# of patients per 12 hour shift

[mannydoc21]

as an intern, i feel my program places too much emphasis on the actual number of patients we see. I feel I am getting great training, however, I am under tremendous stress daily to work faster and see about 18 to 24 patients per shift. Our ER is busy, with an annual volume of 70K, but i know its not as busy as some of the major institutions with 100K+. How many patients does everyone else see on an average 12 hour daytime shift? Does everyone else get excessive pressure to evaluate patients faster?

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[turtle md]

It is my opinion that interns should NOT be seeing that many patients. Intern year, as well as the rest of residency, is to learn how to take care of your patients correctly, so that you can progress to taking care of them quickly as well. Our interns were expected to see about 1 pt/h. Our 2nd years about 1.5 pt/h, and our 3rd years 2 pt/h. As an attending, you may be expected to see 2.5 pt/h, but more than that is a stretch. I am sorry you are getting this pressure.

 

[WilcoWorld]

I agree with Turtle. Where is this pressure coming from? Have you discussed it with your PD? I do not condone laziness or letting charts sit around in an attempt to get out on time, but 2 patients/hour is too many to expect an intern to safely manage.

 

[southerndoc]

I saw a lot of patients as an intern and resident. Initially I was grumpy about it. When attendings would teach things, I found myself just thinking "oh great, they just assigned another patient to my team."

As it progressed I became more comfortable with the volume. Now I'm glad I saw that kind of volume. Working for a fee-for-service group, I average 35-45 patients in 12 hours now. More than the national average, but when you're FFS, you like that kind of volume (it does make you tired quickly though).

 

[Apollyon]

Working for a fee-for-service group, I average 35-45 patients in 12 hours now.

Almost 4/hour? Something's got to give. How much do you talk to the patients? How do you keep your Press-Ganeys from going right in the toilet? Do you just give the drug seekers what they want? (I'm serious.)

 

[dlung]

I agree with all of the above. I think my experience is similar to southerdoc's.

I empathize with your frustration. When I was an intern, we saw 1.5-2.0 pts/hr just by the nature of our ER. It was, and is, stressful as an intern. Once we experimented with an attending "teaching shift" where an extra attending just loitered around and taught stuff. I hated it for the same ridiculous reason as you--I couldn't stand sitting around getting taught for 10 minutes while more patients got assigned to my team!

The positive about starting out with that heavy of a work load is that you're forced to get good at it pretty fast. After 1.5 yrs, 2.0/hr was no problem. Nowadays, if my interns are good, I find that I'm up around 4/hr. This is all assuming you don't get sucked into a 3-hour code. Our attendings, with good resident/pa coverage (and open hospital beds) can see something like 6+ pts/hr.

The cold, hard fact is that when you look for jobs, they'll be asking you how fast you are. It feels like the unofficial community standard of care is inbetween 1.5-2 pts/hr WITHOUT extended providers or scribes. The industry trend is that more and more non-FFS groups are basing part of their paychecks on efficiency (ie #pts/hr or RVUs).

So, seeing 1.5-2.0 pts/hr as an intern is either
1) bad for you, because volume isn't your learning style or it's dangerous for patients, or
2) good for you, because that's what you'll be expected to do anyways, and it'll maximize your efficiency by the end of your training.

 

[deleted109597]

I had a long post, but this progressively worthless forum obliterated it for me.
Thusly, see them at your own pace, as long as it is 1/hour or more. Get faster as you can, because eventually you'll have to be fast to make money, and learning on the job isn't good, that's what residency is for.

 

[Speed Racer]

I saw a lot of patients as an intern and resident. Initially I was grumpy about it. When attendings would teach things, I found myself just thinking "oh great, they just assigned another patient to my team."

As it progressed I became more comfortable with the volume. Now I'm glad I saw that kind of volume. Working for a fee-for-service group, I average 35-45 patients in 12 hours now. More than the national average, but when you're FFS, you like that kind of volume (it does make you tired quickly though).

How do you write 35-45 defendable charts in a 12 hour shift?

I am also an intern at a dispo-factory and as far as being pressured to see patients faster...I SAY F! Them...the patients can wait, the seniors can wait, the attendings can wait. You have to have the will to be purposefully slow enough so that you gain the skills you need to be an efficient upper level. When I try to see >1.5 patients an hour I forget things, my charts suck, I dont think the cases through, I don't start any lines or look anything up. I laugh inside when my seniors say don't worry you will speed up as time goes by...they have no idea that I am working at my slower pace on purpose.....I encourage other interns to do the same...just my 2 cents and I could be horribly mistaken....

 

[Doctor Bob]

I am working at my slower pace on purpose...

I'm hereby revoking your screen name

 

[kungfufishing]

Learning to be "fast" is part of the skill set. I think this really has more to do with learning to group your tasks well as well as learning to be decisive. The talking to patients and exam are somewhat constant, leaving every other area an opportunity to become more efficient and shave time off your processes which you can use to see more patients/help more people/make more money.
Admittedly, I'm kind of an efficiency nut. So.

 

[Jeff698]

The charting system you use goes a huge way towards your efficiency. Paper based templated charts are, hands down, the fasted way to go. They really suck at relaying patient information and are damn near useless for research but they're great for billing. +/- on legal protection. They are, however, built for speed.

I've now use two different computer charting systems: iBex/Picis and MedHost. Each has it's pros and cons but I find the iBex system to be faster for charting only because of its macros. Those are awesome.

In general, computerized charts weren't developed with EP efficiency as their primary goal. They're looking for billing or data collection.

We always talk about pt's per hour averaged over an entire shift but I really think that misses the point. Take my last shift as an example. I did a 12 hour single coverage shift on Sunday. I saw about 4 patients in the first 4 hours. The pace picked up to about 3 pts checking in an hour for the next 3 hours and then spiked up to 5, then 7, then 9, then 5 patients checking in an hour. That's a total of 39 patients or 3 1/4 ppt. Above the average of 2.5 but not greatly. The distribution, however, isn't even. When patients check in unevenly like that, the shift goes to hell in a handbasket.

I really don't think it is the pph averaged over the shift that is important. It's the throughput each hour that can make a great shift or a killer shift. I've had days were I've seen 36 patient in a 12 hour shift were I left on time thinking I had the greatest job in the world. These were evenly distributed throughout the shift. I've also had shifts were I saw the same number but stayed 3 hours after my shift ended to keep my relief from dying and needed to go home and suck my thumb in the fetal position for the next two days.

Take care,
Jeff

 

[mannydoc21]

thanks for the informative replies. One things is for sure, I definitely do not want to end up working in an ED where I am continuously evaluating 36+ patients every 12 hour shift. Wow, I am impressed that some of you can do that without burning out.

 

[Aloha Kid]

1. It's different when you are the attending and making all the money

2. As you go along you will find your short cut methods at things and get better at it.

3. Evaluate your performance regularly and always look for ways to improve your efficiency without compromising your standards. As far as efficiency, the average attending peaks at 2 years out. Take it for what it's worth, but it does mean that during residency you have to learn how to move the meat or you will be in trouble as a new attending with stunted growth 2 years out.

 

[Speed Racer]

I'm hereby revoking your screen name

Driving slow and smooth lets you go fast!!!

 

[southerndoc]

Almost 4/hour? Something's got to give. How much do you talk to the patients? How do you keep your Press-Ganeys from going right in the toilet? Do you just give the drug seekers what they want? (I'm serious.)

Nope, and I was in the 90+ percentile for the nation this past quarter.

As someone mentioned before, it's all about efficiency. I don't sit around waiting on phone calls -- I have a cell phone that return calls are forwarded to. I don't set up my own pelvic exams, I&D's, etc. -- a tech sets it up for me. I still manage to re-evaluate patients after pain meds, inform them timely of lab results, etc.

Yes, seeing 3-4 patients per hour does get tiring. However, when you're getting paid extra to bust your tail, it makes it more tolerable.

 

[Apollyon]

Yeah, none of which happens for me (setup).

Picis/Ibex doesn't help either. Sure, macros are great (like Jeff says), but Picis says 2 seconds for screen changes, tops. Umm...not on our T3. I waste more time - bar none - on waiting for Ibex to change screens than anything else, because I can't do anything else while waiting.

 

[southerndoc]

Yeah, none of which happens for me (setup).

Picis/Ibex doesn't help either. Sure, macros are great (like Jeff says), but Picis says 2 seconds for screen changes, tops. Umm...not on our T3. I waste more time - bar none - on waiting for Ibex to change screens than anything else, because I can't do anything else while waiting.

I will slow down tremendously when we start doing electronic charting. Right now we are using paper templates, which are easy to document and are very efficient. When I work at my part-time hospital (where we dictate), I can only see about 2.5/hr at the most if I stay caught up with dictations. Once I saw 38 patients in a 11 hour shift there, but when I finished the shift, I had only dictated 2 patients. I think it took me 3 hours to dictate the others.

 

[leorl]

as an intern, i feel my program places too much emphasis on the actual number of patients we see. I feel I am getting great training, however, I am under tremendous stress daily to work faster and see about 18 to 24 patients per shift. Our ER is busy, with an annual volume of 70K, but i know its not as busy as some of the major institutions with 100K+. How many patients does everyone else see on an average 12 hour daytime shift? Does everyone else get excessive pressure to evaluate patients faster?

The interns at my program are under the same pressure. We actually told as much to our internal review committee, as we feel that this pressure places more emphasis on turning us into workslaves and it compromises our education. Depending on the day, I definitely am seeing more than the "1 per hour" recommended for an intern. I don't mind, but what I do mind is 2 or 3 attendings who actually clap their hands in your face and say "come on come on!" I try to annoy them back on purpose.

At my institution, attendings do not see their own patients. Some of them sit on the computer looking up flights to aruba or spend the whole time talking to their families while residents do all the work. Then you get backed up because when you need to present, the attending is "too busy" or off the floor. Needless to say it does not generate a very nice collegial feeling, and we recommended to the IRC that attendings see their own patients to move the ER.

 

[leorl]

Peds ER is quicker. Today, I saw 15 patients in 90 minutes and managed to clear the rack before the acidotic camphor ingestion came in.

 

[southerndoc]

I only saw 15 patients in 11 hours today. Weird! The place was dead today.

 

[kungfufishing]

did those of you who think you are being forced to see too many patients stop to think that the "slavedrivers" encouraging you to do so might have done this a couple of times more than you have? That they might actually be doing you a favor? I'm not in your specific scenarios, not even intending to be a jackass (although I am a natural)...just suggesting there might be a legitimate purpose behind it.

 

[Speed Racer]

did those of you who think you are being forced to see too many patients stop to think that the "slavedrivers" encouraging you to do so might have done this a couple of times more than you have? That they might actually be doing you a favor? I'm not in your specific scenarios, not even intending to be a jackass (although I am a natural)...just suggesting there might be a legitimate purpose behind it.

Unlikely that anyone is doing me any favors. If anyone was paying attention they would see that my charts are %50 inaccurate and %50 untruthful, that I don't bother to place a stethescope on most patients. Minimize CC's on patients that I present to conservative attendings so that my team doesn't swell. I have even talked vag bleeders into walking out AMA because I didnt want to spend the time to find a chaperone and do the exam.

I don't think I'm alone, I see my colleagues do all of this and worse on a daily basis. All in the name of moving the meat. So midway through the year I decided to stop the madness and see patients, quickly, efficiently, but at my own damn pace, antsy neurotic seniors and attendings be damed. Its my education and my soul I have to live with.

The dirty truth is that you CAN NOT see patients fast enough if you are in a busy underserved ED, there will always be more and they will just keep coming. The other truth is that %75 of the people don't need to be there. They do not have emergent conditions. So F! them, let them wait till there Doctor opens the office Monday morning.

Again, my personal 2 cents for my situation. But I encourage other interns to seek another way if you feel like something stinks.

 

[Drawing Dead]

I know I'm probably going to be chastised for this post, but here it goes. We all know everyone is different. No body sees patients at the same rate, not even attendings. I'm sure there are interns that see more than seniors (rarely), residents at the same level who work at different speeds, and probably even residents that can out perform attendings. If you're seeing one an hour as an intern, that probably is a good rate, but at the same time, don't rest on your laurels and be content. It's March already, and PGY-2 is 3 &1/2 months away. It's not like we will become 50% more efficient from June 30 to July 1st. It has to be a gradual build.

I pride myself on being able to see more than my share. It makes me feel efficient. We have a site where the volume is low, and I would probably average 12 patients a shift. Many times during my shifts, I would find myself sitting on my ass, reading, and the day dragged on. Our main site, I would see anywhere between 18 and 24 a shift, and do my best to see all the patients myself. Residency is about education, but it's also about training to be an attending. Part of that training would be efficiency. As stated before, many employers are looking for a certain number per hour, so maybe it's a good idea to get used to that now.

 

[southerndoc]

36 patients in 11 hours with incredibly high acuity.

A STEMI, status asthmaticus (on continuous nebs, didn't intubate), status epilepticus (intubated), AFlutter with RVR @ 220, altered mental status from a tricyclic overdose requiring intubation, a stroke (bleed), and a septic patient.

Gotta love the acuity one sees at a 90,000 volume ER!

 

[Drawing Dead]

36 patients in 11 hours with incredibly high acuity.

A STEMI, status asthmaticus (on continuous nebs, didn't intubate), status epilepticus (intubated), AFlutter with RVR @ 220, altered mental status from a tricyclic overdose requiring intubation, a stroke (bleed), and a septic patient.

Gotta love the acuity one sees at a 90,000 volume ER!

If I see patients that sick that fast as an attending, I'll frickin be a millionaire

 

[southerndoc]

If I see patients that sick that fast as an attending, I'll frickin be a millionaire

You'll need a better fee schedule than I have if you're going to be a millionaire!

 

[docB]

You can be faster as an attending than you can as a resident. When I see a patient with chronic back pain who I want to dc or a sick breather who I want to tube I can just do it. I don't have to spend time looking for the attending, explaining the whole thing and letting them take a look. Residents have to staff their cases and that is a big time sink. I'm not saying it's unnecessary. I'm just saying that anyone can be 30-50% faster when they don't have to run everything by someone.

 

[spyderdoc]

I see a similar patient load as Southern. We use Ibex as well (can relate to slowness between pages Apollyon), and I do a lot of my charting at home. It is painful, but I would rather see a few more patients (FFS = $$) and spend some time at home charting. I do a lot of real-time re-assessments in the charts....I've been in my job for 3.5 yrs now, and still going strong.

I sort of equate it to working out....When you first start at a job like this, you are "out of shape" ( I sure was after my previous job of seeing 1.3pts/hr), and it takes a while to get in shape and get in the groove....We do all 8 hour shifts (I do 14 shifts/mo)...On the FT side (lower acuity), I can see 40-45 pts on a busy day, but average around 30-35. . On the main (higher acuity), I will see anywhere from 20-35 patients, depending on how busy it is and how good the flow is...

We are in the process of adding more coverage, which has been nice...It brings me down to 18-22 patients on the 8 hour shift, adn I can usually have all my Ibex charting done by the end of my shift....

We do not do any signing out, in general, and own our patients from start to finish....

 

[WilcoWorld]

I've never had the experience, so this is stipulation, but I would guess that not having sign out would markedly increase efficiency. I find that it takes me at least as long to deal with signed-out patients who still require decision-making as it does for me to see & dispo my own patients from start to finish. Add to this the amount of time it can take to just do sign out when you're working somewhere with over-crowding issues and you have a major time sink. I would gladly trade my 8 hour no overlap shift with lots of sign outs for a 9 or 10 hour overlapping shift with fewer sign outs.

But all of this is getting away from the point of this thread. Yes, as an attending you will need to be able to handle 2.5 patients per hour (preferably more) or you will be in trouble at most places, but does this mean interns should be hurried along? I don't think so. Bad habits are hard to break, and if young doctors are pressured into seeing more patients then they should they will develop bad habits that will stay with them for a whole career. Residents in their second half of training need to learn to manage an ED, which means moving the meat, and the earlier they do this the better. However, early on residents should be allowed the time they need (within reason) to focus on learning how to care for patients.

 

[southerndoc]

We also don't sign patients out generally. Occasionally we will, or if you're the overnight doc (6p-6a), you have 2 hours of single coverage. Usually I will start workups on anybody that comes in during that time and just turn them over unless I can dispo them by 6:30.

 

[Jeff698]

You can be faster as an attending than you can as a resident.

Amen. I felt like I'd lost a lead weight from my leg after graduation. I'm much faster than I was as a resident.

Take care,
Jeff

 

[strongboy2005]

We do all 8 hour shifts (I do 14 shifts/mo)...

Is this a common amount of work for the ER? This averages out to 28 hours per week... Sign me up!

 

[Arcan57]

It's been said, but is worth repeating. It's much better to have your butt handed to you in residency then as a new attending. The septic shock patient that comes in when your census is light is a completely different animal then when every hall bed is full and there are 25-40 in the waiting room. The ability to operate effectively in chaos is a large part of why our specialty exists. It's also a skill that must be honed through practice.

 

[ispic]

I will slow down tremendously when we start doing electronic charting. Right now we are using paper templates, which are easy to document and are very efficient. When I work at my part-time hospital (where we dictate), I can only see about 2.5/hr at the most if I stay caught up with dictations. Once I saw 38 patients in a 11 hour shift there, but when I finished the shift, I had only dictated 2 patients. I think it took me 3 hours to dictate the others.

Yep,
We use First-net which is pretty nice and use the paper templates to aid in the dictation process, but many of us in our program have the same issue - crank out 1 - 1.5/hr (interns) to 2.5 - 3/hr (3rd years), then spend a couple of hours after the shift dictating. I do agree with the other posters, once we're out in the world, since we don't have to present, the numbers should go up. We do 9hr shifts so the fatigue towards the end of the shift is not really as much of a factor as with the 12's. The dictations do add a little to the day, but the shifts are nice though...

 

[jazz]

Nope, and I was in the 90+ percentile for the nation this past quarter.

As someone mentioned before, it's all about efficiency. I don't sit around waiting on phone calls -- I have a cell phone that return calls are forwarded to. I don't set up my own pelvic exams, I&D's, etc. -- a tech sets it up for me. I still manage to re-evaluate patients after pain meds, inform them timely of lab results, etc.

Yes, seeing 3-4 patients per hour does get tiring. However, when you're getting paid extra to bust your tail, it makes it more tolerable.

not doubting you but 35-45 pts/12 hour shift is crazy, especially if you consider that you are probably seeing that number really in 11 hours (since you are not picking up 3 pts your last hour)... so if you're seeing 4 pts/hour, that leaves 15 minutes per pt (including seeing them, examining them, ordering studies, reviewing studies, updating them, speaking with their primaries, calling consultants/admitting, and writing/signing a chart...) ... IF you don't take any time off to eat or go to the bathroom.... again, i find it hard to believe...

maybe i'm just really inefficient, but my numbers are much lower. are you counting pts you are seeing entirely on your own, or do these include PA charts?

also, i'm curious, even with good ancillary/support staff, it seems like a very high number. how long are you stuck at work after a shift finishing charting???

 

[southerndoc]

No, I'm not counting PA patients. I pick up patients til 15 minutes before the end of my shift, but we have a rule that docs can pick and choose patients in the last 90 minutes of their shift. So I won't pick up the abdominal pain, but I will pick up the sore throat.

I usually chart while talking to the patient. And you're right, I rarely take a lunch break. Usually I snack/drink while reviewing labs and such.

 

[Jeff698]

Southerndoc is busier than I am but, on single coverage day shifts, I'll easily see between 35 and 40 patients. Unfortunately, the distribution sucks. I'll sit on my butt in the morning and then get pounded.

I try to stay current on my charting but when more than about 5 patients check in in a given hour (remember, solo coverage means everyone is yours), charting gets put off.

Unlike Southern, I'm not paid FFS so my tolerance for that volume is less than his. Fortunately, we're in the process of adding coverage so with a goal of around 2.5 pph. That is very doable, even with computerized charting.

Make no mistakes, electronic charting is slower than paper templates. Period.

The T Systems that essentially translates their paper chart onto a handheld computer terminal that goes in the room with you is probably as close at you can get but it is likely still slower.

Take care,
Jeff

 

[Apollyon]

The top guy in our group sees 3.5/hr, and has been maintaining that pace for over a year; this includes computerized charting, which adds about 20-25% to the time needed. With T-sheets at the bedside (and knowing southerndoc), I can see how that number can be maintained. However, with Picis, even the 2.5 that Jeff mentions is difficult to maintain, as the guy above I mention is leaps and bounds above the others.

The group I'm joining pays more, sees 1.8/hr at the busy hospital, and has a 98% insured rate. I won't tell you where it is (yet).

 

[southerndoc]

There's no way I will be able to see 3+ patients/hour doing computerized charting. I'm busting my tail to see 2.5/hr where I work part-time if I want to stay current on my dictations during my shift. There was one shift that I saw 35 people in 10 hours at my part-time hospital, and at the end of that shift, I had dictated only 2 people. I was there 3 hours after my shift dictating and cleaning up. Never again!

 

[diphenyl]

Our shifts our 10 hrs, I see typically 15-25 pt's per day keep in mind this ER tends to be decent volume but very high acuity, I chart as I go on a computerized charting system, I usually just fill in the basics of the chart then go back to make it look pretty when I'm wrapping things up. I may come back the next shift and sign the charts but i typicaly finish charting during the same shift.

 

[diphenyl]

Although many of the docs in the group boost their numbers by working the prompt care side over there you can easily exceed 2.5 per hr even with charting. When I do this its usually because I order things for people waiting in the lobby, like an x ray for the sprained ankle, or a UA for the woman w/ dysuria.

 

[melanoleuca]

Unlikely that anyone is doing me any favors. If anyone was paying attention they would see that my charts are %50 inaccurate and %50 untruthful, that I don't bother to place a stethescope on most patients. Minimize CC's on patients that I present to conservative attendings so that my team doesn't swell. I have even talked vag bleeders into walking out AMA because I didnt want to spend the time to find a chaperone and do the exam.

I don't think I'm alone, I see my colleagues do all of this and worse on a daily basis. All in the name of moving the meat. So midway through the year I decided to stop the madness and see patients, quickly, efficiently, but at my own damn pace, antsy neurotic seniors and attendings be damed. Its my education and my soul I have to live with.

The dirty truth is that you CAN NOT see patients fast enough if you are in a busy underserved ED, there will always be more and they will just keep coming. The other truth is that %75 of the people don't need to be there. They do not have emergent conditions. So F! them, let them wait till there Doctor opens the office Monday morning.

Again, my personal 2 cents for my situation. But I encourage other interns to seek another way if you feel like something stinks.

Dude. Dude. While I am sometimes guilty of not pulling out all the stops to keep someone from actually leaving AMA, to actively encourage them is another thing altogether. While I agree that residents are used as cheap labor in many "teaching" institutions and I applaud your willingness to put your education over the group with whom you work's profit, talking people into leaving is plain wrong.

When you are an attending then you can decide quickly to send people home who are there for bogus complaints but I don't think a new resident necessarily has the judgment to do this.

 

[melanoleuca]

The top guy in our group sees 3.5/hr, and has been maintaining that pace for over a year; this includes computerized charting, which adds about 20-25% to the time needed. With T-sheets at the bedside (and knowing southerndoc), I can see how that number can be maintained. However, with Picis, even the 2.5 that Jeff mentions is difficult to maintain, as the guy above I mention is leaps and bounds above the others.

The group I'm joining pays more, sees 1.8/hr at the busy hospital, and has a 98% insured rate. I won't tell you where it is (yet).

I am much faster with electronic charts than I am with paper. We use the T-system and, even with the fact that I always type a summary paragraph with the CC and pertinent history and physical exam findings (because I usually finish my charts later in the sift for any given patient) I can see four or five more in a shift than I can with the paper charts and all of that tedious writing and checking.

 

[Tiger26]

Maybe just a naive M3 here, but for all the private practice folks, do you still see enough interesting pathology to stay interested, or does all that just get sent automatically to the academic centers around you?

 

[docB]

Maybe just a naive M3 here, but for all the private practice folks, do you still see enough interesting pathology to stay interested, or does all that just get sent automatically to the academic centers around you?

It depends on what you mean by "interseting." If you mean super sick septic patients, codes and so on I get plenty of that. We don't transfer any of that stuff to academic centers. If you mean zebras then we see some of that too. The only time we transfer it it my places is if it needs a specialty we don't have which is ENT. Otherwise we don't transfer stuff.

 

[deleted65604]

Interesting pathology is everywhere. I believe it is a misconsception to assume that interesting things don't come to community ERs. Sure, at tertiary care centers, they might have a much higher population of pediatric transplant patients, bizarre congenital hearts, etc., but those things aren't very interesting from an Er perspective. For example, in residency, if a pediatric transplant kid, or adult came into the ER, they pretty much invariably got admitted. You would see the fever in a tranplant patient, walk in and do a brief exam, order basic labs, culture everything and call upstairs for a bed, and they usually said, "Just send them up, we told them to come in." Fascinating pathology with immunocompromise, and weird, rare infections, but from the standpoint of their brief ER visit, not challenging, or even interesting.

 

[Jeff698]

You would see the fever in a tranplant patient, walk in and do a brief exam, order basic labs, culture everything and call upstairs for a bed, and they usually said, "Just send them up, we told them to come in."

Arghhhh! I hate that. Common courtesy, people, that's all I'm asking. If you want me to be your dumping ground, fine. Just the tad bit of courtesy of a simple, brief phone call if you know they're coming in. Grrrr.

Take care,
Jeff

 

[docB]

Interesting pathology is everywhere. I believe it is a misconsception to assume that interesting things don't come to community ERs. Sure, at tertiary care centers, they might have a much higher population of pediatric transplant patients, bizarre congenital hearts, etc., but those things aren't very interesting from an Er perspective. For example, in residency, if a pediatric transplant kid, or adult came into the ER, they pretty much invariably got admitted. You would see the fever in a tranplant patient, walk in and do a brief exam, order basic labs, culture everything and call upstairs for a bed, and they usually said, "Just send them up, we told them to come in." Fascinating pathology with immunocompromise, and weird, rare infections, but from the standpoint of their brief ER visit, not challenging, or even interesting.

This illustrates one of my biggest pet peeves and the biggest waste of resources in current Emergency Medicine: The use of the ED to "facilitate" admission. Because of insurance issues, hospital issues and downright laziness it is just easier for docs to tell patients to go to the ER to get admitted than it is to direct admit them. I tell patients on a several times a day basis "Well my role in this is to be the recording secretary and to call your doctor." I can't believe that the HMOs are saving money by forcing all of these patients through the EDs but that's how it is.

 

[dchristismi]

There is plenty of good pathology at community hospitals... I have seen some weird stuff (and I'm not just referencing the "crochet hook in the urethra" thread.) And I haven't been out all that long.

Had a guy last night who told me he had some chest pain, called 911 although he thought he could drive himself in. He told me he fell asleep in the ambulance, and now it was gone. I got to tell him that no, he'd actually died, cardiac arrested, the BIG ONE, and the medics zapped him and got him back. I have the strips with the torsades to prove it.

Of course, I really didn't have to do much but call cards. But it's still pretty neat to see what a little electricity can do. (Guy had nearly normal labs and a surprising very unexciting post-code EKG.)

 

[jazz]

academic centers are in cities... people who live in neighboring suburbs don't routinely go to academic center ER's -- they go to the nearest community ER

people are people and people have pathology so yes, you see great pathology at community hospitals... and if they get transfered to the academic center b/c you don't have the subspeciality at the community hospital to take care of it, it's b/c YOU diagnosed it...

in a way, it's more challenging at a community hospital.. you're more on your own, fewer subspecialty consults available.... you may end up managing your sick ICU pts longer b/c the Pulm Critical care guy is in the office seeing pts in his private practice and isn't coming in for 2 more hours... or b/c they're stuck in other hospital with a sick pt.... unlike academic centers where there are a bunch of residents and fellows around...