Abdominal pain in women

[Angry Birds]

The more noise they are making, the more likely it is malingering. Filling a vomit bag full of air and noise is almost always marijuana hyperemesis, cyclic vomiting, and/or malingering. My pre-test probability for badness is inversely proportional to the amount of noise/drama.

I'm so glad we have droperidol back. 2.5 mg IV usually silences any noise.

I follow the same diagnostic rule. I don't have droperidol but I immediately order Haldol 5 mg IV or IM if they are retching and it will take time to get the line.
Does Drop. work much better than this?

I just can't stand going into the room with a retching patient.

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[BoardingDoc]

I follow the same diagnostic rule. I don't have droperidol but I immediately order Haldol 5 mg IV or IM if they are retching and it will take time to get the line.
Does Drop. work much better than this?

I just can't stand going into the room with a retching patient.

Drop works faster and more effectively than haldol in my experience. 2.5mg drop ~= 5mg haldol.

 

[RustedFox]

Am I the only one where if you order Haldol, the nurses get all pissy because "its a chemical restraint" and requires them to do more charting?

 

[southerndoc]

The more noise they are making, the more likely it is malingering. Filling a vomit bag full of air and noise is almost always marijuana hyperemesis, cyclic vomiting, and/or malingering. My pre-test probability for badness is inversely proportional to the amount of noise/drama.

I'm so glad we have droperidol back. 2.5 mg IV usually silences any noise.

Word. When the N:E (noise to emesis) ratio is >1, they get the vitamin D (droperidol). No questions asked it's the first line treatment in these cases and works every... single... time.

 

[southerndoc]

Am I the only one where if you order Haldol, the nurses get all pissy because "its a chemical restraint" and requires them to do more charting?

We had some pushback when we started using IV Haldol. Didn't take too long to overcome. Now that we have droperidol, we rarely use Haldol for antiemetic purposes. I've even used droperidol for acute agitaton with great success. Usually use 0.625 mg for migraines and refractory nausea, 1.25 mg for those with the N:E >1, and 2.5 mg for acute psychosis.

I'm telling you, vitamin D is the miracle cure all of the modern age of medicine. I'm tempted to start carrying a prefilled syringe and just injecting patients myself when I'm talking to them. It works really quickly.

 

[BoardingDoc]

Am I the only one where if you order Haldol, the nurses get all pissy because "its a chemical restraint" and requires them to do more charting?

Yes. If anything my nurses start looking at the loud agitated patients and start poking me until I order some.

 

[Angry Birds]

Am I the only one where if you order Haldol, the nurses get all pissy because "its a chemical restraint" and requires them to do more charting?

I had this issue but it has improved recently as I pushed for its usage and the nurses got used to it. Some nurses will ask me to administer it though.

 

[GeneralVeers]

I follow the same diagnostic rule. I don't have droperidol but I immediately order Haldol 5 mg IV or IM if they are retching and it will take time to get the line.
Does Drop. work much better than this?

I just can't stand going into the room with a retching patient.

We lost Droperidol in 2013 for various reasons, and it's finally making a comeback on our formulary. It is highly dissociative, and usually makes people forget their pain/anxiety/vomiting enough to have a normal conversation with them. Haldol works great too, but is far more sedating. I used Vitamin D two days ago on a hysterical 31 yo male who was writhing around on the floor in the CT scanner room demanding "surgery" for his hiatal hernia. After 2.5 mg of Vitamin D, I actually was able to talk to him about his negative CT results and get him to agree to a discharge. It's a miracle drug, and it's a shame there's such a stigma and resistance to prescribing it.

 

[GeneralVeers]

I had this issue but it has improved recently as I pushed for its usage and the nurses got used to it. Some nurses will ask me to administer it though.

Agreed. I'm the go-to doctor for nurses when they have an agitated/crazy patient for whom they need meds.

 

[clibby]

I love vitamin H in abdominal pain! (No droperidol yet) The nurses always give me a hard time giving it even IM when the patient is not in a bed (we have a number of hallway chairs), but I have been slowly converting them. I still struggle to get the CHS folks to believe their pot is the problem even with articles from High Times, but vitamin H gets them out the door in an hour vs the 3-6 with standard antiemetics.

 

[RuralEDDoc]

Is haldol and droperidol really that much better than Ativan? This is a serious question. That’s my go to for all things crazy (but not psychotic). If there’s a better choice in haldol, i need to try it.

 

[southerndoc]

Is haldol and droperidol really that much better than Ativan? This is a serious question. That’s my go to for all things crazy (but not psychotic). If there’s a better choice in haldol, i need to try it.

yes.

 

[Angry Birds]

Is haldol and droperidol really that much better than Ativan? This is a serious question. That’s my go to for all things crazy (but not psychotic). If there’s a better choice in haldol, i need to try it.

Not even close my friend. Haldol is way way better... It's STFU medicine.

 

[GeneralVeers]

In the really really noisy patients I give them Haldol And Ativan. That's gets things quiet for discharge

 

[The Knife & Gun Club]

I recently had a young woman come in with triage note of pelvic pain. Maybe 30 years old. Normal vitals. Did a little computer station eye rolling before walking into the room.

Walk in she’s the most pleasant person. Cracking jokes, sorry for bothering you on Christmas, talking about her job as an accountant. “But doc, I’ll be honest it really hurts. I’ve never felt this before”

Prestest probability for badness goes from 0 to 100 real quick.

Turned out to be a perfed appy with a pelvis full of puss. Didn’t want morphine because “I’m not trying to get high”. Faith in humanity restored.

 

[Apollyon]

I recently had a young woman come in with triage note of pelvic pain. Maybe 30 years old. Normal vitals. Did a little computer station eye rolling before walking into the room.

Walk in she’s the most pleasant person. Cracking jokes, sorry for bothering you on Christmas, talking about her job as an accountant. “But doc, I’ll be honest it really hurts. I’ve never felt this before”

Prestest probability for badness goes from 0 to 100 real quick.

Turned out to be a perfed appy with a pelvis full of puss. Didn’t want morphine because “I’m not trying to get high”. Faith in humanity restored.

Cherish that, because it's a unicorn. Everyone recalls the "normal patients", because they are so rare. Recall that we see the bottom 2% of society.

There is SO much chaff among the the wheat that we become so embittered.

 

[The Knife & Gun Club]

Cherish that, because it's a unicorn. Everyone recalls the "normal patients", because they are so rare. Recall that we see the bottom 2% of society.

There is SO much chaff among the the wheat that we become so embittered.

Yea it was nice to feel like I actually helped this one person.

Christmas was grim man.

 

[VA Hopeful Dr]

In the really really noisy patients I give them Haldol And Ativan. That's gets things quiet for discharge

Hospice uses a transdermal ativan/haldol/dex mix pretty frequently in my area. It's damned near magic how well it works for nausea.

 

[AMEHigh]

I recently had a young woman come in with triage note of pelvic pain. Maybe 30 years old. Normal vitals. Did a little computer station eye rolling before walking into the room.

Walk in she’s the most pleasant person. Cracking jokes, sorry for bothering you on Christmas, talking about her job as an accountant. “But doc, I’ll be honest it really hurts. I’ve never felt this before”

Prestest probability for badness goes from 0 to 100 real quick.

Turned out to be a perfed appy with a pelvis full of puss. Didn’t want morphine because “I’m not trying to get high”. Faith in humanity restored.

What makes your roll your eyes before walking in to see a patient?

 

[dadaddadaBATMAN]

What makes your roll your eyes before walking in to see a patient?

Probably the same thing that made me roll my eyes when I read this post.

 

[AMEHigh]

Probably the same thing that made me roll my eyes when I read this post.

My post?
Well I guess you can explain why my post made you roll your eyes.

I’m not a EM doctor, but come here to learn since I take care of patients that have been seen in the ED. So it’s nice to understand the thought process of EM doctors. But if that’s eye roll worthy to try to understand, oh well.

 

[dadaddadaBATMAN]

My post?
Well I guess you can explain why my post made you roll your eyes.

I’m not a EM doctor, but come here to learn since I take care of patients that have been seen in the ED. So it’s nice to understand the thought process of EM doctors. But if that’s eye roll worthy to try to understand, oh well.

Perhaps I was mistaken, but your post seemed like a very transparent attempt to shame a resident for developing an impression of nonsense prior to walking into the room. It’s entirely possible that my interpretation of your post as a lead in to a holier than thou moment was mistaken.

Sniffing out nonsense is an important skill. it allows one to develop a limited triage process for the order of seeing patients when multiple people check in.

other examples of complaints that are high pretest probability of nonsense are epistaxis, chest pain in a person under 30, asymptomatic hypertension, and back pain.

Any of these can be an actual emergency: epistaxis can be a posterior bleed, chest pain under 30 could be arrhythmia or ptx, asymptomatic htn can turn out to be actual hypertensive emergency (hardly ever) on further history, and back pain could be aaa, cauda equina, etc.

While I always do my best to give the benefit of the doubt and treat every person with empathy, dignity, etc, allowing yourself a momentary internal eye roll when reading the bizarre or clearly non-emergency complaint prior to walking in the room is important for your sanity and also for your ability to suppress these feelings in the room.

 

[The Knife & Gun Club]

What makes your roll your eyes before walking in to see a patient?

The chances that someone that age with normal vitals and a Cheif complaint of pelvic pain will have some emergent pathology necessitating a trip to the ER is low.

More likely they

1) could not be bothered to wait a day to see their primary or OBGYN for an issue that’s better managed by that person

2) have a chronic issue that I either can’t diagnose or can’t treat appropriately in the ED.

Like Batman said above that’s not to say I won’t see and evaluate anyone who walks in, give them the benefit of the doubt, do my best to rule out badness, and treat them with respect and dignity.

In both scenarios 1 or 2, I’ll end up providing some sub-optimal treatment with no proper follow up...and my OBGYN wife will make fun of me for not knowing how ovaries work when I tell her about it over dinner.

 

[AMEHigh]

Perhaps I was mistaken, but your post seemed like a very transparent attempt to shame a resident for developing an impression of nonsense prior to walking into the room. It’s entirely possible that my interpretation of your post as a lead in to a holier than thou moment was mistaken.

Sniffing out nonsense is an important skill. it allows one to develop a limited triage process for the order of seeing patients when multiple people check in.

other examples of complaints that are high pretest probability of nonsense are epistaxis, chest pain in a person under 30, asymptomatic hypertension, and back pain.

Any of these can be an actual emergency: epistaxis can be a posterior bleed, chest pain under 30 could be arrhythmia or ptx, asymptomatic htn can turn out to be actual hypertensive emergency (hardly ever) on further history, and back pain could be aaa, cauda equina, etc.

While I always do my best to give the benefit of the doubt and treat every person with empathy, dignity, etc, allowing yourself a momentary internal eye roll when reading the bizarre or clearly non-emergency complaint prior to walking in the room is important for your sanity and also for your ability to suppress these feelings in the room.

Nope. Wasn’t trying to shame them.
Didn’t know they were a resident.
I’ve been posting on these boards for awhile and I think in general when it comes to medical stuff I’m not trying to shame anyone. Just trying to learn, hence why I asked about depo earlier in the thread.

Like I said I’m not an EM doctor, but am on these forums to learn, to ultimately help my patients.
Obviously I never tell my patients to go the ED for "stupid stuff," but if you all are rolling your eyes about something I’m not aware a patient should not be there for then that’s good to know. Or it’s also helpful for me to counsel patients when they say "the ED didn’t do anything."

Maybe you’re used to other people ****ting on ED doctors and being holier than thou, but you shouldn’t assume that about everyone. I read these posts and ask questions to learn.

 

[AMEHigh]

The chances that someone that age with normal vitals and a Cheif complaint of pelvic pain will have some emergent pathology necessitating a trip to the ER is low.

More likely they

1) could not be bothered to wait a day to see their primary or OBGYN for an issue that’s better managed by that person

2) have a chronic issue that I either can’t diagnose or can’t treat appropriately in the ED.

Like Batman said above that’s not to say I won’t see and evaluate anyone who walks in, give them the benefit of the doubt, do my best to rule out badness, and treat them with respect and dignity.

In both scenarios 1 or 2, I’ll end up providing some sub-optimal treatment with no proper follow up...and my OBGYN wife will make fun of me for not knowing how ovaries work when I tell her about it over dinner.

Thanks for the explanation.
I do a lot of gyn care. Most of my patients who have pelvic pain I obviously do a work up, sometimes it takes time, especially if I need to get imaging. The few times that those patients have ended up in the ED, it’s for uncontrolled pain and it’s either been a cancer finding, ovarian torsion or a very large cyst that seemed to have recently ruptured.

I was genuinely wondering what exactly was eye roll worthy so that I can help my patients and learn. I obviously try to tell people not to go to the ED except for xyz reasons but obviously as you all know that doesn’t always happen.

 

[The Knife & Gun Club]

Thanks for the explanation.
I do a lot of gyn care. Most of my patients who have pelvic pain I obviously do a work up, sometimes it takes time, especially if I need to get imaging. The few times that those patients have ended up in the ED, it’s for uncontrolled pain and it’s either been a cancer finding, ovarian torsion or a very large cyst that seemed to have recently ruptured.

I was genuinely wondering what exactly was eye roll worthy so that I can help my patients and learn. I obviously try to tell people not to go to the ED except for xyz reasons but obviously as you all know that doesn’t always happen.

I know you weren’t. Are you GYN? Gyns work like absolute dogs at our hospital, if there’s a way I can help them out I try to do it. Send some fancy tumor marker that won’t come back for 2 weeks? Quick POCUS to diagnose fibroids and speed up follow up? Happy to do it if people aren’t actively dying in the trauma bay.

A lot of specialists tend to have selection bias so they only see the people that come to the ED and actually have pathology. They never hear about the 3am “pelvic pain” which is really just a 20-something fishing for a free pregnancy test because they didn’t want to spend $15 at the 24 hour CVS.

 

[dadaddadaBATMAN]

Nope. Wasn’t trying to shame them.
Didn’t know they were a resident.
I’ve been posting on these boards for awhile and I think in general when it comes to medical stuff I’m not trying to shame anyone. Just trying to learn, hence why I asked about depo earlier in the thread.

Like I said I’m not an EM doctor, but am on these forums to learn, to ultimately help my patients.
Obviously I never tell my patients to go the ED for "stupid stuff," but if you all are rolling your eyes about something I’m not aware a patient should not be there for then that’s good to know. Or it’s also helpful for me to counsel patients when they say "the ED didn’t do anything."

Maybe you’re used to other people ****ting on ED doctors and being holier than thou, but you shouldn’t assume that about everyone. I read these posts and ask questions to learn.

Honestly more a misidentification.

There’s a few people that like to follow these threads purely to go on long rants about how we don’t understand chronic pain and how Dr. ED never did anything for them, etc

I thought I recalled your user name as on of the ones that did this regularly.

I have incredibly low expectations in general both for patients and outpatient offices: mostly because I assume the patient often misinterprets what was told to them in the outpatient setting.

I can’t tell you how many times I have called someone “sent by my doctor” who’s doctor hadn’t talked to them in three weeks when I call. Eventually I find out the medical assistant or someone else in the office who was tired of them calling told them they needed the ed or whatever.

Chief complaints that I do wish would get filtered from the office:
1. Asymptomatic hypertension (they told me I would have a stroke!)
2. Covid testing
3. Flu like symptoms in years where it circulates
4. Medication refills
5. Depression without si

Pretty much anything else you want to send to me I won’t even think about. The above will earn you a silent place on my **** list, which I will promptly forget ten minutes later.

 

[JacobMcCandles]

Chief complaints that I do wish would get filtered from the office:
1. Asymptomatic hypertension (they told me I would have a stroke!)
2. Covid testing
3. Flu like symptoms in years where it circulates
4. Medication refills
5. Depression without si

Pretty much anything else you want to send to me I won’t even think about. The above will earn you a silent place on my **** list, which I will promptly forget ten minutes later.

These don’t really bother me as they’re easy dispos. It’s the patients that are strictly sent in for particular tests/imaging that they don’t need or could be done as an outpatient. I mainly feel bad for the patient and their unnecessary bill. If a patient gets upset because their doctor sent them in and they don’t require any testing, I usually include information for a new PCP in their discharge paperwork.

 

[dadaddadaBATMAN]

These don’t really bother me as they’re easy dispos. It’s the patients that are strictly sent in for particular tests/imaging that they don’t need or could be done as an outpatient. I mainly feel bad for the patient and their unnecessary bill. If a patient gets upset because their doctor sent them in and they don’t require any testing, I usually include information for a new PCP in their discharge paperwork.

I tend to be very careful doing this, because you’re starting what I view as an unnecessary fight and because often patients don’t know why they were sent.

Might have a shortness of breath sent for pe who then denies symptoms, turns out they have nephrotic syndrome they don’t know about, or suspected malignancy, or whatever.

Between the outpatient doc and the patient I tend to trust the outpatient doc...as long as it’s actually the doc

 

[JacobMcCandles]

I tend to be very careful doing this, because you’re starting what I view as an unnecessary fight and because often patients don’t know why they were sent.

Might have a shortness of breath sent for pe who then denies symptoms, turns out they have nephrotic syndrome they don’t know about, or suspected malignancy, or whatever.

Between the outpatient doc and the patient I tend to trust the outpatient doc...as long as it’s actually the doc

It's quite easy to see which ones were sent in because they're actually worried about something and which ones were sent in because it was 4:30pm.

 

[DoctwoB]

I get that this is the "right" answer at ABEM general or for oral boards; however, I have worked at 6 different hospitals, and I have NEVER encountered an OB/GYN who would take a patient like this immediately to the OR for diagnostic laparoscopy without imaging already done. Perhaps in some academic centers where the residents need procedures numbers and staff is readily available (business hours, etc.) "Diagnostic surgeries" of any kind without imaging are going to be very unusual in a community hospital and you better be ready to trade your own kidney to get it done.

Urologist here. I’ll take an obvious testicular torsion to the OR without imaging. I take call from home though, so usually by the time I’m in the hospital they’ve had imaging. I do appreciate the “he’s down in imaging now but 99% sure we got a torsion here” call though.

 

[AMEHigh]

Honestly more a misidentification.

There’s a few people that like to follow these threads purely to go on long rants about how we don’t understand chronic pain and how Dr. ED never did anything for them, etc

I thought I recalled your user name as on of the ones that did this regularly.

I have incredibly low expectations in general both for patients and outpatient offices: mostly because I assume the patient often misinterprets what was told to them in the outpatient setting.

I can’t tell you how many times I have called someone “sent by my doctor” who’s doctor hadn’t talked to them in three weeks when I call. Eventually I find out the medical assistant or someone else in the office who was tired of them calling told them they needed the ed or whatever.

Chief complaints that I do wish would get filtered from the office:
1. Asymptomatic hypertension (they told me I would have a stroke!)
2. Covid testing
3. Flu like symptoms in years where it circulates
4. Medication refills
5. Depression without si

Pretty much anything else you want to send to me I won’t even think about. The above will earn you a silent place on my **** list, which I will promptly forget ten minutes later.

Nope, wasn’t my username that goes on long rants about the ED.
And nope have never sent a patient to the ED for the reasons you mention.

I do work with obgyns and midwives and they def seem more freaked out by elevated blood pressures and have mentioned to me in passing about telling a patient to go to the ED for 180s/100s in non-pregnant patients, so I’ve slowly been educating them and told them, no don’t tell them to go to the ED. Also, we can blame the fact that people are afraid of getting sued, which is a legit threat.

I know you all don’t want to be seen as the dumping ground, but most doctors are trying to do their best and help patients. So I don’t necessarily blame them for being freaked out by a high blood pressure if they’re not used to seeing those numbers and haven’t been in training of general medicine in 10+ years.

 

[GeneralVeers]

Urologist here. I’ll take an obvious testicular torsion to the OR without imaging. I take call from home though, so usually by the time I’m in the hospital they’ve had imaging. I do appreciate the “he’s down in imaging now but 99% sure we got a torsion here” call though.

Glad you do the right thing by patients. You are one of the rare ones. None of my urologists would touch a testicle (or even come in) until the imaging is done.

 

[bravotwozero]

Am I the only one where if you order Haldol, the nurses get all pissy because "its a chemical restraint" and requires them to do more charting?

Fortunately not a problem at any of my shops. I may occasionally get a raised eyebrow from a rookie nurse when I order it for vomiting, but the veteran nurses can smell cray cray from a mile away and are grateful when I give it to these patients.

 

[WilcoWorld]

Fortunately not a problem at any of my shops. I may occasionally get a raised eyebrow from a rookie nurse when I order it for vomiting, but the veteran nurses can smell cray cray from a mile away and are grateful when I give it to these patients.

It's a drug that I'll talk to the patient and nurse about ahead of time. If I explain that it's a very effective antiemetic, everyone's cool with it. If I just order it without saying anything, about 50% of the time I'll get questions/raised eyebrows.

 

[JacobMcCandles]

If I just order it without saying anything, about 50% of the time I'll get questions/raised eyebrows.

Your department isn't ordering it enough then.