pinipig523

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14yoF comes in w blurry vision to right eye since yesterday, wears soft contacts and one minute she was ok then the next minute she thought her right contact fell out because her vision had become so blurry so quickly. She went to the bathroom at school and checked only to note that her contact was still in place.

She sees me in the ER the next day w/ mom. No pain, no redness, counting fingers at right and 20/70 at left (both w/o correction), no afferent pupillary defect, neg SLE, normal tonopressures. Fundoscopic exam shows maybe a pale retina in right, but no bleed and sharp vessels.

I call our transfer center because we have no ophthalmologist at our ER, I speak to the pediatric ophthalmologist on the other line and I gave her the schpiel.... she thought I was the ophthalmologist because maybe I gave a pretty good "physical exam" over the phone (I had rotated in optho in 1 of my electives as a resident).... and she starts questioning why I didn't do stereo optic exams and if I thought this was a functional defect.. I was like... WTF???

And so I tell her I'm just the ER doc and that I had no idea what she was talking about.... she apologized and asked me to send the patient home because she thought it can't be a CRAO or CRVO or PVD given the story and my exam w/o APD... I tell her that I cannot do that because we need optho to clear her before I can do that... this is a 14yo girl for gosh sakes. She first resists the transfer.... "This is a functional defect, she'll be ok..." she says.

I say, we need to transfer for optho to clear, I cannot in good conscience send a patient home w/o specialist clearance and given such a valuable sensory organ affected, we cannot take this chance. So I transferred and she accepted.

But yeah.... I think I did the right thing. Right?

And what in the world is a functional visual defect??
 

bad virus

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14yoF comes in w blurry vision to right eye since yesterday, wears soft contacts and one minute she was ok then the next minute she thought her right contact fell out because her vision had become so blurry so quickly. She went to the bathroom at school and checked only to note that her contact was still in place.

She sees me in the ER the next day w/ mom. No pain, no redness, counting fingers at right and 20/70 at left (both w/o correction), no afferent pupillary defect, neg SLE, normal tonopressures. Fundoscopic exam shows maybe a pale retina in right, but no bleed and sharp vessels.

I call our transfer center because we have no ophthalmologist at our ER, I speak to the pediatric ophthalmologist on the other line and I gave her the schpiel.... she thought I was the ophthalmologist because maybe I gave a pretty good "physical exam" over the phone (I had rotated in optho in 1 of my electives as a resident).... and she starts questioning why I didn't do stereo optic exams and if I thought this was a functional defect.. I was like... WTF???

And so I tell her I'm just the ER doc and that I had no idea what she was talking about.... she apologized and asked me to send the patient home because she thought it can't be a CRAO or CRVO or PVD given the story and my exam w/o APD... I tell her that I cannot do that because we need optho to clear her before I can do that... this is a 14yo girl for gosh sakes. She first resists the transfer.... "This is a functional defect, she'll be ok..." she says.

I say, we need to transfer for optho to clear, I cannot in good conscience send a patient home w/o specialist clearance and given such a valuable sensory organ affected, we cannot take this chance. So I transferred and she accepted.

But yeah.... I think I did the right thing. Right?

And what in the world is a functional visual defect??
Whenever I ask my self if I did the right thing, I always go to the "What if this was my kid sister" line of thought. When it comes to that line of thinking, I more than 200% believe you did the right thing. No way would I have let a family member walk out of the system before she was professionally cleared.

Nice job for sticking to your guns, I am certain the family appreciated it.
 

WilcoWorld

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I think you did the right thing. What's to be gained by calling it functional when you're concerned you saw a pale retina?

I find it very inconsistent when a consultant is willing to rule out serious pathology based on what you tell them, but will also blow off a very concerning finding (retinal pallor), because they don't trust your exam.

If you don't trust my exam, you shouldn't be willing to call something benign without seeing the patient. If you do trust my exam, then trust what I'm saying and see the darn patient!

I too would like to hear the follow up on this one.
 

Birdstrike

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You will see a lot of psychopathology that mimics real pathology over the years. But you will also see rare and unusual things that don't seem to add up, initially. It's an easy pitfall to dismiss odd presentations as "must be psych" and make an error. It's better to err on the side of caution.
 

BJJVP

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The thing that baffles me about these situations is I don't see a whole lot of benefit in not having this 14 yo pt transferred. Why did the ophthalmologist even fight you on this one? What harm could come from having a specialist evaluate a young pt with vision loss emergently? It's not as if we transfer or consult everyday for vision loss. In 8 yrs, I can count on one hand the number of times I have asked an ophthalmologist to see someone.

I understand it a lot more when the medicine resident fights the chest pain admits. Chest pain is common and most cases turn out to be nothing. I don't agree with the admitting teams' position, but at least I understand it. But a pediatric ophthalmologist refusing to see a 14 yo who suddenly couldn't see in one eye? I always wonder what these guys wrote in their personal statements for their med school/residency applications. This could very well end up being a functional disorder, but so what? Trying to make that case over the phone while trying to refuse the pt is just unreasonable.

The most frustrating part to me is that if the pt ends up having significant pathology, the pt and her parents will probably never know how much you advocated for them. The fact that you wrote about this on this forum shows it was a relatively stressful and/or frustrating experience for you. In addition, they will never know how irresponsible the ophthalmologist was.

Btw, I spoke with my wife, who's an optometrist, who says there is no way, with the exam you described, that anyone could confidently identify a functional problem over the phone.
 

dotcb

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Vison loss with now only able to count fingers? Yeah - that needs an eye doctor.

Also depends on the effort needed to transfer. It sounds like you weren't exactly flying this teenager off an island or something, in which case the answer's easy - transfer for consult.

It does, however, sound like the kid's outside the window for any time-critical intervention.
 

southerndoc

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Why not discharge her to see her immediately in the opthalmologist's office? I do that all the time. They have better equipment, staff, meds, etc. in their office for eye related stuff. We have a great relationship with our ophthalmologists.

I won't do this for a globe rupture, but for nearly everything else, I frequently do this if they need to see an ophthalmologist urgently. They've even been known to go to their office afterhours to meet patients there.

At any rate, if you think a patient needs to see a specialist emergently and you don't have one, whichever facility you call that has an ophthalmologist on-call is required by EMTALA to accept the patient as a transfer.