Concise Workups?

[docflanny]

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I recognize the duty of emergency physicians is to first exclude the differential diagnoses that would cause a patient the highest M&M, but are there any residencies that are noted to more conservative about their workups than others.

ie. use the H&P and evidence-based medicine more to justify, why an additional test is not indicated? Obviously, this is highly attending dependent. Even more so, are there any residencies, that will press you a bit to justify why you might order a test?

In an era of cost-containment, it seems to me that EP will have to be one of the leaders in decreasing unnecessary medical costs. What do you think?

 

[Seaglass]

Most attendings here are like that. It drives the medicine service nuts.

C

 

[ERMudPhud]

In general I think EM is probably more aware of cost and utillity in testing. I think this is because tests cost more when ordered "emergent" and the more you order the longer you may have to wait for everything to come back thus delaying disposition of the patient. Denver General a few years back published a few papers looking at specific tests and whether they changed management. Some of the best examples where LFT's in the diagnosis of cholecystitis and ABG's in the workup of PE. It used to be an unending source of conflict with other services who wanted all the labs done before they were called. In the end they often got their ABG upstairs after their PE was already diagnosed. It amazes me sometimes when following up on patients I've admitted all the extra testing they get right after they are admitted that all comes back negative. I sometimes think the hospitalist are every bit as bad as they accuse us of being in terms of CYA medicine.

 

[DrQuinn]

Agree with ERMudphud...

I think in any academic center, the EM faculty will be less likely to "shotgun" labs. Basically at my program, we "shotgun" the H&P and then order our labs specifically. The times I order an ABG are in EXTREME respiratory distress, codes, traumas (part of the protocol) and after intubations. I dont' get them in the vast majority of my DKA patients... some of my attendings are fine with this, some want it.

Q

 

[docB]

In my private hospitals I've given up trying to not get certain things. I just go ahead and get an ABG on HMO pts with SOB because I know the hospitalists will squawk. Same on many other labs and tests. I don't order CT chest on every CP like they want because I feel the M&M is too great.
Conversely the admin just came down on us and wants no more etoh, drugs and "basic labs" (CBC, Chem7) on the psychs because they are rerely useful and almost all psych is private pay. We're supposed to use a brethalyzer now but none of the ED have them yet.

 

[Sessamoid]

In my private hospitals I've given up trying to not get certain things. I just go ahead and get an ABG on HMO pts with SOB because I know the hospitalists will squawk. Same on many other labs and tests. I don't order CT chest on every CP like they want because I feel the M&M is too great.

This is all very variable depending on who happens to be on call that day. Some internists are fine with a focused workup in the ED, others want everything and the kitchen sink. If it's just me, the only thing that an ABG gets me that a pulse ox doesn't is the ability to rule out carbon monoxide poisoning in a dyspneic patient. Particularly in DKA, I think ABGs are close to useless.

Conversely the admin just came down on us and wants no more etoh, drugs and "basic labs" (CBC, Chem7) on the psychs because they are rerely useful and almost all psych is private pay. We're supposed to use a brethalyzer now but none of the ED have them yet.

If they're seriously schizophrenic, a lot of them will be Medicare due to disability. The ones who are just depressed tend to be uninsured though.

 

[sirsam84]

You speak truth in politics, Sessamoid. Much respect!

 

[docB]

This is all very variable depending on who happens to be on call that day. Some internists are fine with a focused workup in the ED, others want everything and the kitchen sink. If it's just me, the only thing that an ABG gets me that a pulse ox doesn't is the ability to rule out carbon monoxide poisoning in a dyspneic patient. Particularly in DKA, I think ABGs are close to useless.

I agree, but I'm tired of hearing, "What? No ABG? Get it and call me back."

 

[Jeff698]

Conversely the admin just came down on us and wants no more etoh, drugs and "basic labs" (CBC, Chem7) on the psychs because they are rerely useful and almost all psych is private pay. We're supposed to use a brethalyzer now but none of the ED have them yet.

Interesting. Our psych folks won't touch a polluted psych patient until we can prove they're no longer polluted. We use the etoh/tox labs as a way of saying "they're done now...come n' get 'em".

Not that I'm going to complain about our psych folks. There is so much demand for them, they're way overworked and they're consistently (at least to me) the nicest folks.

Take care,
Jeff

 

[southerndoc]

We have an "IOU" (Intoxicated Observation Unit) that is a separate section of the ED. Patients over age 50 or anyone with a serious medical condition by history or presentation are screened in the main ED before being taken back to IOU. The regulars or those that are young without evidence of medical problems are taken to IOU.

The IOU screens each patient with a breathalyzer, finger stick, and vital signs. Tachycardia is treated with fluids first, and if that fails, then the patient moves to the regular ED. If the patient doesn't breathalyze, then serum ETOH is drawn. Patients are breathalyzed on a regular basis until they are sober. The only other alternative for a drunk to leave our ED is to have a family member pick the patient up and agree to stay with the patient until he/she sobers up. (That's by Connecticut law.)

 

[docflanny]

southerndoc,

that's an interesting solution to intoxicated patients. out of curiousity, how many beds are in the iou and how many lucky nurses staff it each night?

for others, does anyone else have an iou, never heard of this before? most EDs I've been to just put them out in the hall.

 

[southerndoc]

The IOU is staffed by a tech that observes the patients. The nurse and physician assigned to a team cover the patient. (The patient is still assigned to a team, and the nurse/physician is still responsible for the patient, but frequent checks on the patient are done by a tech.)

There are about 6 beds in the IOU. We have a new IOU that's about to open that has recliners instead of beds and will be in a lockdown unit to prevent flight risk. My concern is that it may be a little too comfy and people might want to hang out there for the night on a regular basis!

 

[spyderdoc]

The IOU is staffed by a tech that observes the patients. The nurse and physician assigned to a team cover the patient. (The patient is still assigned to a team, and the nurse/physician is still responsible for the patient, but frequent checks on the patient are done by a tech.)

There are about 6 beds in the IOU. We have a new IOU that's about to open that has recliners instead of beds and will be in a lockdown unit to prevent flight risk. My concern is that it may be a little too comfy and people might want to hang out there for the night on a regular basis!

Geez, when I was there, we had "bourboun street", which was the area between the A/B and C side. the drunks were all 4 pointed and lined up on stretchers in that hallway (very occasionally one would be found dead in the AM 😱 ).....they would piss all over themselves and everything....Now they get recliners, and a tech to watch over them! Wow, things sure have come a long way over there!