The double pelvic exam . . .

[Snoopy]

So what's your take on the double pelvic exam? I almost always do my own pelvics on patients (in fact, I've done more pelvics in my last 2 months as an attending than I've probably done in my entire life) but there are some occasions when the patient is clearly going to need a GYN consult and GYN pelvic, and I've always taken the stance that a woman shouldn't have to endure 2 pelvics on the same visit if at all possible.

Perfect example tonight . . . I had a young woman tonight who had had an abortion earlier in the day who came in bleeding so profusely that she had blood all over her socks. In addition, she was in a pretty significant amount of pain. It was very obvious that GYN was going to have to examine this patient and that she was going to be admitted to their service. When I called the GYN resident, he asked what the pelvic had showed. I told him that I had not done a pelvic as I was anticipating their seeing the patient and felt the woman had been through enough without enduring 2 pelvic exams. Additionally, I told him that there wasn't anything that my pelvic exam was going to add to their evaluation and management of the patient. He disagreed saying that lots of women come in saying they are bleeding heavily when they aren't bleeding at all. This was clearly not the case here, although it is often true with the DUB'ers who I always examine and for whom I almost never consult GYN.

What would you guys have done?

To top off the whole situation, the GYN resident chewed out my PA for treating this woman's pain prior to their examining the patient. They're very lucky they didn't happen to say that to me.

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[bulgethetwine]

So what's your take on the double pelvic exam? I almost always do my own pelvics on patients (in fact, I've done more pelvics in my last 2 months as an attending than I've probably done in my entire life) but there are some occasions when the patient is clearly going to need a GYN consult and GYN pelvic, and I've always taken the stance that a woman shouldn't have to endure 2 pelvics on the same visit if at all possible.

Perfect example tonight . . . I had a young woman tonight who had had an abortion earlier in the day who came in bleeding so profusely that she had blood all over her socks. In addition, she was in a pretty significant amount of pain. It was very obvious that GYN was going to have to examine this patient and that she was going to be admitted to their service. When I called the GYN resident, he asked what the pelvic had showed. I told him that I had not done a pelvic as I was anticipating their seeing the patient and felt the woman had been through enough without enduring 2 pelvic exams. Additionally, I told him that there wasn't anything that my pelvic exam was going to add to their evaluation and management of the patient. He disagreed saying that lots of women come in saying they are bleeding heavily when they aren't bleeding at all. This was clearly not the case here, although it is often true with the DUB'ers who I always examine and for whom I almost never consult GYN.

What would you guys have done?

To top off the whole situation, the GYN resident chewed out my PA for treating this woman's pain prior to their examining the patient. They're very lucky they didn't happen to say that to me.

Tough call. To tell you the truth, I almost NEVER call Gyn without having done the pelvic first... it's like calling urology to foley a patient if I haven't tried to myself after the nurses fail.


But I think if you have a compasionate Gyn service in your hospital -- and they understand the infrequency with which you acutally would defer the pelvic and that they understand it is being deferred due to patient comfort and honest judgement as opposed to a "it's a gyn problem, let them sort it out" mentality (which occurs at some community centers) -- then your approach is perfectly appropriate and probably the most humane.

 

[FoughtFyr]

Tough call. To tell you the truth, I almost NEVER call Gyn without having done the pelvic first... it's like calling urology to foley a patient if I haven't tried to myself after the nurses fail.


But I think if you have a compasionate Gyn service in your hospital -- and they understand the infrequency with which you acutally would defer the pelvic and that they understand it is being deferred due to patient comfort and honest judgement as opposed to a "it's a gyn problem, let them sort it out" mentality (which occurs at some community centers) -- then your approach is perfectly appropriate and probably the most humane.

I'm torn too. I hate calling a consult or asking for "help" unless I know specifically what I am asking them to do (e.g., this unstable angina needs to be admitted for rule out and stress testing). That said, I see your point as well and would like to minimize trauma for the patient.

Bulge said it well - "tough call"...

- H

 

[BKN]

So what's your take on the double pelvic exam? I almost always do my own pelvics on patients (in fact, I've done more pelvics in my last 2 months as an attending than I've probably done in my entire life) but there are some occasions when the patient is clearly going to need a GYN consult and GYN pelvic, and I've always taken the stance that a woman shouldn't have to endure 2 pelvics on the same visit if at all possible.

Perfect example tonight . . . I had a young woman tonight who had had an abortion earlier in the day who came in bleeding so profusely that she had blood all over her socks. In addition, she was in a pretty significant amount of pain. It was very obvious that GYN was going to have to examine this patient and that she was going to be admitted to their service. When I called the GYN resident, he asked what the pelvic had showed. I told him that I had not done a pelvic as I was anticipating their seeing the patient and felt the woman had been through enough without enduring 2 pelvic exams. Additionally, I told him that there wasn't anything that my pelvic exam was going to add to their evaluation and management of the patient. He disagreed saying that lots of women come in saying they are bleeding heavily when they aren't bleeding at all. This was clearly not the case here, although it is often true with the DUB'ers who I always examine and for whom I almost never consult GYN.

What would you guys have done?

To top off the whole situation, the GYN resident chewed out my PA for treating this woman's pain prior to their examining the patient. They're very lucky they didn't happen to say that to me.

With a patient who was bleeding less, an argument could be made for waiting, but I think that if she was bleeding all over her socks, someone needed to get in there and take a look right then.

Also, I think that most ladies who have a problem are not that sensitive on the issue of how many pelvics. They just want some help.

 

[DrQuinn]

What I tend to know, if I know that the patient is going to be seen by GYN, I'll do just a quick exam... one glove, cervix open/closed, adnexal tenderness, and blood on my glove. That's it. Much more comfortable, quick, and gives me more information that a full speculum exam.

Q

 

[bartleby]

I almost always do my own brief pelvic, but if OBGYN is clearly going to be involved at some point, but if I typically omit the speculum exam if possible (arguably more uncomfortable than a brief bimanual exam and much less helpful if you aren't going to get cultures).

 

[deleted87716]

If it was a lower GI bleeder, would you skip the DRE and just call a GI consult? Same thing. No matter how obvious the diagnosis appears, if you miss something important as a result of deviating from the standard of care, "trying to be nice to the patient" won't hold much water as a defense.

 

[Apollyon]

If it was a lower GI bleeder, would you skip the DRE and just call a GI consult? Same thing. If you miss something important, "trying to be nice to the patient" won't hold much water as a defense.

If it was a frank lower GI bleeder, would I omit the DRE? Yes. What is it going to tell me - there's blood there? With frank blood, the DRE is redundant and useless. Maybe the anoscope to look for hemorrhoids.

And your argument is flawed - If I miss something that Ob catches, it's not an issue. If I miss something that they miss, they're more on the hook because they're the "experts".

Corey Slovis, Keith Wrenn, and Clifton Meador, with 50 years of EM between them, wrote a book called "A Little Book of Emergency Medicine Rules", one of which is:

"Most women really should have only one pelvic exam during a visit to the ED. If a gynecologist is going to see the patient, let the gynecologist do it."

As people say, it's a tough call. I did have a woman come back on a Sunday late in my residency that had been seen the day before for vag bleeding and was dx as "inevitable ab". She was comfortable passing it at home, as she had had it happen before, but the bleeding was "too much" and she was cramping. I did do the pelvic on this lady, and pulled THE biggest clot I've EVER seen from her cervix, and the cramping resolved. However, she was still oozing. The kicker? Vague chest pain, and the story just wasn't right. VQ that I ordered was "very high prob" (2 apical mismatches). The CP was NOT there yesterday (and the attending on is a NUT for PE). That became an Ob attending problem - patient who needs a D&C with a PE. The decided to take her to the OR, and it became anesthesia's problem, and I do not have an update (although I presume she did well, because it didn't trickle down to us that she blew up in the OR).

I've gotten both from Ob residents - the "holistic" types agree, and the female misogynists in Ob/Gyn don't.

 

[mikecwru]

So what's your take on the double pelvic exam? I almost always do my own pelvics on patients (in fact, I've done more pelvics in my last 2 months as an attending than I've probably done in my entire life) but there are some occasions when the patient is clearly going to need a GYN consult and GYN pelvic, and I've always taken the stance that a woman shouldn't have to endure 2 pelvics on the same visit if at all possible.

Perfect example tonight . . . I had a young woman tonight who had had an abortion earlier in the day who came in bleeding so profusely that she had blood all over her socks. In addition, she was in a pretty significant amount of pain. It was very obvious that GYN was going to have to examine this patient and that she was going to be admitted to their service. When I called the GYN resident, he asked what the pelvic had showed. I told him that I had not done a pelvic as I was anticipating their seeing the patient and felt the woman had been through enough without enduring 2 pelvic exams. Additionally, I told him that there wasn't anything that my pelvic exam was going to add to their evaluation and management of the patient. He disagreed saying that lots of women come in saying they are bleeding heavily when they aren't bleeding at all. This was clearly not the case here, although it is often true with the DUB'ers who I always examine and for whom I almost never consult GYN.

What would you guys have done?

To top off the whole situation, the GYN resident chewed out my PA for treating this woman's pain prior to their examining the patient. They're very lucky they didn't happen to say that to me.

If a person is pouring blood onto the bed, they need resuscitation, not a pelvic exam. They can be examined by gyn. If it's mild to moderate bleeding, yes, you need to do an eval first. I only call gyn for patients who I think have the potential to bleed to death (very rarely).

Just the same, if a person is pouring rectal blood onto the bed, they DO NOT need a rectal exam. I don't care how well you think you can feel internal hemorrhoids and "significant things."

I've had residents ask me to get orthostatics on a hypotensive patient; this a cause for the RESIDENT to get chewed out, not the ais ttending. I tell them "I got those orthostatics for you,.... the guy went into PEA."

A person that suggests that you do not give pain medicine "before their eval" (unless you're sedating the person past the point of consent or consciousness) needs to be brought before their residency director. That idea is outdated, not supported by the literature, and is blatantly inhumane. They need to be have their testicles manually torsed, and pain medicine witheld "until the urologist can get in."

mike

 

[docB]

They need to be have their testicles manually torsed,...

Is that in Roberts and Hedges?

 

[Annette]

Why are guys so squemish about pelvic exams? If you are putting your hand in there, you may as well do the speculum exam. The speculum exam is not that uncomfortable. Someone has to look fairly quickly, and I don't think the patient is REALLY going to mind that much. Quite frankly, I'd like someone to stop the bleeding (EM or Gyn), if it were me.

 

[mikecwru]

Is that in Roberts and Hedges?

It's a section I'm writing for the next edition "Dealing with frustrating consultants."

mike

 

[SoCuteMD]

Why are guys so squemish about pelvic exams? If you are putting your hand in there, you may as well do the speculum exam. The speculum exam is not that uncomfortable. Someone has to look fairly quickly, and I don't think the patient is REALLY going to mind that much. Quite frankly, I'd like someone to stop the bleeding (EM or Gyn), if it were me.

NOT THAT UNCOMFORTABLE?

Please do not propogate that rumor, even if YOU believe it, I know of at least one woman (two, just asked my best friend) who strongly disagrees with you.

 

[Anuwolf]

Why are guys so squemish about pelvic exams? If you are putting your hand in there, you may as well do the speculum exam. The speculum exam is not that uncomfortable. Someone has to look fairly quickly, and I don't think the patient is REALLY going to mind that much. Quite frankly, I'd like someone to stop the bleeding (EM or Gyn), if it were me.

If I was going to get a pelvic exam... I prefer a hand going up there then having some tool (well it depends, haha!)

 

[deleted87716]

And your argument is flawed - If I miss something that Ob catches, it's not an issue. If I miss something that they miss, they're more on the hook because they're the "experts".

Mmm...good luck with that. In most cases, two wrongs aren't going to make a right.

 

[Apollyon]

Mmm...good luck with that.

1. Duty to act
2. Breach
3. Proximate cause
4. Damages

You don't get it, do you? More eyes are better than fewer, especially when I call them in a timely manner. If someone else who is more specialized catches it, it's a done deal. If the specialist misses it, and I miss it, either we're both way off (and, because it's their turf, they have more to lose, even though we're both wrong), or it's something more subtle, and they are held to a higher standard IF there are damages.

If I DON'T call the specialist, THEN it's "good luck with that".

 

[deleted87716]

If the specialist misses it, and I miss it, either we're both way off (and, because it's their turf, they have more to lose, even though we're both wrong), or it's something more subtle, and they are held to a higher standard IF there are damages.

That's an awful lot of "if's" to excuse not doing a pretty simple, straightforward exam. Besides, if "more eyes are better," shouldn't at least one pair of those eyes be yours?

 

[Apollyon]

That's an awful lot of "if's" to excuse not doing a pretty simple, straightforward exam. Besides, if "more eyes are better," shouldn't at least one pair of those eyes be yours?

I do my job, and I do it well. Part of EM is looking a step or two ahead. If the patient is in extremis, I'm in there (as the example above I provided). However, medicine is 30-50% psychological, and I'm big into the dignity thing - and, as some women here have affirmed what hundreds of women I've seen in the ED have let me know, the pelvic isn't the proudest moment.

You are looking too much at the trees and not enough at the forest if your only impression is shirking work. Believe me - with all the EM docs around here, every one - to a person - will tell you that a day without a pelvic is a victory.

 

[signomi]

I've gotten both from Ob residents - the "holistic" types agree, and the female misogynists in Ob/Gyn don't.

Best comment I read this week! (And I'm a woman.)

 

[WilcoWorld]

Pelvics, rectals, testicuar exams...they all gross me out less than a diabetic foot, and I don't shy away from doing any of them. The main gripes I have with a pelvic are:
1) Patients don't seem to like them very much.
2) They take a lot of time - I have to find a chaperone, get supplies, set up, wait for my chaperone, do the exam, and then clean up. That's 15 minutes I could've spent seeing & discharging an ankle pain.

I would never avoid an indicated pelvic for that reason, but I'm just trying to point out that there are a number of reasons that we dislike them.

 

[ERMudPhud]

I think you have to at least look. A few times per year I see someone who is convinced the blood is coming from one hole (anus, vagina, or urethra) when it is actually coming from another. I did have one colleague though who told a nurse to put a foley in a patient and while she was there tell him what hole the blood was coming from. Last month I saw an elderly muslim woman for hematuria. She had been diagnosed three times in the last 3 months with a UTI by her PCP for the same symptoms. She was also getting a metastatic workup for some lesions found elsewhere but no primary had been identified. I think people had been avoiding a cath UA and pelvic for reasons of cultural sensitivity. Cath UA was clean, pelvic showed cervical bleeding and uterine mass.

 

[ERMudPhud]

I understand the philosophy behind avoiding torturing the patient especially at a teaching center. After all by the time the EM1 does a pelvic, discusses it with the EM3 who repeats the exam who turfs it to the attending and then it has to work its way up the Gyn chain of command you could be running out of speculi. But if they are seriously bleeding and going to need a D&C or other procedure. One quick ED exam with whoever needs to be present, i.e the attending, followed by a quick Gyn call isn't going to hurt. Plus if you can honestly say you looked and the blood is pooring out faster than you can suction it away it goes a long way to getting Gyn moving.

 

[caroladybelle]

NOT THAT UNCOMFORTABLE?

Please do not propogate that rumor, even if YOU believe it, I know of at least one woman (two, just asked my best friend) who strongly disagrees with you.

NOT THAT UNCOMFORTABLE!!

Sorry, that is one of the biggest lies..... along with the check is in the mail.....that gets told.