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RANT! Are ER Docs Stupid!

Al Sacchetti, MD
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10:59
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No me gusta!

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I can handle things. I'm Smart. Not Like everybody says!

-Fredo

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David B. L., M.D. -

Al, I think it is great that you are a strong advocate of more is better. I'll preface my comments along the same lines about how I feel about Scott Weingard’s mantra of “bringing the ICU from the upstairs to the downstairs.” As we accept more and more responsibility of definitive care for our patients, the demands on an emergency physician’s time is increasing geometrically. We face a plethora of metrics to enforce performance in certain time frames, time to be seen, LOS till discharge and/or admission, administration of antibiotics, door to balloon, TPA administration, and so on and so on. I love nothing more than taking care of sick patients and performing procedures. I believe this is what attracted most of us to the specialty (hell a few months back after getting the run around to get a consultant to come in to ‘fix’ a ruptured globe, I was ready to see if I could find the necessary info in Robert’s and Hedges and do it myself). But the reality is, if I spend 30 minutes repairing a punctured bleeding dialysis site (while the procedure itself may not take that long, obtaining the equipment and preparation will, then documenting what I have done adds to the time spent), I will be causing a log jam in patients waiting to be seen, increasing the angst in the department. Yes, for most of us even those patients with a tooth ache and chronic back pain patients must be seen in a predefined time frame. Yes we can do it all when called upon, but there are many more practical considerations, and we must be wary of differentiating what we are capable of doing in the ER from what is practical.

Alfred S., M.D. -

I agree completely that what we do is tempered by our individual
sites. What I can do easily at my shop may take half a shift to
accomplish at the hospital down the road. But I think the decision to
do something or order a test should be an individual decision of the
emergency physician and not some general premise that someone else in the medical field is better at it than us.

Unfortunately, those external monitoring parameters we have to meet
are here to stay. We just need to be certain that we don't let them
compromise our care.

Thanks for the comment.

Al

Pierre M., M.D. -

As a community ER doc in Canada, I agree with Al's opinion that we can and do do more than we are given credit for and with Stuart's "We need to know what we need to know and we need to know one step further" mantra.

However, I COMPLETELY disagree with some of the examples Al uses and suggest these as PROOF against his arguments. Al supports the use and ordering of CCTA for low risk chest pain patients and on one episode used his own personal chest pain experience. No evidence that CCTA does anything for real world patient oriented outcomes other than less time in the ED and more radiation exposure. We know it will lead to more downstream testing of these patients with 30% lesions. We know from the PE literature that we are now more likely to cause an acute contrast reaction than we are to find a PE so why does he think we are going to be any better as a specialty with CCTA??? And using the argument that there is a paper on the natural history of small berry aneurysms is not a valid reason to do a test (CT angiogram) which is not proven to change outcomes in any way, other than to expose the patient to double the radiation dose (from a second CT) and exposure to the risk of contrast agents. Thee examples he uses would be great reasons to say that we as a specialty are lost in the dark.

Paul B., M.D. -

Hey Al,

What was the procedure you learned to suture dialysis catheters? I tried to google it but cant get it right.

Thanks!

Alfred S., M.D. -

Pierre:

We can argue for days about the merits of CCTA, but that is not my point.

My argument is that if there is a test, mainly a screening type of test, then Emergency Physicians can learn the indications as well as a consult. We can make informed decisions on whether or not the test should be ordered as well as any other group of physicians. Obviously, this is within reason, we are no going to be ordering kidney biopsies or ERCP's from the ED.

We may disagree on which tests you and I order, but I think we agree on the point that as emergency physicians we should be able to use our judgment on when to order those tests.

Pierre M., M.D. -

Agreed

GoodCPR -

Al, I am also trying to find out the technique to suture those bleeding dialysis fistulas. Can you please give us the link or post a video. Thanks. Great rants as usual.

Sean G., M.D. -

I agree with Pierre's comment( both the "agreed" and the initial one....I agree with the rant on its essence, but the idea put forth that the incidentalomas we find on our sophisticated testing are a benign consequence of modern medicine, I totally disagree. I think we are finding so much shit we never needed to know( CTA for PE/positive D Dimer) a perfect example and this is the real issue with CCTA in my opinion. In America we have this sense if a test exists, why not use it? Well, thats a problem IMO.The fact that we havent reduced mortality from PE but have strained the health care system with our expensive workups since the advent of CTA for PE is a good example. God knows how many cancers we are actually contributing to with our constant desire to Ct everybody.

daniel m. -

One more request for a description of the dialysis shunt suturing trick.
Thanks in advance.

Alfred S., M.D. -

Dan: Sorry for the delay we just got the Perchek button video up on YouTube today.

Here is the link: https://www.youtube.com/watch?v=YpEfJjws_Po

daniel m. -

Thanks Al!

david h. -

wow again dlh

Scott W., M.D. -

Thanks Al. Just a technical question though. You refer to it as a figure 8 type suture. I didn't see you cross threads or did I miss something. Perhaps more of a horizontal mattress? thanks and sorry to bother you.

Alfred S., M.D. -

You are correct, it is a horizontal mattress and not a figure of 8. We used to use figure of 8's before we started using the Precheck Buttons.

Thanks

Al

Jeffrey A., M.D. -

I just listened to your rant and I am frankly dissapointed in the tone and direction you feel we should be heading. Each of us is smart enough to do just about anything. BUT, almost all of us are just trying to keep afloat in the day to business of managing the deluge of patients that arrive every day. I would love to define my practice by critical procedures and complex medical decision making. But I can't. I need to take care of the first 1.5 - 2 hours of a patients care in arder to be efficient and keep the flow moving. That means NOT doing many things in the ED that we could possibly perform. Bringing ICU care to the ED might be great if it came with staff and equipment and time and ...but it hasn't in my ED. Our leaders in EM need to advocate for the specialty based on what is reality and and not what we could theoretically accomplish. We actually need to LIMIT our scope of practice in most cases and rely MORE HEAVILY on our specialists and hospital based colleagues if we are going to survive the on coming Tsunami. ED burnout is a real issue. ED overcrowding is a real issue. EMTALA stopped hospital-hospital dumping but has caused Primary care to ED dumping to increase exponentially. We need to fix the medical access/public health component of our specialty (NOT TOO INTERESTING ON THE PROCEDURE/COMPLEX DECISION MAKING FRONT) before we can talk about expanding our role as the best most, most qualified physicians in the hospital. We can't accomplish both without massive expansion in our ED capabilities and these have been steadily shrinking. We aren't stupid! But realistically we can't do it all either.

Alfred S., M.D. -

I don't disagree with much of what you say. However, your points and mine are not mutually exclusive. In our department we still have to manage the 80+% of discharged patients we see on a daily basis and we still need to do it in a timely efficient manner.

I do disagree with your premise that we can't do it all. The reasons we wind up limiting our practices tends to be more a result of a sub-optimal practice environment more than anything else. I would include in this both hospital politics with the medical staff and physical plant restrictions. There are many examples of ED's similar to what you described but I believe there are also many others closer to our practice.

Kevin M. -

Al,

You need to get out more. Where I work, the closer we get to the answer, the more pleased are my consultants. This is what is expected in the real world. The Academic centers are sometimes quite out of touch with what we really do in the real world. We order whatever we need to to make the diagnosis or exclude life threatening conditions. These docs are my colleagues. We treat each other with respect. We work together. Every hospital has a few boneheads. Most of the time they can be finessed.

Academia is full of egomaniacs who are convinced that its "my way or the highway", legends in their own minds if you will. My medical staff would never consider letting anyone but Board Certified ER docs work in the ED. Why?...because we have truly made a difference in their practice. We have their full support. I think back on all that BS that was present in residency. I am thankful for the full support my residency program gave the residents during training, but don't miss the occasional egomaniacs that populate such hospitals.

Alfred S., M.D. -

Kevin:

I actually practice in a community ED, it happens to be an urban hospital that serves as the community rotation for some residencies, but functions entirely like a community ED.

And I agree we have made a difference in the practices of our consultants which is why we have an excellent relationship with them.

Al

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Episode 140 Full episode audio for MD edition 238:22 min - 100 MB - M4AResumen Mayo 2013 en español Español 80:43 min - 28 MB - MP3EM:RAP 2013 May MP3 81 MB - ZIPEM:RAP May 2013 Written Summmary 857 KB - PDFEM:RAP May 2013 Board Review Questions 635 KB - PDFEM:RAP May 2013 Board Review Questions:Answer Sheet 661 KB - PDF