4:57pm page to the ER for a soft admit?

[glade]

It's always amazing reading these threads on SDN because all the ER people always go both ways. Half of them act like they're superstars, where it's like:

- We're not allowed to order labs or scans on a "fishing expedition" and if we did that, we'd expect to get chewed out.
- The only time I ever call anyone is AFTER I've read the EKG, diagnosed an RCA stenosis, begun all of the interventions, called in the cath lab team, and walked the dog for the Cardiologist. And I'm the sucky ER physician, where the other ER guys razz me for being incompetent.

And then the other half of them are like:

- Oh, by the way, that being said, diagnosis has nothing to do with our profession. We strictly stabilize patients. Not that we don't actually do what those other guys said. Just that if we don't, it's because we choose not to that one day and you can't blame us because we're not responsible for work-ups or diagnoses.

First of all, that's the biggest cop-out of all. "We're not responsible for diagnosis." You aren't? Then you're not a physician. You're an EMT who happens to work in a building. The ER, in actuality, if we cut the crap, doesn't even stabilize patients. They actually only identify unstable patients and BEGIN to stabilize them as they call someone else, be it the ICU, Medicine, Surgery/Trauma, or Ob. So now we're down to "go into ER: we can tell when someone is unstable." OMG, REEEALY?? Can you imagine the boards for ER, then? "Someone comes in with a HR of 156, BP of 74/49, and is unresponsive. Are they (a) stable or (b) unstable?" "Oh, crap, I knew I should have studied this part."

Second of all, why is it that NOBODY has interactions with these mythical amazing ER physicians? I mean, would you guys say your ER physicians DO or DO NOT:

(a) order the same set of labs (i.e., every single lab) on everyone;
(b) drastically over-use CT scans, even when told they aren't needed, as happened to me -- I told an attending they didn't need to perform a head CT on a patient and they did it anyways, so me and the Radiology attending just made fun of them for about thirty minutes;
(c) manage to at the same time NOT order a CT scan on the ONE person who does need one "because you keep telling us not to order CT scans";
(d) call you before they've examined the patient and sometimes before the patient is even in the room;
(e) call you after the patient has been sitting in their room for up to sixteen hours (that's my record) without any intervention other than a one-time order of morphine fifteen hours ago -- best part is when you walk in and the patient is like "is there anyone who works in this place?";
(f) start showering consults on you seemingly just because you reminded them you were around by walking through the ER (e.g., "oh, wow, hey, I have two consults for you!" "me, too!" "did someone say Surgery was down here?" "do you manage PEs?" "I have a patient here for something, but I don't do diagnosis!!")

Really, I don't even get how a physician could say AND THEN STAUNCHLY DEFEND not having to diagnose things. That's an outright admission that you just shotgun and pray, if you don't have a diagnosis. I'd frankly be embarrassed to say something like that, but that's just me.

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[Law2Doc]

...So whether or not these complaints are diffuse and generalizable, I've got nothing to go on but my own experience. which if you generalize it out, says that complaints tend to be more based on perception than fact (kinda similar to all complaints that occur in healthcare).

Um, you cannot generalize out one data point. If n=1, you have no power in your analysis, ever. Basically you have no way of knowing if you are an outlier or the norm. If you want to stick your head in the sand and assume, "we are doing it the right way, so everybody else must be too" I think you are being very unrealistic. Read the thread and see that this complaint isn't limited to a single poster, and you probably should realize that quite a few EDs are giving the field a bad name.

 

[Cerberus]

And that is a fine system IF that initial person has in fact "spent more time doing the workup". What we are complaining about is the rampant calling of consults BEFORE any workup is done, simply because they feel this obligation to say they have called a consult before they sign out. It's just bad ED medicine and it's happening at quite a few places at 5pm (or whatever sign out time various EDs use at various places). And it screws up the house staff big time because at the time they too are supposed to be wrapping things up to sign out themselves, they have to go down to the ED both to do a consult AND to order all these workup tests that should really be done before a consult is called. That's what everyone on this thread is complaining about.

Great that it isn't happening in your ED, but no so great that it is happening in quite a few others and tarnishing EMs rep generally. So those of you doing it the right way really ought to put pressure on your national organizations and at your national meetings and get the rest in line, or live with an undeserved bad rep.

Being told what is or isn't "bad ED medicine" by a surgical resident makes me lol my pants. When surgery starts agreeing to see straightforward surgical abdomen cases without requesting CTs on every patient, I'll maybe consider giving a damn what you think proper ED managment is. Until then...

 

[tkim]

And that is a fine system IF that initial person has in fact "spent more time doing the workup". What we are complaining about is the rampant calling of consults BEFORE any workup is done, simply because they feel this obligation to say they have called a consult before they sign out. It's just bad ED medicine and it's happening at quite a few places at 5pm (or whatever sign out time various EDs use at various places). And it screws up the house staff big time because at the time they too are supposed to be wrapping things up to sign out themselves, they have to go down to the ED both to do a consult AND to order all these workup tests that should really be done before a consult is called. That's what everyone on this thread is complaining about.

Again, I've never seen a consult called without some workup, unless the patient has already declared themselves and needs to go to the OR emergently, or a private surgeon as called ahead to say not to do anything but call him when the patient arrives.

Great that it isn't happening in your ED, but no so great that it is happening in quite a few others and tarnishing EMs rep generally. So those of you doing it the right way really ought to put pressure on your national organizations and at your national meetings and get the rest in line, or live with an undeserved bad rep.

I am not a dues-paying member of any national organization, but it makes no difference. Placing pressure on residencies to 'do a workup before consulting' sounds obvious and ridiculous. If it's as rampant as you say, then it's a department to departmen discussion. It may also be a function of your particular EM residency. I went to a solid, but middle of the road residency, and as mentioned earlier, calling a consult without a workup is unheard of.

 

[glade]

Oh, by the way, Apollyon says that it's easy to make fun of the ER for missing a diagnosis when we get a week to work on the patient and they don't. Nobody said the ER has to "get it right" every time. Heck, sometimes I'll be working on the patient for a week and STILL not get it right. It's not "you got it wrong." It's "you got it wrong because of a total lack of thought, which I can tell based on what you ordered and what you did and what you told me." I get called for a patient for Vascular Surgery and the ER guy doesn't even know the patient had b/l BKAs. That can ONLY mean that they didn't talk to the patient or even pull down the bed sheet. That's not "although I exhaustively worked up the patient, I missed this one-in-a-million diagnosis that only a sub-sub-sub-specialist who wrote the book on exotic tropical rheumatic disorders picked up after thirty years, so sue me."

I just finished talking to an ER attending who ordered a non-contrast CT scan on a patient for abdominal pain, then consulted me. Then, when I told him a non-contrast CT scan would be of no benefit to me, argued that he was REALLY actually concerned with nephrolithiasis. Which still puzzled me as to why he'd start out with a CT scan and also why he'd be consulting me for that. Except that it was obvious he was working backwards since he knew that a non-contrast CT scan CAN detect nephrolithiasis and so his retrospective diagnosis after ordering the wrong test was "whatever I can see with a non-contrast CT." That was made more obvious by the fact that the patient's exam and symptoms were totally incongruent with nephrolithiasis, but he made them up and said "she's having flank pain." And then to cap it all off, he goes "now that you're on consult, you should follow up the CT scan." Now if anyone wants to tell me that's not one of the dumbest conversations you've ever had with a so-called physician, let me know.

 

[glade]

Being told what is or isn't "bad ED medicine" by a surgical resident makes me lol my pants.

The truth is that there isn't any such thing as "bad ED medicine." That because "ED medicine" consists of "whatever I felt like ordering at the time." If they order a CT, fine. If not, fine. If they gave IV fluids, fine. If not, fine. If they over-order stuff, it's because "we're diligent." If they under-order stuff, it's because "that's not my job." So, yes, being told what is or isn't "bad ED medicine" by someone else would make me lol my pants, too, since it's all bad.

 

[tkim]

The truth is that there isn't any such thing as "bad ED medicine." That because "ED medicine" consists of "whatever I felt like ordering at the time." If they order a CT, fine. If not, fine. If they gave IV fluids, fine. If not, fine. If they over-order stuff, it's because "we're diligent." If they under-order stuff, it's because "that's not my job." So, yes, being told what is or isn't "bad ED medicine" by someone else would make me lol my pants, too, since it's all bad.

Seems like whatever we do or don't do, there's a criticism for it - see my previous post regarding that. Hopefully when you graduate you will do something that doesn't require taking call from the ER. Have fun with the rest of residency.

 

[tkim]

Now if anyone wants to tell me that's not one of the dumbest conversations you've ever had with a so-called physician, let me know.

How about - "He needs admission to medicine, and we'll follow. 'Why?' He has diabetes and hypertension and needs management. 'Uh, can't you just write for a sliding scale and his home antihypertensive meds?' Well, no, he really needs to be medically managed and we'll follow."

Saw that all the time in residency. But I'll give credit where credit is due, it wasn't because of incompetence on the part of the surgical service, but sheer unwillingness to do the admission H&P and orders. Much easier to follow the patient as a consult than manage the patient as the primary team.

 

[glade]

Seems like whatever we do or don't do, there's a criticism for it

And see my previous post for the underlying root cause of the criticism. Like I said, getting it wrong or missing a test is no big deal and I do it all the time, too. Doing that with the attitude that "diagnosis isn't my job" and blindly shot-gunning is a problem.

This argument that "whatever we do isn't good enough for you" is merely a defense mechanism. Clearly, there WOULD be something that would be good enough. The problem is it's not an algorithm that can be blindly followed. ER guys always say "fine, when do you want to be called?" Even asking that question indicates you don't know what's going on because there's no "time to be called" for EVERYTHING. That just means you think the endpoint is "call a consult" (which is true) and the only variable is "when -- early or late?" Or it's like "so do you guys ALWAYS want a CT scan or NEVER want one?" What the hell is that? Just because I want a CT scan this one time, doesn't mean that "CT scans should be ordered prior to every surgical consult."

 

[glade]

\it wasn't because of incompetence on the part of the surgical service, but sheer unwillingness to do the admission H&P and orders. Much easier to follow the patient as a consult than manage the patient as the primary team.

Yes and no. First of all, a consult is the same as an H&P (for surgery). We don't write exhaustive H&Ps, which we're famous for. So we don't do that to avoid an H&P.

We DO do that in order to avoid patients that are going to be potential bombshells. Like a person with lots of comorbidities, I'll deflect. Or a person who is schizophrenic and going to be a PITA? Absolutely. Or a person where the surgical issue is secondary? No question. Like, if someone has a soft-tissue abscess AND chest pain, I'll drain the abscess. I WON'T work up the chest pain. Therefore, I'm NOT taking the patient on my service. If you have surgery refusing patients who are simply diabetics and need a sliding scale, as you say, which is literally ONE order, then you either have the strongest surgery department I've ever seen or that's deliberately done in order to maximize reimbursement on an attending level, which residents don't control.

The difference is everyone knows why we're doing that and we admit it. Everyone reading this thread knows why the ER does what IT does, too, but you won't admit THAT.

 

[tkim]

And see my previous post for the underlying root cause of the criticism. Like I said, getting it wrong or missing a test is no big deal and I do it all the time, too. Doing that with the attitude that "diagnosis isn't my job" and blindly shot-gunning is a problem.

Associating rule outs with shotgun orders is your homemade contribution. How many labs does it have to be in order to considered shotgunning? My hospital has standard order sets entered by nurses if we don't get to see the patient in time to put our own orders in. If the LFTs and pancreatic zymes are ordered for what I could have figured out was simple gastro had I chance to see the patient first, then someone will point it out as 'shotgun labs'.

You know what's a shotugn lab that surgery always wants - CRP, WBC. It's useless. I punch you in the leg, your CRP elevates. I yell boo, and your WBC spikes. Yet, that's the first thing asked of me - 'what's the white count.'

This argument that "whatever we do isn't good enough for you" is merely a defense mechanism. Clearly, there WOULD be something that would be good enough. The problem is it's not an algorithm that can be blindly followed. ER guys always say "fine, when do you want to be called?" Even asking that question indicates you don't know what's going on because there's no "time to be called" for EVERYTHING. That just means you think the endpoint is "call a consult" (which is true) and the only variable is "when -- early or late?" Or it's like "so do you guys ALWAYS want a CT scan or NEVER want one?" What the hell is that? Just because I want a CT scan this one time, doesn't mean that "CT scans should be ordered prior to every surgical consult."

No, it's because every surgeon has their own style, and if you happen to get the guy who wants everything done before calling for an obvious diagnosis, they scream. Same for the flipside minimalist who screams about waiting too long to call. There are guidelines for what studies to order, but it's better to memorize what each surgeon's quirks are, check the call schedule and tailor your studies to their preferences, and pray that they didn't switch calls with someone else.

 

[glade]

How many labs does it have to be in order to considered shotgunning?

Again, asking that question indicates you don't have a clue. There's no "how many" to it. There's "what's the point of ordering this?" You don't even get that the way you're approaching the issue is all wrong. If you NEED 500 labs, then 500 labs is appropriate. If you NEED three labs, then fifteen is shot-gunning. Sheesh, how simple is that?

 

[glade]

Holy crap, did he just say the WBC is irrelevant to surgery and unnecessary? This thread is awesome.

That's going in my sig!

 

[tkim]

Again, asking that question indicates you don't have a clue. There's no "how many" to it. There's "what's the point of ordering this?" You don't even get that the way you're approaching the issue is all wrong. If you NEED 500 labs, then 500 labs is appropriate. If you NEED three labs, then fifteen is shot-gunning. Sheesh, how simple is that?

No, if I'm ordering 500 labs in the ER, that's a waste of time and resources. I order the handful needed to rule out the worst in my differential and decide to treat, admit, discharge or consult.

 

[glade]

Actually, you order all the labs you can think of and use the abnormal ones to justify a consult, who will either guide further work-up or validate discharge, thus relieving you of medico-legal responsibility.

 

[45408]

You know what's a shotugn lab that surgery always wants - CRP, WBC. It's useless. I punch you in the leg, your CRP elevates. I yell boo, and your WBC spikes. Yet, that's the first thing asked of me - 'what's the white count.'

You serious, Clark? It's useless?

 

[tkim]

Holy crap, did he just say the WBC is irrelevant to surgery and unnecessary? This thread is awesome.

That's going in my sig!

Be my guest. Isolated leukocytosis is useless in the diagnosis of surgical disease. I've this one go both ways - "Well, his white count's normal - I doubt he has anything going on. 'But he's got RLQ abdominal pain and a fever' Probably some gastro. Admit him to medicine or discharge home."

I've seen people with normal WBC's sent home after being seen by surgery for abdominal pain come back with appys or perfs. I've seen people with mile high WBC's admitted and discharged the next day with nothing.

 

[tkim]

Actually, you order all the labs you can think of and use the abnormal ones to justify a consult, who will either guide further work-up or validate discharge, thus relieving you of medico-legal responsibility.

Aside from the inflammatory leanings, don't you think this is what medicine does? Order labs to confirm/deny diagnosis and guide further workup and consult, if negative discharge, if positive treat.

 

[glade]

Aside from the inflammatory leanings, don't you think this is what medicine does? Order labs to confirm/deny diagnosis and guide further workup and consult, if negative discharge, if positive treat.

Except that they actually have a diagnosis and, according to even your colleagues here, you don't. Again, what you say reveals that you don't even get what the problem is. That's a little fascinating. It's like you went to some bizarro med school where this stuff is all normal.

 

[45408]

Be my guest. Isolated leukocytosis is useless in the diagnosis of surgical disease. I've this one go both ways - "Well, his white count's normal - I doubt he has anything going on. 'But he's got RLQ abdominal pain and a fever' Probably some gastro. Admit him to medicine or discharge home."

I've seen people with normal WBC's sent home after being seen by surgery for abdominal pain come back with appys or perfs. I've seen people with mile high WBC's admitted and discharged the next day with nothing.

That doesn't mean it's useless. It has a sensitivity and specificity like everything else.

 

[glade]

The problem is a lack of diagnostic skill. He's literally at the level of an intern right now, which would be fine if he was an intern (which I'm fairly sure he's not). He expects it to be "well, this patient has a high white count, therefore x" and then that applies to every patient with a high white count. Medicine isn't cookie cutter, but that's how the ER views it because they're never asked to ACTUALLY make a diagnosis. Hence the same actions on every single patient robotically. Every single patient with RLQ pain is an appendicitis because "it usually is." Sure, but that hardly constitutes a diagnostic thought. But that's how an ER physician "thinks" and you can tell just by talking to one of them for a few minutes, as demonstrated here.

The fact that ANYONE would say that the WBC is useless is mind-boggling, the fact that the defense of that statement is "well, sometimes it's high and then you discharge the patient anyways, so clearly it's useless" is even more mind-boggling.

 

[tkim]

The problem is a lack of diagnostic skill. He's literally at the level of an intern right now, which would be fine if he was an intern (which I'm fairly sure he's not). He expects it to be "well, this patient has a high white count, therefore x" and then that applies to every patient with a high white count. Medicine isn't cookie cutter, but that's how the ER views it because they're never asked to ACTUALLY make a diagnosis. Hence the same actions on every single patient robotically. Every single patient with RLQ pain is an appendicitis because "it usually is." Sure, but that hardly constitutes a diagnostic thought. But that's how an ER physician "thinks" and you can tell just by talking to one of them for a few minutes, as demonstrated here.

The fact that ANYONE would say that the WBC is useless is mind-boggling, the fact that the defense of that statement is "well, sometimes it's high and then you discharge the patient anyways, so clearly it's useless" is even more mind-boggling.

I don't know if it's deliberate misinterpretation or simply that you don't understand what I write. But that's okay. What's clear is that you are inflammatory and have an agenda. Good luck with that.

 

[tkim]

That doesn't mean it's useless. It has a sensitivity and specificity like everything else.

Sure. But it's the first thing surgical residents ask on the phone, even before what was found on physical exam. It's the first thing that the surgical resident will point to as a reason to admit or discharge, barring what was found on physical exam. Come down and lay hands on the patient before you decide my consult request was a waste of time. Thanks.

 

[glade]

Come down and lay hands on the patient before you decide my consult request was a waste of time. Thanks.

Oh, the irony, right, guys?

By the way, your words are on here for everyone to read, so simply saying "you're deliberately misrepresenting what I said to start a fight" is a great defense mechanism but ultimately doesn't work. But keep on going with that.

 

[Winged Scapula]

Ok, I think this thread has gone on long enough. Cool it with the insults.

We all can learn from each other and perhaps make our own practices a little better.

For those who receive ED consults, look at the *reality* that the ED faces that they are damned if they do, damned if they don't. There are some specialists who expect to be called the minute the patient arrives, and others who don't want a call unless the patient has been scanned, labbed and completely work-up and diagnosed. They have a difficult job and are rarely appreciated for it.

OTOH, those EM residents and attendings here also need to realize that some of your colleagues do do the things we've discussed and its what makes us upset and angry. So rather than deny these things happen (there are enough of us here, at different hospitals, at different times, to not make it a global lie or happenstance) accept that some of your colleagues aren't representing your field or taking care of patients well.

If users can discuss the problems we face with each other rationally and without personal insults, then the thread can stay open, if not...

 

[danielmd06]

Interesting thread. Sounds like some people from both sides of the fence never got that memo that being a doctor just *might* entail hard work and even involve some unfairness now and then. It's also funny how physicians seem to be so much harder and less understanding with each other than they are with virtually every other ancillary staff member, student, patient, or administration official. Aren't we all on the same team?

The ER at my hospital used to decimate us at sign-out time (PM and AM). It never helped that these particular cases were woefully under-evaluated. A typical line from a resident on the phone to me was "We have a seizure in Room 8" or "we have a head bleed in Room 2." No exam, no lab work, no information...nada. Not even a name or registration number! Just..."we have a consult for you in Room 8." It's easy for me to understand why individuals posting here are frustrated with the ED as a whole if they've been treated like this with regularity, too. Anyway, I always wished we had had an inter-departmental meeting to iron it all out. Ultimately, we worker bees tried to deal with it within our own residency system and cut the ER out of it. They could call with a consult...but who actually went to see it was discussed between the residents themselves.

From my way of thinking...the on-call resident (or AM team) was going to be in the hospital for the next several hours irregardless, so it makes sense to "hold" cases at 4:59:59 PM for that upcoming individual and spare the AM team (or post-call resident) an inefficient loss of time. It stays fair as long as you don't reverse position when you're the one on-call.

 

[glade]

For those who receive ED consults, look at the *reality* that the ED faces that they are damned if they do, damned if they don't. There are some specialists who expect to be called the minute the patient arrives, and others who don't want a call unless the patient has been scanned, labbed and completely work-up and diagnosed. They have a difficult job and are rarely appreciated for it.

Right, but -- serious question here -- whose fault is that? In case people are unaware, Emergency Medicine is a relatively new specialty and the ER used to be covered by internists, surgeons, and family practitioners. Those are people specifically trained to identify and treat medical and surgical problems as specialists. Now, EM physicians are in place in many urban and academic institutions and they're supposed to be "jack of all trades" and trained to, at a basic level, do the same thing. And what it's devolved into is basic triage.

Look at this thread. You have trained and board-certified physicians who honestly and literally believe that diagnosis is not their responsibility. Again I ask: then how can you treat a patient at more than a basic Band-Aid level? If you truly break things down, the EM physician is in place, as I've said before, to merely streamline the movement of patients into the hospital ("throughput"), which constitutes one of their major evaluation checkpoints. That's completely different from what it SHOULD be, as a physician, which is the diagnosis and treatment of disease.

Are we to truly believe that the way that things operate is optimal? You know how much time and money is wasted, inadvertantly or just due to negligence? Are we to say those are unimportant? Or pretend that it doesn't happen? Even if you ignore what I say, read the remainder of this thread: you have people saying they do what they do "because that's what so-and-so service wants." Aren't you a physician, too? You're not the intern of Medicine or Surgery, right? At some point, if some guy is going nuts over you not ordering a CT scan because you didn't do it because there was a medical justification for it based on evidence and scientific papers, then you should seriously ALSO question whether the way things are is sane. And NOT just go "well, I'm just a EM doc, whatever, I go with the flow because the important thing is I make decent money and I don't have to work many shifts every month."

 

[sacrament]

(f) start showering consults on you seemingly just because you reminded them you were around by walking through the ER (e.g., "oh, wow, hey, I have two consults for you!" "me, too!" "did someone say Surgery was down here?" "do you manage PEs?" "I have a patient here for something, but I don't do diagnosis!!")

This has been one of the banes of my existence: walking into the ED and having some random person perk up and exclaim, "Oh hey, are you cards?" Later I figured out that the chest pain unit has a side entrance that, while sort of inconvenient to get to, completely bypasses the bulk of the ED. I started using that, and also took all paperwork, consult notes, EKGs, etc. out into the stairwell to work on. My subjective feel is that my consult load in the ED dropped significantly after that.

I had to rotate through the ED as an IM resident, so I have some empathy for the docs down there and sort of understand why things often turn out the way they turn out. But still. But still.

I often wonder at what point a frivolous consult constitutes insurance fraud. I've been consulted directly by an ED attending for new-onset flutter. The EKG showed normal sinus rhythm in 11 leads and a great deal of artifact in a 12th. When I explained that this was artifact and couldn't be flutter because every other leads was stone-cold normal, he asked how I could discount it so easily and to please just do the consult. The guy was there for like a head cold or something, I have no idea why they even got an EKG.

We get this stuff all the time. Not just the extra-cautious consults... not just "chest pain in a 20-year-old woman with no risk factors and an anxiety disorder." We get that too, but as silly as it is, it least could conceivably, theoretically, be something that wasn't at odds with all recognized human physiology and pathophysiology. No, I'm talking about stuff that really honestly couldn't be anything. And yeah I know, when I'm "out there in the real world" I'll love the easy consults that require zero cognitive effort and that these will put bread on my table. I get it. Except that, really, I'm being serious here: it's thievery sometimes. A significant percentage of my ED consult notes end with some variation of: "I can detect no evidence in the history, physical, lab data, EKG, multiple imaging modalities etc. to even remotely suggest that there is anything that even vaguely resembles cardiac pathology in this patient."

Whatever. I'm sure the ED complains just as much about us as we do about them.

 

[glade]

Later I figured out that the chest pain unit has a side entrance that, while sort of inconvenient to get to, completely bypasses the bulk of the ED. I started using that, and also took all paperwork, consult notes, EKGs, etc. out into the stairwell to work on. My subjective feel is that my consult load in the ED dropped significantly after that.

I go through a back entrance stairwell that drops into a side door off the parking lot, then briskly slide along the wall into patient rooms. I'm not kidding. My hospital is completely computerized, so as soon as I finish seeing the patient, I slide back out into the back entrance stairwell and go up at least two floors (this is irrational, but I feel that one floor up is too close) and do my consult.

I often wonder at what point a frivolous consult constitutes insurance fraud. ...We get that too, but as silly as it is, it least could conceivably, theoretically, be something that wasn't at odds with all recognized human physiology and pathophysiology.

That's the point. The justification is always "this could be something serious." And that comes back to my point: you (meaning, they) are only in the position of having to do that because of the way they are trained. Even they will say "we make sure there's nothing life-threatening." Right, but in doing so, they are ingrained with the mentality that SOB = PE, chest pain = MI, abdominal pain = ruptured AAA, weakness = stroke.

 

[tkim]

Whatever. I'm sure the ED complains just as much about us as we do about them.

Actually cards where I work is remarkable responsive and easy to work with. For some reason I'm required to consult for every NSTEMI before they go to the floor, by hospitalist request. If I need to get an echo, they'll come down later to read it bedside. I've had good interactions with them when I treated a young guy with dilated cardiomyopathy who needed to go into Boston. Can usually get a same-day stress test if I call early enough in the day. Can't complain.

 

[sacrament]

Actually cards where I work is remarkable responsive and easy to work with. For some reason I'm required to consult for every NSTEMI before they go to the floor, by hospitalist request. If I need to get an echo, they'll come down later to read it bedside. I've had good interactions with them when I treated a young guy with dilated cardiomyopathy who needed to go into Boston. Can usually get a same-day stress test if I call early enough in the day. Can't complain.

I'd be responsive and easy to work with, too, if I was getting called for NSTEMIs and dilated cardiomyopathies all day. That's, like, actual stuff that happens to people.

I complain about the ED consults, but at the same tiem I always thank my lucky stars I'm not the neuro consultant. That poor guy just seems to live down there. They get hammered by ceaseless waves of ambiguity. A patient apparently gets a neuro consult if, at any point during their stay in the ED, they utter the word "tingly."

 

[glade]

I'd be responsive and easy to work with, too, if I was getting called for NSTEMIs and dilated cardiomyopathies all day. That's, like, actual stuff that happens to people.

Yeah, I don't mind getting called for a real consult. What's irritating is stuff like -- and this just happened -- some uninsured woman came to the ER yesterday with vague complaints and no abnormalities on labs or scans, was evaluated and discharged. Then she came back with the same complaints and we get the consult "because you guys saw her yesterday." Guess what? We just kicked her out again. But not before the ER scanned her again. Conceivably, we could create the Incredible Hulk if we sent the same guy into the ER every day for a month. It's something to think about. I'm for it, but the ethical ramifications are mind-boggling.

 

[tkim]

I'd be responsive and easy to work with, too, if I was getting called for NSTEMIs and dilated cardiomyopathies all day. That's, like, actual stuff that happens to people.

I complain about the ED consults, but at the same tiem I always thank my lucky stars I'm not the neuro consultant. That poor guy just seems to live down there. They get hammered by ceaseless waves of ambiguity. A patient apparently gets a neuro consult if, at any point during their stay in the ED, they utter the word "tingly."

Yeah, the dreaded code 'grey'. Once or twice a day, someone will come up to me to tell me about some patient with 'numbness' or 'tingling', and try to drop the stroke bomb. Most of the time it's radiculopathy or someone with their 'fibro' flare, so I can avoid the hit. Else it's the neurologist-in-a-box - teleneurology consult after plain head CT.

 

[Rendar5]

Holy crap, did he just say the WBC is irrelevant to surgery and unnecessary? This thread is awesome.

That's going in my sig!

Shrug, apparently you don't believe much in EBM. WBC has a crappy LR for many dx's. It's primary use should be for trending, not for diagnosing. Which is why I never have issues with ordering it, just issues with depending on it for a diagnosis. The exception being when it's superfluously high (which much like ESR is where it gains it's real diagnostic use).

And Sacrament, sorry that you get called for crap like that. You should come by here where we have a better relation with cards. Consultation issues do tend to be real and vary a lot form ED to ED I've been in (some hospitals tend to be crappy about ob/gyn consults for instance whereas others are very good and call only when needed). Interdepartmental educational meetings seem to be the best way to begin to resolve these issues. (prolly why my own program has monthly neuro conferences, that's our own area where we depend on inpatient neuro too much)

 

[glade]

I'd be happy to review any actual EBM that you can provide that in any way indicates that the WBC is non-contributory to the diagnosis of diseases. I'm sure it's fascinating work and for some reason hasn't been embraced by anyone in the medical community (outside of, apparently, the ER).

 

[Rendar5]

Yeah, I don't mind getting called for a real consult. What's irritating is stuff like -- and this just happened -- some uninsured woman came to the ER yesterday with vague complaints and no abnormalities on labs or scans, was evaluated and discharged. Then she came back with the same complaints and we get the consult "because you guys saw her yesterday." Guess what? We just kicked her out again. But not before the ER scanned her again. Conceivably, we could create the Incredible Hulk if we sent the same guy into the ER every day for a month. It's something to think about. I'm for it, but the ethical ramifications are mind-boggling.

Well, here's a change. Something we totally agree happens not uncommonly that is not necessarily the best use of resources and is only really done as CYA medicine.

 

[Rendar5]

I'd be happy to review any actual EBM that you can provide that in any way indicates that the WBC is non-contributory to the diagnosis of diseases. I'm sure it's fascinating work and for some reason hasn't been embraced by anyone in the medical community (outside of, apparently, the ER).

For one example, check out the Rational Clinical Exam for Acute Appendicitis or whatever that series is that tends to appear in JAMA, iirc. I believe this one was 3-5 years ago. It's a series looks at the pos. and neg. LR's for various parts of the H&P and labs. As I said after I fully finished my response, the WBC has it's utility in 2 ways in my mind: at more extreme values and in trending. Initial ED dx doesn't usually fit into this picture. The only time I would use a modestly elevated WBC was if i was intent on proving a SIRS situation for possible sepsis, although there are other ways of also assessing this

EDIT: another exception I remembered that I use in terms of modest WBC elevations (15 in this case as a cut-off, iirc) is in the decision on whether to use Vanco or Flagyl for C Diff. treatment

 

[ForbiddenComma]

The patients admitted without a real workup represent one issue. But unfortunately, that is not all. One doctor at one of my hospitals likes to admit patients even after a workup that is completely negative, and has gotten an infamous reputation as a result.

Part of the problem in this hospital -- and this is key -- is that the service attending does not have to approve each admit. Residents just have to eat it no matter how idiotic the admit. So, if you have some ***** who admits a mild acute gastroenteritis despite negative labs and a negative ultrasound... there is absolutely nothing you can do about it. You have no choice from a medicolegal standpoint but to work them up, bolus them, run IV fluids overnight before you can discharge them, costing state taxpayers God-knows how many thousands of dollars for a ridiculous stomach flu.

Part of the issue is, this ER doc has obviously never seen the inside of a ward (or outpt clinic) for many, many years. She sends all kinds of crap our way and apparently receives very little feedback about how much her admits suck. And I bet this lack of feedback is due to the fact that the facility makes more money from her incompetence than if she actually did her job and sent these kinds of admits away.

It is extremely doc-dependent. Some ER docs here are very good at their jobs but others... well, there is no check on their incompetence.

Before the ER docs in this thread chime in -- yes, yes, I know, *you* personally would never do such a thing, and I am an idiot inexperienced resident for even questioning such an admit. But do try to realize that 1) there are a few incompetent ER docs out there and 2) there seems to be little incentive in the system to keep their *****ic admits in check.

 

[glade]

I googled for it and it's a series from 1996 and it doesn't let me read it without logging in. Got a copy or a place I can find one?

 

[glade]

Part of the problem in this hospital -- and this is key -- is that the service attending does not have to approve each admit. Residents just have to eat it no matter how idiotic the admit.

Medicine where we are is set up that way, too.

If we have a completely negative work-up (which isn't always negative, by the way), we get consulted to "evaluate for discharge." Really. That way there's a signature from a non-ER attending saying "this person has no acute issues and may be discharged from my perspective."

 

[45408]

Part of the problem in this hospital -- and this is key -- is that the service attending does not have to approve each admit. Residents just have to eat it no matter how idiotic the admit. So, if you have some ***** who admits a mild acute gastroenteritis despite negative labs and a negative ultrasound... there is absolutely nothing you can do about it. You have no choice from a medicolegal standpoint but to work them up, bolus them, run IV fluids overnight before you can discharge them, costing state taxpayers God-knows how many thousands of dollars for a ridiculous stomach flu.

Yeah, that sucks big time. We never admit a surgery patient unless our attending agrees to it.

 

[tkim]

I googled for it and it's a series from 1996 and it doesn't let me read it without logging in. Got a copy or a place I can find one?

Try this:

http://www.docstoc.com/docs/20879703/Clinical-Value-of-the-Total-White-Blood-Cell-Count

"Many emergency physicians have observed a surgical consultant discounting the diagnosis of acute appendicitis in a particular patient because of a normal total WBC count or temperature. The data in this study indicate that neither total WBC count nor temperature is a useful indicator of the presence or absence of acute appendicitis in an at-risk population."

http://www.ncbi.nlm.nih.gov/pubmed/20674238?dopt=AbstractPlus

Inadequacy of Temperature and White Blood Cell Count in Predicting Bacteremia in Patients with Suspected Infection.

Seigel TA, Cocchi MN, Salciccioli J, Shapiro NI, Howell M, Tang A, Donnino MW.

Department of Emergency Medicine, Division of Pulmonary Critical Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Abstract

BACKGROUND: Early treatment of sepsis in Emergency Department (ED) patients has lead to improved outcomes, making early identification of the disease essential. The presence of systemic inflammatory response criteria aids in recognition of infection, although the reliability of these markers is variable.

STUDY OBJECTIVE: This study aims to quantify the ability of abnormal temperature, white blood cell (WBC) count, and bandemia to identify bacteremia in ED patients with suspected infection.

METHODS: This was a post hoc analysis of data collected for a prospective, observational, cohort study. Consecutive adult (age >/= 18 years) patients who presented to the ED of a tertiary care center between February 1, 2000 and February 1, 2001 and had blood cultures obtained in the ED or within 3 h of admission were enrolled. Patients with bacteremia were identified and charts were reviewed for presence of normal temperature (36.1-38 degrees C/97-100.4 degrees F), normal WBC (4-12 K/muL), and presence of bandemia (> 5% of WBC differential).

RESULTS: There were 3563 patients enrolled; 289 patients (8.1%) had positive blood cultures. Among patients with positive blood cultures, 33% had a normal body temperature and 52% had a normal WBC count. Bandemia was present in 80% of culture-positive patients with a normal temperature and 79% of culture-positive patients with a normal WBC count. Fifty-two (17.4%) patients with positive blood cultures had neither an abnormal temperature nor an abnormal WBC.

CONCLUSION: A significant percentage of ED patients with blood culture-proven bacteremia have a normal temperature and WBC count upon presentation. Bandemia may be a useful clue for identifying occult bacteremia.

 

[Apollyon]

OK, folks, think of it this way: the doc in the ED is a golfer. He has to tee off, stay on the course, and out of the rough. He just has to get on the green, and then he calls in a specialist putter. Sometimes he'll hole out. The specialist, though, is a specialist putter - the IM docs sometimes 10-putt, and the surgeons 2-putt and hole out.

If you can't understand the analogy, let me know, and I'll clarify it.

(Oh, heck*, let me do it for you: in the ED, we start the workup, and try to figure out the life threats - it's probably not, but, if it is, we want to find it. We're on target for what's going on, but we might not have the definitive diagnosis - given more hours or days, we might get it. Sometimes, what the patient needs is a direct look at the problem - like an ex-lap.)

 

[totalbodypain]

Again, asking that question indicates you don't have a clue. There's no "how many" to it. There's "what's the point of ordering this?" You don't even get that the way you're approaching the issue is all wrong. If you NEED 500 labs, then 500 labs is appropriate. If you NEED three labs, then fifteen is shot-gunning. Sheesh, how simple is that?

:troll:

You ever get the feeling that a conversation is just not going anywhere. This guy obviously has issues with the ED. No amount of talking, texting or typing is going to change this Einstein's opinion. The term that comes readily to mind is Troll. It's like trying to talk a psych patient out of being crazy.... It is a resident's perogative to bitch and complain about doing their job, be it 4am, 5pm or 10 pm.... And the shotgunning comment....priceless! I couldn't even begin to guess at the number of patients I have seen pan scaned after minor trauma and no hard signs thanks to surgery recs, not to mention the CT's requested by surgery for belly pain in male patients before even examing the patient.

 

[glade]

Try this:

http://www.docstoc.com/docs/20879703/Clinical-Value-of-the-Total-White-Blood-Cell-Count

You're going to get pissed off at what I say, but I read that article and here are the things that jumped out at me. This article is a prospective study of who had appendicitis based on "all patients presenting with signs and symptoms that led the managing attending in the ED to conclude that acute appendicitis was the primary diagnostic consideration." Now, based on that 92 out of 293 patients had appendicitis, which means they were right 31% of the time. Which really means that their initial thought that appendicitis was the "primary diagnostic consideration" is the real problem, not the WBC value. That's just being blunt with you. Prior to routine CT scanning being available, evaluation by Surgery was traditionally associated with a negative appendectomy rate quoted at between 15-20%. That means that following evaluation without routine CT scanning, Surgery was right roughly 80% of the time. You may conclude what you wish from that statement.

 

[glade]

I couldn't even begin to guess at the number of patients I have seen pan scaned after minor trauma and no hard signs thanks to surgery recs, not to mention the CT's requested by surgery for belly pain in male patients before even examing the patient.

There is no doubt that Surgery over-orders CT scans, too. There is no specialty that practices "perfectly." However, you attempt to set up the false argument that "since you don't do things perfectly, that absolves us." No, that just means we're both imperfect. However, the ER is worse, and demonstrably so. How? Well, you call specialists to see patients, ostensibly because those specialists are better at evaluating those patients. And those specialists have a problem with how things are done in the ER. Therefore, since they know more than you about their field, it stands to reason that they would be more able to determine that. However, rather than change or learn, you just stay the same and act like everyone else is just asinine.

 

[Law2Doc]

...

OTOH, those EM residents and attendings here also need to realize that some of your colleagues do do the things we've discussed and its what makes us upset and angry. So rather than deny these things happen (there are enough of us here, at different hospitals, at different times, to not make it a global lie or happenstance) accept that some of your colleagues aren't representing your field or taking care of patients well....

Amen.

 

[turquoiseblue]

to the OP--simply and ideally, like im sure anyone else would think, i think that nightfloat should start promptly at their given time and a resident should go home promptly after signout no matter what...hand things to the nightfloat--what else are they there for? not to mention to do it any other way breaks ACGME rules. maybe you could call ACGME about it and file a complaint if the people at the program hold you hostage like that. i was once in a program where the residents expected me to stay many hours after hours after the nightfloat signout---it defeated the whole point of nightfloat and broke ACGME time rules. i think something should have been done about that but that was many years ago. i would have thought things would have changed by now. i remember it being an absolute nightmare. definitely try for change. good luck

 

[Winged Scapula]

to the OP--simply and ideally, like im sure anyone else would think, i think that nightfloat should start promptly at their given time and a resident should go home promptly after signout no matter what...hand things to the nightfloat--what else are they there for? not to mention to do it any other way breaks ACGME rules. maybe you could call ACGME about it and file a complaint if the people at the program hold you hostage like that. i was once in a program where the residents expected me to stay many hours after hours after the nightfloat signout---it defeated the whole point of nightfloat and broke ACGME time rules. i think something should have been done about that but that was many years ago. i would have thought things would have changed by now. i remember it being an absolute nightmare. definitely try for change. good luck

There are no ACGME rules that state you cannot stay and work-up a patient at the end of your "shift". If it is hour 30 of your call that's a different story, but night float isn't working 30 hours.

You just have to know the culture of your program. At mine, even if it was 5:59 am you were still expected to see the new patient and get the ball rolling (in whatever direction it was going - OR, admit, calling attending, etc.) before hand-off to the new guy (not that we left on time but for sake of argument let's say we did). The nicer residents would take the pages for you if you were signing out; others did not (and expected you to handle everything until you officially transferred the pages).

 

[tkim]

Prior to routine CT scanning being available, evaluation by Surgery was traditionally associated with a negative appendectomy rate quoted at between 15-20%. That means that following evaluation without routine CT scanning, Surgery was right roughly 80% of the time. You may conclude what you wish from that statement.

Can't until you cite your stat.