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Diagnosing an Appy

Discussion in 'Surgery and Surgical Subspecialties' started by TimesNewRoman, Aug 10, 2015.

  1. TimesNewRoman

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    I wanted some input from ya'll. I'm a senior EM resident and it seems that whatever I do with diagnosing appy, I'm wrong in the surgeon's eyes. If I have someone with an obvious appy and call before a CT, I get told to do the CT and call back. If I do the CT, I get told that I didn't need it and should have just called. Regardless, it seems like everyone I'm concerned about ends up getting the CT.

    So my question is this: What is your practice? If your ED doc calls with a great story, would you lay hands on the patient and go to the OR? Is it acceptable practice to operate in 2015 without a CT scan? Also, what is your practice setup, as I imagine this affects your decision.

    Thanks!
     
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  3. angleoflouise

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    There is just too much to write about on diagnosis of appy on a forum. Please read the following 15 page chapter on appendix from one of the few trusted surgical texts that surgeons use. Let me know if you have any questions.
     

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  4. TimesNewRoman

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    Thanks, but in this circumstance I'm more interested in practice patterns/variation than what the textbook says.
     
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  5. thedrjojo

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    Peds will go with ultrasound only. Adults, I don't know if I've ever operated on an appendix without a CT scan.
     
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  6. TimesNewRoman

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    Would you?

    If you have an 18yo M - no sig history - temp of 103, leukocytosis with bands, nausea/vomiting, periumbillical pain migrating to the RLQ, guarding RLQ, Rovsing's, etc?

    Also, are you at an academic or community center?
     
  7. thedrjojo

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    I'm a resident at both academic University and a community private academic and a VA. At the University, I might go without(or us), however that picture Id want a CT to r/o abscess. The private University Hospital they'd have the ct before they even called me
     
  8. dpmd

    dpmd Relaxing
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    I am in community practice and the issue is that perfed appys get managed differently than non perfed. The guy you just described as a slam dunk appy has a fever that is higher than a regular appy would give and bands aren't usual either, so he needs a scan to see if he is perfed. Another problem is that women have more potential sources of pain that seems to point to appy and it isn't reasonable anymore to have a high negative appy rate when you operate. Add in the fact that mild appys in kids are sometimes getting managed nonoperatively here and you have a lot of people that need scans. So who might I operate on without a scan? A kid who has a one day or less history with a really good story and exam that actually matches what the ED provider tells me (have been told an excellent story before only to question the patient and discover their pain is mostly on the left and mostly when they pee or something) whose WBC is higher than our algorithm for trial of nonop but not too high, whose crp isn't too high or normal, having an appy on u/s is good but our ultrasonographers aren't great so this isn't a requirement, who doesn't have some other symptoms that make me think something else might be going on (I have had the patient that looks like a slam dunk appy and found their pneumonia by further questioning and getting an xray). Another potential would be a younger adult male with a one day history and a good story/exam and reasonable labs/vitals.

    The issue is that what I feel is right may be completely different from what another surgeon may feel is right, so I never hassle my er doc about it unless they do something silly like scan without any iv contrast so the ct is inconclusive or scan a kid who just had a negative scan the day prior or something. Granted my response may be less than enthusiastic if your 4 am call without a ct is on a patient with a week long history of pain who has resolved pain after a touch of morphine and has a high fever and wbc, but I will remain civil as I request a scan.
     
  9. mikeGR

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    I second everything everyone else said and to answer your question, we may operate on an appy without a CT, but everything has to look 100% right. BTW I didn't see the Alvarado score mentioned here at all...
     
  10. dpmd

    dpmd Relaxing
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    Meh, i ain't pulling out/memorizing a calculator for this.
     
  11. TimesNewRoman

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    It's sensitivity isn't high enough to be routinely used in the ED; although I suppose the specificity is what ya'll care about.
     
  12. Arcan57

    Arcan57 Junior Member
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    Times,
    As painful as it initially can be, the first time I'm consulting a surgeon about a suspected/proven appy I just ask them at what point in the work-up they want to be called. I have 5 general surgeons that rotate call and another 2 that don't take call but have large referral bases from the PCPs. 3 wants scans on everyone, 2 want scans on anyone where the story isn't perfect or if they have two X chromosomes, 1 will take anyone with a good exam and vaguely supportive lab values, and 1 has a sliding scale depending on time of day and how annoyed they currently feel.
     
  13. SLUser11

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    Surgeons are schizophrenic on this issue, and several related issues, when it comes to the ER.

    First, we criticize the EPs for calling us before doing any workup, and accuse them of being "glorified triage nurses."

    Then, if they do a workup, we criticize them for the chosen tests....saying xyz isn't necessary, etc. We make frequent jokes about how you can't sneeze in the ER without getting a CT scan, but we honestly have no concept of what percentage of ER visits for "abdominal pain" are worked up with a CT, or what percentage of these abdominal pain visits result in a surgery consult.

    We can't have it both ways. We can either be content with the ER's workup, or be content with being called immediately upon patient arrival in the ER.

    Anyway, to answer the OP's question, I must first say that I am semi-retired from appendectomies unless they are attached to a larger specimen. That being said, CT scans are necessary in almost all female patients. They are also necessary in male patients with prolonged symptoms or atypical symptoms. An abnormally high WBC may alert to the possibility of phlegmon and abscess. Perforated appendicitis is still treated with appendectomy, so the mere presence of free air shouldn't scare away the surgeon. However, the presence of a phlegmon, plus or minus an abscess, should be treated with bowel rest, IV abx, and IR drain.

    For males with classic symptoms.....RLQ pain, anorexia, leukocytosis, localized guarding....it's okay to simply call surgery, and let them decide if they need a scan.

    On a side note, I was taught as a young doctor that anorexia is universal, and if a patient is hungry, then it's not appendicitis. I now believe that rule to be bull$#@t. When you get young males in the ER with appendicitis, and you ask them if they're hungry, they often reply "I could eat."
     
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  14. dpmd

    dpmd Relaxing
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    I too don't go by anorexia after the so called cheeseburger appy incident in residency that involved a cartman-like 5 y/o who hurled obscenities at everyone including his mother, who did nothing in reaponse to this, while loudly demanding a cheeseburger pre op for his (real) appy.
     
  15. dr zaius

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    We had this discussion in my program not long ago. If the ED consults you, you have a male patient with a classic history and appropriate exam/labs, do you tell them to scan? The attendings were split. The surprising part was that the older attendings were favoring CT because what happens if you get in there and the appendix looks completely and totally normal? The younger attendings seemed more willing to go straight to the OR based on exam/history/labs and Alvarado score.
     
  16. dpmd

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    lol
     
  17. TimesNewRoman

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    Interesting that you would see that much divergence among a single group.
     
  18. Arcan57

    Arcan57 Junior Member
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    Any time you're dealing with risk stratification you're going to have people fall out at various points along the continuum. Also, most residents are going to have a relatively tight practice pattern based on sharing the same training environment but as the individual's clinical experience grows practice patterns diverge. Think about your attendings' threshold for working up PE or low risk chest pain. There are probably one or two that were on the losing end of that dice roll early in their career and now scan and admit everyone with a pulse. I imagine surgeons are affected by similar factors.
     
  19. doc05

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    since it's not 1980, and every hospital has a CT scanner, I can't imagine why you wouldn't scan everyone with a real clinical suspicion. There's a whole lot more in the abdomen besides the appendix, and there's no downside to obtaining the CT anyway.

    the downside to exploring without a CT isn't just the "negative laparoscopy;" it's getting in there and finding something you're not prepared to fix. this can happen with any patient, at any age.
     
  20. Winged Scapula

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    Exposure to any unnecessary ionizing radiation is a valid concern. If you're really unsure (or for the concerns raised by others above), and the benefit outweighs the risk, its reasonable . But to "scan everyone with a real clinical suspicion" and "there's no downside" seems a tad cavalier to me.
     
  21. doc05

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    I'm not so sure about that. The risk of a single CT scan is nil. Realistically, there are very few patients who will have multiple CT scans over a lifetime, and it's really the cumulative effect of radiation that causes issues.
     
  22. DoctwoB

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    I have trouble believing that "very few" patients get multiple CT scans. While I understand my tertiary hospital experience is not necessarily the norm in the community, If I see a patient in the ED that hasn't had multiple prior scans then I am quite surprised. Just think about it: Very common diagnoses like IBS, diverticulitis, or cholecystitis will usually buy you at least a few CT scans.

    That being said, the data on the cumulative effect of medical ionizing radiation in adults is woefully inadequate, with much of it being extrapolated from radiation exposure after the atomic bombs in Hiroshima and Nagasaki. I've seen a few decent studies in the pediatric population, but not much for adults.
     
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  23. dpmd

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    I rarely have an adult patient who hasn't had a ct scan of the belly at some point prior, and i have had some who have had several during the same admit (the repeat because the first had no contrast is entirely too frequent)
     
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  24. Winged Scapula

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    Even if I agreed with your premise that very few get multiple CT scans, we are exposed to ionizing radiation all the time (at least those of us who live amongst sunshine) so why would you unnecessarily *add* to that exposure if you didn't have to?

    Sure its just "one" scan and probably doesn't hurt but if you didn't need the scan to make the diagnosis and treat the patient why take even the small risk? What about the risk of a contrast allergy? What about the cost? I just don't see that the ends always justify the means in this case. There are excellent reasons to do a scan as detailed above but to do it on every one, even a young male with a good history and exam just doesn't sit right with me.
     
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  25. dienekes88

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    I thought direct cost was reduced with scanning (Rao NEJM 1998).

    Increasing demands on residents with respect to night float coverage, minimizing hours, documentation, etc. means that trainees have less time to do careful H&P's. Unfortunately, I think the scanner is filling in for this and proving to be effective. However, this results in a generation of surgical residents who are used to having CT scans.

    Another thought I had was whether it's becoming a part of the culture. It seems like people are driven more by a fear of being wrong than a desire to be right.
     
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  26. vhawk

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    This, and to add to this, surgeons are human beings, and have cognitive dissonance. Many of them arent introspective enough to know when their judgment is being compromised by being too busy (or not being busy at all and having a free OR), being tired, etc. Many of them are also smart enough to come up with a bunch of "legitimate" ad hoc rationalizations for their preference on that day. This is why you get what are seemingly inconsistent plans. And this dissonance causes some distress so it makes them even less patient when they explain why its "so obviously stupid" to get a CT scan....this time.
     
  27. vhawk

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    This is not correct. First, it just is logically lazy and fallacious, as "nil" and "very low but not nil" are fundamentally different categories even if they seem similar most of the time. If the risk of a single scan is nil, then the risk of one single scan, after someone just had a scan (since, after all, risk of the first scan was nil) would be nil. So scans would never kill anyone!

    But its also wrong from an epidemiological perspective. Your rationale towards scanning will almost certainly cause at least one or two cancers during your career. Thats ok, as long as you think the benefits you gain from those scans offset those handful of cancers, but you are looking at it wrong.

    And the reason that "very few people get multiple scans" is because in order to get multiple scans you have to get a first scan. So its a parlay. But if doc05 is out there scanning everyone "just once" then the rate of people who get multiple scans would be super high. Its like saying its hard to sweep a 3 game series...but thats because its hard to win the first 2.
     
  28. doc05

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    You must be at a tertiary care center. Healthy people in the community don't get multiple CT scans.
     
  29. doc05

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    I disagree with using epidemiologic rationale on individual patients. And while I'm not a fan of CT scans in children, I have no issue with CT scans in adults - even if the diagnosis is "straightforward," it's often not. And even a 10% rate of "negative appy's" will cost way too much, both in time and $.

    Then again, I don't do appys anymore, so maybe I'm wrong...
     
  30. dpmd

    dpmd Relaxing
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    Nope. Just a small town community surgeon.

    Edit. Maybe we are considered moderate sized, i never really know how they classify stuff. Anyway we are small enough to not have certain stuff like a colorectal surgeon (until october that is) or transplant in town but big enough the county trauma center is in town and there are 5 other hospitals (3 of which i regularly see patients at)
     
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  31. vhawk

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    I dont know what this phrase means, but I'm pretty sure it doesnt mean anything good. You dont treeat one patient in your entire career.
     
  32. Arcan57

    Arcan57 Junior Member
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    I wish that were true. The prevalence of scanning non-tender abdomens for ruling out "here there be dragons" varies widely among EPs. This combined with certain patient populations' predilection for presenting to the ED whenever they have transient abdominal pain leads to a surprising number of patients who receive essentially yearly CTs abd/pelvis. This is obviously not the surgeons' responsibility but it's something to keep in mind if you haven't reviewed the patient's record yourself.
     
  33. Thanatos

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    I will admit, as a (maybe) reasonable person I feel bad for the ED sometimes as it is virtually impossible to develop a consistent algorithm based on what we tell you....and that has very little to do with the resident you're calling and everything to do with the boss they staff the consult with.

    If the patient was a male between the ages of say 16-50 with a classic story: one day of abd pain that started at the umbilicus and migrated to the RLQ, tender on exam, no other health problems or previous surgeries, I would take them without a scan for a lap appy. The caveat to that would be if they were febrile, had a very high wbc count (like 20) or pain for like a week then I would scan them to look for perforation.

    Otherwise they almost all get scanned. I would scan any female, specifically looking for other gyn pathology, and any older person looking for a colon cancer or diverticulitis with a sigmoid migrating to the RLQ or god only knows what else the hell you might find.

    Another pattern I noticed was not even between attendings, but in the same attending depending on time of day. For example, a classic story for appendicitis rolling in the ED at 8am didn't need a scan. A classic story at 2am typically needed a scan....followed by some IV hydration.....and serial abd exams to make sure it wasn't anything else.....consult to the chaplain to make sure everyones soul was ready to be without the appendix.....until 8am rolled around then we were suddenly clear to go. Not that its not okay to sit on an appy overnight and do it in the morning (and there is literature to support that)....but I used to always be amused by the song and dance of why attending A couldn't come in at 4 am and not bump attending B's first case.

    All that being said I hung up my appendix career 2 months ago for fellowship, and have not reviewed the literature since on this topic.
     
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  34. dpmd

    dpmd Relaxing
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    I try not to let the time of day or my amount of other work alter my workup, but i am human so i know there is going to be some effect even if am not conscious of it.
     
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  35. dpmd

    dpmd Relaxing
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    Also, lol at the tap dancing to avoid a 4am appy. Just nut up and say start them on abx and we will add it on during the daytime because there is no good reason to do this in the middle of the night (unless adding a case on the next day is going to be a huge issue)

    Edit: there isn't even a good reason for me to go back to the hospital in the evening if I have gone home already. That can get admitted and done the next day too.
     
  36. vhawk

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    Just remember this when you are "correcting" your covering resident for their plan to just take the patient because "lets be serious its appendicitis."
     
  37. europeman

    europeman Trauma Surgeon / Intensivist
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    ER docs; you just have to have a conversation about the preferences of the surgeons at your shop period!

    I know upon close introspection, I think I'm guilty of asking for a CT as a delay tactic. For sure. And that's not right.

    The conversation really should change though to why aren't we utilizing high quality ultrasound more often to rule in appys in adults rather than ct
     
  38. TimesNewRoman

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    All three seem reasonable.
     
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  39. dpmd

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    Main reason is our ultrasonographers aren't that good at it even with skinny folks so it is hard to talk the er into doing a study that is likely to be inconclusive which would then delay their dispo. They are all about dispo.
     
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  40. emergentmd

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    I remember the days in residency where getting a scan was difficult (yes it sben 15 yrs) and remember when a radiologist resident questioned me (2nd yr) why I ordered a CT. He left his Box and went to examine the pt, thought he didn't need a CT. hahah.... we did it anyways.

    Fast forward 15 yrs and there is no consensus on getting a CT but I would say 95% of surgeons will not operate unless there is a positive CT for adults. Kids are a different matter.

    I can call, tell them there is a 19 yo healthy male with RLQ pain, fever, WBC, etc... and they still want a CT before coming in.

    There are 2 that would actually get mad at the ER doc if we did a CT scan before calling them when we think its appendicitis. They want a call after the CBC is back which can take 1-2 hrs. They will come in and half the time ask for a CT b/c they were not completely sure. WTF..... I just waited 2 hrs, another hr for him to come in, just to tell me to get a CT which can take another 2 hrs?

    Forget this. I Scan EVERYONE b/c calling the surgeon. These two that may get mad, I just tell them the story was confusing even if it was not. Takes the argument out, they operate, everyone is happy.

    I even asked other surgeons why these two do not want CTs bf surgery and they just Shrug their shoulders.

    No different than every cardiologist wanting a different med b/c taking the pt to Cath. I stopped asking and just let them deal with it.
     
  41. emergentmd

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    Is this a joke? I would then have to U/S everyone, have it inconclusive/neg 90% of the time with my high suspicion. I would then scan them after getting a full bladder. This would take 5 hrs to work them up. And even if I called the surgeon at my shop with a pos U/S, they would either laugh at me or ask me to confirm it with a CT.
     
  42. vhawk

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    Thats, uh...not exactly good medicine there guy
     
  43. emergentmd

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    I assume you are talking to me. If by poor medicine, you mean doing CT on almost everyone before taking them to the OR? Trust me that this is not my choice. This is the doing of the surgery community and I work in a referral center with a slew of surgeons. I have learned in my 15 yrs of practice that 99% of the time they want a CT no matter the physical/lab proof.

    I guess they may come in at 8am when they are in house to lay their hands on the pts. But if they are not in house, they want a CT.

    So why should I make a call on every pt with concerns for an appy before getting a CT?

    I have been through this and let me tell you how this goes.

    Me - Dr. appy, there is a guy here with classic appendicitis. Fever + WBC elevated. Healthy guy, no other issues/surgeries
    Dr Appy (after 30 min before calling me back) - Sounds great. Can you get a CT and then call me back with the results
    Me - (2 hrs later) - Dr. Appy, CT shows an Appy.
    Dr. Appy - Shows up 5 hrs after pt presentation to operate.

    Now.....and I get a CT right on the spot after my exam
    Me (after 90 minutes after exam) - Dr Appy, There is a guy with classic appendictis and CT shows an appy
    Dr. Appy - shows up 2 hrs after pt presentation and does surgery.

    I would say getting a CT right on the spot is great clinical care. Now if the surgical community would like to change their behavior and come in trusting that this pt has an appy+operate without any need for labs, then I would love to call them after my exam.

    The way EM docs handle appys are all the result of the surgical community and if you have an issue with my care, then your colleagues are the ones you should talk to.
     
  44. JayDoc06

    JayDoc06 Fistula Bag
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    It is an impossible game for ER physicians to win for many reasons. Fever does warrant CT scan because that's a late sign and not "classic" and indicates possible perforation or abscess which might change management or more likely something else all together. Also, ER physicians have no idea what a 24 hour call feels like, much less 72. If I am coming back in to do something 68 hours into a weekend call, I feel it is not unreasonable (or lazy or slow like your tone implies) to have a relatively firm diagnosis before calling.
     
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  45. Vandalia

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    There is a huge difference between good medicine and real medicine.

    If good medicine was actually practiced in this country, at least 75% of our hospital beds would be empty and 50% of our physicians would be unemployed.

    I would make an educated guess that in a sane medical system, a triage nurse could dispose of 25% of ED visits, a smart receptionist in primary care could handle 40% of callers over the phone, and a good surgery receptionist could handle 10% of the calls by herself.

    But we don't have a sane system.

    ED: "You have nausea, vomiting and diarrhea after all your kids had the same symptoms? Go back home, rest, and sip stale ginger ale."

    PCP: "Still taking your blood pressure meds? Feeling well? Good blood pressure measurements at home? Call back in 3 months."

    Surgery: "Yes having a bit of soreness at the incision site with no fever is normal on POD 2"
     
    #44 Vandalia, Aug 22, 2015
    Last edited: Aug 22, 2015
  46. vhawk

    vhawk 2K Member
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    So fight it then. Be better. I know that sounds naive but theres a reason your parents used to warn you about jumping off bridges.
     
  47. emergentmd

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    Gotcha..... What a brilliant idea. Starting tomorrow I am going to consult
    1.Surgeons without any labs for clinical appy. What is a CBC/chem going to tell me?
    2. All Hospitalist will be consulted for 70% of my admission as labs have very little relevance
    3. Infected kidney stone? I am going to force urology to admit. Thats what the book says right?

    Dream on buddy.
     
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  48. SLUser11

    SLUser11 CRS
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    I appreciate your enthusiasm (as always), but you must see how truly naïve it sounds. You just passed your boards today! You have to understand that there's a huge disconnect between textbook surgery and real-life surgery, and many things that shouldn't hypothetically affect your decision-making actually play a large role (i.e. your availability, competing interests, kids bedtimes/soccer games/birthday parties, who's calling, your recent outcomes (good and bad), the OR's availability (and responsiveness).

    I agree with you philosophically, but it's just not realistic.
     
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  49. Apollyon

    Apollyon Screw the GST
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    I read this while I am going on the 2nd hour of my 24 hour shift, out of which I MIGHT get 2 hours of sleep. (Yes, this job sucks, but the money isn't bad. It isn't "good", either.) So, yes, I do have an idea. Now, I'm an outlier, but certainly not unique.
     
  50. Psai

    Psai Snitches get zero vicryl
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    yes but if you apply the em multiplier, that's approximately 3.5 hours of sleep
     
  51. emergentmd

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    I completely understanding being a resident is completely different than being an attending with 3 kids, activities all over the place, a wife that is not understanding of your schedule, working from 7a-5p clinic, go straight to call, have a bad call night without sleep, getting back to clinic at 7am. That is why the textbook medicine is much different than clinical medicine. If I was a surgeon, I would ask for a CT on almost all of the appy cases b/c if I am going to go in to operate, I need to know I am actually treating the issue. That is why I am happy to away from textbook medicine when I deal with all specialties especially when its community standard of care

    I remember when I was a resident and I worked 7 straight 13 hr shifts (post shift rounds), off a few dys (with sporadic meetings), and back to 7 straight 13 hr shifts. Doing it as a resident was not a big deal as I was single, sleep when I want, had no one to answer to. If I did 22, 12 hr shifts a month now, my wife would kill me.
     

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