Jump to content
Premed 101 Forums
Sign in to follow this  
medigeek

How do family doctors competently work in ERs?

Recommended Posts

This is more for the newer doctors who only did 2 years of family medicine and don't have much procedural experience. These ERs are often solo staffed with no one to back up. How do they manage the less common events that require procedural skills? Ex. crashing obese patient with a extremely difficult airway. There's no one to back up, so has anyone looked at these outcomes? 

Share this post


Link to post
Share on other sites

This is becoming uncommon to do for new grads. Most of the centres that new GPs without a +1 will work out of now are in smaller communities where really sick patients that predictably fit your example would likely be transferred to a larger, better staffed centre. The family medicine residents who do take on these jobs are typically people who train in rural/remote programs where they have a lot of exposure to procedural skills and a higher level of comfort of not having access to resources. 

Share this post


Link to post
Share on other sites
6 minutes ago, shakeshake said:

This is becoming uncommon to do for new grads. Most of the centres that new GPs without a +1 will work out of now are in smaller communities where really sick patients that predictably fit your example would likely be transferred to a larger, better staffed centre. The family medicine residents who do take on these jobs are typically people who train in rural/remote programs where they have a lot of exposure to procedural skills and a higher level of comfort of not having access to resources. 

Less common? Sure. I know several who will be doing it this year though. Some ERs ~2 hours or so from the GTA are practically begging for shifts to fill during the summer time as well. If you're more north than that they will take almost anyone. 

Sick patients will be transferred yes, after they are stabilized. And stabilizing an obese big beard angioedema crashing patient's airway isn't something the paramedics will be capable of doing. 

Do agree with rural residencies providing those experiences, but I wonder how much? You'd need at least 100-150 intubations to have any decent proficiency. Other procedures you can certainly get away with very low numbers.  

Share this post


Link to post
Share on other sites
Just now, medigeek said:

Less common? Sure. I know several who will be doing it this year though. Some ERs ~2 hours or so from the GTA are practically begging for shift to fill during the summer time as well. If you're more north than that they will take almost anyone. 

Sick patients will be transferred yes, after they are stabilized. And stabilizing an obese big beard angioedema crashing patient's airway isn't something the paramedics will be capable of doing. 

Do agree with rural residencies providing those experiences, but I wonder how much? You'd need at least 100-150 intubations to have any decent proficiency. Other procedures you can certainly get away with very low numbers.  

 

You're right, the care for people who deteriorate quickly is likely suboptimal in these places. I guess what I am saying is that what I have seen is that often there is some level of triaging that happens when EMS pick up a patient in terms of which hospital they go to depending on what they predict will happen. But again, you're right this is only as good as the person doing the triaging is. 

Share this post


Link to post
Share on other sites
1 minute ago, shakeshake said:

 

You're right, the care for people who deteriorate quickly is likely suboptimal in these places. I guess what I am saying is that what I have seen is that often there is some level of triaging that happens when EMS pick up a patient in terms of which hospital they go to depending on what they predict will happen. But again, you're right this is only as good as the person doing the triaging is. 

Yeah. Although I'm just curious on what the approach is for the people working in these settings. Is there mental preparation on steps to take based on what comes in the door? Hmm.

Share this post


Link to post
Share on other sites

Im interested in doing rural family medicine and doing broad scope practice including picking up ER shifts (with or without a +1). It's reassuring to hear that there are still opportunities without the FRCPC training 

Share this post


Link to post
Share on other sites
2 minutes ago, COMMANDO said:

Im interested in doing rural family medicine and doing broad scope practice including picking up ER shifts (with or without a +1). It's reassuring to hear that there are still opportunities without the FRCPC training 

There are very few FRCPC docs at most medium sized hospitals. There are also not many +1s at rural ERs. 

Share this post


Link to post
Share on other sites
Just now, medigeek said:

There are very few FRCPC docs at most medium sized hospitals. There are also not many +1s at rural ERs. 

Medium sized hospital as in those outside of London, Hamilton, Toronto, Kingston, Ottawa aka Niagara, Windsor, Burlington, KW are medium sized?

Share this post


Link to post
Share on other sites
40 minutes ago, COMMANDO said:

Medium sized hospital as in those outside of London, Hamilton, Toronto, Kingston, Ottawa aka Niagara, Windsor, Burlington, KW are medium sized?

Yeah and you'd be surprised how many regular family docs still work in large community settings in the GTA or nearby. 

Share this post


Link to post
Share on other sites
1 hour ago, medigeek said:

 You'd need at least 100-150 intubations to have any decent proficiency. Other procedures you can certainly get away with very low numbers.  

 

Do +1 EM residents typically reach that number of intubations during the training year? Asking out of curiosity, as two to four weeks of anesthesiology rotations looks to be the norm after a brief glance of some of the different +1 EM programs around Canada. Residents would be intubating non-stop during those weeks to achieve those numbers, I would imagine! 

Share this post


Link to post
Share on other sites
2 hours ago, medigeek said:

This is more for the newer doctors who only did 2 years of family medicine and don't have much procedural experience. These ERs are often solo staffed with no one to back up. How do they manage the less common events that require procedural skills? Ex. crashing obese patient with a extremely difficult airway. There's no one to back up, so has anyone looked at these outcomes? 

I've met older doctors who had this kind of training and work in these kinds of settings and for some, not all, but for some it was actually worrying how little they knew, even about basic emerg knowledge a med student would know.

Share this post


Link to post
Share on other sites

I think smaller hospitals and communities can be desperate for coverage and will take anyone as the logic is that something is better than nothing. It's not great for the patient, but there has always been a segregation of service quality between urban and rural that I'm not sure we will ever be able to bridge.

Share this post


Link to post
Share on other sites
10 hours ago, icewine said:

Do +1 EM residents typically reach that number of intubations during the training year? Asking out of curiosity, as two to four weeks of anesthesiology rotations looks to be the norm after a brief glance of some of the different +1 EM programs around Canada. Residents would be intubating non-stop during those weeks to achieve those numbers, I would imagine! 

I did 85 over 4 weeks as a student and that is hard to get unless the volume and culture is there. You are more likely to get 40 or 50. 

There is no way to get sufficient numbers, especially RSIs, to be sufficiently competent at airway over 1 year. I think video scopes and the obvious low frequency of difficult airways makes the overall outcomes decent. 

But again curious on the comfort level behind working in these settings. 

 

Share this post


Link to post
Share on other sites
11 hours ago, Edict said:

I've met older doctors who had this kind of training and work in these kinds of settings and for some, not all, but for some it was actually worrying how little they knew, even about basic emerg knowledge a med student would know.

Curious. What sort of training do you mean?

Share this post


Link to post
Share on other sites

So anecdotal and only one example but I work as a RN in a rural emerg (we see around 30000 patients/year) and probably our most competent doc in terms of procedures is a recentish fm grad ( no + 1) who did his residency in a rural fm program. They are excellent and myself and the other nurses have the most confidence in them especially with procedures, over any of our other docs including those with much more experience and the +1’s. In my province the EHS can also call life flight from scene as well if they think it warrants it in consultation with their oversight. 

Share this post


Link to post
Share on other sites
49 minutes ago, Rahvin13 said:

So anecdotal and only one example but I work as a RN in a rural emerg (we see around 30000 patients/year) and probably our most competent doc in terms of procedures is a recentish fm grad ( no + 1) who did his residency in a rural fm program. They are excellent and myself and the other nurses have the most confidence in them especially with procedures, over any of our other docs including those with much more experience and the +1’s. In my province the EHS can also call life flight from scene as well if they think it warrants it in consultation with their oversight. 

Can you name some examples of differences in procedural skills that you've seen? 

Share this post


Link to post
Share on other sites
2 hours ago, medigeek said:

Can you name some examples of differences in procedural skills that you've seen? 

Much more confident and competent in stuff like central line insertions; abdominal (or any) paracentesis; pretty much anything that benefits from ultrasound. Most all our other ed docs won’t even attempt that stuff and just wait for IM to do it. I’ve also seen them get some pretty difficult intubations including a bad throat bleed a little while ago. Any traumas or resus I’ve ever been in with this person always go smoother as well.

Share this post


Link to post
Share on other sites
2 minutes ago, Rahvin13 said:

Much more confident and competent in stuff like central line insertions; abdominal (or any) paracentesis; pretty much anything that benefits from ultrasound. Most all our other ed docs won’t even attempt that stuff and just wait for IM to do it. I’ve also seen them get some pretty difficult intubations including a bad throat bleed a little while ago. Any traumas or resus I’ve ever been in with this person always go smoother as well.

So what happens when they're unable to intubate? What's their approach. 

Assuming they go direct +/- bougie --> glidescope --> maybe another form of video with a bougie --> LMA and wait for help OR cric if there's no help/can't ventilate. 

Share this post


Link to post
Share on other sites
4 minutes ago, medigeek said:

So what happens when they're unable to intubate? What's their approach. 

Assuming they go direct +/- bougie --> glidescope --> maybe another form of video with a bougie --> LMA and wait for help OR cric if there's no help/can't ventilate. 

Yeah that’s pretty much it. We don’t have in house anesthesia/Sx after regular OR hours and no ENT coverage so if we can’t get an oral tube we cric and fly them out. 

Share this post


Link to post
Share on other sites
51 minutes ago, Rahvin13 said:

Yeah that’s pretty much it. We don’t have in house anesthesia/Sx after regular OR hours and no ENT coverage so if we can’t get an oral tube we cric and fly them out. 

Guessing the rate of crics is higher than what you'd see in places with adequate support etc. 

Share this post


Link to post
Share on other sites
7 hours ago, Rahvin13 said:

So anecdotal and only one example but I work as a RN in a rural emerg (we see around 30000 patients/year) and probably our most competent doc in terms of procedures is a recentish fm grad ( no + 1) who did his residency in a rural fm program. They are excellent and myself and the other nurses have the most confidence in them especially with procedures, over any of our other docs including those with much more experience and the +1’s. In my province the EHS can also call life flight from scene as well if they think it warrants it in consultation with their oversight. 

4 hours ago, Rahvin13 said:

Much more confident and competent in stuff like central line insertions; abdominal (or any) paracentesis; pretty much anything that benefits from ultrasound. Most all our other ed docs won’t even attempt that stuff and just wait for IM to do it. I’ve also seen them get some pretty difficult intubations including a bad throat bleed a little while ago. Any traumas or resus I’ve ever been in with this person always go smoother as well.

2

That is a good reflection on rural FM training. It is only one example but I would imagine most recent graduates of rural FM training would be similarly skilled. Though I must say I do find surprising your confidence in procedures favoring the rural FM graduate over the +1 EM graduate(s). I would have expected a similar proficiency between them. Again though, only one example.

Share this post


Link to post
Share on other sites
On 4/3/2019 at 11:51 PM, medigeek said:

This is more for the newer doctors who only did 2 years of family medicine and don't have much procedural experience. These ERs are often solo staffed with no one to back up. How do they manage the less common events that require procedural skills? Ex. crashing obese patient with a extremely difficult airway. There's no one to back up, so has anyone looked at these outcomes? 

I think that the 2 year of family medicine residency has > 3 months of elective, so you could book anesthesia, ICU, CCU to gain more procedural skills.

For common procedures, the more ER exposure you get, the more comfortable you become. 

I do think that the rural family medicine residents who do a lot of ER as in their regular FM blocks have good exposure to procedures more than GTA FM residents.

A lot of ER doctors who work in GTA are 2 years without +1, although now they are hiring exclusively +1 in Toronto. In anywhere 1-2 hours away from Toronto, a lot of ER doctors are young grads without +1. You become comfortable by being the only person, and by getting some exposure during residency I would say. 

Share this post


Link to post
Share on other sites

It does help that rural ERs are well equipped with great airway equipment. As far as I've heard anyway. Mcgrath, c mac etc. It is by far the most difficult procedure to master as an ER doctor whereas most other procedures you can gain proficiency in very quickly. 

Share this post


Link to post
Share on other sites
On 4/4/2019 at 12:17 AM, medigeek said:

Less common? Sure. I know several who will be doing it this year though. Some ERs ~2 hours or so from the GTA are practically begging for shifts to fill during the summer time as well. If you're more north than that they will take almost anyone. 

Sick patients will be transferred yes, after they are stabilized. And stabilizing an obese big beard angioedema crashing patient's airway isn't something the paramedics will be capable of doing. 

Do agree with rural residencies providing those experiences, but I wonder how much? You'd need at least 100-150 intubations to have any decent proficiency. Other procedures you can certainly get away with very low numbers.  

 

I will be doing single coverage ER this summer out of residency. From advice of those around me, and my own thoughts, the situation you describe is incredibly rare, especially in a low volume center like where I will be. With 5-15 patients a day just based on probability you won't see as many emergent cases. Despite this, I made sure back-up was good as well and there will always be a physician back-up in the community who is more experienced with procedures if I find that I need extra help. 

Then of course, knowing your principles, doing as much reading as you can, and having a good plan for these scenarios is optimal. Start with VL, know your airway algorithm, prepare for surgical airway, use techniques that maintain airway reflexes if you are particularly concerned. Simulation can't be understated for High Acuity Low Opportunity scenarios; take extra courses to fill in knowledge gaps.

And lastly, something that often goes unsaid is that, unfortunately there is an understanding that due to nature of the location that these patients live that health care outcomes may not be as good compared to living across the street from a Toronto hospital. You just simply can't get Icatibant and a specialist with an airway fellowship to your patient in five minutes. But you do the best that you can to bridge health care disparities.

The more you think about it, it's pretty backwards that the areas with the lowest amount of resources also have practitioners with the least formal training.

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now
Sign in to follow this  

×