5 reasons EM is Harder than it looks.

[Candidate2017]

If an ER doc came to a thread about appreciating the work of psychiatrists and said “but psychiatrists aren’t real doctors, they just punt inpatients from their psychiatric hospital to their local ER for asymptomatic hypertension and for disimpactions when they’re constipated” that we would find that kind of interspecialty browbeating distasteful?

There are some psychiatric patients who would love to have their psychiatrist's finger in their rectum. So yeah, no. Brown isn't a good color on the nice rug in my office either. Also, some antipsychotics can cause fatal constipation, so not sending to ER would be bad.

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[MedicineZ0Z]

That's a nice review of ER practice in a tertiary academic setting. In the community, the negatives of ER get exacerbated horribly.

From a radiology perspective, there's a gross over-utilization of imaging in the name of cookbook medicine. The pre-test probability on the stuff that gets seen at the local doc-in-the-box ER/urgent care or smaller ERs (usually by midlevels) is low and the actual positive rate is crazy low. It's all done in the name of 'moving the meat' but there's absolutely limitations on how many studies can be read by a radiology service.

There's absolutely a "lemme order a bunch of stuff and let radiology/the labs tell me whats wrong with this patient" vibe.

Part of this is cause you only get credit for catching things and no credit for utilizing less resources. Miss 1 PE out of 300 vague SOB/chest pains that kill the person? Well you're screwed. And any cancer arising from those 299 scans will be many years later. Not to mention no one will ultimately care that you ordered that many scans. They will only care about the 1 single case you missed.

Start financially rewarding doctors for ordering less tests and drastically increase malpractice coverage for physicians. Then you'll see a big change.

 

[guytakingboards]

Part of this is cause you only get credit for catching things and no credit for utilizing less resources. Miss 1 PE out of 300 vague SOB/chest pains that kill the person? Well you're screwed. And any cancer arising from those 299 scans will be many years later. Not to mention no one will ultimately care that you ordered that many scans. They will only care about the 1 single case you missed.

Start financially rewarding doctors for ordering less tests and drastically increase malpractice coverage for physicians. Then you'll see a big change.

I'm all in favor of tort reform but I think you misunderstand radiology as a resource. It absolutely is not finite. There's a shortage of rads currently and with the ever increasing crush of studies being ordered, that shortage will pretty much never get caught up. (AI ain't gonna be a saving grace any time soon). Once turnaround times start to rise to unreasonable/unsafe rates, utilization will come under further scrutiny. Will that squeeze ER doctors and noctors? Hell yes. Decision support in the CPOE is already here and administrators have the ability to track and subsequently put downward pressure on ordering. Especially if reimbursements stop favoring the over-ordering model.

 

[Kuratz]

Totally agree that an ED doc's job is hard and something I wouldn't want to do. But blaming IM for the over-utilization of imaging? Lol. Come on.

We have ED docs exclusively staffing the ED at an academic center and our positive PE rate on CTAs is close to 1%. I just don't buy that with a rate that low they are at all thinking about being a steward of imaging use and the threshold is exceedingly low to image. They do it because it's a damn good test, convenient and an easy consult for another physician (Rad).

One might ask "well aren't these quick, easy RVUs for Radiology so why do you care?". And the answer is that when CMS goes to look at healthcare expenditures they'll see an enormous amount used for imaging and instead of realizing the value it provides they will cut reimbursement. So then in the future we'll get hosed reading these insane volumes for less and less.

 

[MedicineZ0Z]

I'm all in favor of tort reform but I think you misunderstand radiology as a resource. It absolutely is not finite. There's a shortage of rads currently and with the ever increasing crush of studies being ordered, that shortage will pretty much never get caught up. (AI ain't gonna be a saving grace any time soon). Once turnaround times start to rise to unreasonable/unsafe rates, utilization will come under further scrutiny. Will that squeeze ER doctors and noctors? Hell yes. Decision support in the CPOE is already here and administrators have the ability to track and subsequently put downward pressure on ordering. Especially if reimbursements stop favoring the over-ordering model.

But what's the solution? You only need to miss 1 case in the US to get screwed.

We could perhaps order more d-dimers, and that is literally all I can think of whatsoever. The issue with the d-dimer is that if you wait 90 minutes to get it, you might be waiting another 60 minutes for it to result then another 2 hours until you have a CT that's read. With a full waiting room, docs often just do the CT and move on, especially if dissection is anywhere remotely on the differential. Now some places order d-dimers on all chest pains. It would be interesting to see how it could be better utilized to cut down on CT ordering.

 

[CliveStaples]

I mean, I don't think that the evaluation for PE is something that should be done sort of willy-nilly, especially at academic centers. It shouldn't be done because it's convenient, or easy, or because it's so much faster than waiting for a D-Dimer result.

Once you have a patient with chest pain, you incorporate your decision rules (Wells and PERC) to determine what, if any, testing is necessary for evaluating for a PE. If your ER is ordering too many CT scans in your opinion, then the question that needs to be asked is if there needs to be better quality control on ensuring that Wells and PERC are being adhered to correctly.

If you feel that too many CT scans are ordered and PERC/Wells are being followed, there's really little else that can be done since this is the standard of care until we find additional tools to reduce our patients' pre test probabilities. We have made some small strides with age-adjusted D-Dimers and the YEARS criteria for changing out D-Dimer cutoff. All that to say, we have a very evidence-based approach to PE evaluations and I wonder if it just needs to be utilized correctly (and the answer isn't D-Dimers for everybody).

 

[MedicineZ0Z]

I mean, I don't think that the evaluation for PE is something that should be done sort of willy-nilly, especially at academic centers. It shouldn't be done because it's convenient, or easy, or because it's so much faster than waiting for a D-Dimer result.

Once you have a patient with chest pain, you incorporate your decision rules (Wells and PERC) to determine what, if any, testing is necessary for evaluating for a PE. If your ER is ordering too many CT scans in your opinion, then the question that needs to be asked is if there needs to be better quality control on ensuring that Wells and PERC are being adhered to correctly.

If you feel that too many CT scans are ordered and PERC/Wells are being followed, there's really little else that can be done since this is the standard of care until we find additional tools to reduce our patients' pre test probabilities. We have made some small strides with age-adjusted D-Dimers and the YEARS criteria for changing out D-Dimer cutoff. All that to say, we have a very evidence-based approach to PE evaluations and I wonder if it just needs to be utilized correctly (and the answer isn't D-Dimers for everybody).

And there's the freak cases of PERC negative PEs. I've seen it myself. And not to mention a lot of these patients are over age 50.

Again, you need a solution for missed cases. Will it be no fault compensation for the patient/family? Will it be acceptable to miss very atypical cases? In many, or actually almost all countries in the world, it's acceptable to miss very atypical presentations. And good luck with a lawsuit even for more typical misses if it wasn't clear cut, let alone for atypical. But in the US? You can easily find an expert witness that says you should have scanned someone head to toe. And the people who wrote PERC and Wells aren't going to be there to help.

Now I don't personally order nearly as many scans as it sounds. But ultimately you need a solution for those missed cases, before practice patterns can change.

 

[Redpancreas]

Psychiatrists usually have a 24 hour clause set by contract or hospital bylaw. If the hospital wants us to see ED consults ASAP, the CEO can dip into their pocket to pay us thousands per shift to standby, like they do for ortho etc. But they don't. Unlike ortho, cards, etc, psychiatrists aren't called in to fix things like set a fracture or put in a balloon. No, we are consulted to soak up liability, read tea leaves as to whether it's ok to release from the ED a stranger who made threats to shoot themselves and others, and add our names next to the EM physician on the defendant list.

Also, there aren't many psych emergencies. Emergencies are related to lethal harm or med reactions (DRESS, SJS, NMS, SS). But the patient is already in the ED/hospital, so there should be no lethality issues and med reactions are within the domain of EM, IM, CC etc.

There isn't. Likely because our purely cognitive work requires us to spend more time and thought on patients, as reflected in our hefty notes (which no one wants to read, except lawyers), relative to other specialties. We are also the only specialty that routinely testifies in court during residency.


Psychiatrists have a bit of insight about the BS in the ED. We spend a chunk of residency in the ED for emergency psych and psych consults. Some programs have psych residents rotate in the ED as... EM residents. Despite a significant portion of ED (and FM) visits being related to psychiatric complaints, how many EM programs require EM residents to rotate on the psych ward?

During training, many EM physicians would tell me about the "tricks" to get patients accepted to the psych ward. Seriously, do you not see "Psychiatry" emblazoned on my white coat? Who do you think you will be asking to admit your ED patients tonight?

So when we stroll into the ED after lunch, it's because we know. Or better yet, when we decline to ever work in the ED.

Interesting insights into Psychiatry and this is what I suspected to some extent, but it feels good to hear it from someone with more experience. Based on what you're saying I wonder what the purpose of having a "psych consults" rotation for residents is. If I were designing a residency, I would focus put inpatient skills in the Psych inpatient units with more emphasis on outpatient skills and have a 1 resident take hospital call where they see these liability-soaks and have that heavily protocolized.

In regards to having a bit of insight into the ED, I would say any admitting service (IM, GS, Surgical Subspecialties, etc.) have that same insight (if not more) into the potential BS/tricks the ED uses to get a patient admitted to the floor (telling nurses to document nadirs in O2 sats, etc.). If they're in a squeeze between their utilization management time and they're on the fence between admit/dc and their obs unit is full, they may do these things. Taking that into account, it's still a very tough, but necessary job and I don't they are the only field guilty of leveraging technicalities.

 

[Redpancreas]

Totally agree that an ED doc's job is hard and something I wouldn't want to do. But blaming IM for the over-utilization of imaging? Lol. Come on.

We have ED docs exclusively staffing the ED at an academic center and our positive PE rate on CTAs is close to 1%. I just don't buy that with a rate that low they are at all thinking about being a steward of imaging use and the threshold is exceedingly low to image. They do it because it's a damn good test, convenient and an easy consult for another physician (Rad).

One might ask "well aren't these quick, easy RVUs for Radiology so why do you care?". And the answer is that when CMS goes to look at healthcare expenditures they'll see an enormous amount used for imaging and instead of realizing the value it provides they will cut reimbursement. So then in the future we'll get hosed reading these insane volumes for less and less.

It's not just IM. When a patient is coming onto a service, imaging is helpful in discriminating which service to send the service to (disposition). Abdominal Pain radiating to the back? The CT shows acute pancreatic inflammation? Admit to IM/MICU based on clinical factors. Perforated viscous? Send to /GS/SICU depending on other clinical factors. It's ED's job in a way to make that distinction hence why they need to order those tests.

 

[Taddy Mason]

Interesting insights into Psychiatry and this is what I suspected to some extent, but it feels good to hear it from someone with more experience. Based on what you're saying I wonder what the purpose of having a "psych consults" rotation for residents is. If I were designing a residency, I would focus put inpatient skills in the Psych inpatient units with more emphasis on outpatient skills and have a 1 resident take hospital call where they see these liability-soaks and have that heavily protocolized.

In regards to having a bit of insight into the ED, I would say any admitting service (IM, GS, Surgical Subspecialties, etc.) have that same insight (if not more) into the potential BS/tricks the ED uses to get a patient admitted to the floor (telling nurses to document nadirs in O2 sats, etc.). If they're in a squeeze between their utilization management time and they're on the fence between admit/dc and their obs unit is full, they may do these things. Taking that into account, it's still a very tough, but necessary job and I don't they are the only field guilty of leveraging technicalities.

This is very hospital and residency program dependent. In the community 24hrs to see a consult isn’t uncommon depending on the hospital. In larger and academic centers there can be a much larger consult volume. As examples, at the program affiliated with my med school, ECT, ED consults, and floor consults are handled by 1 resident with a fairly generous window to see new consults from the time they finish ECT for the day until ~3/3:30pm, with anything after that being pushed off until the next day and no evening/overnight/weekend coverage. In my current program we have a fairly busy C/L service that does transplant evals in addition to general psych consults and ED and substance use consults are covered by 2 separate services. There are generally 2-3 residents, a midlevel, and ~4-5 med students seeing new consults from 8-4/4:30 and anything after that is put off until the next day unless it’s deemed to be urgent and then seen by whomever is on call. The ED consult service has 2 residents from 8am-10pm and any consults after that are seen by whomever is on call with the expectation that the patient is seen within 30min unless there’s something more emergent going on. A nearby program has 24/7 psych consult coverage completely separate from whatever comes in the ED (and no standalone psych ED). So definitely a lot of variability depending on volume/need.

 

[Cognovi]

Our emergency radiologsts' coping mechanism to the phenomenon of IM asking for extra scans before admission is that they will not read studies ordered after the bed request is logged. Those go onto the inpatient study queue for the daytime radiologists even if the patient is still boarding in the ED.

 

[CliveStaples]

And there's the freak cases of PERC negative PEs. I've seen it myself. And not to mention a lot of these patients are over age 50.

PERC isn't perfect, but I think it would be difficult to be sued successfully if you document that you considered PE and they were truly PERC negative.

I don't feel too bad about patients over 50 getting D-Dimers to evaluate for PEs (in low risk Wells scores). I feel bad when people get CT scans that were low risk Wells and should have had D-Dimers first.