- Joined
- Jul 12, 2004
- Messages
- 5,278
- Reaction score
- 4,969
Just had a string of night shifts at my ER in Northern California. It was thankfully quiet. Saw 1/hr. Each shift there were a few patients wondering if they had COVID-19.
The purpose of this post is to ask how all of you guys are thinking about medical decision making in this new world. Because how I'm handling respiratory complaints now is much different than how I did 6 months ago or even 3 months ago.
Here is one of my cases:
69 yo woman, healthy, remote history of follicular lymphoma in remission. Lives in Maine and arrived here in NorCal a few weeks ago to visit family. For the past 10 days has had a cough, and for the past 3 days subjective fever (or measured, I can't remember). She said "everybody in my family, children, grandchildren all have the same thing and they all got better. But I'm not." Some SOB. Some fatigue. These last two symptoms are not pronounced. Rest of ROS is basically negative.
PMH / PSH: As above
Meds: None
NKDA
No other pertinent family / social history, e.g. not a smoker
Vitals: Temp 98.2, HR 80, BP 150/70, RR 16, SpO2 94-97%
Pertinent exam: Unremarkable (no distress, can speak normally, she is wearing a mask, lungs are clear, she would cough a few times and it sounded productive, otherwise she does not appear ill).
So, normally I think most ER docs in this case, if we were not operating within the scope of COVID-19, would do either
1) no workup and d/c w/wo Abx
2) CXR and d/c w/wo Abx
3) CXR and BMP/CBC and d/c w/wo Abx
4) CXR, BMP/CBC, lactate, BCx and dispo w/wo Abx
I personally would have spent 3-5 minutes in the room, determined she is not sick, and then would probably do #2 above (CXR, CBC/BMP) and tell the patient you are either going home with or without antibiotics depending on those tests. But frankly there are any number of correct ways to handle this patient and the point of this thread is not to get angry at and tease people for their choice.
What I find now is that I'm not even entertaining working up routine respiratory patient complaints unless they have
1) many abnormal vital signs like RR > 24, SpO2 < 90%, hypotension. (I'm not even sure I care about isolated fever)
2) old and with many comorbidities.
Sometimes it's hard not to ignore. They might have several complaints like bloody diarrhea, cough, fever, or whatever.
So with my patient, I educated her as best as I could about COVID-19. I felt there was a low chance. She had symptoms for 10 days. (Plus I can't even test her for COVID-19.) Then we talked about what else she could have, like bacterial PNA, PE, etc. I decided at the end of the day to get a CXR as I felt if she had radiographic lobar PNA with 10 days of symptomology she could have bacterial PNA and would have given her Abx. I didn't even get labs. How would a WBC of 5, 10, or 15 change my mgmt?
Very interesting how it's becoming easier to safely discharge well-appearing patients with a markedly reduced (or no) workup.
The purpose of this post is to ask how all of you guys are thinking about medical decision making in this new world. Because how I'm handling respiratory complaints now is much different than how I did 6 months ago or even 3 months ago.
Here is one of my cases:
69 yo woman, healthy, remote history of follicular lymphoma in remission. Lives in Maine and arrived here in NorCal a few weeks ago to visit family. For the past 10 days has had a cough, and for the past 3 days subjective fever (or measured, I can't remember). She said "everybody in my family, children, grandchildren all have the same thing and they all got better. But I'm not." Some SOB. Some fatigue. These last two symptoms are not pronounced. Rest of ROS is basically negative.
PMH / PSH: As above
Meds: None
NKDA
No other pertinent family / social history, e.g. not a smoker
Vitals: Temp 98.2, HR 80, BP 150/70, RR 16, SpO2 94-97%
Pertinent exam: Unremarkable (no distress, can speak normally, she is wearing a mask, lungs are clear, she would cough a few times and it sounded productive, otherwise she does not appear ill).
So, normally I think most ER docs in this case, if we were not operating within the scope of COVID-19, would do either
1) no workup and d/c w/wo Abx
2) CXR and d/c w/wo Abx
3) CXR and BMP/CBC and d/c w/wo Abx
4) CXR, BMP/CBC, lactate, BCx and dispo w/wo Abx
I personally would have spent 3-5 minutes in the room, determined she is not sick, and then would probably do #2 above (CXR, CBC/BMP) and tell the patient you are either going home with or without antibiotics depending on those tests. But frankly there are any number of correct ways to handle this patient and the point of this thread is not to get angry at and tease people for their choice.
What I find now is that I'm not even entertaining working up routine respiratory patient complaints unless they have
1) many abnormal vital signs like RR > 24, SpO2 < 90%, hypotension. (I'm not even sure I care about isolated fever)
2) old and with many comorbidities.
Sometimes it's hard not to ignore. They might have several complaints like bloody diarrhea, cough, fever, or whatever.
So with my patient, I educated her as best as I could about COVID-19. I felt there was a low chance. She had symptoms for 10 days. (Plus I can't even test her for COVID-19.) Then we talked about what else she could have, like bacterial PNA, PE, etc. I decided at the end of the day to get a CXR as I felt if she had radiographic lobar PNA with 10 days of symptomology she could have bacterial PNA and would have given her Abx. I didn't even get labs. How would a WBC of 5, 10, or 15 change my mgmt?
Very interesting how it's becoming easier to safely discharge well-appearing patients with a markedly reduced (or no) workup.