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THIS
This is why applying principles of market-based capitalism to healthcare doesn't work.
Another way to look at the problem with our “specialty”
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This is why applying principles of market-based capitalism to healthcare doesn't work.
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Most abscesses in the ED are empirically drained. Occasional bedside US, but otherwise rarely formal imaging.
This is so low on my list of medicolegal concerns.
Why would you ever want to catch it?
Abscesses essentially never have that much pus.
Yeah, we drain more abscess in the ED than almost anyone else. We know abscesses. You sound early on the curve.
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I think you mean “fellow”. Guys, we got a wild Jenny on our hands here
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Lol at breaking up all the loculations... Unless you did everything under real-time image guidance (which is just not standard or common practice unless you are IR) you can never be sure you "broke all the loculations".
A tiny amount of loculated infection can be treated by antibiotics, just as, tiny abscesses "too small to drain" seen on imaging are treated with antibiotics.
A tiny amount of loculated infection can be treated by antibiotics, just as, tiny abscesses "too small to drain" seen on imaging are treated with antibiotics.
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I guess I am a little late on abscess train convo but I too am unsure why all abscesses need US guidance or needs to be sent to ER. Any abscess that is not on face, hands, breasts, genital, or pilonidal region can be done in office. At least as long as you have an 11 blade, gloves, and some lido w/ epi. And unless its a large abscess, I think current guidelines rec against packing 2/2 no real improvement in outcomes and with very likely increased amount of pain suffered by the patient due to our overzelous nature of packing holes.
And yes, it pays half decent as a complicated abscess w/ a 99213 attached.
And yes, it pays half decent as a complicated abscess w/ a 99213 attached.
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This!
Plus in the end, if we can fix their problem, patients are often unsatisfied because the result isn’t what they expected. “This G tube doesn’t look like my old one”. Sorry?
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I love a thread about the future of our specialty turned into "how do you &$@*(! treat an abscess".
What do you think happens to abscesses without EM physicians, antibiotics, and ultrasounds? Are they invariably fatal? In normal substrate, they spontaneously drain or can be lanced to expedite the process. Do it yourself at home, done and done. So much over-medicalisation and over-triage of simple problems in modern medicine.
Back to the major issue voiced by the OP – I get his point. 95% of chest pain cases can be safely managed with an algorithm. 95% of sore throats are bland. 95% of respiratory complaints are fairly straightforward. Argue about the precise percentage, but there is diminishing added value from a board-certified EM physician for many cases versus a generalist or a nurse specialist. Other countries *do* have emergency physicians, but they don't routinely staff their EDs with a full panel of board-certified physicians like hospitals in the U.S. – midlevels, trainee house staff, registrars, etc. with supervision. There are absolutely generalisability issues for this model to the U.S., but the underlying principle could be the same.
What do you think happens to abscesses without EM physicians, antibiotics, and ultrasounds? Are they invariably fatal? In normal substrate, they spontaneously drain or can be lanced to expedite the process. Do it yourself at home, done and done. So much over-medicalisation and over-triage of simple problems in modern medicine.
Back to the major issue voiced by the OP – I get his point. 95% of chest pain cases can be safely managed with an algorithm. 95% of sore throats are bland. 95% of respiratory complaints are fairly straightforward. Argue about the precise percentage, but there is diminishing added value from a board-certified EM physician for many cases versus a generalist or a nurse specialist. Other countries *do* have emergency physicians, but they don't routinely staff their EDs with a full panel of board-certified physicians like hospitals in the U.S. – midlevels, trainee house staff, registrars, etc. with supervision. There are absolutely generalisability issues for this model to the U.S., but the underlying principle could be the same.
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Yea I hate that, happens all the time too
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I'm a family medicine resident. I'd love to do simple I and Ds. The problem is no office has the equipment and capabilities to deal with complications. Lidocaine overdose, anaphylaxis, major bleeding. The ED is a space ship compared the PCP office. Can you imagine the outcry when something goes wrong and the PCP doctor can't manage it. Why start a procedure when you know you won't be able to manage the complications.
Fair enough, but, what are the chances of an aberrant artery that you might cut while doing your I&D? I mean, I remember once in residency when there was an abscess directly over the femoral artery. I thought it was manageable, but, my attending was losing her sht. So, we punted and called surgery.
As for lidocaine overdose, well, if you do that from a local, then, my friend, that's just malpractice. Likewise, anaphylaxis? That's one of the true, literal emergencies. That's rare enough that I wouldn't be expecting it with every anesthetic.
I see everything you say, but, as a competent FM doc, I'm confident in your excellent training, that, if something did occur, you could manage it effectively until further help arrived. And, trust me, if the pt showed up to the ED, with the allergic reaction or bleeding controlled, I would (not literally) kiss your feet.
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I do kyphoplasties, spinal cord stimulators and epidural steroid injections in an outpatient office I share with PCPs, and I'm not having any catastrophic outcomes. How come you're having them with simple I&Ds?
I get not wanting to do procedures in primary care, where high volume patient flow is King. But let's not act like we're doing a heart transplant when it's a glorified zit popping.
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Dentists use lidocaine all the time, have a risk of hitting a pretty large artery, and have less training at dealing with emergencies than FP's do.
The only reason FP's don't have the equipment is because they didn't order it. My FP does I&D's. I know because he knows I'm an ER doc and he was talking about a pilonidal abscess he did earlier in the day and was regretting not having any suction equipment available.
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If I remember correctly; Leon is in Europe, where everything including spoons is considered a deadly weapon. So, I see how lidocaine and #11 blades could be hard to come by.
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Fellow in what?
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I never really fully understood why people freak out about lidocaine and arteries.
I've seen 10cc of 2% lidocaine get pushed IV because someone picked up the wrong syringe and used it as a flush; thinking it was saline instead.
You know what happened ? Nothing.
I mean, we use it to break V-tach, after all.
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My guess is something like Scandinavian Pediatric Oncology, or something like that.
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Lidocaine over dose?
Come on guys.... That's perfectly under your control. It doesn't just happen out of no where.
Major bleeding????? I mean come on!!!!
Most abssesses that come to the ER are quarter sized, no one will die from complications of popping it.
This is just so hilarious.
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I would never want a physician to do something/a procedure they are not comfortable with, but what you're saying just sounds...I don't now how to say it without sounding like a jerk....crazy. I'm not trying to be a jerk I swear.
Disclaimer: I'm a dermatologist, not FP or EP.
Lido overdose:
Follow that and document amounts. Could a rare untoward thing happen? Sure, but we are physicians. Part of our every day jobs include some amount of risk taking. I have been practicing for 5 years (with about 20 colleagues) and have never heard of a lido overdose happen...and we're sticking lidocaine in probably 10 or so people a day each sometimes.
Anaphylaxis? I suppose, but again, see above about some amount of risk taking. When you weigh the risk to benefits, it is so much more cost effective for one to just drain an abscess in office than to send to an ED. Could an anaphylaxis happen? I guess. I think every good office should have a crash cart of some sort if they are not close to an ED. Just know how to recognize Vasovagal and now how it's different than anaphylaxis. If you do any procedures in your office you WILL have people vasovagal. The first time it happens, it seems like the end of the world...after that it's like, ok, this is a little blip in my day..no worries...nurse, can you get this pt in trendelenberg, get them some water/juice, and sit with them for 15 or 20 mins?
Major bleeding? from what? if you have an abscess on an abdomen or forearm, or back I'm not sure how that would happen with a simple I and D. I think out of 5 years I have heard of one of our patients having to go to the ED for bleeding (someone tagged an artery on the ankle...maybe peroneal? from doing a DEEP biopsy (not a simple I and D). If you have a hyfrecator in your office and some hands to hold pressure, you should be good in almost all instances.
Again, I'm not at all advocating for people to do any procedures they are uncomfortable with doing. However, the risks you list are so rare to happen. We as non ED clinicians should really be taking those risks (SUPER DUPER UPER low risks) so we can keep these pts out of the ED and let the ED docs take care of more acute issues.
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This…. is sad.
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I think the OPs post is a great example of what happens in someone’s training when their quotes adverse events to use them as an excuse for not doing something, and the trainee never questions the probability of that happening and their ability to deal with the complications.
Trainee: “Why don’t we do IDs in the office?”
Attending: “Are you prepared to manage a major hemorrhage? What if they become septic? What if they get lidocaine toxicity??? Man you’re going to get someone killed.”
Trainee: “OK!” Then repeat the same dogma 100 times to other trainees.
I had this happen to me recently when I was working with trauma surgery. PGY7 Senior resident wigged out that I did a blind fem stick for blood because of the “risk of pseudo aneurism formation.” Like yes that is concern #107 on my list and I’m fairly confident I know how to hold pressure, and luckily I have the vascular surgery residents computer station literally 3 down from mine.
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I had a visceral reaction to this and was going to jump on the train denigrating you, but then I realized that this is the same sort of logic employed by ED docs all the time to defer low risk, in-scope procedures to other specialists. Things like paras, small joint taps, etc.
“Healthcare”
I am fine with you sending me any procedure you are not comfortable doing. I&d takes me less than 5 minutes majority of the time.
but just to address some or the ludicrous points from the other poster and a few of yours that raised my eyebrows
1. To get a lidocaine overdose you really have to work at it. It is literally given in infusion forms inpt. Look up the max dose, don’t ever give close to it (not remotely difficult to avoid, esp with epi)
2. given your concerns regarding anaphylaxis I will assume you have never prescribed bactrim, cephalexin, or any other medication essentially? Any one of those could cause anaphylaxis…and it could happen at home! The horror!
3. major bleeding: don’t do it over a damn artery. If you aren’t sure, just send it to us. It’s not like it’s any different than the standard
4. You can buy a pack of scalpels for like $10 on Amazon. Lidocaine is mostly showmanship and for the stabby stabby, because pressing out he pus hurts like a b*tch anyway. I can and have drained many abscesses without local, it isn’t a big deal in the non-anxious (now vanishingly rare admittedly)
5. to the other poster 500 Cc of pus is ludicrous. I am not touching anything that big, it needs the OR not the ed. Send this to us since we are apparently now the only way to be admitted.
most abscesses have like 3-10 Cc of pus if they are large.
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I don't think I've ever done an I&D that had complications. A few times I've done one and it was incomplete and they went to the OR within the next few days.
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This thread has been interesting with the outside commentary. Most FPs I know are a little more comfortable with procedures than what's displayed here, but I digress..
As posted on page 1, I totally don't mind being sent abscesses; they're quick, easy, require no testing, bill well, and the patient is generally grateful afterwards.
But PCPs please just be honest with the patient and state, "It looks like you need an incision and drainage, and that's not a procedure I perform in the office." or something rather than make up some excuse about not having proper equipment available.
I rarely order any testing for abscesses (no matter how big they are or where they're located) and it's much harder to do my job if a PCP tells the patient they're being sent to the ED for a test that isn't indicated. Be aware that if you send a patient to the ED for "a CBC, CT scan, and sedation in a procedure room" there is an excellent chance that the I&D will be performed in a hallway bed with no testing, an 11 blade, and the 5cc of lido that comes in the lac tray for analgesia..
As posted on page 1, I totally don't mind being sent abscesses; they're quick, easy, require no testing, bill well, and the patient is generally grateful afterwards.
But PCPs please just be honest with the patient and state, "It looks like you need an incision and drainage, and that's not a procedure I perform in the office." or something rather than make up some excuse about not having proper equipment available.
I rarely order any testing for abscesses (no matter how big they are or where they're located) and it's much harder to do my job if a PCP tells the patient they're being sent to the ED for a test that isn't indicated. Be aware that if you send a patient to the ED for "a CBC, CT scan, and sedation in a procedure room" there is an excellent chance that the I&D will be performed in a hallway bed with no testing, an 11 blade, and the 5cc of lido that comes in the lac tray for analgesia..
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I think the logic is more about petting burning dogs. It’s not that I’m worried about bleeding or iatrogenic septic arthritis so much as I am having the ER turn into the procedure suite of choice for literally everybody. Once people start treating the ED as an IR suite you don’t have to schedule or get pre authorized you start having a lot of nonsense that requires an inordinate amount of physician time.
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They already do this at most of my hospitals. After 4PM the floor and ICU demands we go up and put vas-caths, lines, and chest tubes in everyone, not to mention intubations. It's not fair to force one lonely ED doc to do all this after midnight. I politely decline everything except the intubations.
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Forget that stuff, the ER is already exactly that for nursing home patients, those with a broken widget, and those who want *whatEVer* at all hours.
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This is why I laugh when people say we can't do primary care. Yes we wouldn't be super good at it at first but the nature of the ED we deal will a lot of stuff like HTN, widgets, psych, calling and dealing with multiple specialists in real time and so on.
well yeah, but we all hate it because
1. It’s not what we trained to do
2. We do a crappy job at it and we damn well know it
that self awareness is the reason we don’t hang a shingle.
I could probably be a passable fm doc after a few years, but I’d hurt a fair number of folks in the process and I bet I still would t be as good as if I did a residency in it
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Come on, seriously!?
If these are your reasons for not managing something then by that logic you shouldn't be managing hypertension, diabetes, repairing lacs, or pretty much doing any medicine at all because most procedures use some form of anesthesia and most medications can cause anaphylaxis!
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Anesthesiologist here. I've had a few cases of anaphylaxis. Mostly those that happened right after ancef and 2 that I suspect was from paralytic. I have done several thousand cases and I haven't seen any reaction to local. Only had one patient come in to pain clinic with documented allergy to local from an allergist.
I've also had one patient given bactrim on my ed rotation as an intern. Watched him for a while and then discharged. He came back an hour later hypotensive and needing fluid/epi but ended up ok.
I've also had one patient given bactrim on my ed rotation as an intern. Watched him for a while and then discharged. He came back an hour later hypotensive and needing fluid/epi but ended up ok.
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I am just a pharmacist so I can't comment on much of this other than the risk of lidocaine OD - there is a simple calculation you can do prior to administering it - I get asked to do it on occasion for our docs/PA - you have to use a quite a bit before it becomes a problem (I have never seen someone need anywhere near the max for an abscess thou).
I have seen one sad case of a rxn to a local anesthetic (marcaine I think) from an OB office when they were placing an IUD - they said anaphlyaxis vs inter-arterial injection (I don't know the anatomy there if that is possible or not) that lead to cardiac arrest.
But I did grow up on farm and my dad often would drain an abscess on one our pigs using a pocket knife that he dipped in alcohol and then sprayed the wound with iodine. It was actually quite satisfying to see the amount of puss you could get out of one. He barely graduated high school and rarely had any complications, and good thing is the pigs wouldn't sue if something bad happened.
I have seen one sad case of a rxn to a local anesthetic (marcaine I think) from an OB office when they were placing an IUD - they said anaphlyaxis vs inter-arterial injection (I don't know the anatomy there if that is possible or not) that lead to cardiac arrest.
But I did grow up on farm and my dad often would drain an abscess on one our pigs using a pocket knife that he dipped in alcohol and then sprayed the wound with iodine. It was actually quite satisfying to see the amount of puss you could get out of one. He barely graduated high school and rarely had any complications, and good thing is the pigs wouldn't sue if something bad happened.
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This is why I admit all simple I & Ds to the surgeon so they can drain them in the OR. The patient might require the anesthesia team.
but the surgeon usually just wants me to call life flight and have the patient choppered out to a tertiary care center since we don’t have a SICU here.
These are unnecessarily harsh, even if in jest.
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Not really.
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Lol, I think everyone’s made their point quite clear.
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Your excellent EM training.
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Had an FM PGY3 in the peds ER doing an big thigh lac. Poked my head in and see TWO 10 mL vials of lido w/o epi drained on the table. Said he’d used all of it. You should probably let boss man know about that one dude, that’s a lot of lido.
Dude was completely unaware there even was a max dose for lidocaine. We went to med school at the same place, and I’m sure this was covered at least a few times.
200 mg of lidocaine, into a 15kg child… 13 mg/kg.
Kid was fine, said their tongue felt fuzzy, but fine. Attending called poison and admitted the kid for obs.
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That violates the golden rule of medication administration. If you’re needing to grab a second vial/bottle, stop and ask yourself if you’ve ****ed up some calculation.
As an aside, 20ml into a 15kg kid? Did he have to sew the kids leg back on or something?
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Thanks.
You know; that's the kind of thing you learn in.... what's it called... ?
That thing.... that PLPs don't do... but they think they get certificates for it and stuff...
Oh yeah ! - RESIDENCY !
THAAAT was it.
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Seriously, every time I read some post either on here or Reddit or whatever about some PLP getting a "certificate"; my brain immediately goes here:
(Edited for funnier photo that more accurately depicts what goes on in my head).
That's Jenny McJennyson, ABC-123-NP; second from left - proudly displaying her "certificates".
(Edited for funnier photo that more accurately depicts what goes on in my head).
That's Jenny McJennyson, ABC-123-NP; second from left - proudly displaying her "certificates".
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Large superficial laceration running vertically down the thigh. Very long but not very deep, just deep enough for sutures for cosmetics. Could have been done with far, far less lido.
How anyone gets through med school and 3 years of residency without learning about lidocaine toxicity, the dangers of using adult meds in peds, or how to properly numb and close a lac is beyond me.
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Agree with points above that you have to be aware of local anesthetic toxicity. I’ve personally never seen it and essentially never think about it anymore though. If you need more than a 10 cc syringe then it’s time to start thinking about if a nerve block or sedation would just work better.
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LOL at the massive derail. I am not going to lie, I found the initial topic very interesting, and am a little disappointed at the turn towards abscess management!
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Those pigs need a better lawyer
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Because you have an "M DEE" after your name. You learned this kind of stuff, along with about 2,340 other little factoids because you paid $200,000 over 4 years to read about 15 different books, go to school and study 80 hrs / week, and then get tested on it over and over and over and over and over
"M DEE"
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At one of my ER's, the ED / ENT was numbing a guys throat to do a PTA or direct laryngoscopy or something. I can't remember the procedure. They gave nebulized 4% lidocaine and put lido directly on the tongue. Maybe they even numbed the back of the throat with a needle. I don't recall the specifics but I do recall the pt developing uncontrollable seizures, needing intubation and ICU admission.
You are SUCH a buzz kill!
