CMP, CBC, and UA for sprained ankle? Defensive medicine?

[ebrown1985]

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I worked in a hospital lab for a number of years, and found that any patient in the ER would (almost automatically) have a CBC, CMP, and UA/UC test ordered-- even patients with ailments such as sprained ankles, or a broken finger etc. Is there a medical reason for this, or is this just another effect of defensive medicine?

 

[ProfMD]

I am not sure what that is - but it doesn't sounds like its for patient care. Not everyone needs labs.

It could actually open you up for more litigation, if there was an abnormal lab that you did not follow-up on.

Some places will insist on a urine pregnancy test for women of childbearing age before sending them to radiology.

 

[Psai]

Probably because when you have to see a certain number of patients per hour or other bs metrics to stop the government and insurance companies from paying you, it's a lot quicker to automatically shotgun labs and imaging than it is to think about what the patient needs

 

[badasshairday]

No. Not defensive medicine. Just dumb medicine.

 

[Raryn]

Some places have nursing protocols that if a patient meets SIRS, they go down a sepsis pathway regardless of what else is going on.

It's absolutely bonkers, because it leads to situations where a patient with a HR of 92 and a RR of 21 (both measures by nursing and both due to acute pain) meets "SIRS" with the nurse "ordering" the cbc/cmp/UA/cxr/lactate. The even more insane situation is if it activates a protocol to bolus the patient with some NS before they're even seen by a doctor (which I've never seen, but I have heard secondhand may exist some places).

 

[Tenk]

Never seen that, and I've worked in quite a lot of shops in multiple states. Definitely not the norm.

 

[cbrons]

Some places have nursing protocols that if a patient meets SIRS, they go down a sepsis pathway regardless of what else is going on.

It's absolutely bonkers, because it leads to situations where a patient with a HR of 92 and a RR of 21 (both measures by nursing and both due to acute pain) meets "SIRS" with the nurse "ordering" the cbc/cmp/UA/cxr/lactate. The even more insane situation is if it activates a protocol to bolus the patient with some NS before they're even seen by a doctor (which I've never seen, but I have heard secondhand may exist some places).

Yeah... aren't there CMS guidelines for this? Also for automatic broad spectrum antibiotics?

Ive heard some really crazy stuff... like automatic Rocephin and Vanc in the ambulence if you meet SIRS criteria and are of a certain age (was talked about on EMCrit).

SIRS seems like such a stupid concept, and sepsis guidelines in general are overly broad and do not really make much sense (especially the "everyone except ADHF gets a 30 cc/kg fluid challenge").

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[Raryn]

Yeah... aren't there CMS guidelines for this? Also for automatic broad spectrum antibiotics?

Ive heard some really crazy stuff... like automatic Rocephin and Vanc in the ambulence if you meet SIRS criteria and are of a certain age (was talked about on EMCrit).

SIRS seems like such a stupid concept, and sepsis guidelines in general are overly broad and do not really make much sense (especially the "everyone except ADHF gets a 30 cc/kg fluid challenge").

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SIRS is a concept with excellent sensitivity to get you to consider (systemic) infection, and obviously no specificity. Spring down the hall and you will probably meet SIRS, but you obviously don't have a focus for infection and will be back to normal pretty quickly. There's some question of there being septic patients who don't meet SIRS, but that all depends on whose definition of sepsis you use, and for a quick initial screen it isn't bad.

OTOH, the new (q)SOFA score in the sepsis guidelines that came out in February seems useless. The only things in the qSOFA are RR, HoTN, and AMS... and if you need a scoring system to tell you to investigate AMS or HoTN, you should probably go back to medical school (or become a pathologist). The full SOFA is even worse, going from 4 reasonably easy parameters to remember (SIRS) to ~8 parameters each with 4-5 different numbers to keep in mind because of how points are tallied up. It's practically impossible to calculate without an app/website and doesn't really affect management at all. An elevated SOFA just tells you that the patient has organ dysfunction... which you can see from the organ dysfunction you had to identify to calculate the SOFA.

Edit: small point for clarity

 

[Brahnold Bloodaxe]

Just another stone in the road to Dr. Watson + midlevels.

 

[Psai]

Some places have nursing protocols that if a patient meets SIRS, they go down a sepsis pathway regardless of what else is going on.

It's absolutely bonkers, because it leads to situations where a patient with a HR of 92 and a RR of 21 (both measures by nursing and both due to acute pain) meets "SIRS" with the nurse "ordering" the cbc/cmp/UA/cxr/lactate. The even more insane situation is if it activates a protocol to bolus the patient with some NS before they're even seen by a doctor (which I've never seen, but I have heard secondhand may exist some places).

What, no blood cultures x2 before auto vanc/zosyn/mero/micafungin? Amateurs.

See this is why nurses that want to practice medicine need to go to medical school. This is the big leagues, not little league softball

 

[Ho0v-man]

I worked at a hospital where the "protocol" in the ER was quite frankly whatever the nurses wanted. Nursing admin had way too much power. I'm talking about the nurses ordering a bunch of BS, the doctors cancelling, and the nurses reordering it. Crazy stuff like full lab panels and full body CT on patients in the lobby. Bonkers.

Edit: ironically never a urine. Heaven forbid any of this actually save time.


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[shoal]

cant think of a single reason to get a cbc and cmp on an ankle sprain. now syncope and ankle pain or red hot swollen ankle..


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[gracie369]

Sprained ankle. Usually from ataxia 2/2 celiac disease. GI consult for biopsy. A u/a is just completely ridiculous and unjustified.

 

[ProfMD]

Sprained ankle. Usually from ataxia 2/2 celiac disease. GI consult for biopsy. A u/a is just completely ridiculous and unjustified.

Big time apologies to our colleagues in community practice, but your post reminded me of this video:

 

[wholeheartedly]

i agree that a lot of it is probably. b.s. but after seeing some pretty strange things come through the lab I actually started asking (in a non-challenging acting more curious sort of way) what was the reason for doing x, y, z. I found that knowing the whole story, things made a bit more sense.

Like mentioned above, my first thought with the sprained ankle was what was the mechanism? if it's a teen playing soccer, i'd agree the testing seems weird. if it's a 70 year old who fell and sprained it for no obvious reason, then I'd think the testing would be warranted.

But again, there's definitely a lot of b.s. too.

 

[deleted245139]

SIRS is a concept with excellent sensitivity to get you to consider (systemic) infection, and obviously no specificity. Spring down the hall and you will probably meet SIRS, but you obviously don't have a focus for infection and will be back to normal pretty quickly. There's some question of there being septic patients who don't meet SIRS, but that all depends on whose definition of sepsis you use, and for a quick initial screen it isn't bad.

OTOH, the new (q)SOFA score in the sepsis guidelines that came out in February seems useless. The only things in the qSOFA are RR, HoTN, and AMS... and if you need a scoring system to tell you to investigate AMS or HoTN, you should probably go back to medical school (or become a pathologist). The full SOFA is even worse, going from 4 reasonably easy parameters to remember (SIRS) to ~8 parameters each with 4-5 different numbers to keep in mind because of how points are tallied up. It's practically impossible to calculate without an app/website and doesn't really affect management at all. An elevated SOFA just tells you that the patient has organ dysfunction... which you can see from the organ dysfunction you had to identify to calculate the SOFA.

Edit: small point for clarity

SOFA and qSOFA are largely worthless in the ED and derived from a large pool of icu patients. Alot of these studies lack generalization to the ED. Take the France central line trial for example (3site).
Taken as is, I appreciate the sentiment, and the drive to identify this stuff early, but then you get the upcoming recommendations from the 3rd surviving sepsis campaign, and it's then taken as gospel, adopted by CMS and now we are held to an unreasonable standard (30cc/kg bolus, chf be damned for example).

No real point to this, just illustrates the carousel we are all on

 

[Zebra Hunter]

SOFA and qSOFA are largely worthless in the ED and derived from a large pool of icu patients. Alot of these studies lack generalization to the ED. Take the France central line trial for example (3site).
Taken as is, I appreciate the sentiment, and the drive to identify this stuff early, but then you get the upcoming recommendations from the 3rd surviving sepsis campaign, and it's then taken as gospel, adopted by CMS and now we are held to an unreasonable standard (30cc/kg bolus, chf be damned for example).

No real point to this, just illustrates the carousel we are all on

It's largely worthless because they decided to exclude emergency medicine doctors from the conversation. You know, the people that have to implement that 30cc/kg bolus and <3hr appropriate abx. They probably would have gone ahead with SOFA and qSOFA anyways, even with our input.

 

[deleted245139]

Lol exactly

 

[Psai]

SOFA and qSOFA are largely worthless in the ED and derived from a large pool of icu patients. Alot of these studies lack generalization to the ED. Take the France central line trial for example (3site).
Taken as is, I appreciate the sentiment, and the drive to identify this stuff early, but then you get the upcoming recommendations from the 3rd surviving sepsis campaign, and it's then taken as gospel, adopted by CMS and now we are held to an unreasonable standard (30cc/kg bolus, chf be damned for example).

No real point to this, just illustrates the carousel we are all on

I forget if I heard it here or in real life but someone was at like 1.95 L of the 2 L that they needed to be "compliant with measures" and they refused to allow the fluids in the antibiotics and other meds to count as part of the 2 L so he got dinged. That was stupid on multiple levels

 

[Frazier]

One has to be careful looking down on MDM from the outside and remember hindsight is 20/20.

Some of those tests can make sense given a complete clinical presentation...

CC may be merely "sprained ankle", but then you find out it's a 78yoF w HTN, DM2, self-caths, and lives alone. Her HPI notes she's been feeling somewhat weak lately and she now wonders if that contributes to her "clumsiness hurting her ankle". Looking a little pale on exam and clocking a temp of 37.9

Who knows what went on in the interview.

That said, sometimes things can become autopilot in the ED... but if an otherwise healthly 18 year old comes in with a sprained ankle from a soccer match out on the quad when Tanner nailed a wicked crossover -- pt not even meeting ankle rules and my workup included CMP, CBC, etc... They'd be like "hmmm, no." Depends on your shop, I guess.

 

[wholeheartedly]

One has to be careful looking down on MDM from the outside and remember hindsight is 20/20.

Some of those tests can make sense given a complete clinical presentation...

CC may be merely "sprained ankle", but then you find out it's a 78yoF w HTN, DM2, self-caths, and lives alone. Her HPI notes she's been feeling somewhat weak lately and she now wonders if that contributes to her "clumsiness hurting her ankle". Looking a little pale on exam and clocking a temp of 37.9

Who knows what went on in the interview.

That said, sometimes things can become autopilot in the ED... but if an otherwise healthly 18 year old comes in with a sprained ankle from a soccer match out on the quad when Tanner nailed a wicked crossover -- pt not even meeting ankle rules and my workup included CMP, CBC, etc... They'd be like "hmmm, no." Depends on your shop, I guess.

Like I said above, only more detailed.

lol

 

[Frazier]

Like I said above, only more detailed.

lol

"Brilliant minds..." 😉