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Chest pain case

Discussion in 'Emergency Medicine' started by Penguin10, Aug 7, 2015.

  1. Penguin10

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    I'm an NP who saw the following patient as an outpatient and referred him to ED for evaluation. The ED MD work-up diverged significantly from what I expected, making me think my pre-test for various problems was out of whack.

    I'm interested in what your ddx and work-up would be for this case? Appreciate your feedback.

    A 28 y/o male without significant past medical history was awoken from sleep around 3 a.m. by a left sided chest pain. Pain was continuous, worse with deep breath and with movement. No cough. No SOB at rest.

    He rides bike as his only means of transportation and found that when he rode later in the day his pain increased and he felt very short of breath. After getting out of bed he noted that he felt lightheaded at times while up and moving around. In the early afternoon he developed a fever to 101 F. I saw him after no improvement at at about 19:30.

    No hx of similar. No personal or fhx of DVT, PE, PTX, lung disease. No DVT risk factors. No regular meds. Took some type of herbal remedy for fever.

    PE:
    T 101, HR 94-97 (he thinks his resting HR usually 60-70), RR 20, BP 96/64 (usually 120s systolic), SPO2 96-97% on room air at rest.

    NAD. I though maybe his external jugular veins were a bit prominent at 90 degrees. RRR, no murmur. CTAB. His right calf may have been slightly larger than left, but no obvious sign of DVT.

    In the ED he was still febrile, initial HR 104 bpm, BP 104/64, otherwise comparable vital signs.
     
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  3. Gadofosveset

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    1. Tuberculosis
    2. Tuberculosis
    3. Tuberculosis
    4. Lyme disease
    5. if altered --> Nutmeg poisioning
     
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  4. Birdstrike

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    In regards to this hypothetical, fictional patient, and considering that without examining said patient I cannot be absolutely certain what I would do:

    Considering known baseline vital signs, you have a patient with relative hypotension, tachycardia, and pleuritic chest pain.

    Absolutely, rule out PE. CBC, CMP, troponin (not so much for MI but because myocarditis/pericarditis) can present like this in young people) ekg, and chest X-ray.

    If chest X-ray is negative for pneumothorax, definite lobar pneumonia or other definitive diagnosis, then CT chest with contrast (assuming appropriate creatinine) with PE protocol (atalectasis or other non-specific Cxr findings would not stop me from ordering the ct).

    However, did you call the ED physician and give him this obvious PE rule-out all wrapped up nice with a bow on top, like you did in your post, or was it one of these "Go to the ER" things where the guy shows up and tells the ER doctor, "I'm fine doc. My nurse practitioner said it's definitely rib inflammation or pleurisy. When can I go home"?

    Communication

    Communication

    Communication

    If you want a specific diagnosis ruled out, call the ED, speak to a specific doctor, get his name, and put it down in your office note with what you told the doctor needs to be ruled out. Otherwise, just saying, "Go to the ER" assures you of nothing. There's so much that can go wrong, and so much that can get miscommunicated between your words, the patient, to the triage nurse and whichever doctor sees the patient, if the patient ever even shows up or sees someone who got your intended message, at all.
     
    #3 Birdstrike, Aug 7, 2015
    Last edited: Aug 7, 2015
  5. dotcb

    dotcb ---------
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    I would start w/ EKG and CXR and see what they show. If normal, I'd consider blood testing and r/o PE.
     
  6. b-real

    b-real What, me worry?
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    So what was the ED work up and dispo?
     
  7. princekc

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    ^^ so what was it?
     
  8. emergentmd

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    Not reading anyone else's response and this case has a variation of workups. If it were me, I am quite sure it is not cardiac. Sounds infections/pulmonary/ maybe PE.

    Me?

    1. CXR/CBC/EKG. May throw in Trop but don't think needed
    2. If everything neg, CXR neg for pneumonia, then CT chest PE protocol.
    3. If that is negative, call it a bronchitis, throw him a ZPAK.

    doing this, I would be able to sleep well at night.

    Other thoughts is pericarditis. I would warn him if he doesn't feel better in a few dys, here is cards number for an ECHO.

    But this really all depends on my instinct. If dude looks fine, texting on the phone, eating a Big Mac, watching TV then its a CXR/EKG then dispo with ZPAK

    If dude looks legit and hates going to the doctor, I would bring it all the way to a CT chest with SED rate, MI panel, CPK, call cards for a follow up in 2 dys
     
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  9. Zebra Hunter

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    Why would you give him the specific dx of bronchitis and then give him abx?
     
  10. Apollyon

    Apollyon Screw the GST
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    I think it's sarcasm/reality as the path of least resistance.
     
  11. TooMuchResearch

    TooMuchResearch i'm goin' to Kathmandu...
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    I find that if I say antibiotics won't help but Decadron will make you feel better, almost everyone is fine with that.
     
  12. Birdstrike

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    It's a sacrificial offering to The Gods of Patient Satisfaction.
     
  13. link2swim06

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    Probably nothing but I'd want to gather enough evidence to r/o pericarditis, myocarditis, pneumonia, and PE for this age bracket.

    I'd start with EKG and CXR.

    The worst case scenario imo is he is in early cardiogenic shock from acute myocarditis that you could miss, let him go home and die. Although you can r/o this out with a good exam and/or with basic labs and an ultrasound probe.

    Of course you don't want to send him home with a PE either but, i'd be +/- on a d-dimer, it would depend on my level of concern after talking to him. He is PERC negative...


    Probably getting fluids (PO or IVF) and going home with motrin with a diagnosis of "chest pain."
     
    #12 link2swim06, Aug 8, 2015
    Last edited: Aug 8, 2015
  14. TimesNewRoman

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    The problem with this is that you are not appropriately applying Baysean statistics. PERC criteria are intended for people you are confident don't have a PE - people who's pretest probability is so low that you think you are going to do harm by ordering unnecessary tests. I don't think that's him.

    Besides, his ED triage VS actually are tachycardia, i.e. not PERC neg.

    You can't say you are confident that he doesn't have a PE. You have a previously healthy patient with acute onset pleuritic chest pain, dyspnea, tachycardia, relative hypotension, borderline large leg, high/normal respiratory rate. Sounds like a PE is fairly high on his differentially. Arguably even equal probability as other diagnoses - and if you're going to say that, you're actually already to a moderate risk on Well's....(probably a stretch, but still).

    We're in the business of finding rare diseases that could kill patients. You have to rule out a PE in this patient. And FYI: I tend to be fairly test averse.
     
  15. link2swim06

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    Didn't see the initial HR...regardless there are other things that are much higher than PE in the diff dx. He would be a person that a negative d-dimer would r/o PE for me. I originally said I'd be +/- on the dimer because I'd have to see how much I believed this guy in person first. I'd argue a PE, in a 20 something year old male is unlikely unless there is more to the history. He has no risk factors and although it certainly happens it is not the most probable diagnosis. It's most likely going to be a musculoskeletal or the start of a viral illness or something else.

    I'd be pretty surprised if it turned out to be a PE. For a PE to be big enough to make you nearly hypotensive I'd expect more tachycardia and more hypoxia. Also if he is going to be febrile from a blood clot then why did he suddenly become febrile when it embolized and not when it was a DVT (presumably growing over the past few days)? Also only the calf is swollen (maybe?)...so this is a calf DVT (which almost never make clinically significant PEs) or are we saying this is a proximal DVT and we only noticed the calf swelling on exam? PE is certainly on the diff dx, but infection is higher imo.

    PE and myocarditis are the two big can't misses for this case but I suspect he probably is tachy because he is febrile and dry, he has a RR of 20 because that's what lazy triage nurses document, and he has pain from a viral illness.
     
  16. filhodeinferno

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    Fever, tachy, hypotension, CP...

    I'd start with CBC, BMP, EKG, Trops, VBG w/lactate, CXR. 1 L bolus and see how vitals respond. Probably add a dimer with intention to CT if positive since leg swelling and SOB.

    If labs negative, vitals improve with fluids I'd be comfortable calling it viral or bronchitis or bull crap. Wouldn't be surprised to have some positive findings with this guy.
     
  17. emergentmd

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    From my years of experience, our pt population is not the smartest. Although not the best practice, my life is much easier. Let me explain pts that comes into the ED with a cough with +/- fever

    1. I tell them they have a viral infection, they give me a look like "WTF... I spent 2 hrs here and got nothing but a lecture on why I don't need the abx I came here for". They leave unhappy. It is a viral infection, they get better in 3 dys. The still are not happy that they didnt get their abx

    2. Same pt goes home with a viral infection, gets superimposed bacterial bronchitis, sick for 5 dys. Goes to another ER/PCP get abx. They get better. They complain or what their bills written off

    3. They have a bacterial infection, I don't give abx, they get worse or pneumonia. I am really screwed.

    Amoxil/zpak is my friend. Everyone leaves happier. Unless I am very sure its viral, I throw them some abx and everyone is happier.
     
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  18. emergentmd

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    Back to the case. I know we all learned of PERC. Ottawa Ankle.... blah blah blah. Great to recite on tests or make you feel smarter. Useless in real medicine.

    Follow PERC and YOU WILL miss some PEs. 1 missed PE a year and you will have that following you forever.

    If dude looks legit and has not come to the ER much for anything, he is getting everything including CT chest. With the CT chest, I essentially ruled out everything IMO other than myocarditis/pericarditis. Add a CK, CKMB, sed rate and this myo/peri goes down even further. If he goes home and he ends up with peri/myo then I don't think many can blame me for sending him home esp if i give him cards f/u in 2 dys.

    Labs, CXR, then CT chest. In my shop, I get this back in 2 hrs. I go home happy, he goes home happy. My risk of a bad outcome is very low. Use PERC and I would never be able to sleep at nights.
     
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  19. emergentmd

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    From my experience,

    1. I have had neg D dimers (even the sensitive ones) with Positive DVT/PEs. not many but 3-5 over past 15 yrs. I am not willing to take that risk. If I am concerned about a PE, he is getting a CT chest. I rarely order Ddimers. This dude assuming he is legit, had a decent risk for a PE IMO
    2. You can rationalize why he likely doesn't have a PE. I agree with you that out of 100, you may get 1 that is a PE. Trust me, you would sleep better doing a CT chest.

    Now if dude has 10 visits to ED in last year, is watching cartoons, asking when the next meal is, if he can go outside and smoke..... then dude is getting a zpak after a neg cxr
     
  20. dotcb

    dotcb ---------
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    The plural of anecdote is not evidence...
     
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  21. Birdstrike

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  22. Birdstrike

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    I love it when people recite that quote. And people love to recite that quote about "the pleural of anecdotes." It's a popular way to say to someone, "your stories don't mean anything to me" as a way to shut them down. But what is an anecdote, as told by a physician?

    It's an event, a clinical case, recited to others by a physician.

    What is the pleural of anecdotes?

    The sum of all the clinical cases and experiences you've had as a physician, ie, your experience as a physician which forms your clinical judgement.

    What is the absolute number one thing each and every physician bases just about every single clinical decision we ever make, on?

    They base just about all of their clinical decisions across all of their years on "the pleural of all their anecdotes" or the sum of their clinical experiences.

    Data people love to recite that quote. And they don't like it when someone says, "What a minute. I saw a patient that tells me otherwise. I've had clinical experiences that tell me your 'data' is incomplete or flawed." But God forbid, whatever you do, do not discount your own clinical experience and the "plural of your own anecdotes."
     
    #21 Birdstrike, Aug 9, 2015
    Last edited: Aug 9, 2015
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  23. link2swim06

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    Medico-legally aside, I don't think catching 100% of PE isn't necessarily a good thing. This means you are scanning a ton of people who don't have PEs.

    There are complications from anticoagulation therapy.
    There are complication of a CTA from radiation exposure (especially in women to breast tissue).
    There is possible anaphylaxis from contrast.
    etc, etc...


    Yes, you will have found all the PEs, but you will have created a whole lot of iatrogenic harm through the process.
     
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  24. shookwell

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    If he looked ok, ECG, CXR, NSAID, home.

    If he looked bad, maybe a troponin.
     
  25. emergentmd

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    If you are new attending, you will have lots to learn. Practice by the precise teachings of academia and you will be known as a terrible doctor. I dare you follow the PERC rule, ottowa ankle rule, blah blah bhah rule and you have many of complaints and bad outcome.

    Hold out on abx to most pts b/c its viral and your life will be full of complaints.

    Do I over order labs, CTs, give too much abx. Of course. If this saves me 2-3 suits, 20 complaints a year then to me its well worth it. Sorry..... just being practical.

    BTW.... I am well aware of the risks of rads, abx, etc.....

    Once admin and the lawyers tell me that I am bullet proof to practice true medicine and I would order 90% less tests.
     
  26. Birdstrike

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    My truth detector, SAYS.....



    This post is absolutely: True. These are the truths "evidence based medicine" falls flat on its face unable to reconcile, and largely ignores, regarding the real world. Unfortunate? Maybe. But true nonetheless. We didn't create the system we have to function in, but the quicker you learn how balance the unfortunate realities of it all, the better.
     
  27. filhodeinferno

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    I agree with you guys, and I'm sure once I am set loose in the wild as an attending I will tow the same line you do...however, as residents, I'm not sure how appropriate it is for us to be thinking this way. There is a time to sit there and apply the evidence and do things by the book, and that time is residency. Once we are out in the world worried about lawsuits and satisfaction scores we can start scanning and giving antibiotics to everyone who passes through the door.
     
  28. Birdstrike

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    Yes. Definitely go by the book in residency, on the Boards, etc.
     
  29. Tallerand

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    I'm really surprised by the people on this thread who went straight to a CTPE. I'm in agreement PE needs to be ruled out but this patient should be d dimered not get a CTPE. I think most people on here would say pneumonia is most likely diagnosis. The physical exam given states "no obvious sign of DVT." Thus this patient has a wells of 1.5(for tachycardia) and is low risk and appropriate for a d dimer. From both a patient safety and departmental flow perspective a d dimer is the appropriate test here. Additionally I would look for R heart strain on the EKG and a troponin bump(obtained for myocarditis) for massive PE to influence my decision making.

    If i wanted to test more and the exam was equivocal for DVT I'd do dopplers. Of course if there were signs of a DVT he'd be moderate risk Wells and despite evidence that we can do a d dimer with moderate risk wells score I would probably CTPE the patient.
     
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  30. traxus

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    I'm a new attending (one year out) and I practice by EBM as much as I can but use my gestalt to differ from the guidelines as well. For every PE rule out, I use PERC and Revised Geneva score to order d-dimer, CTPA as needed. Now, my perspective is that while I may miss one thing or another during the year and throughout my career as long as I have the appropriate evidence as to why I didn't do x,y, or z then I am appropriately covered medico-legally. I also practice in Texas.

    If I were to perform CTPA and CTs on most of my patients, then the department will crawl to a standstill and the waiting room will fill to the brim. There's a risk of keeping someone out in the waiting room and have them crump on you versus bringing them back into a room. I have partners who do that and that makes for a dangerous situation in an already packed department.

    That's my 2 cents.
     
  31. goodoldalky

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    I'd be suspicious for acute pericarditis as well. Did you do an EKG or radiograph before sending him to the emergency department? In reality I am looking at the EKG and CXR, and really that determines whether I'm doing anything else or sending him home.
     
  32. WilcoWorld

    WilcoWorld Senior Member
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    There are a lot of reasonable workups described above, but my guess is that this patient went home (with instructions to follow up within 72 hours), did fine, and didn't see a provider again for 5 years until he sprained his ankle.
     
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  33. iish

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    To the OP, what was the w/u done by the ED? How was it divergent from your expectations?
     
  34. TooMuchResearch

    TooMuchResearch i'm goin' to Kathmandu...
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    Here's the thing:
    1. Our attendings have the same lawsuit risk as those practicing without residents.
    2. Part of our attendings' pay is satisfaction and performance based.

    So if you can do it during residency without the bosses adding a bunch more tests than you want to order AND your bosses don't feel obligated to give everyone antibiotics for satisfaction scores, that means you can easily keep your same practice pattern beyond residency.
     
  35. goodoldalky

    goodoldalky Member
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    In general, the pressure of productivity and patient satisfaction is higher outside of an academic setting. You will learn that every job is different and will have different pressures and expectations, as a result local practice patterns and standards of care can vary.
     
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  36. emergentmd

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    I understand your delay issue. At my shop a bedside BMP + CT chest PE takes about 1-2 hrs. Thus the pt is dispoed with in 2 hrs. If I did a D dimer, it takes about 90 minutes. If its elevated even if my suspicion is low, I would then have to go to the CT. Ad another 1-2 hrs and they are in the ED for 3-4 hrs. So a BMP+CT about the same time as getting a D dimer. But this is a small issue IMO.

    I also work in Texas, I get the Med mal issue. I know its difficult to get sued. The problem is if a 30 YO healthy person dies b/c they had a PE with a neg Ddimer, PERC rule, then it would be indefensible. You might as well just pay out. Even if you go to court, do you realize how many hours you will have wasted in Deposition, delays, etc?

    I can see the lawyer now. "doctor, so if you have a neg D dimer, then the Pt can not have a PE?". There would be countless experts who would tell the jury (including myself) that I have had a handful of pts with a positive DVT/PE and neg D dimer.

    Anyhow, everyone has their own practice style. I prefer to avoid suits by sometimes over ordering tests when the time cost is minimal. BTW, my practice style can't be too bad/too much ordering as my doc to dispo/admit time is usually in the top 3 in my hospital. My sats are usually ver good. My amount of testing is on the low end. My RVU/pt on the low end.

    So i suspect I under work up most pts. But in this case, if dude looks legit.... pt getting a CT chest.
     
  37. Tiger26

    Tiger26 Senior Member
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    Disagree entirely--you guys must be getting CTs on every ankle and wrist sprain just to rule out an occult fracture as well.

    With low pretest probability and a negative dimer, you'll have every major PE researcher in the world on your side.

    Every reader of this forum has a PE at some microscopic level floating around in them right now--if you didn't, you'd be ebola hemorrhaging all over the place from your coagulopathy
     
  38. Birdstrike

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    I wish you were right, but you're dead wrong on this point. Please read about this case, where that should have happened, but didn't, with two of biggest names you could ever hope wouldn't take the other side, taking the other side:


    http://epmonthly.com/article/gross-negligence-a-slippery-slope-for-dubious-expert-testimony/
     
  39. emergentmd

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    If you have read my posts on this thread, i am not a CT of every CP/SOB.

    But for the case above, and if dude looks legit.... YES he gets a CT.

    But again, in my shop I am on the bottom 3rd of RVU/tests ordering and top 3rd on times. So I am sure I am not a clogger.
     
  40. Tiger26

    Tiger26 Senior Member
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    Yes but that was a low pretest probability but still PERC positive scenario where a dimer wasn't obtained--apples to oranges comparison
     
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  41. Birdstrike

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    Was there even a single pediatric patient included in the PERC study?

    Are there even any decision rules, validated or not, that apply to pediatric PE?

    How much U.S. been studied regarding the value of d-dimers in kids?

    From what I can tell,

    "The Pulmonary Embolism Rule-out Criteria (PERC) rule identified 8 clinical criteria for adult patients...There are no such tools for pediatric patients."

    http://pediatrics.aappublications.org/content/early/2013/08/28/peds.2013-0126.full.pdf
     
    #40 Birdstrike, Aug 10, 2015
    Last edited: Aug 10, 2015
  42. Angry Birds

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    Since I work as a solo doc, I don't score any points with anyone for ordering one less test. I do, however, get criticized for *not* ordering XYZ test.

    But, you have to balance this with the issue of clogging up the ER.

    So far, I feel like I've hit the right balance, since I am fresh out of residency where I was trained as a minimalist, and now as an attending in the community I've learned to add a little bit more to the work-up for a variety of reasons. I'm still a throughput machine... In fact, I've learned that sometimes ordering some basic labs right out at the gate (i.e. CBC, CMP, UA and sometimes Troponin, coag's)--sometimes before I even get a chance to evaluate the patient--will save me tons of time in the long run, i.e. working in parallel instead of in series. Does this increase the cost of medical care in the United States overall? Probably. But, so far this hasn't seemed strong enough an issue to overrule a host of other factors as a community doctor.
     
  43. emergentmd

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    Experience helps immensely. I have had other docs ask me why I ordered a CT for PE and my only reason is b/c the pt just felt different.

    I remember a 50 YO guy come in with classic kidney stone hx/exam. Workup neg, Spiral CT neg. I went with CT with IV and found a renal infarct. I RARELY order this with a neg CT. Why? Who knows.... it just felt like something was going on.
     
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  44. LaBusqueda

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    DING, DING, DING!!

    Eventually you can catch the reasonable people who you can talk to. But I remember some written complaints and press ganey written comments on not rx'ing Abx and not doing X rays (all with exact clinical contact and appropriate). It doesn't matter.
    They will go down the street and threaten not to return for their next, I'm insured BS complaint. And that DOES matter to those who really control things.
     
  45. Doctor Bob

    Doctor Bob EM/CC
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    I gave up caring about patient complaints a long time ago. After the "I didn't get percocet for my sunburn" and "He refused to give my toddler dilaudid for his cut chin", I stopped trying to please people.

    For every "he didn't give me what I wanted" complaint, there's a "holy s*** I had no idea my bill would be this high and I never would have agreed to all of these tests" complaint.
     
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  46. Over9000

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    I don't think the lawyers know this one...

    I'd test this guy till the cows came home.

    I could never get behind the idea that being thrifty on investigations is somehow always good. That kind of gobbledygook is spewed to our young and impressionable medical students and ancillary helper staff in the hope to curb health care spending. The whole bollocks is masqueraded as "good medicine".

    I really don't care about health care spending. I'm not going to get sued by not doing something reasonable. No physician should care about health care spending.

    Why on God's Green Earth does your field tolerate patient satisfaction scores?!
     
  47. Birdstrike

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    And no decision rule will ever supplant that.
     
  48. Birdstrike

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    Because the Founding Fathers of the specialty (some of whom get paid large sums to testify against Emergency Physicians in dubious court cases, interestingly) doubled down on hospital-based medicine years ago (by banning the fellowship pathway in favor of the residency-only pathway) which combined with the collapse of physician-owned groups in favor of corporate mega-groups has rendered Emergency Physicians as powerless to do anything but comply when told to comply, and agree when told to agree, by the two players they gave up all control to: Hospital Administrators and Contract Management Group Administrators.
     
  49. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner
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    I like how your soap box is so high that somehow people arguing that the plural of anecdote isn't data is wrong, but you saying actual relevant, clinically obtained data is worthless because you've seen something else.
    This is when EBM (or anti-EBM, in your case) becomes religion. Prove there's a God and I'll show you the Flying Spaghetti monster. Find Nessie and I'll show you Bigfoot. It just so happens that your greegree is different than mine. Maybe you like Macs, and I like my computer to work with the other 90% of the world.
    Remember, there's plenty of anecdotes that strokes resolve "in front of your eyes" with tPA, but the data paid for by the drug companies themselves shows that it happens at the same rate as it does with saline. But heaven forbid you try to convince someone what they saw was a natural phenomenon and not some spiritual, higher being related occurance.

    In the end, if you really want to overdo everything, and cause a million little harms to prevent one big harm, then feel free. It's not like anybody can stop you. But if you want to be intellectually honest, treat every patient like they're a family member, and do for them what you would do for your mom.
     
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  50. Birdstrike

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    I don't see it as black or white. It's not a choice between EBM or clinical judgement. It's about balance. If you accept faulty EBM you lose. If you ignore good EBM, you lose. If you allow biased EBM to override good clinical decisions, you lose. If you over-rely on your clinical judgement based on dogma and ignore strong EBM you lose. I just think it's about balance. I just see people batting around decision rules as if they're unquestionable gospel and I think it's worth point out potential pitfalls. There are so many pressures pushing doctors to act against their better judgement nowadays I think people early on in their careers need to examine these pressures very critically. I think it it could save some heartache down the road, that's all. That's my opinion. You're an academic EM attending so you're not one I'm worried about. What does my opinion matter anyways?
     
    #49 Birdstrike, Aug 11, 2015
    Last edited: Aug 11, 2015
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  51. Birdstrike

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    Also...

    I agree with this sentiment. But if you really do want to be "intellectually honest" let's also acknowledge that our mothers and family members would not sue us when we did our job well, fill out a terrible Press-Ganey report based on factors we couldn't control, complain to administration about opiates or antibiotics not given, go online and write a slanderous review or expect to be seen immediately for a non-emergency when a trauma is coming in. So I agree with the ideal as a goal, but the factors influencing us aren't always as sweet as our mommas and our job just aren't that simple anymore.
     
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