents do those, albeit with extremely poor technique), I decided to also just make up a story.

Today, some guy came into the hospital with a gun. He was waving it around and threatening to kill people and he even took someone hostage. I was at home at the time, but when I saw this on the news, I immediately jumped into action. Even though I was post-call, I knew what to do! I had to return to the hospital! So I drove in, slamming into two telephone poles and running over five people in the process. (It's OK, I'm a doctor.) When I saw the guy, I didn't know what to do because he had a gun, so I picked up my car and threw it at him. He shrieked and was immediately pasted into the wall. I was a hero. All the hot nurses with perky breasts ripped off their shirts and jumped around me in a circle. The older nurses slunk off, their saggy breasts not fit for the sunlight. I was a hero. The end.

 

[gasnewby]

It is not fair to Apollyon (or anyone else) to cut and paste comments made over the course of the last 24 hours to depict who he is or what contributions he's made to SDN.

and i wouldn't. but i was merely fulfilling his request:

Find a post where I berated another specialty and pumped myself up at the same time (there is one post out there somewhere among my ~9800 where I told a story where I was flabbergasted, but I can't think of it right now - when I do, I'll post it) - you can't.

Non-interns are welcome to post in the Intern forum (if only because I like posting here ) and actually can provide some assistance and insight to those suffering through internship.

yes but he's just here to intern-bash. you, on the other hand, offer insight and advice.

 

[OB1🤙]

As an anesthesia intern, I am not beholden to anyone (which is nice), and therefore would like to offer the following observations:

1) The ER where I'm at this year does not have a residency, and does all of the above consult crap mentioned. I've absolutely seen the ER call other services for I&Ds, central lines, taps, etcetcetc.

2) This ER is staffed mostly by non-EM trained personnel, and often by clinical researchers with IM backgrounds moonlighting for extra cash. This leads to all sorts of shenaniganery, as you can imagine. Some of these guys are actually pretty good, and some are mind-blowingly awful.

3) I've come across 2 EM-boarded docs. Both are outstanding, and their clinical judgment and skills are excellent. N=2 may not mean much, but they're clearly head and shoulders above the other staff down there (as they should be).

Story: I'm on gen med call, happily sleeping like a baby at 4AM on a slow night, when my pager goes off. Surprised to see the ER's # on there (for admits there's an admit pager the resident carries), I call back. A nurse picks up the phone frantically, and says "Dr. Bruin? We need a central line down here right now."

My sleep-soaked brain takes a few seconds to try and make heads or tails of this, but I can't piece together a logical series of events that would result in an ER RN paging a random intern for a central line.

So I say, "Uhhhh, you know I'm just an intern, right? I can't just come down there and put in a central line without supervision. Where is the attending?"

"He's down here but he's busy, and he asked me to find someone who can put in a central line. So I'm going down the list of people that are on call tonight."

"OMG WTFBBQ you cannot be serious right now. No, I cannot come down there and put in a central line. Sorry. Have the attending page a senior resident if he really needs help."

How this conversation took place in a real hospital in a major city is still beyond me. And the fact that an attending asked a nurse to "just go down the list" of people on call until he found some poor sucker willing to drag themselves down to the ER at 4AM to do his job is just sicksicksick.

 

[doc02]

The EM guys will let that story slide since you took great care to explicitly state that EM-trained docs are great and smart and multi-talented and that your ER is messed up and consult-happy because of all the IM guys staffing it.

 

[doc02]

Here's the thing when it comes to the ER: I actually sort of don't blame the EM guys for doing what they do, in a way. I mean, their job is literally to just move people either into or out of the hospital (notice I didn't say "admit" because the primary team admits). The real silliness is that this ever became a specialty and it did so 90% because of the economics of a hospital. In other words, they're like quasi-administrators because they're in place to streamline patient movement and thus save the hospital money. That's even how they rate themselves: how quickly did I move the patient? Yes, you can argue that "patient outcomes" have also improved, but it's as a result of patients getting moved to their physicians faster, not because some EM guy is down in the ER treating patients for inpatient problems (they do yeoman's work on patients who are basically non-urgent outpatients who abuse the ER as a clinic and take advantage of America's "we don't turn anyone away" policy).

But if we're going to have this pretense about EM guys diagnosing things, then they should be able to diagnose. Instead, they're like nurses. They say something, if they're right it's because they "knew it";if they're wrong, they just go, "well, it's not my job to diagnose, anyways, maybe next time, eh?" People were talking about I & Ds. That's illustrative of so much about the ER. Can they do I & Ds? Sure, just not correctly. Sometimes it works, and then that's fine. Sometimes it doesn't and then you get consulted when they return. What's that all about? I thought you knew how to do them. So why are you "seeing if you can do it" and then calling someone when you can't? That doesn't count as being able to do a procedure.

What about chest tubes? Ignore the fact that, as someone said, they're not that great at doing them. How about the fact that they do them and then don't follow the patient? That's the biggest no-no ever, but they get away with it because "we're EM, we don't do chronic care." At best, that's purely being a technician. In reality, it's not even that because I wouldn't call them good technicians, either.

 

[Blade28]

Wait...they have to keep track of how quickly they admit/discharge patients? How is this data used?

 

[Bertelman]

Wait...they have to keep track of how quickly they admit/discharge patients? How is this data used?

There are several data points that are measured in the ER. When the patient is placed in a room, when they are sen by the Doc, when they are seen by consults, when they are discharged/admitted. There are specific computer programs that work solely to track these events.

 

[doc02]

Wait...they have to keep track of how quickly they admit/discharge patients? How is this data used?

Let me break it to you: that's the main criteria on how EM judges itself. That's also why any time you talk to an EM physician, they will suddenly blurt out those stats on how many patients came through the ER and so on. That's their entire focus. If they had M&M's it would go like so:

EM Resident: Next case is P.G., a 50 y/o male who presented with complaints of increasing SOB. He stayed for fifteen hours before being transferred to the floors. Questions?

EM Attending: Fifteen hours? Why so long? The standard of care is a maximum of ten hours' stay in the ER with that CC!

EM Resident: Well, we forgot about him until shift change ...

EM Attending: Say no more. Next case?

 

[Blade28]

Wow. I didn't know that. I can see how that may present a potential conflict of interest.

 

[doc02]

Wow. I didn't know that. I can see how that may present a potential conflict of interest.

Yes, but now you undoubtedly understand why they do things the way they do, don't you?

 

[Faebinder]

Let me break it to you: that's the main criteria on how EM judges itself. That's also why any time you talk to an EM physician, they will suddenly blurt out those stats on how many patients came through the ER and so on. That's their entire focus. If they had M&M's it would go like so:

EM Resident: Next case is P.G., a 50 y/o male who presented with complaints of increasing SOB. He stayed for fifteen hours before being transferred to the floors. Questions?

EM Attending: Fifteen hours? Why so long? The standard of care is a maximum of ten hours' stay in the ER with that CC!

EM Resident: Well, we forgot about him until shift change ...

EM Attending: Say no more. Next case?

 

[Blade28]

Yes, but now you undoubtedly understand why they do things the way they do, don't you?

Yeah, sure do.

 

[aussiegirl]

Same in Australia - when I did my ED term earlier this year, if you went to the staff bathroom, they had triumphant posters on the back of every toilet door proclaiming how "well" the hospital was doing in those stats. At least there was something to use if the toilet paper ran out...

 

[doc02]

I used the white coats of the EM attendings. (And we hadn't run out of toilet paper.)

 

[Faebinder]

I used the white coats of the EM attendings. (And we hadn't run out of toilet paper.)

Really doc02, I mean I am no fan of the ER... but maybe you should keep those spontaneous thoughts in your head. I got enough **** on my service (which is colorectal) without you adding your poop habits.

 

[doc02]

I was just warning you before you sat in their seat, that's all. That's the kind of caring person I am.

 

[Sheesh]

Me: "Can you draw me up 5mg of Lopressor?"
RN: "I can't push that up here!"
Me: "I know, I'll push it."
RN: "Do you know how to push it?"
Me: "Not really, no. I thought I'd just shove it in there."
RN: "Oh my God! You can't do that! I'd better come with you to show you how to do it."
Me: "That would be great! Thanks so much."

LOL!!

That is so true!

I gave IV lopressor the other day and the nurse just let me stay on the floor while she pushed it so I could be called if there was problem.

 

[OTD]

Farbar, just last night I was again consulted to place a central line in the ER, that story is in "call stories" if you are intersted. It happens several times each week, not just occasionally. I have experience at several different hospitals and it happens in all of them. There is no EM residency in any of those hospitals though and that is likely why they call Surgery for the majority of lines (I am sure they put a few in when they are bored or want to for some other reason).

 

[Ypo.]

I was reading this thread, and I couldn't help thinking to myself that Doc02 has got to be Kinetic. I recognize the posting style; good for quite a few laughs, but then starts to go into long lecture-style monologues about how the world works. Finally the underlying malignancy comes out full-force. Ultimately he can't contain his own personality.

 

[Tired]

I was reading this thread, and I couldn't help thinking to myself that Doc02 has got to be Kinetic. I recognize the posting style; good for quite a few laughs, but then starts to go into long lecture-style monologues about how the world works. Finally the underlying malignancy comes out full-force. Ultimately he can't contain his own personality.

You think?

Actually, I have recently come to the opinion that a user on this board with >2000 posts is also Kinetic . . .

 

[Ypo.]

.dp