Is the practice of medicine sane?

[Old_Mil]

I was just doing some math.

If I work 12 shifts a month, that's 144 a year.

Over my projected 10 year career, that's 1440 shifts.

Averaging 30 patients a shift, that's 43,200 patient encounters before I get to retire.

Is it inevitable given those numbers that at some point I'm predestined to have one - if not more major misses?

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[Hercules]

Yes. Get it out of the way early to take the pressure off.


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[bravotwozero]

Fortunately you practice in the great white north, where you don't have to worry about frivolous lawsuit crap. Just be responsible and not commit gross negligence, and you'll be alright.


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[GeneralVeers]

It think the statistic is one lawsuit every five years on average for an EP. That being said we all probably miss major stuff all the time that doesn't result in lawsuits, and a lot of the time we may not even know. If the patient goes to another hospital, we might not be informed of a miss.

 

[gman33]

People make mistakes.
Doctors are people.

Doctors make mistakes.

The current system of how these mistakes are handled does not make any sense.

 

[NotWayneBrady]

People make mistakes.
Doctors are people.

Doctors make mistakes.

The current system of how these mistakes are handled does not make any sense.

So what needs to happen before it's fixed...?

 

[gman33]

So what needs to happen before it's fixed...?

That is a very complicated question.

If you are talking primarily about lawsuits, there are very few cases where a doctor is really responsible for the bad outcome that occurs.
Missing a diagnosis is bad, but it is really the patient's genetics and lifestyle that caused the bad event in the first place.
The system needs to allow for some missed diagnosis without demonizing the doctor.
That is about the only way that we will ever control healthcare spending in this country.

Under the current system, almost every CP I see needs a workup of some kind, and most get admitted.
The reason, I am looking for a needle in a haystack.

This is going to really over simplify the workup of CP, but in a reasonable system, I could probably d/c almost every CP I see, probably without getting much more than an EKG.

When there are bad outcomes, we should look at the standard workups and system issues that lead to the event.
If an individual doc (or system issue) is messed up, there should be actions that help improve things.
This may make it so another patient has a better outcome.

If someone dies from something bad, no amount of money is bringing that person back.
Should the family be compensated?
Maybe, but I also believe that people should have life insurance and other mechanisms in place in case tragedy strikes.
But that is personal responsibility, which is not valued all that much in our current culture.

 

[NotWayneBrady]

The system needs to allow for some missed diagnosis without demonizing the doctor.
That is about the only way that we will ever control healthcare spending in this country.

I think it is much too easy to paint a picture of a big evil/greedy/rich/lazy doctor when people are looking for someone to blame rather than just dealing with a tragic event. It's an easy story to sensationalize, and people flock to point fingers with very little understanding of the actual circumstances. Malpractice sounds like it sucks, it's not something I'm looking forward to dealing with at all.

 

[deleted109597]

The tort system isn't about justice. It's about money. That's why they sue doctors and hospitals, but not nurses. That's why if random guy X hits someone with his car, there's not much to do, but if random guy X is in a truck with some corporate or city sticker on it, it's a paycheck. Sucks, but that's what you get.

 

[Birdstrike]

To answer the thread question: Is the practice of "Medicine" sane?

Yes. If you practice a low stress, no-call (or little call), outpatient specialty, where you don't have to work nights, weekends or holidays and get to live with healthy circadian rhythms, then yes, it's sane. Anything else requires at least a little bit of willful suspension of judgement, involuntary lack of sanity, or a large dose of youthful ignorance, at least in specialty choice.

 

[sum dude]

I was just doing some math.

If I work 12 shifts a month, that's 144 a year.

Over my projected 10 year career, that's 1440 shifts.

Averaging 30 patients a shift, that's 43,200 patient encounters before I get to retire.

Is it inevitable given those numbers that at some point I'm predestined to have one - if not more major misses?

If it makes you feel better...it'll be one you never expect. It's always those. With that said, there are worse things in the world, so carry on.

 

[GeneralVeers]

It's part of the job and one that no physician can avoid, no matter how defensively you practice. If you're not accepting of that fact, then EM and perhaps medicine in general is not the field you should go into.

 

[sawboned]

Indeed the major misses suck/will suck. Not really sure how to get around that one.

I agree with all the prior posts.... Just to share a personal anecdote regarding malpractice in the US.

It is insane but doesn't entirely have to be. In 10 years working a high acuity inner city trauma center, three patients an hour, renowned litigious city, I was named (and dropped) three times. Ug. I perceived myself as genuinely concerned and always trying to do the right thing. And yes the cases were all ones I didn't see coming and were like, WTF! My one major "miss" (with the retrospectascope turned on full power), resulted in no action whatsoever.

10 years at a rural shop, one patient an hour (with highish acuity), reasonable, salt of the earth, low litigious population, patient compensation fund to settle disputes, not even close to to named even once (yet, knock on wood).







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[brk81144]

had one today that semi blew my mind. 55 yo female with burning epigastric pain and pleuritic chest pain. Couldn't perc so I got a dimer which was positive. Ct shows no pe but calcified coronaries. Trop negative x2. Was heart score 3 for age and risk factors. Got a stress echo done in the er where the patient developed st elevation on ekg. Went to cath lab and had a 100%lad. I write this one off as nothing as soon as she hit the door... Made me think about discharging chest pain

 

[RustedFox]

had one today that semi blew my mind. 55 yo female with burning epigastric pain and pleuritic chest pain. Couldn't perc so I got a dimer which was positive. Ct shows no pe but calcified coronaries. Trop negative x2. Was heart score 3 for age and risk factors. Got a stress echo done in the er where the patient developed st elevation on ekg. Went to cath lab and had a 100%lad. I write this one off as nothing as soon as she hit the door... Made me think about discharging chest pain

This is precisely why (to the critique of many forum regulars)... I admit all chest pain over the age of 30 with any risk factors. See "other thread" in which there was much debate about HEART scores and "low risk" and all that "academic" nonsense being ultimately.... purely academic.

 

[coachB]

This is precisely why (to the critique of many forum regulars)... I admit all chest pain over the age of 30 with any risk factors. See "other thread" in which there was much debate about HEART scores and "low risk" and all that "academic" nonsense being ultimately.... purely academic.

Unfortunate that's how you see it. This patient most likely would have done well by the criteria of the studies you dismiss. She had a 100% occlusion? So she had collaterals. Negative troponins mean there was no ischemia. The studies you refer to include close follow up. Had she been stressed a couple days later it is extraordinarily unlikely she would have had an adverse outcome. On the other hand, the harm you do to patients by admitting them all to the hospital is real. I understand that it's a broken system and physicians feel the need to protect themselves first. But the system results in a lot of patient harm that goes unrecognized because it's often less obvious, but no less real.

 

[WilcoWorld]

Unfortunate that's how you see it. This patient most likely would have done well by the criteria of the studies you dismiss. She had a 100% occlusion? So she had collaterals. Negative troponins mean there was no ischemia. The studies you refer to include close follow up. Had she been stressed a couple days later it is extraordinarily unlikely she would have had an adverse outcome. On the other hand, the harm you do to patients by admitting them all to the hospital is real. I understand that it's a broken system and physicians feel the need to protect themselves first. But the system results in a lot of patient harm that goes unrecognized because it's often less obvious, but no less real.

Agree with your points, except I'd say "Negative troponins mean there was no infarction." Otherwise, very well put.

 

[coachB]

Agree with your points, except I'd say "Negative troponins mean there was no infarction." Otherwise, very well put.

You're right. That sounds like a better way to phrase it. Thanks.

 

[shoal]

Unfortunate that's how you see it. This patient most likely would have done well by the criteria of the studies you dismiss. She had a 100% occlusion? So she had collaterals. Negative troponins mean there was no ischemia. The studies you refer to include close follow up. Had she been stressed a couple days later it is extraordinarily unlikely she would have had an adverse outcome. On the other hand, the harm you do to patients by admitting them all to the hospital is real. I understand that it's a broken system and physicians feel the need to protect themselves first. But the system results in a lot of patient harm that goes unrecognized because it's often less obvious, but no less real.

Negative troponin does not equal no ischemia. If the occlusion is blocking the release of the troponin, you still have an infarct. Be careful.


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[GeneralVeers]

Negative troponin does not equal no ischemia. If the occlusion is blocking the release of the troponin, you still have an infarct. Be careful.


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Evidence for this?

 

[turkeyjerky]

Evidence for this?

Maybe he send troponins off on all his cardiac arrest patients?

 

[shoal]

i have no evidence, but steve smith spouts it off all the time. perhaps not the lecel of amal but close. http://hqmeded-ecg.blogspot.com/?m=1

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[RustedFox]

Unfortunate that's how you see it. This patient most likely would have done well by the criteria of the studies you dismiss. She had a 100% occlusion? So she had collaterals. Negative troponins mean there was no ischemia. The studies you refer to include close follow up. Had she been stressed a couple days later it is extraordinarily unlikely she would have had an adverse outcome. On the other hand, the harm you do to patients by admitting them all to the hospital is real. I understand that it's a broken system and physicians feel the need to protect themselves first. But the system results in a lot of patient harm that goes unrecognized because it's often less obvious, but no less real.

"Most likely".

Sure, most likely - until they don't.

First person you save at a code is yourself.

 

[gman33]

Neg stress test means nothing, especially in women. They have a much higher percentage of cardiac disease that is not properly evaluated with a stress test.

Problem is that many of these patients who get obs or admit no longer really get any type of real risk stratification. Many just get a couple more trops and get shown the door.

 

[coachB]

i have no evidence, but steve smith spouts it off all the time. perhaps not the lecel of amal but close. http://hqmeded-ecg.blogspot.com/?m=1

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I don't see anything regarding this topic in the link you provided. Sounds rather nonsensical, but I'm always open to listening to evidence.

 

[coachB]

"Most likely".

Sure, most likely - until they don't.

First person you save at a code is yourself.

What does that even mean? You say that about just about anything. Your job is managing probabilities. If you are not comfortable with that, or don't like what the evidence tells you, then you are in the wrong business. As I said, I understand the pressures of an irrational and unfair system. But be just as willing to recognize the harm you are causing on a regular basis. And don't fool yourself into thinking you made some big save in this case because you likely didn't.

 

[RustedFox]

What does that even mean? You say that about just about anything.

It means precisely what it says; those patients (in this specific example: a high-risk situation like chest pain) will most likely do well, given their risk-stratification. Most likely. When they don't (and they won't)... you're left standing in liability quicksand. That's more than likely; that's an eventual certainty - given your proposed approach. I can't help but think of the little girl from the "Aliens" movie... "They mostly come out at night. Mostly."

Your job is managing probabilities. If you are not comfortable with that, or don't like what the evidence tells you, then you are in the wrong business.

I know all about managing probabilities. You're forgetting to manage the probability that your inevitable big miss (in this situation) will bring you big trouble.

As I said, I understand the pressures of an irrational and unfair system. But be just as willing to recognize the harm you are causing on a regular basis. And don't fool yourself into thinking you made some big save in this case because you likely didn't.

I think you're overestimating the risk of harm for an admitted low-risk patient. A small percentage of those "soft admits" will have bad outcomes related to contrast dye from their diagnostic cath. A small percentage will catch a nosocomial infection. A small percentage of those will develop a DVT from immobility. Sure. I get all that - but 100% of them are going to have another name on the chart, a full set of troponins, and better access to follow-up with cards, or whatever. Which is worse for the patient... shaking off a nosocomial bug, or dying of sudden cardiac arrest far away from help? In addition; when those complications from admission DO happen... guess WHERE they happen? - In the hospital, when intervention is easy.Which happens more frequently? Don't fool yourself into thinking you're some guardian against iatrogenic harm, because you likely aren't.

Furthermore, in your example above - you count on the patient getting a follow-up stress in a few days. How many young people (with risk factors; either known or as-yet undiagnosed) are ACTUALLY going to follow-up for their stress test? They're not. I have this discussion with patients all the time when they ask about it. Their logic is reduced to this simple sentence:

"If you're telling me that its not a heart attack; then that's good. I'm okay and ready to go. I'm done. Thanks."

I literally had someone say this to me two shifts ago with regard to chest pain and dispo: "If it ain't a heart attack, then I don't care about nothin' else."

Period. That's all they think. It either is or it isn't a "heart attack". They don't even know what those two words actually mean. They don't understand this continuum that is coronary artery disease/ACS/NSTEMI/STEMI. They don't understand "risk stratification". Like Paul Simon wrote: "Still a man hears what he wants to hear, and disregards the rest."

Boys and girls: we're talking about one of the highest-risk complaints in existence. Play it smart. When was the last time that "the system" stood up for you, and recognized you doing "the right thing" and avoiding iatrogenic harm in the setting of professional risk? Never.

Coach; I'm willing to bet that you work in academia.

 

[startupquick]

Rusted Fox,

You are really off base here. You are basing your practice on the off chance that something bad happens and that it comes back to bite you. but the cost you impose on the system, on the patient, all just to cover your ass is overwhelming. more harm than good and cost is excessive.

admitting every patient over 30 with chest pain? really?
isn't your job to risk stratisfy and see who is safe to follow up and who needs emergent evaluation and treatment? otherwise what good are you doing?

the leaders in our field, mattu, smith, are using the heart score. you can even modify it as wake forest does. negative trop, heart score less than 3 = 1.7 risk of adverse cardiac event in next 30 days. being the risk adverse sally that you are, you could add on a delta trop at 3 hours. this gets you to risk of less than 1%. you could even use shared discussion, discuss risks, document the risks of going home vs admission. cover your bases. Most will want to go home and you can document that they chose outpatient vs. inpatient.

perhaps the most surprising thing is is how the hospitalists are even taking some of these admissions? no chance this would happen anywhere i work.

is your personal admission rate 80%?

madness.

 

[RustedFox]

Pfft...

Do as you will, with your one-post count.

Am I risk averse? Sure. I've seen too many oddball cases to rely on these scoring systems with a situation as high-risk as this one. Others? Sure, I'll do different things.

The hospitalists take 'em, run the trops, consult cardio, and street 'em the next day. I get zero pushback.

A three hour trop will not fly in my shops. It takes an hour or so to get the FIRST one back, and that's if the nurse remembered to draw the labs. I'm a one-and-done guy.

Shared discussion ? (Especially with the patient described by me above) Risk/benefit ? Shared decision making ? In the words of Sweet Brown: "Ain't Nobody Got Time fo' Dat".

Its easy.

Chest Pain? Admit. Next patient.

Mock me all you want to. I'm certain (and maybe they'll chime in) that malpractice madness and "the system" played a large role in the Great Birdstrike Rage Quit and losing OldMil to Canada. Your card will get pulled one day, too. Will you defend "saving the system money" then ? "More harm than good" ? Maybe - but NO harm is coming to me.

 

[Doctor4Life1769]

Pfft...

Do as you will, with your one-post count.

Am I risk averse? Sure. I've seen too many oddball cases to rely on these scoring systems with a situation as high-risk as this one. Others? Sure, I'll do different things.

The hospitalists take 'em, run the trops, consult cardio, and street 'em the next day. I get zero pushback.

A three hour trop will not fly in my shops. It takes an hour or so to get the FIRST one back, and that's if the nurse remembered to draw the labs. I'm a one-and-done guy.

Shared discussion ? (Especially with the patient described by me above) Risk/benefit ? Shared decision making ? In the words of Sweet Brown: "Ain't Nobody Got Time fo' Dat".

Its easy.

Chest Pain? Admit. Next patient.

Mock me all you want to. I'm certain (and maybe they'll chime in) that malpractice madness and "the system" played a large role in the Great Birdstrike Rage Quit and losing OldMil to Canada. Your card will get pulled one day, too. Will you defend "saving the system money" then ? "More harm than good" ? Maybe - but NO harm is coming to me.

So EVERY chest pain gets an admission?
What if it is musculoskeletal in a young person?
What if it is anxiety in a young person?
If there are risk factors, middle/elderly aged, women > 45 yo, sure I agree... Otherwise?

 

[RustedFox]

So EVERY chest pain gets an admission?
What if it is musculoskeletal in a young person?
What if it is anxiety in a young person?
If there are risk factors, middle/elderly aged, women > 45 yo, sure I agree... Otherwise?

In those situations, yes - I discharge, and I make damn sure that there's no question in my charting as to the origin of the pain.

"30" is the new "40", when it comes down to people and their risk factors. Young people aren't healthy. They're fat, hypertensive, diabetic, smoking, drug-using liars.

 

[Doctor4Life1769]

In those situations, yes - I discharge, and I make damn sure that there's no question in my charting as to the origin of the pain.

"30" is the new "40", when it comes down to people and their risk factors. Young people aren't healthy. They're fat, hypertensive, diabetic, smoking, drug-using liars.

Lol, this is true. Then again, those would also be considered risk factors.

 

[RustedFox]

Lol, this is true. Then again, those would also be considered risk factors.

Exactly. However, the 33 year old who hasn't been to a physician in 10 or so years won't tell you that they have these things because "they've never been checked". They will lie to you about smoking/EtOH/drugs, and if they do take any meds for risk factor modification, they reconcile it with "well, I take the meds, so I really don't have high blood pressure/diabetes/etc", and they won't tell you that, either.

 

[Doctor4Life1769]

Exactly. However, the 33 year old who hasn't been to a physician in 10 or so years won't tell you that they have these things because "they've never been checked". They will lie to you about smoking/EtOH/drugs, and if they do take any meds for risk factor modification, they reconcile it with "well, I take the meds, so I really don't have high blood pressure/diabetes/etc", and they won't tell you that, either.

I know the ED is done after ordering CBC, CMP, AMI panel X 1, CXR.
Lipids are checked by the admitting physician.
If obese, I'd order lipids. If non-fasting blood sugar > 200 and they have possible symptoms, they're diabetic. Add on HbA1c - I know, not ED thing as admitting physician will order.

I think the tricky part is that let's say you have a 30 y/o obese M who presents with chest pain that is negative AMI X 3, echo normal. I've noticed cardiology where I am ordering stress tests and if negative then saying "atypical cp, likely non-cardiac in origin, rule out pulm etiology, ok for DC." You get that lipid panel and it is abnormal (not barely abnormal, but not exactly horrendously abnormal either). I advocate diet and lifestyle modifications but we all know that won't happen. With obesity and ASCVD risk increasing in the younger 30-something population, should one consider risks/benefits and go ahead and start them on a low intensity statin and then monitor and adjust as indicated?

 

[deleted109597]

With obesity and ASCVD risk increasing in the younger 30-something population, should one consider risks/benefits and go ahead and start them on a low intensity statin and then monitor and adjust as indicated?

I mean, if you want to keep on the "I GOT MINE" feel good theme of the thread by doing something not helpful or harmful, then sure. Statins cost money, but have zero health benefit. They make the lipid numbers lower. They don't change risks. You would do the same by advocating them to cut their legs off to make some arbitrary weight guideline. Sure, the number is right, but are they really better now?
Same for their admission. Or their needless CT. Or any number of other things we do that help some of us sleep at night.

What's worse is one of our strongest proponents of common sense medicine is now getting ready for a prison sentence. Anyone arguing a similar is going to be painted with the same brush likely. (Oh, you're like him)

 

[RustedFox]

I know the ED is done after ordering CBC, CMP, AMI panel X 1, CXR.
Lipids are checked by the admitting physician.
If obese, I'd order lipids. If non-fasting blood sugar > 200 and they have possible symptoms, they're diabetic. Add on HbA1c - I know, not ED thing as admitting physician will order.

I think the tricky part is that let's say you have a 30 y/o obese M who presents with chest pain that is negative AMI X 3, echo normal. I've noticed cardiology where I am ordering stress tests and if negative then saying "atypical cp, likely non-cardiac in origin, rule out pulm etiology, ok for DC." You get that lipid panel and it is abnormal (not barely abnormal, but not exactly horrendously abnormal either). I advocate diet and lifestyle modifications but we all know that won't happen. With obesity and ASCVD risk increasing in the younger 30-something population, should one consider risks/benefits and go ahead and start them on a low intensity statin and then monitor and adjust as indicated?

''

You're asking the EP to involve himself in risk factor counseling and modifications and statins and adjustments ?

 

[Doctor4Life1769]

I mean, if you want to keep on the "I GOT MINE" feel good theme of the thread by doing something not helpful or harmful, then sure. Statins cost money, but have zero health benefit. They make the lipid numbers lower. They don't change risks. You would do the same by advocating them to cut their legs off to make some arbitrary weight guideline. Sure, the number is right, but are they really better now?
Same for their admission. Or their needless CT. Or any number of other things we do that help some of us sleep at night.

What's worse is one of our strongest proponents of common sense medicine is now getting ready for a prison sentence. Anyone arguing a similar is going to be painted with the same brush likely. (Oh, you're like him)

Fair points.
Clearly, the risk of a statin isn't quite the same as an amputation.
A lot of what we do is CYA medicine, but that is the nature of our political and healthcare climate.

 

[shoal]

i have to admit that the past few posts have been very entertaining. perhaps ive been far too cavailar in my chest pain discharges. chest pain x 3days constant, neg ekg cxr,labs,troponin no concerns for pe or dissection i send you home. maybe i should rethink this

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[GeneralVeers]

i have to admit that the past few posts have been very entertaining. perhaps ive been far too cavailar in my chest pain discharges. chest pain x 3days constant, neg ekg cxr,labs,troponin no concerns for pe or dissection i send you home. maybe i should rethink this

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I actually practice similarly. I would add clearly reproducible chest wall pain, or pain with movement of the shoulder. The odds of someone having a cardiac arrest or bad outcome within 30 days even if they have coronary disease is < 1%. If you have negative troponin, EKG, and no risk factors that number becomes far far less. As has been said above. It's a numbers game. We can't admit every patient, so it's about risk reduction. Once you get into the 1:1000 odds, it's reasonable to send home. It's like playing the BAD lottery, you just hope you're not a winner.

 

[deleted109597]

Shared discussion ? (Especially with the patient described by me above) Risk/benefit ? Shared decision making ? In the words of Sweet Brown: "Ain't Nobody Got Time fo' Dat".

Chest Pain? Admit. Next patient.

So if that's your actual practice pattern, then why do they need you? A midlevel, a nurse, or even the triage computer itself could make that binary decision. I'm being serious. Either you're hyperbolizing about how you actually practice, or you're not actually using the knowledge you paid for.

We can't admit every patient, so it's about risk reduction. Once you get into the 1:1000 odds, it's reasonable to send home.

RustedFox can apparently.
Also, the 1:1000 thing is a pretty good cutoff. Use Nexus? PECARN? Rochester, Philly, or Boston for pediatric FUO? You're playing odds. If you don't want to roll the dice, leave the casino. You don't have to leave medicine to be sane, and if enough people would actually leave states with such ****ty environments, we could fix a lot of problems.

 

[GeneralVeers]

So if that's your actual practice pattern, then why do they need you? A midlevel, a nurse, or even the triage computer itself could make that binary decision. I'm being serious. Either you're hyperbolizing about how you actually practice, or you're not actually using the knowledge you paid for.

RustedFox can apparently.
Also, the 1:1000 thing is a pretty good cutoff. Use Nexus? PECARN? Rochester, Philly, or Boston for pediatric FUO? You're playing odds. If you don't want to roll the dice, leave the casino. You don't have to leave medicine to be sane, and if enough people would actually leave states with such ****ty environments, we could fix a lot of problems.

Exactly. In Texas it's near impossible to prove "Wanton Disregard" or "Negligence" if your patient has a non-concerning EKG, negative troponin, is chest pain free, and has good follow-up instructions (including return to ER).

 

[startupquick]

@RustedFox

Your job is to do what's best for patient, not what best for you. You are being paid to stratify risk for these patients that are coming in with chest pain. Scoring systems are great guidelines, but use your history and physical, labs and common sense. discuss risk with patient. Takes less than 1 minute. Discharge. F/u w Pcp in 1-2 days. Document.

Multiple risk factors? Concerning story. EKG changes? Elevated trop? Old? Admit.

But this blanket admit everyone over 30 is a joke.

 

[TooMuchResearch]

What does that even mean? You say that about just about anything.

It means precisely what it says; those patients (in this specific example: a high-risk situation like chest pain) will most likely do well, given their risk-stratification. Most likely. When they don't (and they won't)... you're left standing in liability quicksand. That's more than likely; that's an eventual certainty - given your proposed approach. I can't help but think of the little girl from the "Aliens" movie... "They mostly come out at night. Mostly."

Your job is managing probabilities. If you are not comfortable with that, or don't like what the evidence tells you, then you are in the wrong business.

I know all about managing probabilities. You're forgetting to manage the probability that your inevitable big miss (in this situation) will bring you big trouble.

As I said, I understand the pressures of an irrational and unfair system. But be just as willing to recognize the harm you are causing on a regular basis. And don't fool yourself into thinking you made some big save in this case because you likely didn't.

I think you're overestimating the risk of harm for an admitted low-risk patient. A small percentage of those "soft admits" will have bad outcomes related to contrast dye from their diagnostic cath. A small percentage will catch a nosocomial infection. A small percentage of those will develop a DVT from immobility. Sure. I get all that - but 100% of them are going to have another name on the chart, a full set of troponins, and better access to follow-up with cards, or whatever. Which is worse for the patient... shaking off a nosocomial bug, or dying of sudden cardiac arrest far away from help? In addition; when those complications from admission DO happen... guess WHERE they happen? - In the hospital, when intervention is easy.Which happens more frequently? Don't fool yourself into thinking you're some guardian against iatrogenic harm, because you likely aren't.

Furthermore, in your example above - you count on the patient getting a follow-up stress in a few days. How many young people (with risk factors; either known or as-yet undiagnosed) are ACTUALLY going to follow-up for their stress test? They're not. I have this discussion with patients all the time when they ask about it. Their logic is reduced to this simple sentence:

"If you're telling me that its not a heart attack; then that's good. I'm okay and ready to go. I'm done. Thanks."

I literally had someone say this to me two shifts ago with regard to chest pain and dispo: "If it ain't a heart attack, then I don't care about nothin' else."

Period. That's all they think. It either is or it isn't a "heart attack". They don't even know what those two words actually mean. They don't understand this continuum that is coronary artery disease/ACS/NSTEMI/STEMI. They don't understand "risk stratification". Like Paul Simon wrote: "Still a man hears what he wants to hear, and disregards the rest."

Boys and girls: we're talking about one of the highest-risk complaints in existence. Play it smart. When was the last time that "the system" stood up for you, and recognized you doing "the right thing" and avoiding iatrogenic harm in the setting of professional risk? Never.

Coach; I'm willing to bet that you work in academia.

Several local hospitals staffed by SDGs and hospital employee EPs protocolized HEART low risk = home +/- stress within 3 days.

Our hospital's no show rate for our post-ED outpatient stress is about 20%.


This is all going to be very system/geography dependent. It's clearly not how the game is played in your area, yet.

 

[shoal]

i dont feel that rustedfox deserves all the bashing he is getting, as im unsure of where he practices but im sure a few bad outcomes and if the system allows its easier to admit. i get significant pushback so its not an easy slam dunk. but i do have an obs department where i can put low risk chest pain for repeat trop and stress as long as it isnt a weekend.

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[RustedFox]

@RustedFox

Your job is to do what's best for patient, not what best for you. You are being paid to stratify risk for these patients that are coming in with chest pain. Scoring systems are great guidelines, but use your history and physical, labs and common sense. discuss risk with patient. Takes less than 1 minute. Discharge. F/u w Pcp in 1-2 days. Document.

Multiple risk factors? Concerning story. EKG changes? Elevated trop? Old? Admit.

But this blanket admit everyone over 30 is a joke.

I see that you took your three posts over to another thread, in which you out yourself as a resident.

Thanks for letting me know what my job is there, rezzie. Found some pics of you on your program's website:

Let us know when you graduate to solid foods (and solid reasoning).

 

[RustedFox]

So if that's your actual practice pattern, then why do they need you? A midlevel, a nurse, or even the triage computer itself could make that binary decision. I'm being serious. Either you're hyperbolizing about how you actually practice, or you're not actually using the knowledge you paid for.

RustedFox can apparently.
Also, the 1:1000 thing is a pretty good cutoff. Use Nexus? PECARN? Rochester, Philly, or Boston for pediatric FUO? You're playing odds. If you don't want to roll the dice, leave the casino. You don't have to leave medicine to be sane, and if enough people would actually leave states with such ****ty environments, we could fix a lot of problems.

I thought for awhile about this during shift last night. Sure, the obvious ones with a clear-cut non-cardiac etiology (non-cardiac story, antecedent trauma, repetitive stress injury, no risk factors either diagnosed or suspected) can go home, yes. Its also worth mentioning that I work in SnowbirdLand where my average patient is (no exaggeration) 64+ years old. My hospital doesn't see patients in their thirties with CP a lot. I admit them. I get no pushback whatsoever. Those 30-somethings that I do see with chest pain are typically the "cigarettes and mountain dew for breakfast, copenhagen and percocets for lunch, kiss my cousin and shine my belt buckle before bed" crowd that would just love to have that jackpot lawsuit to continue their meth habit.

Unrelated note: 20mg of melatonin at 2 AM - I got four and a half hours of sleep and feel fully rested. I'm going to a spring training game.

 

[fahimaz7]

This might be the most contentious post on this forum in quiet some time.

 

[WilcoWorld]

I'd like to ask for how long so many of us have been practicing substantially differently than the way @RustedFox describes?

I trained in a litigious state and, from 2005-2008, pretty much all of my faculty would put all chest pains that were not OBVIOUSLY non cardiac in the ED Obs unit. It seems to me that low risk chest pain is what Obs units were built for. At my 1st post-residency job, in a less litigious state, things relaxed a little bit, but most docs still defaulted to Obs for the majority of low risk chest pain. The protocol called the "Low Risk Chest Pain Protocol" included Obs admission for serial trops, serial ECGs and a Cardiology consultation.

It's only been since about 2014 that I've started seeing the majority of my colleagues (and myself) discharging 40 year olds with normal ECG's and negative troponins. Even to this day, if I'm discharging a CP patient, I employ shared decision making and my note will reflect that. If I have a 37 year old who is afraid to go home, I Obs him.

While his discussion of the topic is not particularly nuanced, I'd say that RustedFox's practice is not too far off from what appeared to be the norm up until very recently. Add to that the fact that he practices in the Malpractice Capitol of the World and I'd cut the guy some slack.

 

[fahimaz7]

Today we were discussing changing our low-risk obs protocol to be less inclusive (ie rule out less patients). Our consensus opinion is that we use it too often and have too many patients getting stress tests (Academic center and this is the opinion of both the ED and cardiology). Keep in mind that our admit rate from there is 10-20% (quiet high if you ask me). We already send home a large majority of our chest pain patients.

We are debating going to an ultra sensitive trop x1 + heart score < 3, etc to help identify these truly low-risk patients.

This would follow what is being done in Maryland

https://hippoemergency.files.wordpr...luation-and-disposition-guideline-final-1.pdf

 

[deltamed]

Rusted Fox,

You are really off base here. You are basing your practice on the off chance that something bad happens and that it comes back to bite you. but the cost you impose on the system, on the patient, all just to cover your ass is overwhelming. more harm than good and cost is excessive.

admitting every patient over 30 with chest pain? really?
isn't your job to risk stratisfy and see who is safe to follow up and who needs emergent evaluation and treatment? otherwise what good are you doing?

the leaders in our field, mattu, smith, are using the heart score. you can even modify it as wake forest does. negative trop, heart score less than 3 = 1.7 risk of adverse cardiac event in next 30 days. being the risk adverse sally that you are, you could add on a delta trop at 3 hours. this gets you to risk of less than 1%. you could even use shared discussion, discuss risks, document the risks of going home vs admission. cover your bases. Most will want to go home and you can document that they chose outpatient vs. inpatient.

perhaps the most surprising thing is is how the hospitalists are even taking some of these admissions? no chance this would happen anywhere i work.

is your personal admission rate 80%?

madness.

I'm not in this field but you are saying you'd d/c home all patients with a 1% risk of an adverse cardiac event in the next 30 days. Wouldn't that mean you'd get an event for every 100 patients you saw like that? It wouldn't take too long in practice to reach a few of those events...

I personally think thats how medicine should be practiced, except the liability system doesn't expect you to be right 99% of the time.


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