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Agree largely.
If "my chest pain is gone" + significantly long duration + negative single HS TnI, then bye.
If "my chest pain is gone" + significantly long duration + negative single HS TnI, then bye.
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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
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.
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.
I think that applies in the setting of EKG changes or positive biomarkers.
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
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.
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.
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.
Because it’s better than writing: “still having chest pain but gonna discharge anyways because f it!”
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.
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.
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.
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.
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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 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.
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.
One of my partners admitted a pt with a low TSH due to tachycardia...his HR averaged 104-108 (sinus).
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.
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.
Five star answer, here.
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.
🤷♀️
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'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.
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.
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.
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."
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”.
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