Putting the Myths of EM Docs to Rest!!

[elwademd]

No...what matters is that the patient is being admitted and that we've ruled out the very serious conditions that can quickly kill you with respect to your symptoms. We are taught to think of the worst things first and work our way down. For example, the neutropenic fever is going to be admitted whether or not we have a source at that moment for a specific diagnosis. The 70 something old female with syncope that has a no etiology discovered in the ED is going to be admitted for further workup. The examples you listed above, "copd exacerbation, pneumonia, sepsis," are ones made in the ED all the time and not the types of situations I describe when workup is not finished, at least where I am and in my experience. I can not speak for any other ED.

i was just using the diagnoses/diseases listed by the poster above me (dr. mcninja).

i understand that at times, the diagnosis is not/can not be made in the ed, and the patient needs to be admitted. i also understand that, at times, the work up is still pending. amongst the things that bother me are more along the lines of the minimum not having been done- i am, however, at an institution that does not have er residents, and there are plenty of times where it simply seems to be more about g.o.m.e.r. than simply and/or critically thinking about the patient.

for that 70 year old with syncope, she may need to be admitted, but i'd like to hear some of her home meds, any cardiac history, her blood pressure and heart rate in the field, blood pressure upon arrival to the ed, orthostatic blood pressure, and ekg findings (if any). i've had that 70 year old patient, and those things weren't known, and was told that it didn't matter and that i needed to "see the patient now". of course, that wasn't you either. but to me, those things are important and vital to some sort of plan of action.

the patient with neutropenic fever will need to be admitted, but knowing whether they're a cancer patient on chemo vs. a transplant patient vs. hiv positive can be a crucial piece of info over the phone.

when i was in medical school, it seemed that the er physicians thought and did a lot for patients. in residency, the thinking seems to stop past "the patient is going to be admitted". again, i'm at an institution without er residents, and thus the er attendings (whom do not have admitting privileges) have less/no incentive to teach... and in some cases have less/no incentive to think critically. however, i realize that not all er physicians are like this, and i still have a healthy respect for the er and what it does.

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[Dr. Will]

i was just using the diagnoses/diseases listed by the poster above me (dr. mcninja).



for that 70 year old with syncope, she may need to be admitted, but i'd like to hear some of her home meds, any cardiac history, her blood pressure and heart rate in the field, blood pressure upon arrival to the ed, orthostatic blood pressure, and ekg findings (if any). i've had that 70 year old patient, and those things weren't known, and was told that it didn't matter and that i needed to "see the patient now". of course, that wasn't you either. but to me, those things are important and vital to some sort of plan of action.

the patient with neutropenic fever will need to be admitted, but knowing whether they're a cancer patient on chemo vs. a transplant patient vs. hiv positive can be a crucial piece of info over the phone.

I completely agree with what you posted. These are all very important aspects of the history that need to be communicated with the admitting team and I usally have this info when I call up. I try to work up what I can and won't call until those results are in. Also do what I call a "chart biospy" to see what I can figure out (especially with patients like neutropenic fever). To just admit them based on complaint without any assocaited info or even parts of the workup done are completely inappropriate.

 

[fang]

What I'm getting out of this thread is that people will complain anytime another doctor creates more work for them personally. This is irrespective of whether that other doctor is making good/safe choices for their patients, and includes situations like sending a pt to the ED from clinic when they're not actually dying/bleeding, calling a consult early (before the w/u is complete perhaps), or all those questionable general medicine admissions.

 

[Bitsy3221]

I love how you combined TWO DIFFERENT posts by TWO DIFFERENT posters to come to some sort of "conclusion."

How is it you quote two people and then use both of them to form a unified opinion?

In realty, the real basis of me forming an opinion is the countless interactions I have had with the ED in multiple institutions; these two quotes from two EM docs just seem to highlight the attitudes shared by many. Besides, the times I have gotten called on the patient referred to the ER from surgery clinic the one--and only--order written on the chart is "Page Surgery".

My point, and my experience, is that despite what your individual policies may be that there are many ER physicians who call consults way, way too early in the diagnostic process, I suppose in an effort to be efficient. I can't tell you the number of times I get the "hey, I got a kidd-o down here with abdominal pain" and when I ask for the temp/WBC count/description of the pain I am met with silence. As busy as you all are in the ED (which I do appreciate--I have seen the waiting room!) we as just as if not more busy up on the floors, so calling us "early since they will get admitted anyway" doesn't really help move the process along. I get a consult, I HAVE to see it ASAP even if things aren't back yet--it's our hospital policy. So I get pulled away from taking care of verified-sick patients or out of the OR to go sit in the ED and wait for labs to come back or pester radiology to get a scan done and read, since once the ED docs see me there they sign-off on taking care of the patient. The moment I walk in the door, I often get asked by nursing for orders before I even see the patient, since the ED doc tells them "it's surgery's patient." Please understand that I can not call an attending to present a case for admission or to go the OR without all the pieces of information (history, exam, labs, x-ray), so you are not doing anyone a favor or speeding up the process by calling me while "things are still cookin'". As much of a pain as it is for the ED, it is far more expensive and far less efficient to admit someone to the hospital for a workup that can be done in the ED.

I just don't think that an ER doc can or should immediately group someone into the "admit" vs. "discharge home" group; especially without a somewhat thorough workup being done. I also don't think that an ER doc should say that a clinic is lazy by sending someone to the ER, yet they are being efficient by calling early consults. Your two quotes just illustrated the double standard that many, many docs hold high. I did not mean it to be a personal attack directed at you two individually (Dr. McN--we often agree on other posts!)

And don't even get me started on the "I don't think this guy has anything, and can probably go home but I need to get a surgery consult on the books before I send him" page.......

 

[Dr. Will]

My point, and my experience, is that despite what your individual policies may be that there are many ER physicians who call consults way, way too early in the diagnostic process, I suppose in an effort to be efficient. I can't tell you the number of times I get the "hey, I got a kidd-o down here with abdominal pain" and when I ask for the temp/WBC count/description of the pain I am met with silence. As busy as you all are in the ED (which I do appreciate--I have seen the waiting room!) we as just as if not more busy up on the floors, so calling us "early since they will get admitted anyway" doesn't really help move the process along. I get a consult, I HAVE to see it ASAP even if things aren't back yet--it's our hospital policy. So I get pulled away from taking care of verified-sick patients or out of the OR to go sit in the ED and wait for labs to come back or pester radiology to get a scan done and read, since once the ED docs see me there they sign-off on taking care of the patient. The moment I walk in the door, I often get asked by nursing for orders before I even see the patient, since the ED doc tells them "it's surgery's patient." Please understand that I can not call an attending to present a case for admission or to go the OR without all the pieces of information (history, exam, labs, x-ray), so you are not doing anyone a favor or speeding up the process by calling me while "things are still cookin'". As much of a pain as it is for the ED, it is far more expensive and far less efficient to admit someone to the hospital for a workup that can be done in the ED.

I completely agree with you on this. I do not call until I have a specific question or reason for admission. Otherwise I feel you're jumping the gun, and I agree it's poor form. Not all belly aches are surgical. Not all broken bones require ortho to come down. There have been times, however, that I've had to call b/c the attending has wanted it and I quickly apologize to the consultant and tell them that it's not coming from me. I personally do not agree with this practice. Luckily it's far and few between where I've had to do that.

I also agree about just "handing" off the patient when a consult is called or a patient is admitted. As long as the patient is in the ED and my name is on the chart they are my patient and you are the consultant. I will continue my treament/workup unless the consultant/admitting team want me to do something different, which is usually communicated. And yes, I realize that you don't have a full set plan at times, and you may dissapear for a while until it's figure out. It's unfortunate that others don't and pester you about it. When I see it happen with my patients, I usually try to tell the patient's nurse I'll let them know when I do.

I just don't think that an ER doc can or should immediately group someone into the "admit" vs. "discharge home" group; especially without a somewhat thorough workup being done. I also don't think that an ER doc should say that a clinic is lazy by sending someone to the ER, yet they are being efficient by calling early consults. Your two quotes just illustrated the double standard that many, many docs hold high. I did not mean it to be a personal attack directed at you two individually (Dr. McN--we often agree on other posts!)

And don't even get me started on the "I don't think this guy has anything, and can probably go home but I need to get a surgery consult on the books before I send him" page.......

While dispo is important and sometimes you can "eyeball" a patient and tell somethings going on that will cause an admit, I do disagree with jumping the gun to get them admitted/call consultants. You got to do some of the workup to narrow down at least what's going on so the patient can go to the right service and get the right treatment. Most EM physicians stand by the "we diagnose/treat at the same time," philosophy.

And yes...calling the consultant to dispo the patient for you is pretty lame. If you're that concerned you gotta up your level of workup. I do, however, call consultants for patients who have a significant history/recent admission with them out of courtesy and to see if there's anything specific they want done (especially if they have scheduled follow up in the next few days.)

 

[Blade28]

And don't even get me started on the "I don't think this guy has anything, and can probably go home but I need to get a surgery consult on the books before I send him" page.......

We get those "consults" all the time too. Or the "hey, while you're here in the ER, can you come lay hands on my patient just to clear him from a surgical standpoint?" This can happen 2-4 times a night, and while it sounds simple to just "clear" the patient, you have to write a full consult H&P, discuss it with your senior, etc.

I also hate getting consulted when the requesting ER physician (1) hasn't performed an H&P, or (2) just looked at the triage chief complaint sheet and called for a consult based on that, or (3) maybe has done an H&P, but not a thorough one (e.g. didn't actually look at the unclothed abdomen, or didn't do a rectal), or (4) doesn't actually look at the ordered XR/CT (we all know the radiologist's final read is the final say, but you can at least look at the film! We stress this to all the med students/residents on our services).

Or, now that I think about it, (5) goes ahead and calls Bed Control or the OR with orders BEFORE WE EVEN SEE THE PATIENT.

 

[BADMD]

Please understand that I can not call an attending to present a case for admission or to go the OR without all the pieces of information (history, exam, labs, x-ray), so you are not doing anyone a favor or speeding up the process by calling me while "things are still cookin'".

The junior surgery resident tried to convince me of this when I was resident and I can tell you that it just isn't true. If a patient actually has an abnormal physical exam and a history that goes with a surgical illness, I find that an early surgical consult before everything is back, cuts 1-2 hours off their ED time. That won't be the case for your average belly pain with normal vitals type patient, but for the ones who seem sick, you better believe that is cuts down their ED stay and time to OR.

I just don't think that an ER doc can or should immediately group someone into the "admit" vs. "discharge home" group; especially without a somewhat thorough workup being done.

Actually, for a lot of patients, you can group them into "sick," "not sick" and "don't know." If someone is going to need to be admitted, then I want to start the process early. If a white count, imaging or other testing isn't going to change the disposition, then I'm going to start the admit process. My hosptial has limited numbers of bed and I'm competing with my fellow EPs and community docs for those beds. While I won't send them to the floor without getting the relavent labs, imaging and inital therapy, I'm not going to let the lack of CBC keep me from requesting a bed for someone who needs to be admitted.

Understand that I'm happy to and often do extensive diagnostics and treatment in the ED (I'm a firm believer that severe sepsis and septic shock patients need to meet there goals before leaving the ED), but I want that bed earmarked for the patient if they need it.

And don't even get me started on the "I don't think this guy has anything, and can probably go home but I need to get a surgery consult on the books before I send him" page.......

No argument, that is just weak.

 

[f_w]

We get those "consults" all the time too. Or the "hey, while you're here in the ER, can you come lay hands on my patient just to clear him from a surgical standpoint?" This can happen 2-4 times a night, and while it sounds simple to just "clear" the patient, you have to write a full consult H&P, discuss it with your senior, etc.

A lame attempt to have more people in the trajectory if the poop hits the fan.

But to be honest, you also have to mention the academic hospitals where chairmen of surgery issued edicts that 'no belly pain should leave the hospital without a real doctor (--> surgeon) having laid hands on him'. At times, these 'laying hands' curbsides are the legacy of such a policy instituted 30 years ago. Some of this simply falls into the realm of petty academic power games. When your budget or the importance of your service is dependent on the number of consults you provide, the temptation is great to fluff your numbers on the backs of junior residents (not limited to general surgery. same applies to ortho, ophtho, ent and gyn).

or didn't do a rectal), or

I am sure you love if that rectal has been 'saved' for you, 'so the patient doesn't have to undergo it twice' (same applies to pelvics being 'deferred' for the gyn resident to perform).

(5) goes ahead and calls Bed Control or the OR with orders BEFORE WE EVEN SEE THE PATIENT.

My wife is an ophthalmologist. At one occasion (in private practice), she got called to evaluate a patient for what turned out to be a corneal foreign body to find the anesthesiologist pre-opping the patient once she got there. The patient had been referred in from a military optometry clinic with the diagnosis of 'ruptured globe' and the ED provider had decided to 'get the ball rolling' without actually looking at the eye himself... (a 25Ga cannula, some bupivacine drops and a flick of the wrist later the patient was healed).

 

[8744]

On the other hand, I have had several acute abdomens who were so obviously surgical candidates that you hardly even needed to do any labs. One turned out to be a perforation and the other turned out to be a acute appendicities. Both ended up in the OR.

When I called the resident they wouldn't come down until we got the CT with PO contrast, all of the labs, and who knows what else. We'll get all of that stuff but there is no point delaying the definitive treatment by working linearly. The surgeon can evaluate and assemble his team while waiting for the results saving valuable time. My attending called the resident and then the attending and we got it squared away. I understand that surgery residents are tired, overworked, and generally living ****ty lives but occasionally we need you guys to move fast.

And I have never, ever seen any chart with the order, and nothing else, "Consult Surgery." maybe you guys donn't know where we write the orders.

 

[Blade28]

But to be honest, you also have to mention the academic hospitals where chairmen of surgery issued edicts that 'no belly pain should leave the hospital without a real doctor (--> surgeon) having laid hands on him'. At times, these 'laying hands' curbsides are the legacy of such a policy instituted 30 years ago.

That's a good point that I hadn't considered. I need to see if there are politics at work here...

 

[f_w]

When I called the resident they wouldn't come down until we got the CT with PO contrast, all of the labs, and who knows what else.

We had a little game: 'GS bingo'.

- If you got the CT on a belly pain, the GS resident would chew you out for 'increasing morbidity by wasting time on this clear-cut appy that by the power of this large testes he would have taken to the OR right away'

- If you didn't get the CT on a belly pain, the GS resident would chew you out for wasting his time with this incompletely worked up patient.

Yes, those guys where overworked. Most where competent, few where cool.

 

[Apollyon]

We had a little game: 'GS bingo'.

- If you got the CT on a belly pain, the GS resident would chew you out for 'increasing morbidity by wasting time on this clear-cut appy that by the power of this large testes he would have taken to the OR right away'

- If you didn't get the CT on a belly pain, the GS resident would chew you out for wasting his time with this incompletely worked up patient.

Yes, those guys where overworked. Most where competent, few where cool.

Well, that's the ortho thing, too (but, thank heavens, not where I'm at now):

"Where's the films? Call me when you have them."

"Why are you calling me so late? You got films? This patient needed to be seen by us as soon as they got here!"

Can't win either way.

 

[fineline]

That's the ER for you: all cookbook. "You get mad when I call you late, now you get mad when I call you early, when do I call?!?! *sob*" They want you to tell them some protocol, as if all patients are the same, or tell them something so they don't have to think. I'm being serious, I've never heard any complaint more pathetic than that because it just demonstrates to me that they really don't "get it" when it comes to dealing with medicine. I mean, that's what I expect a layperson to ask, not a trained and board-certified physician.

 

[Dr. Will]

That's the ER for you: all cookbook. "You get mad when I call you late, now you get mad when I call you early, when do I call?!?! *sob*" They want you to tell them some protocol, as if all patients are the same, or tell them something so they don't have to think. I'm being serious, I've never heard any complaint more pathetic than that because it just demonstrates to me that they really don't "get it" when it comes to dealing with medicine. I mean, that's what I expect a layperson to ask, not a trained and board-certified physician.

Now you're just reaching for anything to argue/complain about when it comes to the ED.

 

[fineline]

That's a "reach"? That's all the ER does is call people. That's like if you call it a "reach" to complain about how Pediatricians treat children.

 

[Dr. Will]

That's a "reach"? That's all the ER does is call people. That's like if you call it a "reach" to complain about how Pediatricians treat children.

"It's not your fault."

 

[fineline]

By the way, I got another one of those "we've got a guy down here with [fill in medical problem]." And I go, "uh huh" and wait for more and the only other thing I get is "...anyway, the guy doesn't really want to stay, so can you come and see him quickly?" And I'm like, "uh ...were you planning on telling me more than 'this guy has this disease, we think'?" Seriously, I'm waiting for the day someone calls and is like, "we have someone down here with SOB and by the way, did you watch 'Dancing With the Stars' yesterday?" It would make just as much sense.

 

[Dr. Will]

By the way, I got another one of those "we've got a guy down here with [fill in medical problem]." And I go, "uh huh" and wait for more and the only other thing I get is "...anyway, the guy doesn't really want to stay, so can you come and see him quickly?" And I'm like, "uh ...were you planning on telling me more than 'this guy has this disease, we think'?" Seriously, I'm waiting for the day someone calls and is like, "we have someone down here with SOB and by the way, did you watch 'Dancing With the Stars' yesterday?" It would make just as much sense.

Many of the EM docs that have posted on this thread have already stated that this type of situation is lame. Why do you keep complaining to us about it, and continuing to insult those of us that actually agree with some things you say? If it's that big of a deal to you where you are, say something about it and generate some conversation with those that are doing this. Not everyone shares the same experience with you. Yet you continue to generalize that we all do this.

 

[tkim]

If it's that big of a deal to you where you are, say something about it and generate some conversation with those that are doing this.

He has, before. That's all I'll say about that.

 

[fineline]

You know what I find interesting? No matter what anyone writes on here, the response is either "that never happens, you're lying and you are a rotten liar" or "OK, I'm sure that happens in like central Mississippi and the guys who do it happen to be white supremacists and nobody likes them, but everyone I know does it differently." It's great that everyone on this board apparently is a superb EM physician and excellent in every way and thoughtful and conscientious ...am I forgetting any positive adjectives? LOL.

 

[fineline]

He has, before. That's all I'll say about that.

Toupee!

 

[tkim]

Toupee!

I believe you meant to say 'zing'.

 

[fineline]

I believe you meant to say 'zing'.

All of my posts are well-thought out and carefully crafted, so you can trust that I meant what I wrote.

 

[Mman]

On the other hand, I have had several acute abdomens who were so obviously surgical candidates that you hardly even needed to do any labs. One turned out to be a perforation and the other turned out to be a acute appendicities. Both ended up in the OR.

Doesn't a perfed appy get antibiotics for a period of time (days) and then go to the OR later to take it out after the inflammation has calmed down?

perhaps a surgeon could straighten me out on this one

 

[tkim]

All of my posts are well-thought out and carefully crafted, so you can trust that I meant what I wrote.

Toupee. I completely understand. Honestly, I do.

 

[fineline]

Even if you know the appendix is perforated, not necessarily. And it's not the case that people know who is perforated necessarily. And also it's not the case that what some people call "obvious surgical abdomens" are that. So, in summary: BOOGALOOO!

 

[fineline]

Toupee. I completely understand. Honestly, I do.

Excellent. Excellent.

 

[tkim]

Excellent. Excellent.

And I also understand why you didn't write 'zing'.

 

[fineline]

It's because the "z" is broken on my keyboard and I didn't think you'd understand if I wrote "ing."

 

[tkim]

It's because the "z" is broken on my keyboard and I didn't think you'd understand if I wrote "ing."

Well, your 'h' key works and you certainly can type out 'hubris'.

 

[fineline]

Well, your 'h' key works and you certainly can type out 'hubris'.

I don't know what that means, but I'm awesome anyways.

 

[Blade28]

I don't know what that means, but I'm awesome anyways.

Didn't watch 300?

 

[fineline]

I was too busy kicking Spartan ass and taking Spartan names. Like "Damokles" and "Achaikos." Those were two of the names I took.

 

[tkim]

I don't know what that means, but I'm awesome anyways.

Still bitter. Can't blame you.

 

[fineline]

Still bitter. Can't blame you.

Wow, he knows me so well it's like we're dating! Kiss me, soulmate!! (No tongue, however, it's a little early for that.)

 

[8744]

Doesn't a perfed appy get antibiotics for a period of time (days) and then go to the OR later to take it out after the inflammation has calmed down?

perhaps a surgeon could straighten me out on this one

But an obvious acute abdomen (and these were obvious) is an emergent surgical consult no matter what they end up doing.

The other thing is, I must go to a good EM program (or a bad one?) because we end up doing extensive work-ups on almost all of our patients including (by necessity) managing critical care patients while they wait for an ICU bed, sometimes for five or six hours. I have never even heard of a resident or attending at my program calling a consult without a thourough work-up, much less without even laying hands on the patient, except if it is something obvious like an acute MI or a very obvious and bran-new stroke. But for garden variety abdominal pain? Chest pain? AMS? Not a chance.

Dude, I diagnosed a guy with tropical sprue by based on a careful history and few judicious labs (B12, etc.). If you don't think EM makes diagnosis then you haven't spent enough time in the ED. We just don't beat obvious things to death.

I think we should all just admit that their are lazy, crappy doctors in every specialty who, as much as possible, just punch the clock and do as little work as is necessary to stay legal and protect their paycheck.

 

[chimichanga]

300 was a great movie...

 

[Miami_med]

300 was a great movie...

You see old friend, I brought more soldiers than you did.

 

[elwademd]

I think we should all just admit that their are lazy, crappy doctors in every specialty who, as much as possible, just punch the clock and do as little work as is necessary to stay legal and protect their paycheck.

well said!

 

[NinerNiner999]

Docs in clinics send patients to the ER because that's the pathway to hospital admission, many diagnostic studies, possibly surgical intervention, etc., NOT to take advantage of the superior management or diagnostic skills of the ER doc.

This practice is unacceptable. The pathway to admission is though a phone call to the admissions office, no the ED. If private docs wish to admit their patients, the ED is not the way to do it. Ever.

 

[deleted50478]

This practice is unacceptable. The pathway to admission is though a phone call to the admissions office, no the ED. If private docs wish to admit their patients, the ED is not the way to do it. Ever.

It is unreasonable to think that a primary care doc, who might get called at home daily and at all hours of the night, to re-open his clinic every evening to evaluate patients to decide whether or not admission is warranted. It would also be wrong for the primary care doc to directly admit lots of patients he hasn't even evaluated. That leaves the ED. He shouldn't send patients to the ED if their stories aren't convincing or sound like complaints that can wait until morning, but if he is concerned ER referral is his only option.

 

[f_w]

This practice is unacceptable. The pathway to admission is though a phone call to the admissions office, no the ED. If private docs wish to admit their patients, the ED is not the way to do it. Ever.

We are back in the world of dogmatic proclamations it seems.

There are plenty of situations where the patient receives a benefit from being routed through the ED rather than ending up on the floor without the availability of a licensed independent provider to evealuate him/her upon arrival in the hospital. In a community hospital setting (sans hospitalist or residents), the PCPs won't be able to see a patient they sent to the hospital until evening rounds.

Not every patient referred from primary care for admission should go through the ED, but there are certainly the ones that should.

 

[kungfufishing]

So, instead of drive to the hospital to see the patient you just admitted, route them through the ED? The sign says "emergency" not "convenience".

Of course there are scenarios when a patient should be funneled through the ED, but a direct admit is not one.

 

[deleted109597]

In a community hospital setting (sans hospitalist or residents), the PCPs won't be able to see a patient they sent to the hospital until evening rounds.

Heh heh. I'm not sure what planet you exist on, but evening rounds often don't exist in community hospitals, and even in resident hospitals they only exists because the residents are there, not because the attendings are making them.
That's not to say there aren't doctors that don't make evening rounds, but from my experience, it is the exception, and not the norm.
Also, in community hospitals, strange things happen, like nurses changing dressings instead of residents having to do it. The real world is definitely very strange.

 

[Winged Scapula]

Heh heh. I'm not sure what planet you exist on, but evening rounds often don't exist in community hospitals, and even in resident hospitals they only exists because the residents are there, not because the attendings are making them.
That's not to say there aren't doctors that don't make evening rounds, but from my experience, it is the exception, and not the norm.
Also, in community hospitals, strange things happen, like nurses changing dressings instead of residents having to do it. The real world is definitely very strange.

Guess what...they'll also remove sutures, staples, drains, take verbal orders, arrange Visiting Nurses, etc.

It IS a very strange world in hospitals without residents.

 

[doc02]

Guess what...they'll also remove sutures, staples, drains, take verbal orders, arrange Visiting Nurses, etc.

It IS a very strange world in hospitals without residents.

Actually, the world without residents is the way things are supposed to be. Residency programs are just a demonstration of how things become one you put a powerless group of people in between two opposing forces (attendings, who know they want stuff done and also know they don't have to be the ones doing it, and nurses, who know they have to do stuff and are looking for someone else to do their jobs). Enter the resident!

 

[Winged Scapula]

Actually, the world without residents is the way things are supposed to be. Residency programs are just a demonstration of how things become one you put a powerless group of people in between two opposing forces (attendings, who know they want stuff done and also know they don't have to be the ones doing it, and nurses, who know they have to do stuff and are looking for someone else to do their jobs). Enter the resident!

I also forgot to add: very rare middle of the night calls to reorder Tylenol or a bowel prep in these hospitals without residents.

 

[f_w]

Heh heh. I'm not sure what planet you exist on, but evening rounds often don't exist in community hospitals,

Well, don't know whether I live in 'often', but they exist here, in my dinky little community hospital. If the various clinic and private docs have some of their own patients on the floor, they usually drop by on the way home to check on them.

Also, in community hospitals, strange things happen, like nurses changing dressings instead of residents having to do it. The real world is definitely very strange.

Right, but the RNs won't be able to make a decision about discharge, change in antibiotics or all those other little things licensed independent providers do.

 

[Blade28]

Guess what...they'll also remove sutures, staples, drains, take verbal orders, arrange Visiting Nurses, etc.

Yeah, I was shocked to learn that nurses at our private hospitals here can take orders such as pulling JPs, removing staples, changing WoundVacs, etc.

 

[Winged Scapula]

Yeah, I was shocked to learn that nurses at our private hospitals here can take orders such as pulling JPs, removing staples, changing WoundVacs, etc.

Its pretty amazing when you train at an academic hospital. I was moonlighting a few weeks back and saw the world's largest decub in consult. I was muttering something while the nurse was in the room about putting a vac dressing on and she offered to put it on for me.

Heck yeah I said, envisoning myself cutting sponges for 45 minutes to fit this beastly wound. She did a great job on it when I checked later.