Chest Pain Free

[Mount Asclepius]

I never understand it when other physicians make a distinction whether or not a patient is chest pain free. GERD and musculoskeletal chest pain don’t always resolve instantly. NSTEMIs are occasionally pain free on evaluation. We don’t treat pain from other organs or body parts the same way. My approach to ACS is based upon history, risk factors, exam, experience and objective evidence including EKGs/troponins. Pain or pain free is mostly irrelevant to me. Do you agree or disagree?

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[RustedFox]

Agree largely.
If "my chest pain is gone" + significantly long duration + negative single HS TnI, then bye.

 

[TrailRun]

Isn’t the premise (perhaps not entirely true) that pain = ongoing ischemia? Where I trained cardiology seemed to take that into account to decide urgent cath versus heparin gtt and delayed (although time of day probably had a greater impact)

 

[CoolDoc1729]

I never understand it when other physicians make a distinction whether or not a patient is chest pain free. GERD and musculoskeletal chest pain don’t always resolve instantly. NSTEMIs are occasionally pain free on evaluation. We don’t treat pain from other organs or body parts the same way. My approach to ACS is based upon history, risk factors, exam, experience and objective evidence including EKGs/troponins. Pain or pain free is mostly irrelevant to me. Do you agree or disagree?

I mean if you’re worried the pain was from something being occluded, it would probably stop hurting because it wasn’t occluded anymore .. it also matters to me if a kidney stone or gallstone patient stops having pain

 

[Janders]

If I think the chest pain is ongoing ischemia (i.e. there are EKG changes or troponin changes) then yes, I do care, because I want to nitro them or get them to cath or whatever.

If I think it is unlikely to be ongoing ischemia, but possible (ie first trop negative, pain 8h, but HEART of 5 and I want to admit them) then I don’t care. I see it used as a technique to block admissions (We can’t admit ongoing CP here! We dont have a cath lab!)… usually can counter with a quick second troponin to prove not uptrending.

 

[southerndoc]

Isn’t the premise (perhaps not entirely true) that pain = ongoing ischemia? Where I trained cardiology seemed to take that into account to decide urgent cath versus heparin gtt and delayed (although time of day probably had a greater impact)

I think that applies in the setting of EKG changes or positive biomarkers.

 

[lucid_leprechaun]

I never understand it when other physicians make a distinction whether or not a patient is chest pain free. GERD and musculoskeletal chest pain don’t always resolve instantly. NSTEMIs are occasionally pain free on evaluation. We don’t treat pain from other organs or body parts the same way. My approach to ACS is based upon history, risk factors, exam, experience and objective evidence including EKGs/troponins. Pain or pain free is mostly irrelevant to me. Do you agree or disagree?

On the one hand refractory pain in the setting of myocardial injury is an indication for emergent cath. For high risk/normal testing patients I’m not sure it matters much. Pain state can also be important when looking at a Wellens/reperfusion EKG

 

[RoyBasch]

If you really think its a true NSTEMI (which in my experience with cardiologists, they believe this is based entirely on positive troponins, they seem fairly unmoved by "typical history" or "EKG changes"), then ongoing pain refractory to treatment with antiplatelets, anticoagulants, and nitro is a sign of ongoing ischemia due to persistent blockage and should be regarded as an indication to cath immediately. Again, whether this happens or not, is more a function of the time of day. I find it pretty hard to get interventional cardiologists to cath an NSTEMI patient without a clear cut STEMI on EKG in the middle of the night regardless of the presence or absence of pain.

If the pain resolves, delaying the cath I think is reasonable.

That being said, this only applies in my mind to patients who are really suspected by me/and the cardiologist of having a true NSTEMI. You're typical run-of-the-mill negative troponin but high risk chest pain patient getting admitted, doesn't need an emergent cath regardless if their still having pain or not.

If I think the patient has atypical non-cardiac chest pain, long duration (greater than 6 hours) with a negative troponin, I don't really care if their chest pain is ongoing or not. If every chest pain patient had to resolve their pain to be discharged, I wouldn't be able to discharge a single one of them.

I mean residency/the text books will teach you "refractory" pain is always an ongoing impetus to admit/further work up. But I think as you get more experienced you kinda make a judgement call on this. I mean I send patients I think are full of **** home with "ongoing pain" all the time. If I didn't I would hardly be able to discharge anyone.

But sometimes you see a normal/reasonable person (not a lot of ER visits) with unexplained ongoing symptoms and my gestalt is they are "real" (i.e. they appear visibly uncomfortable in my esteem not "it's 10 out of 10 abdominal pain doc" but they are on their phone and smashing a big mac). I will admit/workup/both based on their "ongoing pain." So sometimes, it matters.

 

[thegenius]

I never understand it when other physicians make a distinction whether or not a patient is chest pain free. GERD and musculoskeletal chest pain don’t always resolve instantly. NSTEMIs are occasionally pain free on evaluation. We don’t treat pain from other organs or body parts the same way. My approach to ACS is based upon history, risk factors, exam, experience and objective evidence including EKGs/troponins. Pain or pain free is mostly irrelevant to me. Do you agree or disagree?

What I chart and what I do are different (with respect to chest pain). It's not good DOCUMENTING that you are sending someone home with chest pain. So all chest pain resolves prior to discharge LOL. However I often send home people with chest pain (or any kind of pain) if it isn't an emergency.

 

[Tenk]

Because it’s better than writing: “still having chest pain but gonna discharge anyways because f it!”

 

[turkeyjerky]

I mean if you’re worried the pain was from something being occluded, it would probably stop hurting because it wasn’t occluded anymore .. it also matters to me if a kidney stone or gallstone patient stops having pain

Why do you care if a pt w/ renal colic stops having pain? Biliary, I get, since the natural history of cystic duct obstruction is to evolve into cholecystitis (plus concern over choledocolithiasis). Assuming you mean complete resolution of pain, rather than improvement of pain to 'bearable' territory.

I agree with the OP. Whether or not the patient has ongoing pain at the time of evaluation affects my interpretation of diagnostic results quite a bit, however I don't understand the continued emphasis on documenting 'pain has resolved'. If anything, I tend to be far more reassured when someone still has pain in front of me. I think it's a holdover from a prior era.

Although, it does seem to me like a lot of other docs like document this type of thing for all sorts of pain w/ negative workups (HA, abdominal pain, MSK pain, etc).

Interesting corollary in my mind is tachycardia. With Bouncebacks! publicizing the sign of unexplained tachycardia as a common sign of severe pathology, a lot of people are careful to ducument that initial tachycardia has resolved. But a number of medmal cases from one of those newsletters have highlighted that physicians reliance on the resolution of presenting tachycardia as a reassuring finding was a major mistake. Similiar issue as requiring resolution of fever prior to discharge in peds.

 

[Mount Asclepius]

I don't think you need to document that they were pain free at discharge. You also don't need to document that they were still in pain. Low risk chest pain with negative testing goes home regardless of pain status. If you are clinically concerned regarding the pain, consider ruling out dissection and/or admission. I think documentation regarding pain status at discharge is a relic of a past era when pain was a vital sign and an opioid crisis was created.

 

[Mount Asclepius]

Interesting corollary in my mind is tachycardia. With Bouncebacks! publicizing the sign of unexplained tachycardia as a common sign of severe pathology, a lot of people are careful to ducument that initial tachycardia has resolved. But a number of medmal cases from one of those newsletters have highlighted that physicians reliance on the resolution of presenting tachycardia as a reassuring finding was a major mistake.

Agree with the rest of your post (including requiring resolution of fever in pediatric patients) other than this section on tachycardia. Unexplained tachycardia is important. Tachycardia at discharge has an association with death following discharge from the ED.

Unanticipated death after discharge home from the emergency department - PubMed

Agree though that there is the potential for false reassurance if tachycardia has resolved. I still think it is important to ensure resolution even if you have to wade through all the initial inaccurate triage vital signs where the nurse checked vitals right after the patient ran into the ED.

 

[thegenius]

I don't think you need to document that they were pain free at discharge. You also don't need to document that they were still in pain. Low risk chest pain with negative testing goes home regardless of pain status. If you are clinically concerned regarding the pain, consider ruling out dissection and/or admission. I think documentation regarding pain status at discharge is a relic of a past era when pain was a vital sign and an opioid crisis was created.

OK

 

[thegenius]

Agree with the rest of your post (including requiring resolution of fever in pediatric patients) other than this section on tachycardia. Unexplained tachycardia is important. Tachycardia at discharge has an association with death following discharge from the ED.

Unanticipated death after discharge home from the emergency department - PubMed

Agree though that there is the potential for false reassurance if tachycardia has resolved. I still think it is important to ensure resolution even if you have to wade through all the initial inaccurate triage vital signs where the nurse checked vitals right after the patient ran into the ED.

Without reading the paper it's "abnormal vital signs" and not just tachycardia.

I remember that paper and I remember that ultimately we are looking at a handful of deaths. it's 35 unexplained deaths WITH POTENTIAL ERROR out of 387,000 visits.

The reasons were multifactorial...and from the abstract they include "Four themes repeatedly emerged: atypical presentation of an unusual problem, chronic disease with decompensation, abnormal vital signs, and mental disability or psychiatric problem or substance abuse that may have made it less likely that the patient would return for worsening symptoms."

Hard to turn that 35 --> 0, in fact it's probably impossible. I d/c unexplained tachycardia that isn't profoundly tachycardic on lots of healthy patients especially kids with fevers (provided not > 20-30 over normal after you give tylenol/motrin), young adults who have a neg workup and their HR is like 95-115 or so. I start to think if it's 120...and I care if it's 130-140.

 

[CoolDoc1729]

Why do you care if a pt w/ renal colic stops having pain? Biliary, I get, since the natural history of cystic duct obstruction is to evolve into cholecystitis (plus concern over choledocolithiasis). Assuming you mean complete resolution of pain, rather than improvement of pain to 'bearable' territory.

I agree with the OP. Whether or not the patient has ongoing pain at the time of evaluation affects my interpretation of diagnostic results quite a bit, however I don't understand the continued emphasis on documenting 'pain has resolved'. If anything, I tend to be far more reassured when someone still has pain in front of me. I think it's a holdover from a prior era.

Although, it does seem to me like a lot of other docs like document this type of thing for all sorts of pain w/ negative workups (HA, abdominal pain, MSK pain, etc).

Interesting corollary in my mind is tachycardia. With Bouncebacks! publicizing the sign of unexplained tachycardia as a common sign of severe pathology, a lot of people are careful to ducument that initial tachycardia has resolved. But a number of medmal cases from one of those newsletters have highlighted that physicians reliance on the resolution of presenting tachycardia as a reassuring finding was a major mistake. Similiar issue as requiring resolution of fever prior to discharge in peds.

If the renal stone’s pain is tolerable, then they can go home. If it stops without much intervention, then I tell them it probably passed. If they are writhing still with their 4-5 mm stone then I admit them and call urology in the am and then they typically go to OR from the waiting room and get their cysto and stent so they can go home. I go home in the am either way, I don’t care on a higher level, but it does affect dispo if they are not drug seeking or insane.

 

[Mount Asclepius]

Without reading the paper it's "abnormal vital signs" and not just tachycardia.

I remember that paper and I remember that ultimately we are looking at a handful of deaths. it's 35 unexplained deaths WITH POTENTIAL ERROR out of 387,000 visits.

The reasons were multifactorial...and from the abstract they include "Four themes repeatedly emerged: atypical presentation of an unusual problem, chronic disease with decompensation, abnormal vital signs, and mental disability or psychiatric problem or substance abuse that may have made it less likely that the patient would return for worsening symptoms."

Hard to turn that 35 --> 0, in fact it's probably impossible. I d/c unexplained tachycardia that isn't profoundly tachycardic on lots of healthy patients especially kids with fevers (provided not > 20-30 over normal after you give tylenol/motrin), young adults who have a neg workup and their HR is like 95-115 or so. I start to think if it's 120...and I care if it's 130-140.

You kind of need to read the paper to discuss the paper.

It was a heavily emphasized paper in my training and I still think it holds merit. Tachycardia matters.

I don’t necessarily disagree with some of your other conclusions though.

I frequently discharge well-appearing, febrile, tachycardic kids with viral URIs without much thought or a recheck of vital signs. On the flip side, I almost never discharge a tachycardic adult and give significant attention to the ones that I do. Meth as an etiology being somewhat excluded.

 

[Zebra Hunter]

You kind of need to read the paper to discuss the paper.

It was a heavily emphasized paper in my training and I still think it holds merit. Tachycardia matters.

I don’t necessarily disagree with some of your other conclusions though.

I frequently discharge well-appearing, febrile, tachycardic kids with viral URIs without much thought or a recheck of vital signs. On the flip side, I almost never discharge a tachycardic adult and give significant attention to the ones that I do. Meth as an etiology being somewhat excluded.

Wait, are you being serious about “almost never discharging a tachycardic adult?”

I have to imagine you are significantly exaggerating because otherwise that is an absurd practice pattern that is undoubtedly causing more harm than good. Nursing home patient with long standing afib with a rate in the low 100s who came in for her 4th fall of the year? Drunk patient who was brought in for being drunk? Clearly viral illness in an adult? Patient with known inappropriate sinus tach? Young patient with anxiety? Patient with minimally concerning symptoms and a completely normal workup who has a HR in the 110s?

Most of these I’m not even getting labs on, let alone keeping them till they are not tachycardic.

 

[Mount Asclepius]

Wait, are you being serious about “almost never discharging a tachycardic adult?”

I have to imagine you are significantly exaggerating because otherwise that is an absurd practice pattern that is undoubtedly causing more harm than good. Nursing home patient with long standing afib with a rate in the low 100s who came in for her 4th fall of the year? Drunk patient who was brought in for being drunk? Clearly viral illness in an adult? Patient with known inappropriate sinus tach? Young patient with anxiety? Patient with minimally concerning symptoms and a completely normal workup who has a HR in the 110s?

Most of these I’m not even getting labs on, let alone keeping them till they are not tachycardic.

Yes. I rarely discharge persistently tachycardic adults, and especially not unexplained tachycardia. This is how I was trained. This is also our local practice pattern.

I give chronic atrial fibrillation patients their rate control medications. I don’t discharge tachycardic drunk patients. Adult patients solely with viral URAs aren’t usually persistently tachycardic. Rarely ever see a patient with previously diagnosed inappropriate sinus tachycardia. I’ve caught PEs in young patients primarily with anxiety who are persistently tachycardic. Have caught blood loss anemia from not clearly presenting GI bleeding patients with unexplained tachycardia. Labs can be helpful.

Your condescending tone isn’t necessary.

 

[johhnybgood]

Yes. I rarely discharge persistently tachycardic adults, and especially not unexplained tachycardia. This is how I was trained. This is also our local practice pattern.

I give chronic atrial fibrillation patients their rate control medications. I don’t discharge tachycardic drunk patients. Adult patients solely with viral URAs aren’t usually persistently tachycardic. Rarely ever see a patient with previously diagnosed inappropriate sinus tachycardia. I’ve caught PEs in young patients primarily with anxiety who are persistently tachycardic. Have caught blood loss anemia from not clearly presenting GI bleeding patients with unexplained tachycardia. Labs can be helpful.

Your condescending tone isn’t necessary.

Are you saying you keep patients in hospital just for tachycardia?

If I do labs/work up and have determined no acute process and pt hr is still 112===>goodbye. But I agree that unexplained tachycardia in otherwise well appearing patient at least makes me investigate and do a little work up.

 

[Mount Asclepius]

Are you saying you keep patients in hospital just for tachycardia?

If I do labs/work up and have determined no acute process and pt hr is still 112===>goodbye. But I agree that unexplained tachycardia in otherwise well appearing patient at least makes me investigate and do a little work up.

I usually perform a workup of some sort for unexplained persistent tachycardia, which typically includes at least labs/EKG. I’ve admitted patients for observation who are persistently tachycardic, but almost always after workup/treatment and with some guess regarding the etiology of their tachycardia. I also have discharged tachycardic patients, but it’s just not very often and almost never unexplained.

 

[Rekt]

I actually agree with Mount for the most part but thought your alcohol example was interesting as I don't bat an eye at a tachycardic alcoholic. Patients typically can't fake vital signs so it's probably the thing I consider the most during an eval. But I do often discharge tachycardic patients. My hospitalist would come down and beat me with a hammer if I tried to admit someone for tachycardia. interesting how different our work environments can be.

 

[Zebra Hunter]

Yes. I rarely discharge persistently tachycardic adults, and especially not unexplained tachycardia. This is how I was trained. This is also our local practice pattern.

I give chronic atrial fibrillation patients their rate control medications. I don’t discharge tachycardic drunk patients. Adult patients solely with viral URAs aren’t usually persistently tachycardic. Rarely ever see a patient with previously diagnosed inappropriate sinus tachycardia. I’ve caught PEs in young patients primarily with anxiety who are persistently tachycardic. Have caught blood loss anemia from not clearly presenting GI bleeding patients with unexplained tachycardia. Labs can be helpful.

Your condescending tone isn’t necessary.

Man, I have to doubt that the entire local practice pattern of BC EM docs is to admit nearly every single tachycardic ER patient. Maybe it’s because I live in Texas, and the medmal climate is so much better here than many other locations. Sure, get a workup on these patients if there isn’t a clear, non-concerning etiology…but admitting all of them? Your hospitalists just accept them without any push back? Because even as an EM docs, there is no way I’d even accept this as a handoff, and would immediately discharge them if my sign out was “work up back and normal, wait to see if fluids improve the HR.” Of course, I’ve never even witnessed a colleague admit someone solely for sinus tachycardia.

Are you following up on these patients to see if the admission actually lead to finding anything of import?

Low 100s with afib is technically rate controlled from an EM standpoint, rate control recs are less than 110, although I’ll go up to 120 if they are completely asymptomatic, or bed bound nursing home patients. Give them an oral dose and discharge them.

Alcohol intoxication is known cause of tachycardia. Unless they were found down, have a unclear HPI, I’m not sure how admitting or even working up a clear cut drunk patient is going to benefit them.

I see persistently tachycardic viral syndrome adults daily. This was like a 10 patients a shift thing during COVID surges.

If their pre-test probability is low, you’re likely frequently misdiagnosing these anxious, young patients with PEs.

 

[Mount Asclepius]

Man, I have to doubt that the entire local practice pattern of BC EM docs is to admit nearly every single tachycardic ER patient. Maybe it’s because I live in Texas, and the medmal climate is so much better here than many other locations. Sure, get a workup on these patients if there isn’t a clear, non-concerning etiology…but admitting all of them? Your hospitalists just accept them without any push back? Because even as an EM docs, there is no way I’d even accept this as a handoff, and would immediately discharge them if my sign out was “work up back and normal, wait to see if fluids improve the HR.” Of course, I’ve never even witnessed a colleague admit someone solely for sinus tachycardia.

Are you following up on these patients to see if the admission actually lead to finding anything of import?

Low 100s with afib is technically rate controlled from an EM standpoint, rate control recs are less than 110, although I’ll go up to 120 if they are completely asymptomatic, or bed bound nursing home patients. Give them an oral dose and discharge them.

Alcohol intoxication is known cause of tachycardia. Unless they were found down, have a unclear HPI, I’m not sure how admitting or even working up a clear cut drunk patient is going to benefit them.

I see persistently tachycardic viral syndrome adults daily. This was like a 10 patients a shift thing during COVID surges.

If their pre-test probability is low, you’re likely frequently misdiagnosing these anxious, young patients with PEs.

Most initially persistent unexplained tachycardia resolves in the ED with treatment (whether it’s IV fluids, pain meds, antipyretics, etc.) and appropriate evaluation to rule out non-concerning pathology. Most of these patients aren’t admitted. I just said I didn’t discharge them right away. Either their tachycardia resolves or you find a reason they are tachycardic and admit them if appropriate. If you have good rapport with your hospitalists they shouldn’t have a problem rarely admitting unclear abnormal vital signs for observation.

You’d be amazed at the number of old people that end up being bacteremic on chart review who initially presented after a fall, are afebrile with a normal WBC, and are relatively asymptomatic because they’re old and a poor historian. Falls (including seemingly mechanical) usually make up one of the top 3-5 chief complaints for people who are admitted and diagnosed with sepsis.

You won’t find anything if you don’t look. I think it’s important to consider dysrhythmia, dehydration, sepsis and PE in patients that have initially persistent unexplained tachycardia, just like I consider ACS, PE, aortic dissection and pneumothorax for every adult patient that presents with chest pain.

I’d argue that you might occasionally minimize associated shortness of breath or chest pain in patients primarily presenting with anxiety. If they are tachycardic and symptomatic, I’d hardly argue it’s a misdiagnosis. On the other hand it’s a missed diagnosis if you don't look.

You allow intoxicated patients to metabolize and then bill for their obs time. Most of the time their tachycardia resolves spontaneously.

In our SDG we don’t sign out patients. You can do a lot during a 2-3 hour ED LOS.

I’d guess the vast majority of us have very similar practice patterns. Vital signs are vital and one of the most important aspects of assessing patients. If some want to be nonchalant with vital signs that is their prerogative.

Funny how I get flack for mentioning not ignoring objectively abnormal vital signs when I primarily pointed out ignoring something subjective like pain. I guess this thread has run its course, or I got what I should have expected.

 

[thegenius]

One of my partners admitted a pt with a low TSH due to tachycardia...his HR averaged 104-108 (sinus).

 

[turkeyjerky]

Most initially persistent unexplained tachycardia resolves in the ED with treatment (whether it’s IV fluids, pain meds, antipyretics, etc.) and appropriate evaluation to rule out non-concerning pathology. Most of these patients aren’t admitted. I just said I didn’t discharge them right away. Either their tachycardia resolves or you find a reason they are tachycardic and admit them if appropriate. If you have good rapport with your hospitalists they shouldn’t have a problem rarely admitting unclear abnormal vital signs for observation.

You’d be amazed at the number of old people that end up being bacteremic on chart review who initially presented after a fall, are afebrile with a normal WBC, and are relatively asymptomatic because they’re old and a poor historian. Falls (including seemingly mechanical) usually make up one of the top 3-5 chief complaints for people who are admitted and diagnosed with sepsis.

You won’t find anything if you don’t look. I think it’s important to consider dysrhythmia, dehydration, sepsis and PE in patients that have initially persistent unexplained tachycardia, just like I consider ACS, PE, aortic dissection and pneumothorax for every adult patient that presents with chest pain.

I’d argue that you might occasional minimize associated shortness of breath or chest pain in patients primarily presenting with anxiety. If they are tachycardic and symptomatic, I’d hardly argue it’s a misdiagnosis. On the other hand it’s a missed diagnosis if you don't look.

You allow intoxicated patients to metabolize and then bill for their obs time. Most of the time their tachycardia resolves spontaneously.

In our SDG we don’t sign out patients. You can do a lot during a 2-3 hour ED LOS.

I’d guess the vast majority of us have very similar practice patterns. Vital signs are vital and one of the most important aspects of assessing patients. If some want to be nonchalant with vital signs that is their prerogative.

Funny how I get flack for mentioning not ignoring objectively abnormal vital signs when I primarily pointed out ignoring something subjective like pain. I guess this thread has run its course, or I got what I should have expected.

It is kinda funny, isn’t it? My main point in bringing up tachycardia wasn’t to say that it should be blown off, rather that its resolution might not be as reassuring as we typically think.

One of my partners admitted a pt with a low TSH due to tachycardia...his HR averaged 104-108 (sinus).

Oof. How did he pull that off? Must have mad skillz.

 

[thegenius]

Oof. How did he pull that off? Must have mad skillz.

No f'ing clue. What a ridiculous waste of a bed. I would have given that dude metoprolol ER 50 mg PO and off he goes.

 

[RustedFox]

Most initially persistent unexplained tachycardia resolves in the ED with treatment (whether it’s IV fluids, pain meds, antipyretics, etc.) and appropriate evaluation to rule out non-concerning pathology. Most of these patients aren’t admitted. I just said I didn’t discharge them right away. Either their tachycardia resolves or you find a reason they are tachycardic and admit them if appropriate. If you have good rapport with your hospitalists they shouldn’t have a problem rarely admitting unclear abnormal vital signs for observation.

You’d be amazed at the number of old people that end up being bacteremic on chart review who initially presented after a fall, are afebrile with a normal WBC, and are relatively asymptomatic because they’re old and a poor historian. Falls (including seemingly mechanical) usually make up one of the top 3-5 chief complaints for people who are admitted and diagnosed with sepsis.

You won’t find anything if you don’t look. I think it’s important to consider dysrhythmia, dehydration, sepsis and PE in patients that have initially persistent unexplained tachycardia, just like I consider ACS, PE, aortic dissection and pneumothorax for every adult patient that presents with chest pain.

I’d argue that you might occasional minimize associated shortness of breath or chest pain in patients primarily presenting with anxiety. If they are tachycardic and symptomatic, I’d hardly argue it’s a misdiagnosis. On the other hand it’s a missed diagnosis if you don't look.

You allow intoxicated patients to metabolize and then bill for their obs time. Most of the time their tachycardia resolves spontaneously.

In our SDG we don’t sign out patients. You can do a lot during a 2-3 hour ED LOS.

I’d guess the vast majority of us have very similar practice patterns. Vital signs are vital and one of the most important aspects of assessing patients. If some want to be nonchalant with vital signs that is their prerogative.

Funny how I get flack for mentioning not ignoring objectively abnormal vital signs when I primarily pointed out ignoring something subjective like pain. I guess this thread has run its course, or I got what I should have expected.

Five star answer, here.

 

[TeddyBoomBoom]

In our SDG we don’t sign out patients. You can do a lot during a 2-3 hour ED LOS.

Wait wut?

You don’t sign out patients?? I’m so confused…..

 

[Mount Asclepius]

Wait wut?

You don’t sign out patients?? I’m so confused…..

I don’t follow your confusion. This is pretty common in a productivity-based compensation environment. Billing goes to the physician seeing the patient. Nothing to the second physician getting signed out a patient unless they are in obs (some places split the billing between docs, but we don’t other than for obs). Only really sign out obs patients such as psych patients waiting for placement, or patients metabolizing alcohol/drugs. Rarely other sign outs. Works well for our group.

 

[TeddyBoomBoom]

I don’t follow your confusion. This is common in a productivity based compensation environment. Billing goes to the physician seeing the patient. Nothing to a second physician getting signed out a patient unless they are in obs. Only really sign out obs patients such as psych patients waiting for placement, or patients metabolizing alcohol/drugs. Rarely other sign outs. Works well for our group.

I wasn’t being a jerk. Seriously.

I also work for a sdg. We have a pretty reasonable sign out culture. Imminent dispos we take care of. Anyone waiting for scans, bloodwork, etc, gets signed out. The money all basically evens out and we go home earlier than waiting around for a single patient.

🤷‍♀️

 

[Mount Asclepius]

I wasn’t being a jerk. Seriously.

I also work for a sdg. We have a pretty reasonable sign out culture. Imminent dispos we take care of. Anyone waiting for scans, bloodwork, etc, gets signed out. The money all basically evens out and we go home earlier than waiting around for a single patient.

🤷‍♀️

No worries, didn't perceive you that way. Some people like a sign out culture. I don't.

 

[WilcoWorld]

Without reading the paper it's "abnormal vital signs" and not just tachycardia.

I remember that paper and I remember that ultimately we are looking at a handful of deaths. it's 35 unexplained deaths WITH POTENTIAL ERROR out of 387,000 visits.

The reasons were multifactorial...and from the abstract they include "Four themes repeatedly emerged: atypical presentation of an unusual problem, chronic disease with decompensation, abnormal vital signs, and mental disability or psychiatric problem or substance abuse that may have made it less likely that the patient would return for worsening symptoms."

Hard to turn that 35 --> 0, in fact it's probably impossible. I d/c unexplained tachycardia that isn't profoundly tachycardic on lots of healthy patients especially kids with fevers (provided not > 20-30 over normal after you give tylenol/motrin), young adults who have a neg workup and their HR is like 95-115 or so. I start to think if it's 120...and I care if it's 130-140.

Agree that getting 0.01%-->0% is not achievable. So that's not how I apply the findings of that paper. Instead of never dc'ing someone with those risk factors I try to keep them in mind, and, when discharging someone with those risk factors present I do a little extra "don't sue me, because you'll loose" documentation.

 

[BoardingDoc]

No worries, didn't perceive you that way. Some people like a sign out culture. I don't.

I've always found this type of culture interesting. Do you routinely stay quite late after your shift as a result? Are you only picking up quick dispos in your last 1-2 hours?

I'm in the same boat as @TeddyBoomBoom in that our group cleans basically everything up, but if CT is backed up for some reason, I sure as hell am not waiting another 1-2 hours just to get the scan done and read, nor would I expect my colleagues to.

 

[RoyBasch]

Agree that getting 0.01%-->0% is not achievable. So that's not how I apply the findings of that paper. Instead of never dc'ing someone with those risk factors I try to keep them in mind, and, when discharging someone with those risk factors present I do a little extra "don't sue me, because you'll loose" documentation.

I think this is an excellent point, what can we do practically to make a 0.01% miss rate lower?

I really don't think there is anything. The amount of over-workup and over-diagnosis you would commit to get that terminal 0.01% is mind boggling. I suspect you would ultimately harm more patients (over-diagnosis>requires invasive confirmatory procedure>risk of complication harm from procedure) trying to rule out this last 0.01% that by definition have very subtle signs and a LOW pre-test probability. And that's not even accounting for the collateral harm to other patient's whose care is compromised by long ER LOS, wait room times, and hospital overcrowding from unnecessary admits.

most widely accepted clinical decision rules are designed for a miss rate already orders of magnitude higher, such as HEART score being powered to risk of MACE in 60 days of 1-2%,which is already 100x higher than the existing miss rate.

 

[Mount Asclepius]

I've always found this type of culture interesting. Do you routinely stay quite late after your shift as a result? Are you only picking up quick dispos in your last 1-2 hours?

I'm in the same boat as @TeddyBoomBoom in that our group cleans basically everything up, but if CT is backed up for some reason, I sure as hell am not waiting another 1-2 hours just to get the scan done and read, nor would I expect my colleagues to.

Our group in general schedules 8-9 hours shifts with in theory 7-8 hours of patient pickup and a ‘built in’ hour at the end of the shift to clean up. In reality though most stop picking up in their pod after 6-7 hours leaving ~1-2 patients for the oncoming physician in their pod to see as soon as they arrive to replace them.

We’re double covered almost the entire night. I usually work the slightly earlier night shift. I pickup every patient in my pod for 7 hours (8 hours scheduled). No one relieves me as it slows down to single coverage for a period of time for the late night doc and also for the early morning doc. I only rarely pick up longer than 7 hours if it’s crazy busy and the later doc who is briefly single coverage at the end of their shift is okay with me helping them out. My shifts average around 10.5 hours, which is what I plan on for shift length. I don’t consider my shifts 7 or 8 hours. I consider them 10.5 hours. I work hard picking right up until the 7 hour mark seeing whatever walks in the door. I can typically dispo almost everything in the next 2-3 hours. IV access issues, clotting labs, and imaging delays can make things occasionally problematic. Sure, I hate as much as the next person getting a vague CVA presentation within the tPA window, elderly abdominal pain, or train wreck requiring transfer to a quaternary level of care towards the very end of my shift. If I don’t see those patients though I’m missing out on a level 5 or cc chart. If I see a lot of patients, then I know my paycheck is going to at least look pretty nice. If I get out before 10.5 hours, which occasionally happens, then I enjoy the bonus of getting out early even if I’m disappointed that my paycheck won’t be as nice.

I average more pts/hr than our group average. Some docs don’t pickup more complicated patients towards the end of their shifts. They also don’t make as much money as I do. They probably get out a little earlier on average. I don’t mind working 10.5 hours. I think 10 hours is about the maximum amount of time you can work at high productivity on an ED shift. I think there is a study that showed this, but can’t find it at the moment. Some of you probably work 12 hour shifts. So if I’m only working 10.5 hour shifts, am I really getting out late?

Other docs also enjoy working with me as they know I won’t shirk difficult patients or have poor work ethic. Some docs are known for the opposite. That’s not the kind of reputation I want.

I don’t like people signing out to me, and so I don’t sign out my patients to others to have to clean up. Like any group we have some docs who aren’t as strong. I don’t want to clean up their messes for no pay. It wouldn’t even out as I wouldn’t equally sign out the same kind of things they’d sign out. Ultimately, our environment only works when you are paid for your work. We don’t all make equal money, because we make what we earn. That is what’s fair about it. I don’t fault you or @TeddyBoomBoom for your way of doing things. It has advantages. It’s just not for me or our group.

 

[GonnaBeADoc2222]

What an odd way of practicing Emergency Medicine.

I am very conservative, and DC many a tachycardic patient (low 100s to low 110s), if after an extensive and reasonable workup nothing is discovered.

Who says 100 is the magic number? Humans like base 10 I suppose.

If you turn over enough rocks, you will find some bugs.

Positive blood cultures in afebrile falls? How many were contaminants?

All these PEs you're finding I'm guessing are small, subsegmental, and peripheral. Likely physiologic and not clinically significant. Now the anxious 34 yo is on Eliquis. Hopefully they don't bump their head.

 

[RustedFox]

What an odd way of practicing Emergency Medicine.

I am very conservative, and DC many a tachycardic patient (low 100s to low 110s), if after an extensive and reasonable workup nothing is discovered.

Who says 100 is the magic number? Humans like base 10 I suppose.

If you turn over enough rocks, you will find some bugs.

Positive blood cultures in afebrile falls? How many were contaminants?

All these PEs you're finding I'm guessing are small, subsegmental, and peripheral. Likely physiologic and not clinically significant. Now the anxious 34 yo is on Eliquis. Hopefully they don't bump their head.

Yeah, it was Veers who first said: "I'm going to guess that in a few years that these small PEs are going to be called physiologic and we will do nothing about them."

 

[Mount Asclepius]

What an odd way of practicing Emergency Medicine.

I am very conservative, and DC many a tachycardic patient (low 100s to low 110s), if after an extensive and reasonable workup nothing is discovered.

Who says 100 is the magic number? Humans like base 10 I suppose.

If you turn over enough rocks, you will find some bugs.

Positive blood cultures in afebrile falls? How many were contaminants?

All these PEs you're finding I'm guessing are small, subsegmental, and peripheral. Likely physiologic and not clinically significant. Now the anxious 34 yo is on Eliquis. Hopefully they don't bump their head.

First, evaluated or explained tachycardia is different than ignored or disregarded tachycardia. Second, degree of tachycardia matters. @thegenius correctly pointed out earlier that the number matters. I don’t think anyone is trying to argue that tachycardia is black and white where crossing a line completely changes everything. I doubt many of you are discharging people frequently with HRs 120s-140s. Sure, if negative evaluation and improving or only low 100s its probably more common. Ignoring tachycardia though isn't wise in my opinion. I prefer to see discharge vital signs without sustained tachycardia. It's also hard to defend in peer review if someone comes back with a bad outcome and they were discharged tachycardic.

Unrelated to that, two recent patient examples in last month to speak to your questions:

80s year old with dementia presented from SNF following mechanical fall with out any significant complaints. Generally weak though. No SIRS (this isn't a tachycardia example). 2 out of 2 blood cultures with gram negative rods. UTI with mild urinary retention. I could pull up a fairly extensive list of similar examples. Blood culture contamination rate is fairly low. Don't always expect SIRS to lead you to the diagnosis in older adults.

30s year old with obesity presented with anxiety also endorsing shortness of breath. Persistent tachycardia 100s-120s. Pending CTA experiences PEA cardiac arrest. Post-ROSC CTA with extensive bilateral PE with large clot burden and right heart strain. Yeah, I hope they don’t bump their head.

I'm suprised at some of the criticism in this forum. Even a Zebra Hunter seems to think looking for horses that aren't even Zebras is wrong. You aren't going to catch atypical presentations of common illnesses if you don't know when to look and then look. I'm not talking about chasing after atypical or even typical presentations of uncommon illnesses. You have to get good at finding needles in haystacks in this job. What an odd way not to practice emergency medicine.

 

[Zebra Hunter]

Dude, no one is criticizing working up a tachycardic patient with an unclear etiology. You are being questioned regarding your statement of “almost never discharging a tachycardic adult”.