4:57pm page to the ER for a soft admit?

[45408]

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There are no ACGME rules that state you cannot stay and work-up a patient at the end of your "shift". If it is hour 30 of your call that's a different story, but night float isn't working 30 hours.

If turquoise was staying "hours and hours" past the end of night float, it could violate the 10 hour rule between shifts.

 

[45408]

Can't until you cite your stat.

Negative appendectomy rate in the era of CT: an 18-year perspective.
Raja AS, Wright C, Sodickson AD, Zane RD, Schiff GD, Hanson R, Baeyens PF, Khorasani R.

Center for Evidence Based Imaging, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA. [email protected]

Abstract
PURPOSE: To estimate the correlation between the negative appendectomy rate (NAR) and the rate of preoperative computed tomography (CT) in patients suspected of having acute appendicitis who presented to the emergency department during an 18-year period.

MATERIALS AND METHODS: This retrospective institutional review board-approved, HIPAA-compliant study was performed in a 719-bed tertiary care adult teaching hospital with 58,000 annual emergency department visits. The authors obtained a waiver of informed consent and used the medical records system to compare patients suspected of having appendicitis who presented to the emergency department between 2003 and 2007 to those who presented between 1990 and 1994, the period just before CT became commonly used at the authors' institution for the evaluation of appendicitis. Surgical and pathology reports were reviewed to determine the NAR, and the authors queried the radiology databases to determine the proportion of appendectomy patients who underwent preoperative imaging. Outcome measures included the NAR, the proportion of appendectomy patients who underwent preoperative CT, and the annual number of appendectomies performed. The chi(2) test for trend was used to assess for changes in proportions, and linear regression was used to evaluate numeric trends.

RESULTS: From 1990 to 2007, the NAR decreased significantly from 23.0% to 1.7% (P < .0001), the annual number of appendectomies decreased significantly from 217 per year to 119 per year (P = .0003), and the proportion of patients undergoing appendectomy who underwent preoperative CT increased significantly from 1% to 97.5% (P < .0001).

CONCLUSION: There was a significant reduction in both the NAR and the number of appendectomies in patients who presented to the emergency department during an 18-year period, which was associated with a significant increase in the use of preoperative abdominal CT.

 

[Apollyon]

Negative appendectomy rate in the era of CT: an 18-year perspective.
Raja AS, Wright C, Sodickson AD, Zane RD, Schiff GD, Hanson R, Baeyens PF, Khorasani R.

What's funny is that the lead author in that study is an EM doc. (I knew him as a med student, but actually first saw him on the NYC subway in an ad for Kaplan - seriously!)

I don't know if the rest of them are EM, also, or not - actually, looks like 2 EM, one IM, and the balance radiologists.

 

[Rendar5]

nice study. I was aware of the ~20% negative rate prior to CT, didn't realize that CT had dropped it so low, though.

Anyway glade, if youc an't find that study, just look up in various sources the +LR's and -LR's of leukocytosis . All tend to fall under 10 for the +LR's and above 0.1 for -LR's, traditional cut-offs for indicating clinical significance. Most studies have more traditional cut-ofs for where leukocytosis begins. Main issue is likely that in the ED the overall pt population has a higher than normal WBC anyway, whether it's from disease or a more normal stress response.

 

[45408]

nice study. I was aware of the ~20% negative rate prior to CT, didn't realize that CT had dropped it so low, though.

I guess my question is now how many cases of appendicitis are missed/delayed until they show radiographic findings. I'm surprised it's as low as 1.7%, and I wonder if that's been reproduced elsewhere.

 

[Winged Scapula]

If turquoise was staying "hours and hours" past the end of night float, it could violate the 10 hour rule between shifts.

Perhaps. However, there is not a "rule" about the 10 hours between shifts (at least not at the time Turquoise was a resident). It is a suggestion.

The wording from ACGME:

"Adequate time for rest and personal activities must be provided. This should consist of a 10-hour time period provided between all daily duty periods and after in-house call. "

 

[ERDude]

...

 

[Law2Doc]

...
Lastly, I will say flat out that Glade's not so subtle contention that ER docs have no clinical/diagnostic skill is 100% not true. ...

Although I wouldn't put words in his mouth, I think he really was just going off on the ED resident who absurdly basically suggested it was "not his job" to diagnose patients, just to stabilize them.

 

[45408]

-Had an APPY go to the OR WITHOUT CT...yes, it was awesome. Young guy, classic sx, tender as hell in RLQ but otherwise well appearing. Popped the bedside US on myself, found a non compressible tubular structure that I fig'd was an inflamed appendix.

LOL, you still used imaging though is it really that rare? out of the dozen or so appendectomies I've seen/done so far at this program, at least two of them were done based strictly on history. They were both young males though, and I don't think I'd do one on a woman just based on history.

 

[tkim]

Negative appendectomy rate in the era of CT: an 18-year perspective.
Raja AS, Wright C, Sodickson AD, Zane RD, Schiff GD, Hanson R, Baeyens PF, Khorasani R.

Center for Evidence Based Imaging, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA. [email protected]

Abstract
PURPOSE: To estimate the correlation between the negative appendectomy rate (NAR) and the rate of preoperative computed tomography (CT) in patients suspected of having acute appendicitis who presented to the emergency department during an 18-year period.

MATERIALS AND METHODS: This retrospective institutional review board-approved, HIPAA-compliant study was performed in a 719-bed tertiary care adult teaching hospital with 58,000 annual emergency department visits. The authors obtained a waiver of informed consent and used the medical records system to compare patients suspected of having appendicitis who presented to the emergency department between 2003 and 2007 to those who presented between 1990 and 1994, the period just before CT became commonly used at the authors' institution for the evaluation of appendicitis. Surgical and pathology reports were reviewed to determine the NAR, and the authors queried the radiology databases to determine the proportion of appendectomy patients who underwent preoperative imaging. Outcome measures included the NAR, the proportion of appendectomy patients who underwent preoperative CT, and the annual number of appendectomies performed. The chi(2) test for trend was used to assess for changes in proportions, and linear regression was used to evaluate numeric trends.

RESULTS: From 1990 to 2007, the NAR decreased significantly from 23.0% to 1.7% (P < .0001), the annual number of appendectomies decreased significantly from 217 per year to 119 per year (P = .0003), and the proportion of patients undergoing appendectomy who underwent preoperative CT increased significantly from 1% to 97.5% (P < .0001).

CONCLUSION: There was a significant reduction in both the NAR and the number of appendectomies in patients who presented to the emergency department during an 18-year period, which was associated with a significant increase in the use of preoperative abdominal CT.

Thanks.

The 31% positive appendicitis rate quote in the previous study does not take into account the 60 patients admitted directly to the surgery service without CT scan. Unsure of whether that meant all or some of the 60 patients clearly had appendicitis and were taken to the OR with CT, or some were admitted for observation and serial abd exams. If all had obvious appendicitis signs by history and physical to allow bypassing CT, then the rate of positive dx of appendicitis is closer to 50%. But that doesn't matter.

Comparing the 77% positive appendicitis dx by surgeons, versus a 31% - 50% dx by CT scan is a difficult comparison to make. The ED doc should have a lower threshold to scan than a surgeon to cut to diagnose appendicitis because of the invasiveness of surgery.

The reason why the NAS rate was - almost had to be, a number greater than zero was that the lower the NAS rate, the greater the chance of missing a true appy. I recall my surgery attending say that if your dx rate was 100%, it meant you were underdiagnosing and letting cases slip by.

 

[Winged Scapula]

I recall my surgery attending say that if your dx rate was 100%, it meant you were underdiagnosing and letting cases slip by.

That is true. A negative appy rate is accepted because of the risk of missing one can be greater than a straightforward appy. The accepted negative appy rate is higher in women of childbearing age.

 

[glade]

When I have an admission that is soft or is for reasons other than medical necessity (eg. the dreaded social admit) I am upfront with the admitting service ("hey Dr. so-and-so, I have a patient that I need to bring in, it's kind of a softy, but I really don't feel comfortable sending this person home, here's why....").

Admitted for social reasons, or because "you don't feel comfortable sending this person home"? Because those are two different reasons altogether. If someone told me flat out "hey, we need to keep this patient for social reasons and here's why" I'd probably be OK with that because everyone has to deal with those. But if you tell me "even though you've evaluated the patient as I requested, I'm going to ignore your evaluation because I don't feel comfortable sending the person home," that's pitiful. And usually it consists of a "great" explanation like "well, the person just doesn't look great to me." Wow! OK! And then we always admit the patient and discharge them like three hours later, as soon as they are moved out of the ER.

Lastly, I will say flat out that Glade's not so subtle contention that ER docs have no clinical/diagnostic skill is 100% not true. I take great pride in my diagnostic/therapeutic/procedural skills and that is what I see in the vast majority of my colleagues

I don't have any baseline opinion of anyone's diagnostic skills. The only way I know what your diagnostic skills are is based on your diagnosing things. Fair enough? And what I've seen are people who either don't give any crap and just consult on a trigger ("No vitals, no labs, no orders? Whee!") or will order the same tests on everyone and also don't examine the patient ("The registrar told me the complaint was abdominal pain, I'll order a CT scan and consult Surgery and they'll think I'm a genius for having the CT scan ordered and the patient drinking contrast already."). That's it. I have no stories of awesome diagnoses to tell, to be honest. We've gotten some ER attendings picking up appendicitis, but again it was because they just routinely scanned the abdomen and the Radiologist read it as "likely early appendicitis, correlate clinically" and they told us it was appendicitis and we came down to do the clinical correlation.

But regardless, as Law2Doc said, what blows my mind is that anyone would say that "our job isn't diagnosis." And not only did one person say that, but a lot of ER guys agree. Because I see that argument forwarded A LOT by EM physicians. So it's not like that's some rouge out-of-control guy who doesn't speak for everyone else. I'm pretty sure that's a normal opinion of people who are in EM. And that mentality is the problem that leads to all of this random ordering and lack of systematic thought down there. My opinion.

 

[Rendar5]

But regardless, as Law2Doc said, what blows my mind is that anyone would say that "our job isn't diagnosis." And not only did one person say that, but a lot of ER guys agree. Because I see that argument forwarded A LOT by EM physicians. So it's not like that's some rouge out-of-control guy who doesn't speak for everyone else. I'm pretty sure that's a normal opinion of people who are in EM. And that mentality is the problem that leads to all of this random ordering and lack of systematic thought down there. My opinion.

To be fair, the intent of his thoughts isn't that our job isn't diagnosis, but rather that the diagnosis isn't the primary end-point of our job. The primary end-points are 1. stabilization and 2. Disposition. In the course of doing our job we should have obtained 1. a diagnosis we're ruling out or 2. a suggested diagnosis (sometime we do need to confirm the possible dx, sometimes we don't. A favorite concept of mine is that we indict, we don't convict. Law2doc can tell me if that's a poor metaphor that).

This is fundamentally different than inpatient medicine in that a large degree of uncertainty is accepted, and that we get to write "possible X" or "the chief complaint" as a diagnosis.

Pt comes in with a 10/10 headache. I need to treat the pain and figure out 1. do they need a CT, 2. do they need an LP, and 3. do they have to be admitted or followed up with a neurologist or followed up with a PMD. Now if it's a SAH, I need to dx it, if it's a cavernous sinus thrombosis or a tumor or a vertebral artery dissection, I need to dx it. If it's meningitis, I have to dx it, or at least strongly suggest it. but if my tests are negative, I don't need to know whether it's a migraine, tension, or cluster headache. I don't need to diagnose pseudotumor cerebrii. If it's a post-LP headache, figuring out how to treat the pain may suggest a dx, but if pt refuses a blood patch and it responds to caffeine, maybe it was maybe it wasn't. In short, sometimes I have to dx as part of our job of stabilization and disposition, sometimes I don't.

YOu don't have to agree with this and you're free to believe that our job should have the same primary end-goals as everyone else in medicine. But there is a thought process and reasoning behind what we do (by and large)

And Glade, I agree with what you suggest is a proper social admit and an improper one. I've seen some attendings do both. And I personally have done proper ones that the other person simply disagrees with, where I simply won't understand the resistance to it and have to piss people off with. Even if we agree on definitions, it's interesting how two people can see the same case differently and still disagree.

 

[NateintheED]

To be fair, the intent of his thoughts isn't that our job isn't diagnosis, but rather that the diagnosis isn't the primary end-point of our job. The primary end-points are 1. stabilization and 2. Disposition. In the course of doing our job we should have obtained 1. a diagnosis we're ruling out or 2. a suggested diagnosis (sometime we do need to confirm the possible dx, sometimes we don't. A favorite concept of mine is that we indict, we don't convict. Law2doc can tell me if that's a poor metaphor that).

This is fundamentally different than inpatient medicine in that a large degree of uncertainty is accepted, and that we get to write "possible X" or "the chief complaint" as a diagnosis.

Pt comes in with a 10/10 headache. I need to treat the pain and figure out 1. do they need a CT, 2. do they need an LP, and 3. do they have to be admitted or followed up with a neurologist or followed up with a PMD. Now if it's a SAH, I need to dx it, if it's a cavernous sinus thrombosis or a tumor or a vertebral artery dissection, I need to dx it. If it's meningitis, I have to dx it, or at least strongly suggest it. but if my tests are negative, I don't need to know whether it's a migraine, tension, or cluster headache. I don't need to diagnose pseudotumor cerebrii. If it's a post-LP headache, figuring out how to treat the pain may suggest a dx, but if pt refuses a blood patch and it responds to caffeine, maybe it was maybe it wasn't. In short, sometimes I have to dx as part of our job of stabilization and disposition, sometimes I don't.

Rendar,

THANK YOU!

You got at exactly what I was trying to say much better than I was able to.

 

[glade]

Pt comes in with a 10/10 headache. I need to treat the pain and figure out 1. do they need a CT, 2. do they need an LP, and 3. do they have to be admitted or followed up with a neurologist or followed up with a PMD. Now if it's a SAH, I need to dx it, if it's a cavernous sinus thrombosis or a tumor or a vertebral artery dissection, I need to dx it. If it's meningitis, I have to dx it, or at least strongly suggest it. but if my tests are negative, I don't need to know whether it's a migraine, tension, or cluster headache. I don't need to diagnose pseudotumor cerebrii. If it's a post-LP headache, figuring out how to treat the pain may suggest a dx, but if pt refuses a blood patch and it responds to caffeine, maybe it was maybe it wasn't. In short, sometimes I have to dx as part of our job of stabilization and disposition, sometimes I don't.

See, the problem is your entire post is half and half. I don't think anyone is like "well, you ruled everything out but you didn't specifically determine that this was a tension headache, so I'm still irritated." We're talking about "you say you have a headache? Well, I'll get a CT scan and consult Neurology." And then maybe you find a SAH, but that was based on chance, not because there was any actual clinical thought behind it. Or worse, you find something like chronic subdurals which have nothing to do with anything and THAT triggers a consult. It's never the case that someone did a systematic and thought-out evaluation of the patient and ordered tests based on that evaluation. Like I said, for me it's like "you say you have right lower quadrant pain? I bet it's appendicitis." Fine, odds are that they're right. Not GREAT odds, it's like a 55% chance for all comers, let's say. But if it's right, they go "wow, I did great." Based on what? You said it was appendicitis for no other reason than "right lower quadrant pain" and didn't talk to or lay hands on the patient. If they're wrong, same thing. I'm not even talking about the "right" or "wrong" batting average. I'm saying it's the fact that there's no thought process behind it regardless.

Another example: every person who hits their head gets a head CT. Now, if you do that, you'll have massive numbers of negative CT scans. Ask Radiology: does that happen? Yes. Does that mean ANY negative CT scan was wrong to order? No. But does that mean that a lot of the ones ordered were due to pure laziness or lack of clinical thought? Yes. Or what if the CT does happen to pick up something? Does that justify it? Not really. That's like playing the lottery. Just because you won, what does that mean? It's intent, not outcome. I can live with missed diagnoses, but not when they're mindlessly missed. I can live with over-ordered tests, but not when they're knee-jerk ordered. I can live with consults, but not when there was no workup.

 

[MJB]

ADMIT? or DISCHARGE?


I too have noticed the penchant for shift change admissions. Annoying.


What would be fair to say regarding the % of patients that come to the ED that actually NEED to be there....or...are "unstable".

10? 15 tops?

 

[Rendar5]

See, the problem is your entire post is half and half. I don't think anyone is like "well, you ruled everything out but you didn't specifically determine that this was a tension headache, so I'm still irritated." We're talking about "you say you have a headache? Well, I'll get a CT scan and consult Neurology." And then maybe you find a SAH, but that was based on chance, not because there was any actual clinical thought behind it. Or worse, you find something like chronic subdurals which have nothing to do with anything and THAT triggers a consult. It's never the case that someone did a systematic and thought-out evaluation of the patient and ordered tests based on that evaluation. Like I said, for me it's like "you say you have right lower quadrant pain? I bet it's appendicitis." Fine, odds are that they're right. Not GREAT odds, it's like a 55% chance for all comers, let's say. But if it's right, they go "wow, I did great." Based on what? You said it was appendicitis for no other reason than "right lower quadrant pain" and didn't talk to or lay hands on the patient. If they're wrong, same thing. I'm not even talking about the "right" or "wrong" batting average. I'm saying it's the fact that there's no thought process behind it regardless.

Another example: every person who hits their head gets a head CT. Now, if you do that, you'll have massive numbers of negative CT scans. Ask Radiology: does that happen? Yes. Does that mean ANY negative CT scan was wrong to order? No. But does that mean that a lot of the ones ordered were due to pure laziness or lack of clinical thought? Yes. Or what if the CT does happen to pick up something? Does that justify it? Not really. That's like playing the lottery. Just because you won, what does that mean? It's intent, not outcome. I can live with missed diagnoses, but not when they're mindlessly missed. I can live with over-ordered tests, but not when they're knee-jerk ordered. I can live with consults, but not when there was no workup.

That's nice and all but if you look at EM clinical guidelines there is actual reasoning behind when to get and when not to get a head CT in trauma and in the setting of headache in our field. Most headaches I don't get CT's on and most traumas I also don't get CT's on. I try to stick roughly to ACEP Guidelines on both issues, which are generally a mix of level A and B evidence with a bit of level C evidence for stuff like coumadinized patients. For headaches, CT's are done at maybe 15% rate and are positive a little over 5% of the time according to the guidelines.

Unfortunately, I don't think you actually have the opportunity to see how it works in your own ED cause of selection bias. You could be correct, or you could be incorrect. But in general you're not going to get to see any of the headaches or head traumas that are not scanned unless you actually work in the ED.

Now there are places that do knee jerk head CT's on some issues and I had the delight of getting reamed out by a visiting ED resident for not ordering a head CT on a syncope pt...(still dont' quite understand why they were insistent on it's necessity, there was a clear cause and it's not like neurologic syncope is something you can see easly) But again, you're not gong to be in a position to judge overall whether they do that or not unless you're seeing all comers.

MJB: 15-25% admission rates are the norm for EDs, it varies depending on location and the patient population. If it's any higher you're outside the norm and either the population is exceedingly sick, the healthy population avoids the ED, or you're in an ED that overadmits.

 

[NateintheED]

See, the problem is your entire post is half and half. I don't think anyone is like "well, you ruled everything out but you didn't specifically determine that this was a tension headache, so I'm still irritated." We're talking about "you say you have a headache? Well, I'll get a CT scan and consult Neurology." And then maybe you find a SAH, but that was based on chance, not because there was any actual clinical thought behind it. Or worse, you find something like chronic subdurals which have nothing to do with anything and THAT triggers a consult. It's never the case that someone did a systematic and thought-out evaluation of the patient and ordered tests based on that evaluation. Like I said, for me it's like "you say you have right lower quadrant pain? I bet it's appendicitis." Fine, odds are that they're right. Not GREAT odds, it's like a 55% chance for all comers, let's say. But if it's right, they go "wow, I did great." Based on what? You said it was appendicitis for no other reason than "right lower quadrant pain" and didn't talk to or lay hands on the patient. If they're wrong, same thing. I'm not even talking about the "right" or "wrong" batting average. I'm saying it's the fact that there's no thought process behind it regardless.

Another example: every person who hits their head gets a head CT. Now, if you do that, you'll have massive numbers of negative CT scans. Ask Radiology: does that happen? Yes. Does that mean ANY negative CT scan was wrong to order? No. But does that mean that a lot of the ones ordered were due to pure laziness or lack of clinical thought? Yes. Or what if the CT does happen to pick up something? Does that justify it? Not really. That's like playing the lottery. Just because you won, what does that mean? It's intent, not outcome. I can live with missed diagnoses, but not when they're mindlessly missed. I can live with over-ordered tests, but not when they're knee-jerk ordered. I can live with consults, but not when there was no workup.

This is a VERY presumptuous (and to me, offensive) post. How in the world do you know how we as individual physicians practice? If, as you contend, the EM physicians you deal with never lay a hand on the patient prior to consulting you, then they are clearly wrong. BUT they also are very clearly in the minority. Labs are another story. There is a role for ordering certain labs straight from triage. Certain complaints WILL require certain labs.

This also shows your complete ignorance of how EM is practiced. Not every headache gets a CT scan, let alone a Neuro consult. Yes, if the headache has features suggestive of an SAH (or tumor or something else bad), they get a scan. But if they don't, or have had a scan in the past, no scan. Neuro only gets called if I can't break the headache (which is rare). Otherwise, its outpatient f/u. And if the scan DOES find something incidental, then we are obligated to obtain appropriate follow-up. Are you suggesting that newly discovered chronic SDH does NOT deserve a neurosurg consult?

Same thing with RLQ pain. If it has features suggestive of appy, I'm getting the CT. And if CT+, then yes, I'm glad I found it. And honestly, yes, if a patient is tender in their RLQ, they probably will get the CT. Can show me evidence for any clinical criteria with enough negative predictive value to eliminate the need for CT? It ain't the WBC, that's for sure! Either way - no surgical problem, no surgery consult.

Finally, not every person who hits their head gets a head CT. This carries caveats - old people and people on coumadin all get scanned. Obviously people involved in multi-trauma get scanned. But your average young person with no LOC, low mechanism, and normal mental status may not. +/- on the drunk ones. And I very rarely scan the average little kid brought in by parents after a ground-level fall while running around, with no LOC, no vomiting and normal mental status.

Bottom line: Your ED's practice for you is an n of 1 in the study of ED practices. This is not generalizable to the broader population.

 

[Rendar5]

To be fair, I do advocate for shotgunning for appies in the setting of isolated RLQ tenderness without a clear and significant explanation for it. That does depend on my examining the patient first, but it sounds like your issue is more on CTing for RLQ pain as opposed to doing it for tenderness. If you know of some approach to avoid that, I'm all ears, but I've heard of and seen a significant number of cases where isolated tenderness is the only sign or symptom of it.

Unfortunately, u/s rarely if ever finds the +appy's at my hospital. Our techs just aren't trained/experienced enough for it.

 

[NateintheED]

ADMIT? or DISCHARGE?


I too have noticed the penchant for shift change admissions. Annoying.


What would be fair to say regarding the % of patients that come to the ED that actually NEED to be there....or...are "unstable".

10? 15 tops?

Actually needing to be in the ED and being truly "unstable" are 2 very different sets of criteria. How many truly hemodynamically unstable appys has anyone seen? Kidney stones? Isolated fractures? All of these do need to be in the ED, whether it be for eventual surgery, pain control, or reduction/splintng. Recent evidence suggests the truly non-urgent are actually the minority of our patients, and most reasonably busy places have a "fast track" open at least part of the day for these patients.

 

[Rendar5]

MJB: to answer your broader question more exactly, I only gave you admission rates. As far as people who actually need to be there I'd estimate 50-80% (that's a made up number by me as opposed to the last one I gave you). These are lay people and all they know is their chief complaint. They don't know what factors make a disease dangerous or not dangerous and come for bothe treatment and disposition that they honestly don't know if they can get here or at their PMD.

Just a few examples of cases that belong in the ED that really aren't that unstable or dangerous:
1. Basic injuries do belong there though they rarely get admitted. I'd contend that closing lacs reduces infection rate and are more effectively and properly done in the ED than in a primary doctor's office.
2. Basic gastroenteritis and food poisoning with moderate dehydration are another example. They are often good enough to go home after one anti-emetic and some IVF.
3. 1st time syncope is very scary for patints and I'd be concerned if they didn't think it was necessary to see a doctor, but from the medical perspective, the majority of these in young patients can go home (unfortunately none of the clinical prediction rules are effective enough for global usage).
4. 1st trimest bleeds? Many women have not had their first ob visit yet, cannot come in to the office for several days, and can't see their os nor do they know their Rh status or if they need a rhogam shot. I would not expect a lay person to realize that minimal bleeding is not associated with an increase risk of miscarriage.
5. Acute pain (not chronic): I see plenty of cases where pt's are dumb and did not even try tylenol. But there are plenty more cases where someone needs assistance breaking a migraine. And trust me, there's nothing like an IV dose of compazine to stop a status migraine in it's tracks (I mean that literally, I've never seen any other migraine drug with a near 100% cure rate), or a kidney stone patient comes in and is fine as long as he can get narcotics on top of his NSAIDS.

All those types of cases nicely elevate the clinically meaningful level of ED visits. Course as a med student I thought most ED cases were BS (which didn't phase me as I had other reasons to enter the field).

 

[MJB]

MJB: to answer your broader question more exactly, I only gave you admission rates. As far as people who actually need to be there I'd estimate 50-80% (that's a made up number by me as opposed to the last one I gave you). These are lay people and all they know is their chief complaint. They don't know what factors make a disease dangerous or not dangerous and come for bothe treatment and disposition that they honestly don't know if they can get here or at their PMD.

Just a few examples of cases that belong in the ED that really aren't that unstable or dangerous:
1. Basic injuries do belong there though they rarely get admitted. I'd contend that closing lacs reduces infection rate and are more effectively and properly done in the ED than in a primary doctor's office.
2. Basic gastroenteritis and food poisoning with moderate dehydration are another example. They are often good enough to go home after one anti-emetic and some IVF.
3. 1st time syncope is very scary for patints and I'd be concerned if they didn't think it was necessary to see a doctor, but from the medical perspective, the majority of these in young patients can go home (unfortunately none of the clinical prediction rules are effective enough for global usage).
4. 1st trimest bleeds? Many women have not had their first ob visit yet, cannot come in to the office for several days, and can't see their os nor do they know their Rh status or if they need a rhogam shot. I would not expect a lay person to realize that minimal bleeding is not associated with an increase risk of miscarriage.
5. Acute pain (not chronic): I see plenty of cases where pt's are dumb and did not even try tylenol. But there are plenty more cases where someone needs assistance breaking a migraine. And trust me, there's nothing like an IV dose of compazine to stop a status migraine in it's tracks (I mean that literally, I've never seen any other migraine drug with a near 100% cure rate), or a kidney stone patient comes in and is fine as long as he can get narcotics on top of his NSAIDS.

All those types of cases nicely elevate the clinically meaningful level of ED visits. Course as a med student I thought most ED cases were BS (which didn't phase me as I had other reasons to enter the field).

Thank you. That's a very reasonable response and is appreciated. Unfortunately, I've seen a few too many "I think I'm pregnant" patients...or my personal favorite...the DNR with "weakness" that is non-communicative.

Other examples....the guy that was in last night with "chronic pancreatitis" who presents with "classic chest pain" and still gets the entire workup, "syncope" lady that is on HCTZ, Lasix, and hasn't sipped any water in like 2 days while at the nursing home...(syncope=patient telling nurse she is "lightheaded)

The ED obviously serves a great purpose when properly utilized, but I'd be lying if I said I haven't noticed the "shift change shuffle"...

 

[Droopy Snoopy]

The ED obviously serves a great purpose when properly utilized, but I'd be lying if I said I haven't noticed the "shift change shuffle"...

The corollary to this is the post-shift change shuffle, when the turnover patient gets admitted based on the opinions of the outgoing doc who is now home sleeping. You the resident are not convincing the new attending that his colleague is mistaken, especially since he just wants to clean house anyway.

 

[Rendar5]

The corollary to this is the post-shift change shuffle, when the turnover patient gets admitted based on the opinions of the outgoing doc who is now home sleeping. You the resident are not convincing the new attending that his colleague is mistaken, especially since he just wants to clean house anyway.

🙄God I hate when this happens.

MJB: we do get those pt's and they do suck, though I'm not quite I understand what you're sayign with a the chronic pancreatitis pt with chest pain? he got a full work-up for pancreatitis when he presented with chest pain or vice versa? Unfortunately both are high mortality/morbidity diseases, so depending on the H&P, it might not be unreasonable to r/o both in some way if there's significant features of both.

Nursing homes are notorious places for sending ED's both jokes of pt's and people who they waited too long to send (the other day had a pt who fell 3 times with no complaints before they decided to send him to us at the family's request. he had a very nice C1 fx that was impinging on the vertebral artery) . Depends on the NH and the doc in charge there and what nurses come on. I'm not sure what shoudl'v ehappened with ur presyncope pt. Needed to be seen by a doc regardless, whether it was ED or NH doc

 

[glade]

How in the world do you know how we as individual physicians practice?

This is a typical EM response. Like I said, if you read SDN, you'd imagine that every EM physician is on top of their game. Then you get confused because it's funny how, apparently coincidentally, every EM physician YOU know is the opposite of this. Then you read all these other people who have the same complaints about the ER as you do. Wow. Sounds like THEY also, apparently coincidentally, know EM physicians who are the opposite of that. But we're to believe that, other than the ones we know, every other EM physician is on top of their game. OK, sounds plausible.

I mean, I'd be a little more willing to believe it if you guys didn't go to the extreme and be like "if we ever call a consult and don't know everything about the patient and have them completely worked up, we EXPECT to be yelled at ...no, no, we DEMAND it! Because we have such high standards in the ER!" Like, all I hear so far from the EM guys on here are how they're so great that by the time the consultant gets the patient, there's literally nothing left for them to do except stand in the middle of the ER and stammer out "could ...could you teach ME how to do [fill in their own specialty]??"

 

[Doctor Bob]

These threads are sometimes interesting... but the tune is always the same.

ED: We're super awesome at what we do. Non ED specialties don't appreciate what we do. They don't want to take our admissions. And so on.

Non-ED: We're super awesome at what we do. ED docs don't appreciate what we do. They dump on us at shift change. And so on.

And we reach an impasse. We seem to reach an impasse because the philosophy and mindset of the ED versus literally every other field of medicine is different.

The ED is a field of sensitivity
Everyone else is a field of specificity

As such, we approach things differently in the department and it causes issues when we interface with other specialties. Plus, any time we call another specialty we're creating work for them. And worse than that, we're creating unscheduled work. While the idea of unscheduled work is the norm in the ED, it's not the norm everywhere else in the hospital/office. So that too creates friction and resentment a lot of the time when we call.

So how does EM being a field of sensitivity come into play? Our focus is not to figure out what the person has; rather we're there to screen out all the bad things they might have and show that they don't have them. And every ED doc has a different level of clinical expertise and a different point at which they feel comfortable saying the immediate threats to life have been ruled out. So at sign out, the standards of the oncoming ED doc are being applied to a bolus of potential admits and if the incoming guy has a lower admit threshhold than the outgoing guy, you get a load of admits all at once. When it goes the other way you never hear about it so it's a non issue to the inpatient side.

We're not malicious about admissions. For every admit we send your way we've deflected 10-20 patients from you that otherwise you might have to address. And we're not ill intentioned about dumping an admit on you at your shift change. It's just that we don't get to schedule our patient flow so if we hold on to people longer than necessary we get backed up. Even when the waiting room is empty. Because we know that the bus is just around the corner ready to dump another load of patients on us too. And dammed if that bus doesn't come right before our shift change also.

Love,
-The ED

 

[danielmd06]

We seem to reach an impasse because the philosophy and mindset of the ED versus literally every other field of medicine is different.

Agreed, but it's debatable whether or not this is as it should be.

Plus, any time we call another specialty we're creating work for them. And worse than that, we're creating unscheduled work. While the idea of unscheduled work is the norm in the ED, it's not the norm everywhere else in the hospital/office. So that too creates friction and resentment a lot of the time when we call.

Sort of...but you've really oversimplified it. What you leave out is the elephant in the room...namely, the less work YOU do...the more work WE do. And vice versa. So there is an obvious vested interest on the part of both parties here. Sound like a system that could be abused? Sure. This system is abused regularly by lots of ED staff and residents in tertiary care centers where you have armies of admitting doctors and sub-sub-specialists available for every call (half completed or not) 24/7.

Furthermore, the problem that certain physicians seem to disagree about here is what "creating work" means. Notice that most of the senior non-ED people here aren't complaining about fully worked-up and examined patients. Theses are legitimate consults that all of us expect. What most of the non-ED people ARE complaining about are people in the ED who are clearly under-evaluating patients at sign-out time (or in general) and calling the rest of the hospital to quickee-quickee makee-makee all better.

And in academic institutions there is really no recourse for overworked, sleep-deprived, vulnerable residents on admitting services from laziness on the part of ER residents. Think about it. If we call our attendings with incomplete examinations and histories, we get torpedoed. If you do it to us...nothing happens and no one cares.

And the second part of your statement is blatantly offensive. You are insinuating that non-ED doctors are offended because of "unscheduled work" that you in the ER are "used" to? You people work shifts. We don't. Unscheduled chaos is therefore fitting into a COMPLETELY different schedule. And please don't whine about how we "knew what we were getting into." I refer you back to my statement above. Most specialists/internists/surgeons don't care about the "unscheduled work" that has been properly evaluated. The people here who are complaining are mostly frustrated about "unscheduled work" that has not been seen (at all!), not been physically examined, not had a proper history, or not had proper labs (I'd keep going but I think I've made my point), and are tossed our way by our fellow residents who don't seem to have any concern for the patient whatsoever.

So how does EM being a field of sensitivity come into play? Our focus is not to figure out what the person has; rather we're there to screen out all the bad things they might have and show that they don't have them.

This can be debated endlessly both ways by well-meaning individuals on both sides. I suggest that a triage nurse (or fourth year medical student) can ask 40 seconds' worth of questions, do a minimal "focused" exam, order a pre-set algorithm of tests/scans, and call a specialist. You are supposed to be better than that.

If you "make a diagnosis" and "figure out" what a person has, you may find that you actually don't need to call that special someone.

For every admit we send your way we've deflected 10-20 patients from you that otherwise you might have to address.

This is YOUR job. We aren't supposed to have to address it. Rhetorically speaking, you knew that when you signed up for ER...right?

It's just that we don't get to schedule our patient flow so if we hold on to people longer than necessary we get backed up.

I absolutely understand. And everyone else should, too. No one has a right to be angry with the ER because of the pace or tempo of patient flow. It is what it is.

Love,
-The ED

Back at ya. "From the Department of Sleep Medicine...with love!"

Look, I realize that my post is coming off a bit acerbic. I don't mean it to. I'm not trying to hate on the ER. Hopefully, this came across the way I meant it...as pointed, constructive criticism.

 

[Doctor Bob]

Rather than argue back point by point (because we all have our points of view and I can't convince you of mine any more than you can convince me of yours), I will just make one observation.

And please don't whine about how we "knew what we were getting into."

(and moments later)

This is YOUR job. We aren't supposed to have to address it. Rhetorically speaking, you knew that when you signed up for ER...right?

We all knew what we were getting into... and if we didn't, then we didn't research our job enough. So either side complaining about it now is silly.

I suggest that a triage nurse (or fourth year medical student) can ask 40 seconds' worth of questions, do a minimal "focused" exam, order a pre-set algorithm of tests/scans, and call a specialist. You are supposed to be better than that.

But for the record, telling an ER doc that the job they are doing is no better than that of a triage nurse or 4th year medical student is pretty irritating, rather misinformed, and not likely to facilitate further reasoned discourse.

 

[danielmd06]

??

Hello pot, my name is kettle.

Right. I was being very, very sarcastic. It doesn't translate well via internet.

 

[Doctor Bob]

Right. I was being very, very sarcastic. It doesn't translate well via internet.

Haha... and now my post is completely different because I edited it as you were copying it.

You win again interwebs!!

 

[danielmd06]

But for the record, telling an ER doc that the job they are doing is no better than that of a triage nurse or 4th year medical student is pretty irritating, rather misinformed, and not likely to facilitate further reasoned discourse.

I didn't say that any generic ER doctor is doing no better than a nurse or medical student. I specifically said taking 40 seconds' worth of history (etc) was no better than a triage nurse or fourth year medical student could do.

And that would be a true statement.

 

[glade]

We seem to reach an impasse because the philosophy and mindset of the ED versus literally every other field of medicine is different.

The ED is a field of sensitivity
Everyone else is a field of specificity

That's a very fair statement. But unfortunately, that's the problem, honestly. The ER is "the test" and it has varying amounts of sensitivity. The problem is that a lot of people find that it is TOO sensitive, which leads to a lot of false positives (i.e., consults). And the reason for that, if we're going to continue to be honest about the subject, is that there is seemingly no repercussion to the ER (at least as it applies to residency; private practice may be another matter). Meaning, there's no reward to the ER to move its threshold because the only "positive" is that residents look at you and smile and actually treat you humanely; on the other hand, you'll have to work more, the ER gets more crowded, and there's a higher risk of you getting sued. But if you go the other way, the only "negative" is that residents hate your guts, which is irrelevant because they can only show it so much or else they get disciplined; meanwhile, your job gets easier, the ER "flows" better and the administration gets all excited about what a bang-up job the ER is doing. There's no downside to making your ER as "sensitive" as possible, is there?

I mean, I get that being in the ER is difficult in that you're "damned if you do, damned if you don't." You could send someone out and have someone catch wind of it and they go "what??? You sent THAT home??? Are you mad?? THIS IS SPARTA!!!" Or you could keep it and have someone "check it out" and have the same person come down and go "what are you, an idiot?? I have to see this??" But that's my real point all along. This may make things worse (in terms of inflaming the discussion), but my opinion is that by creating the field of EM, we're CREATING this problem by making a field of people who, no offense, aren't specialized in evaluating these specific diseases. In other words, you are what it sometimes feels like the ER is: a primary care clinic for the poor and uninsured. If I sent everyone in the ER to a primary care physician, like an FP, and expected them to do a lot of surgical diagnosis, it would be no better and probably would be worse. If I sent everyone in the ER to a surgeon and expected them to do a lot of medical diagnosis, I can guarantee it would be worse. But if I sent everyone to BOTH internists AND surgeons, I can guarantee it would be better.

So what does that mean? Well, that just means what I said all along. That EM was instituted and created by people to fulfill a purpose, really, of "moving people along." Which, as I said, is wholly different from "being a physician" (i.e., diagnosing and treating disease). That doesn't mean you NEVER diagnose or treat diseases. It just means that if you don't, it's no big deal. Someone else will. The important part is that people were "moved to the right person." But the problem is that you guys have M.D. behind your name, so it gets irritating because, no matter how you want to cut it, at some point this devolves into being what people see it as: doing the work of a triage nurse.

 

[Doctor Bob]

Lots of stuff

Lots more stuff

I see your points... <shrug> I just take a different stance on the same points than you and see the same things from a different angle and have thusly formed different opinions.

I reiterate...

because we all have our points of view and I can't convince you of mine any more than you can convince me of yours

I think we'll just have to agree to disagree.

 

[Rendar5]

That's a very fair statement. But unfortunately, that's the problem, honestly. The ER is "the test" and it has varying amounts of sensitivity. The problem is that a lot of people find that it is TOO sensitive, which leads to a lot of false positives (i.e., consults). And the reason for that, if we're going to continue to be honest about the subject, is that there is seemingly no repercussion to the ER (at least as it applies to residency; private practice may be another matter). Meaning, there's no reward to the ER to move its threshold because the only "positive" is that residents look at you and smile and actually treat you humanely; on the other hand, you'll have to work more, the ER gets more crowded, and there's a higher risk of you getting sued. But if you go the other way, the only "negative" is that residents hate your guts, which is irrelevant because they can only show it so much or else they get disciplined; meanwhile, your job gets easier, the ER "flows" better and the administration gets all excited about what a bang-up job the ER is doing. There's no downside to making your ER as "sensitive" as possible, is there?

I mean, I get that being in the ER is difficult in that you're "damned if you do, damned if you don't." You could send someone out and have someone catch wind of it and they go "what??? You sent THAT home??? Are you mad?? THIS IS SPARTA!!!" Or you could keep it and have someone "check it out" and have the same person come down and go "what are you, an idiot?? I have to see this??" But that's my real point all along. This may make things worse (in terms of inflaming the discussion), but my opinion is that by creating the field of EM, we're CREATING this problem by making a field of people who, no offense, aren't specialized in evaluating these specific diseases. In other words, you are what it sometimes feels like the ER is: a primary care clinic for the poor and uninsured. If I sent everyone in the ER to a primary care physician, like an FP, and expected them to do a lot of surgical diagnosis, it would be no better and probably would be worse. If I sent everyone in the ER to a surgeon and expected them to do a lot of medical diagnosis, I can guarantee it would be worse. But if I sent everyone to BOTH internists AND surgeons, I can guarantee it would be better.

So what does that mean? Well, that just means what I said all along. That EM was instituted and created by people to fulfill a purpose, really, of "moving people along." Which, as I said, is wholly different from "being a physician" (i.e., diagnosing and treating disease). That doesn't mean you NEVER diagnose or treat diseases. It just means that if you don't, it's no big deal. Someone else will. The important part is that people were "moved to the right person." But the problem is that you guys have M.D. behind your name, so it gets irritating because, no matter how you want to cut it, at some point this devolves into being what people see it as: doing the work of a triage nurse.

Which would be good and all except it ignores the other aspects of our job which are stabilization and treatment of patients with disease processes that are of immediate threat to life and limb (and eye). and the other end of the specturm: acute care. majority of people go elsewhere for follow-up but most cases are not "admit to the correct service" or call the correct consult. So if you want to considuer us triage nurses, that's fine and all and you're entitled to your opinion. And it may even apply to EPs who aren't doing what they should. But it does indicate ignorance as to to the scope and nature of our intended practice.

 

[glade]

And again, that's being specious. Because the ER doesn't really do stabilization of life-threatening problems. It BEGINS the stabilization. Meaning, if someone comes in unstable, do you stabilize them and THEN call a consult? No, and nor should you. But you make it sound like you do, unintentionally, I'm sure. The reality is that as an unstable patient is presenting, you call a consult while you get vitals, draw blood, and so on. I mean, you say you deal with "eye-threatening" injuries. Really? I mean, you really deal with them, rather than call Optholmology? Because if someone came in with an eye-threatening injury, I'd call Optho. I'm pretty sure if I didn't, someone would find that to be extremely odd. If a trauma comes in, sure, you may be trained to start ATLS, but you REALLY wouldn't call the trauma team? If so, your hospital is set up in a manner that really doesn't follow ATLS guidelines.

But whenever we get into these arguments, it's like "well, we stablize people in life-threatening situations." It's like the final defense. Listen, we all watched "ER" (well, I didn't, I found it to be silly), but ER is not like the show where there are hundreds of explosions and plane crashes happening every day and people are getting rolled in while people are yelling "PEOPLE!! PEOPLE!! LISTEN UP!!! I GOT ANOTHER GUY WHO WAS SHOT THREE TIMES, THEN HIT BY A CAR, THROWN INTO A KNIFE FACTORY, DRAGGED DOWN THE BLOCK BY A DOG, AND PULLED INTO A LEAKY GAS MAIN!!!" and people jump into action and start doing neurosurgery in the parking lot.

 

[Rendar5]

And again, that's being specious. Because the ER doesn't really do stabilization of life-threatening problems. It BEGINS the stabilization. Meaning, if someone comes in unstable, do you stabilize them and THEN call a consult? No, and nor should you. But you make it sound like you do, unintentionally, I'm sure. The reality is that as an unstable patient is presenting, you call a consult while you get vitals, draw blood, and so on. I mean, you say you deal with "eye-threatening" injuries. Really? I mean, you really deal with them, rather than call Optholmology? Because if someone came in with an eye-threatening injury, I'd call Optho. I'm pretty sure if I didn't, someone would find that to be extremely odd. If a trauma comes in, sure, you may be trained to start ATLS, but you REALLY wouldn't call the trauma team? If so, your hospital is set up in a manner that really doesn't follow ATLS guidelines.

.

We deal with eye injuries to initial degrees in terms of diagnosing them (globe ruptures, which I've diagnosed twice this year), acute angle closure glaucoma), but of course they get ophtho consults for care.

In terms of stabilization, some times we simply start and pass off resuscitation, soemtiems we complete the resuscitation and then pass off. Terminating an eclamptic seizure or an INH induced one or status epilepticus should all essentially be complete by the time someone sees them. Basic EGDT can sometimes fully resuscitate and stabilize a septic patient before they go to the ICU or sometimes cancel a potential ICU admission, though in this case severe sepsis obviously won't be fully stabilized til the ICU gets ahold of them. Angioedema can fully stabilized in the ED plenty of times, if anaesthesia isn't available soon enough). Anaphylactic shock should be fully stabilized by ED prior to admission,(and admission is for observation for second-phase anaphylaxis). Those are just several examples

 

[glade]

Yeah, but see the thing is what we mean by "diagnosis." I've diagnosed globe rupture, too. I looked at someone's eye and was like "woah, that looks messed up. Let's get Optho to look at this." Now, I could certainly say that I "diagnosed" globe rupture, but I don't know what the heck is the relevance. That's sort of the level of diagnosis that I see on a daily basis in the ER, where it's like "I identified there was a problem and then I got it to the appropriate person." But all too often, that turns into a little chart of a person with:

Head hurts? Call Neurology, unless something hit your head first. Then call Trauma.
Chest hurts? Call Cardiology.
Trouble breathing? Call Medicine.
Abdomen hurts? Call Surgery.
Are you female? Call Ob-Gyn.
Are you small? Call Pediatrics.
Limbs hurt? Call Orthopedics, but make sure it's before you get imaging.

Now, I get that this sounds offensive because it portrays your specialty as non-thinking and, really, non-essential. But I don't know what to tell you. All I know is that on a daily basis we get the silliest calls. I mean, even look at your own post. You're avoiding a ICU admission for someone who is in septic shock? Why? What does that accomplish? You're patting yourself on the back for a job well done, but that's actually the person I WANT to see. The problem is that every so often our ER does that, too, where it's like "oh, OK, people keep insulting us as being non-medical, so let me demonstrate my medical skillz." And then it's actually even worse, but then people get mad about THAT and then the ER guy goes "WTH, you said you wanted medical skillz, now you're upset at me for treating a septic patient down here in a corner room. What do you want??" It's frustrating because the whole concept is wrong.

 

[turquoiseblue]

I see ER docs in a smiliar way as glade does....as an ER doc, as seen on these posts, you can be technical about things and act like you know more than the general public, but overall calling stabilizing patients and calling consults is the main job of an ER doc, so i guess you can't be mad at an ER doc for calling you in for your expertise, but at the same time i noticed some ER docs act so clueless sometimes and can only do what they do best--stabilize and consult. no offense though. it's a great job, emergencies are a rush, and they get great pay.

 

[danielmd06]

I see your points... <shrug> I just take a different stance on the same points than you and see the same things from a different angle and have thusly formed different opinions.

I reiterate...


I think we'll just have to agree to disagree.

Fair enough.

For the record, I am really not saying the same thing as glade and turqoiseblue. In fact, I disagree with comments from both of them. Perhaps reading my posts closely will explicate the differences.

And please note in my comments that I am inferentially stating that I think ER doctors *can* and *should* be doing more than a "triage nurse" or a "fourth year medical student." You ARE better than that. So please ACT like that. Be professional. Work hard. Don't take the easy road. Your colleagues will respect you. And I daresay our thoughts matter more in the end than the hospital administration.

It seems obvious to me from these many posts that at least some physicians in the ER are doing so. Emulate them!

 

[Rendar5]

Yeah, but see the thing is what we mean by "diagnosis." I've diagnosed globe rupture, too. I looked at someone's eye and was like "woah, that looks messed up. Let's get Optho to look at this." Now, I could certainly say that I "diagnosed" globe rupture, but I don't know what the heck is the relevance. That's sort of the level of diagnosis that I see on a daily basis in the ER, where it's like "I identified there was a problem and then I got it to the appropriate person." But all too often, that turns into a little chart of a person with:

Head hurts? Call Neurology, unless something hit your head first. Then call Trauma.
Chest hurts? Call Cardiology.
Trouble breathing? Call Medicine.
Abdomen hurts? Call Surgery.
Are you female? Call Ob-Gyn.
Are you small? Call Pediatrics.
Limbs hurt? Call Orthopedics, but make sure it's before you get imaging.

Now, I get that this sounds offensive because it portrays your specialty as non-thinking and, really, non-essential. But I don't know what to tell you. All I know is that on a daily basis we get the silliest calls. I mean, even look at your own post. You're avoiding a ICU admission for someone who is in septic shock? Why? What does that accomplish? You're patting yourself on the back for a job well done, but that's actually the person I WANT to see. The problem is that every so often our ER does that, too, where it's like "oh, OK, people keep insulting us as being non-medical, so let me demonstrate my medical skillz." And then it's actually even worse, but then people get mad about THAT and then the ER guy goes "WTH, you said you wanted medical skillz, now you're upset at me for treating a septic patient down here in a corner room. What do you want??" It's frustrating because the whole concept is wrong.

Gross globe rupture isn't difficult to determine, something more subtle though requires some knowledge. Me diagnosing globe rupture is vital because it tells ophthalmology whether they need to haul ass and drive in to the hospital at 4AM or they need to follow the patient in their clinic tomorrow.

I'm kind of confused why you have us consulting people when majority of the time most cases don't need consultation. But I'm sure from your perspective, that's the only cases you tend to see.

I'm talking about the fully resuscitated pt without severe sepsis whose lactate goes from 4.0 to 1.0 with fluid hydration with normalization of vitals. Depends how much you use lactate clearance as a marker. ED's goal in sepsis overall is pretty straightforward. Establish EGDT with appropriate necessary procedures, perform initial resusc., then send to the ICU/floor depending on severity and resusc status. EDIT:I relooked at my post so I don't see where you're getting this idea that I'm avoiding an ICU admission or the idea that this is somehow commonplace.

Not sure why you're suggesting every case gets a consult, but oh well

 

[glade]

Not sure why you're suggesting every case gets a consult, but oh well

I'm not suggesting that and I know that's not the case. However, of the consults that we do get, it's probably close to 70% that are either silly or just dumped on us based on chief complaint. In my opinion, even if you're "deflecting" tons of cases, that's still uncalled for. In fact, that's part of my unscientific observation. Some of the better EM attendings, at least when it's slow they'll work things up a little. But when the ER gets busy, it's like a sieve. Any reason to give us a consult and it happens. That shouldn't occur. If my service gets busy I still have to do what I'm supposed to do for each patient.

 

[45408]

I mean, I get that being in the ER is difficult in that you're "damned if you do, damned if you don't." You could send someone out and have someone catch wind of it and they go "what??? You sent THAT home??? Are you mad?? THIS IS SPARTA!!!"

But it was pretty awesome when the attending kicked the resident down the elevator shaft.

 

[glade]

Yeah, but why were they both half-naked? That seemed completely unnecessary.

 

[Doctor Bob]

Yeah, but why were they both half-naked? That seemed completely unnecessary.

That's how we dress in the ED. It's hospital policy.

I was so excited when I finally got issued a sword and shield.

 

[glade]

If that was true, I'd be a lot more willing to take consults from females down in the ER. (Actually, that's not true at all. I've seen some pretty ugly female attendings down there that I almost consulted Plastics for.)

 

[Rendar5]

If that was true, I'd be a lot more willing to take consults from females down in the ER. (Actually, that's not true at all. I've seen some pretty ugly female attendings down there that I almost consulted Plastics for.)

aww, you should work in NYC sometime. Our attendings tend to be pretty up there.

 

[keeping-it-real]

This entire thread is a bit over-the-top. No matter what specialty you're in, the name of the game is minimizing work and nobody wants to do extra work if they can avoid it. In this regard, though, each specialty is just as guilty as the next of creating extra, unwanted work.

For every medicine resident that complains about the 4:57 admit, there is one that hears the words "chest pain" over the phone and sends the patient to the ER. For every general surgeon that begrudges a 'soft' consult for abdominal pain, there is one that won't admit a healthy 25 y/o and wants medicine to do the admission. For every ortho resident.... The list goes on and you can substitute whatever residency you prefer. The bottom line is that we all, at some point, create work for somebody else. The pots and kettles need to take a look in the mirror.

For the ER-specific bashing in this thread, I think much of it is probably uncalled for. I don't think any doctor, regardless of specialty, should be beating his/her chest with elitism. The reality is that most fields of medicine are straight-forward, moderately intellectual undertakings with tasks that could likely be performed interchangeably by people from the various specialities.

To briefly defend ER medicine, I think that many other specialties oversimplify the role of the ER doctor; and this is most likely due to the fact that each specialist is much more knowledgeable in the specific area of consult and is more prone to critique the ER for mistakes that they consider basic. The lack of depth in ER medicine, though, is more than made up for by the breadth of knowledge and expectation of appropriately managing a busy department. I've been off-service, rotating through just about every specialty in the hospital. I've also had the opportunity of overseeing various off-service specialties rotating through the ER. The reality is that no one specialty is significanty more difficult than the other, and any resident who thinks he/she can manage a specialty better than those currently training in the specialty is delusional. Thinking that any non-ER resident could come down to the ER and effectively manage 7-10 active patients and coordinate a busy department is no less arrogant than me claiming that I could operate on an appendix because I did a rotation as a student and know the anatomy of the abdomen.

Interspecialty criticism is a purposeless undertaking and it's unfounded that any specialty think theirs more important than any other. And we all work hard but sometimes create extra work for others. Hopefully we try to minimize the amount of work we create, but many times it's unavoidable. Everyone needs to realize that nobody has clean hands.

 

[ForbiddenComma]

To be fair, I did not intend for my original primal scream here to be a sweeping indictment of EM as a field. Almost everyone here has rotated through the ER at some point, myself included, and we have some idea of what you guys struggle with.

But tossing up worthless admits with absolutely no regard for colleagues up on the floors... that is what bugs me. A lot of ER docs apparently forgot a long time ago what life is like on the floors and on the units, and apparently regard them as the proper place to rehydrate the routine AGE or "stabilize" the new-onset just-barely-DM2 with polydipsia x5 months, with sugars in the mid-200s and pristine VBGs, BMPs and urine ketones. (yes, both happened to our service today.)

And the earlier discussion of head CTs hit home. Where I went to med school, they will CT your head for any. reason. at. all. Or none at all. Punched in the face? Head CT. MVA, no matter how minor, no matter what your history? Head CT. HA? Head CT. Stubbed your toe and have a history of epilepsy? Head CT.

I don't know, but I wouldn't be surprised if this is because the ER chief happened to miss an epidural once like 10 years ago or something and now is obsessed with irradiating the heads of anyone who comes through his doors. It is amazing how many such "rules" come into place because of one single bad outcome.

Anyway, it would be nice if all ER docs got decent feedback on their admits, so they can at least determine their own signal-to-noise ratios. I hear that some houses are pretty good about that, and I commend them, but I have yet to rotate at such a place.

 

[glade]

Wonderful call so far. Got two patients where the ER physician literally did nothing but open up a patient's chart, saw that they were operated on within two weeks, and placed a consult for "post-operative complaints." And the patients said I was the first physician to see them. AWESOME! 👍

 

[glade]

But tossing up worthless admits with absolutely no regard for colleagues up on the floors... that is what bugs me. A lot of ER docs apparently forgot a long time ago what life is like on the floors and on the units

Ever have an ER resident rotate on your service? It's pretty hilarious. By the end of it, they literally are cursing the ER like "WTF, ANOTHER CONSULT?? MOTHER(BLEEP)ERS!!" That's the end of the rotation. The beginning of the rotation is pretty funny, too, because it'll be like they think they're the mobile unit of the ER. They'll be telling you about the patient like "yeah, this guy has belly pain (5 sec pause), can you come see it?"