Hemoperitoneum s/p methotrexate for ectopic. OB wanted to discharge?!

[iish]

Had what I thought was a straight forward case that Ob had drastically differing views on. Wanted to get others' thoughts.

34 F, G1P0, undergoing IVF, L fallopian ectopic 6 days ago now s/p methotrexate comes to ED w/ sharp L sided pelvic pain. No vaginal bleeding or spotting. Notes previous cramping and bleeding in the 2-3 days after taking methotrexate and has since felt well. No N/F, fevers, chills, diarrhea, dysuria. Abd exam notable for mild LLQ/pelvic tenderness, no peritonitis. Pelvic exam w/ L adnexal tenderness, no adnexal fullness.

I got a TVUS which showed moderate hemoperitoneum adjacent to where the ectopic was located. I called Ob and the resident came down, did an exam, talks to her attending, and tells us that her pelvic was mostly negative and that sometimes this sort of pain can be seen with methotrexate 1 wk out and that TVUS findings of hemoperitoneum can be equivocal. Her recommendation was to send the patient home since she wasn't convinced there was blood in the pelvis and from what I heard in terms of her presentation to the Ob attending she presented a very skewed picture.

This all made me go cross eyed briefly. I figured Ob would gladly admit the patient for serial abdominal exams and obs for at least a day. As far as I was concerned, we had a 34 yo F with a highly probably ruptured ectopic despite stable 4hr CBC. I'm not saying she had to be taken to the OR immediately though at least had to be watched. In my experience, ruptured ectopics can open up very rapidly and lead to very brisk and fatal bleeding.

Despite the Ob resident's resistance and my attending speaking with the Ob attending who did not want to admit the pt, we admitted the patient. Ob turns around and discharges her 30 min later despite the pt telling us that pain was now spreading to the R side of her pelvis.

Was I unreasonable in forcing this admission? Was Ob unreasonable in not wanting to admit for serial abd exams and obs?

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[Birdstrike]

I think it's completely reasonable to push the OB attending to take responsibility for the patient. In fact, I think that's probably the only reasonable option, in a similar hypothetical.

"Patient admitted to OB. Care transferred to Dr X at *TIME STAMP*. Further and all care per doctor X at this time," and no other involvement in the case by you after that time. Done. Finito. "Elvis has left the building."

What they do after that, I don't think you can control unless you think there's gross negligence, ie, the OB attending has white powder on his upper lip and breath that smells like a 40 oz of malt liquor & gives your nurse an order to discharge a patient with a BP of 50/30, HR of 120, or something like that. Then you have an ethical duty to protect the patient, and would have to call your administrator on duty and try to call a back up OB attending. That should be rare, a once in every 10 years, or hopefully never, type of scenario.

Now, how much blood is acceptable in the pelvis after methotrexate for an ectopic? I don't know, but it sounds like a good question for an Obstetrician to come personally and explain to the patient at bedside.

 

[goodoldalky]

Was I unreasonable in forcing this admission? Was Ob unreasonable in not wanting to admit for serial abd exams and obs?

No and yes.

 

[Mighty Mouse]

just because a consultant tells you to discharge doesn't mean you have to. you're the one clicking "discharge" from the ED. if a plan doesn't fit with what you think should happen, then work a new solution, even if means keeping the patient in the ED for a prolonged period of time and treating patient yourself.

 

[WilcoWorld]

Have you followed up to see how the patient did?

I would never discharge this patient on my own, or even after an over-the-phone consultation. But if the OB service interviewed and examined the patient, AND wrote a note recommending discharge, AND set up close follow up, AND the patient remained stable throughout the ED stay, AND the patient had a good social situation (could return easily if things got worse/will be able to get to follow up appointment)...well, then I'd come around to discharging this patient.

 

[Art Vandalay]

Sounds very unreasonable to discharge this patient.
The resistance makes no sense...financially it can be justified....medically it can be justified...ethically it can be justified. Immediate Discharge only makes one vulnerable to bad outcomes

 

[The White Coat Investor]

Despite the Ob resident's resistance and my attending speaking with the Ob attending who did not want to admit the pt, we admitted the patient. Ob turns around and discharges her 30 min later despite the pt telling us that pain was now spreading to the R side of her pelvis.

Weird pissing match. The patient is probably wondering why your two services can't play on the same team. "I'll show you...I'll admit the patient if you force me to, but I'm discharging them right afterward!" That saves the OB zero work, saves the patient zero dollars, etc.

Seems a better way would be to relent and just watch the patient overnight (I do lots of things because another doctor is more worried about a patient than I am), or to come down to the ED and the two of you go into the patient's room, explain the situation together, and let the patient choose whether to go home or stay overnight.

 

[dotcb]

I try to avoid the conflict. I would request to speak to the Ob attending in person to discuss my concerns. I would make sure that they had performed a history and physical on the patient and that the consultation note was completed and present in the medical record. I would review the discharge plan and see if it seemed reasonable.

 

[deleted547339]

Thankfully we have a fairly responsible hospitalist group where I'm training. If OB recommended discharge, I would thank them then call the hospitalist and ask them to admit for serial hct.

 

[22031 Alum]

Had what I thought was a straight forward case that Ob had drastically differing views on. Wanted to get others' thoughts.

34 F, G1P0, undergoing IVF, L fallopian ectopic 6 days ago now s/p methotrexate comes to ED w/ sharp L sided pelvic pain. No vaginal bleeding or spotting. Notes previous cramping and bleeding in the 2-3 days after taking methotrexate and has since felt well. No N/F, fevers, chills, diarrhea, dysuria. Abd exam notable for mild LLQ/pelvic tenderness, no peritonitis. Pelvic exam w/ L adnexal tenderness, no adnexal fullness.

I got a TVUS which showed moderate hemoperitoneum adjacent to where the ectopic was located. I called Ob and the resident came down, did an exam, talks to her attending, and tells us that her pelvic was mostly negative and that sometimes this sort of pain can be seen with methotrexate 1 wk out and that TVUS findings of hemoperitoneum can be equivocal. Her recommendation was to send the patient home since she wasn't convinced there was blood in the pelvis and from what I heard in terms of her presentation to the Ob attending she presented a very skewed picture.

This all made me go cross eyed briefly. I figured Ob would gladly admit the patient for serial abdominal exams and obs for at least a day. As far as I was concerned, we had a 34 yo F with a highly probably ruptured ectopic despite stable 4hr CBC. I'm not saying she had to be taken to the OR immediately though at least had to be watched. In my experience, ruptured ectopics can open up very rapidly and lead to very brisk and fatal bleeding.

Despite the Ob resident's resistance and my attending speaking with the Ob attending who did not want to admit the pt, we admitted the patient. Ob turns around and discharges her 30 min later despite the pt telling us that pain was now spreading to the R side of her pelvis.

Was I unreasonable in forcing this admission? Was Ob unreasonable in not wanting to admit for serial abd exams and obs?

Not knowing the complete story, fluid in the pelvis could simply mean the methotrexate worked. The resolving pregnancy has to go somewhere and usually extrudes through the tube into the pelvis. Whether I admitted would depend on exam, vitals, and CBC. But it wouldn't be automatic just because of the hemoperitoneum, which maybe you assumed. Edit: if her hemoglobin was stable (I would've done a 6-hour check) rupture was highly unlikely. That amount of bleeding would definitely affect the CBC.

 

[GeneralVeers]

Not knowing the complete story, fluid in the pelvis could simply mean the methotrexate worked. The resolving pregnancy has to go somewhere and usually extrudes through the tube into the pelvis. Whether I admitted would depend on exam, vitals, and CBC. But it wouldn't be automatic just because of the hemoperitoneum, which maybe you assumed. Edit: if her hemoglobin was stable (I would've done a 6-hour check) rupture was highly unlikely. That amount of bleeding would definitely affect the CBC.

If I'm keeping her for a "6 hour check" that means she's getting admitted to OB for obs. If I kept any patient in the ED for 6 hours, the nurses would behead me and burn my corpse.

 

[22031 Alum]

If I'm keeping her for a "6 hour check" that means she's getting admitted to OB for obs. If I kept any patient in the ED for 6 hours, the nurses would behead me and burn my corpse.

That's fine. Where I work there's a separate observation unit that doesn't require admission. And I know plenty of people who'd be fine with discharge after a stable serial Hgb over 4 hours. My point was, fluid in the pelvis does not equal admission for a treated ectopic.

 

[iish]

Ob attending's response to my attending was "I haven't eaten, I'm tired, and I've been delivering babies all night long. Feel free to admit and waste a spot in the hospital." Attending never came down to examine the patient.

I understand a stable Hct 4, 6 hrs out or whatever, but the concern I had wasn't so much that she was bleeding so rapidly that she was going to exsanguinate in front of my eyes but rather that even a small bleed 2/2 ectopic can open up and lead to rapid exsanguination. It may not, but it could. In this case, I don't feel comfortable with 1 serial Hct to discharge, especially if the pt's pain is worsening.

 

[Birdstrike]

Ob attending's response to my attending was "I haven't eaten, I'm tired, and I've been delivering babies all night long. Feel free to admit and waste a spot in the hospital." Attending never came down to examine the patient.

If he is too old, too tired, or too anything to do his job, then instead of saying these words, "I haven't eaten, I'm tired, and I've been delivering babies all night long," he needs to man up, do the right thing, and say this instead,

"I haven't eaten, I'm tired, and I've been delivering babies all night long. I'm now an impaired physician and I'm no longer able to do my job and respond to this consult. I'll be calling one of my partners to come fill in for me, because that's the right thing to do, rather than allowing this patient, and you, to suffer due to my inadequacies."

But you'll never hear those words, because it takes an uncommon amount of humility, self awareness and ethics to say them.

The concept of doctors working hard and being tired is not a new one. Being overtired and over worked is not an excuse to be an intolerable jerk that doesn't give a ---- what happens to other living human beings. If I had a dime for every time I encountered this situation, I'd be retired on my own private island. Schedule double coverage OB call, work shifts, call in back up, have a cup of coffee and suck it up...WHATEVER. People should be fired for this crap, yet it's a chronic form of abuse laid upon EM physicians and upon patients, and we tolerate it?

What you want to say is this:

"I also haven't eaten, I'm tired, and I've been getting crushed with traumas, codes and piles of non-emergency non-sense I'm required to see at light speed and I've been arguing with prima donna consultants who either don't want to or don't have the strength to do their jobs all night long, and it's my 5th night shift in a stretch of 7 and I hate nights and barely have been able to sleep a wink during broad daylight between these shifts, and I don't give a crap that you're too tired to want to do your job, because I found a way to still do mine."

But you can't say that, because the ED is the end of the line. It's where responsibility has rolled so far down the hill, it's got nowhere else to roll to other than brown-plop right on the ED docs forehead who hopefully has the patience, rest and conscience to do the right thing when no one else will do it. It can be a thankless job, but thank God this world has heroes like you all to do the right thing. Keep up the good work and remember, you'll be rewarded for doing the hard thing and the right thing in the long run. Karma will be a b---- for these people. God bless.

 

[sum dude]

I've had two ruptured ectopics in the past 6 months. Both had "stable" Hgb's when I first saw them (>12). Both had "stable" Vs's in triage (SBP>100). Both were mildly tachycardiac. Both had mod to sever ttp on exam, hemoperitoneum on US, and ended up being hypotensive. Both got type/crossed and emergency release blood once they became hypotensive with "stable hemoglobins". Both Ob's (at different Community hospitals) requested a repeat Hgb, and I told them no, come see the pt. Both pt's had large blood loss, ended up getting multiple units of blood (the first pt's hemoglobin dropped from 12 to 7 in a repeat poc Hgb, which at least got the Ob to hurry up) and taken to OR w/o the repeat Hgb. Both pt's were lucky they got to the OR quickly, and both got over 3 units a piece of pRBC's, and both had large amounts of blood loss. Both also did fine in long term.

Lesson of story: EM physician's understand hemorrhagic shock as much as much as any other physician in the hospital. I guarantee you see as many shock patients as anyone else in the hospital (unless you work a major trauma center w/ multiple surgeons), and know that Hgb lags behind shock. I will guarantee you can identify hemorrhagic shock in a patient better than an ob resident, so stick to your guns. Repeat Hgb is crap, and it's your job to do the right thing for the patient, Residents be damned. The right thing would be to admit obs to OB service, let them cycle the pt and figure it out when the pt becomes hypotensive.

http://www.intjem.com/content/7/1/26

 

[BJJVP]

Not knowing the complete story, fluid in the pelvis could simply mean the methotrexate worked. The resolving pregnancy has to go somewhere and usually extrudes through the tube into the pelvis. Whether I admitted would depend on exam, vitals, and CBC. But it wouldn't be automatic just because of the hemoperitoneum, which maybe you assumed. Edit: if her hemoglobin was stable (I would've done a 6-hour check) rupture was highly unlikely. That amount of bleeding would definitely affect the CBC.

Does it make a difference to you if the US demonstrated simple free fluid vs complex fluid/heterogenous fluid? I believe the OP stated the US showed hemoperitoneum, which suggests that something other than simple free fluid was seen. Maybe the OP can clarify this.

 

[22031 Alum]

Does it make a difference to you if the US demonstrated simple free fluid vs complex fluid/heterogenous fluid? I believe the OP stated the US showed hemoperitoneum, which suggests that something other than simple free fluid was seen. Maybe the OP can clarify this.

Complex/heterogenous is precisely what a resolving ectopic or tubal abortion would look like. It's blood and clot and tissue.

 

[BJJVP]

Complex/heterogenous is precisely what a resolving ectopic or tubal abortion would look like. It's blood and clot and tissue.

I haven't seen this. Not saying you are wrong...I honestly haven't ever had an US performed on asymptomatic women with treated ectopics. If what you say is true, then what is your criteria for taking someone to the OR? A drop in Hgb or hypotension? Presumably most of them had pain when the ectopic was diagnosed, and my understanding is that a good percentage of them develop worse pain after methotrexate. So even pain would be a somewhat unreliable indicator for determining whether an ectopic has ruptured or is resolving. Again, I am not arguing with you. It just seems that the path taken by the OBs in the OP's case is not aligned with what I believe the OBs at my hospital would do. I am not sure they would or should take all of these to the OR, but to simply discharge them immediately seemed a little cavalier to me. But, in all fairness, the ectopics I have seen did not have the presentation that the OPs did.

 

[22031 Alum]

I haven't seen this. Not saying you are wrong...I honestly haven't ever had an US performed on asymptomatic women with treated ectopics. If what you say is true, then what is your criteria for taking someone to the OR? A drop in Hgb or hypotension? Presumably most of them had pain when the ectopic was diagnosed, and my understanding is that a good percentage of them develop worse pain after methotrexate. So even pain would be a somewhat unreliable indicator for determining whether an ectopic has ruptured or is resolving. Again, I am not arguing with you. It just seems that the path taken by the OBs in the OP's case is not aligned with what I believe the OBs at my hospital would do. I am not sure they would or should take all of these to the OR, but to simply discharge them immediately seemed a little cavalier to me. But, in all fairness, the ectopics I have seen did not have the presentation that the OPs did.

Without my hands on the patient I can't really describe with a checklist who goes to the OR and who doesn't, because there's a gradation between the obvious surgical abdomen and the obvious "she's fine." Vitals, Hgb, exam, exam, exam. Less so the ultrasound. But seeing the patient is by far the most important thing. Now, when I was a senior resident I dispo'd most patients without the attending seeing them, but our volume was stupid high so we became experienced quickly. If there was any question, though, the attending came over. That's the unacceptable part of this case, IMHO.

 

[Birdstrike]

Without my hands on the patient I can't really .... But seeing the patient is by far the most important thing...

ding ding ding ding ding

We have a winner here, folks!

 

[met19]

Reading this entire thread I see two issues and both resolve about GME training.
1) the conversation after the skewed gyn resident presentation from the ED to GYN attending. Did the gyn attending know of the difference btwn the actual presentation and what the resident said? Also when I have these attending to attending conversations above the resident level: I usually include phrases such as "this is my concern or I am not sure you have the whole picture or can you please see the patient...."
2) there are 2 professionalism issues here that seriously should be addressed- the gyn attending not seeing the patient and the skewed presentation by the gyn resident. The later is corrected by a discussion from program director to program director about a resident deficiencies. The former should be an email from the EM attending to his/her chair as an FYI.

 

[gro2001]

Agree with above, the devil is in the details.
Also agree that the OB attending really should have seen the patient.
Also agree that I don't really understand why the would fight so hard to discharge the patient unless there is some detail I am missing. Usually the private IVF patients are the VIPs of the OB service. Why the rush to kick them out the door in this case?

But also there are other options. As I see it, this is what an ER doc could have done:

1) Taken the OB recs at face value, discharged the patient.
2) Taken the OB recs with a grain of salt and discharged the patient:
a) after observing longer in the ER and RN staff be damned, possible getting another CBC or even a repeat US
b) having the patient swear to return to the ER for re-evaluation in 6, 8, 10, 12 or 24 hours or if pain gets any worse
c) after insisting/begging/threatening/pleading with the OB attending to come see the patient (and documenting as such)
3) Disregard recommendations and force admit to OB

Which one of those is the best option is really dependent on the details of the case.

What PGY year was the resident?

 

[iish]

Agree with above, the devil is in the details.
Also agree that the OB attending really should have seen the patient.
Also agree that I don't really understand why the would fight so hard to discharge the patient unless there is some detail I am missing. Usually the private IVF patients are the VIPs of the OB service. Why the rush to kick them out the door in this case?

But also there are other options. As I see it, this is what an ER doc could have done:

1) Taken the OB recs at face value, discharged the patient.
2) Taken the OB recs with a grain of salt and discharged the patient:
a) after observing longer in the ER and RN staff be damned, possible getting another CBC or even a repeat US
b) having the patient swear to return to the ER for re-evaluation in 6, 8, 10, 12 or 24 hours or if pain gets any worse
c) after insisting/begging/threatening/pleading with the OB attending to come see the patient (and documenting as such)
3) Disregard recommendations and force admit to OB

Which one of those is the best option is really dependent on the details of the case.

What PGY year was the resident?

Resident was an intern. Given his/her confidence in the situation, I did not expect them to be 9 mos into this whole doctoring business.