Diagnosing an Appy

[dynx]

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.

Almost kidding but not really:
In my experience if the ER calls you with a "slam dunk" appy. And thats the key: "slam dunk" or variation of that. then just send them home. No CT scan, no observation. Just discharge them. Its not an appy.

This isn't helpfull at all but I doubt you want to hear my whole rant about how useless ER docs are. Our main hospital has figured this out and now I get called by PAs or other extenders. At least they save some money in the process of triage after not seeing, diagnosing or otherwise serving the patient in any fashion whatsoever. I mean I can ask a monkey on the phone a bunch of easy questions they cant answer because they haven't done any actual evaluation. I bet the patients would like to see some monkeys too. I'll bring it up at the next meeting.

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[emergentmd]

Almost kidding but not really:
In my experience if the ER calls you with a "slam dunk" appy. And thats the key: "slam dunk" or variation of that. then just send them home. No CT scan, no observation. Just discharge them. Its not an appy.

This isn't helpfull at all but I doubt you want to hear my whole rant about how useless ER docs are. Our main hospital has figured this out and now I get called by PAs or other extenders. At least they save some money in the process of triage after not seeing, diagnosing or otherwise serving the patient in any fashion whatsoever. I mean I can ask a monkey on the phone a bunch of easy questions they cant answer because they haven't done any actual evaluation. I bet the patients would like to see some monkeys too. I'll bring it up at the next meeting.

Got it. Trust me, nothing off my back if you think we are useless. I guess the next time a surgeon doesn't want to go to the hospital to deal with their floor patients b/c they have a lac they want me to repair, a fistula that doesn't stop bleeding, a central line they want me to place; I will tell him that this monkey is too useless to care for his problem. Let me put that on my things to do.

In all seriousness, if you had surgeons work in the ED and only dealt with abdominal pain, you would say the same thing to your surgical colleagues. I am also very sure that they would have about the same success, order the same amount of test, consult the same amount of times as an ED doc. Surgeons like you think abdominal pain evaluation is some mythical skill. Trust me, I know. I can teach a medical student in 1 wk how to evaluate abdominal pain as well as the best surgeons I know. Trust me.... and I am not kidding about this.

Anyhow, I wish you took call for my shop. If you had this same attitude, and gave me lip every time I called you.... things would change very fast. Surgeons think that somehow they can make ED docs lives difficult. I can tell you with certainty, I hold your quality of life with a much stronger grip than you every bother my life. If you gave me lip like that over the phone, you would get calls at 2am for a consult, 15 min bf your shift ends. You attitude would change very quickly.

But I am sure your one of those guys that can talk tough on the internet but a sheep when the ED calls you.

 

[deleted547339]

Almost kidding but not really:
In my experience if the ER calls you with a "slam dunk" appy. And thats the key: "slam dunk" or variation of that. then just send them home. No CT scan, no observation. Just discharge them. Its not an appy.

This isn't helpfull at all but I doubt you want to hear my whole rant about how useless ER docs are. Our main hospital has figured this out and now I get called by PAs or other extenders. At least they save some money in the process of triage after not seeing, diagnosing or otherwise serving the patient in any fashion whatsoever. I mean I can ask a monkey on the phone a bunch of easy questions they cant answer because they haven't done any actual evaluation. I bet the patients would like to see some monkeys too. I'll bring it up at the next meeting.

And to think, I so enjoyed the collegial conversation between the surgeons and EM folks up to now on this board.

Yes, there is something magical when two similar people who graduate from similar med schools with similar grades and board scores split and go into EM and gen surg. One becomes a genius - a god of medicine; the other becomes a monkey. That makes sense.

Edit: This is really a shame. A good surgical consultant is great, and the good surgery residents are some of my favorite residents in the hospital. That being said, a perpetually angry surgeon puts a damper on my day. As said above, I can put a damper on a d-bag consultant's day as well.

 

[emergentmd]

Got it. Trust me, nothing off my back if you think we are useless. I guess the next time a surgeon doesn't want to go to the hospital to deal with their floor patients b/c they have a lac they want me to repair, a fistula that doesn't stop bleeding, a central line they want me to place; I will tell him that this monkey is too useless to care for his problem. Let me put that on my things to do.

In all seriousness, if you had surgeons work in the ED and only dealt with abdominal pain, you would say the same thing to your surgical colleagues. I am also very sure that they would have about the same success, order the same amount of test, consult the same amount of times as an ED doc. Surgeons like you think abdominal pain evaluation is some mythical skill. Trust me, I know. I can teach a medical student in 1 wk how to evaluate abdominal pain as well as the best surgeons I know. Trust me.... and I am not kidding about this.

Anyhow, I wish you took call for my shop. If you had this same attitude, and gave me lip every time I called you.... things would change very fast. Surgeons think that somehow they can make ED docs lives difficult. I can tell you with certainty, I hold your quality of life with a much stronger grip than you would ever bother my life. If you gave me lip like that over the phone, you would get calls at 2am for a consult, 15 min bf your shift ends. You attitude would change very quickly.

But I am sure your one of those guys that can talk tough on the internet but a sheep when the ED calls you.

 

[Winged Scapula]

Agreed -- there's room for venting and some good natured joshing, but gross insulting generalizations about others is inappropriate.

 

[dynx]

Got it. Trust me, nothing off my back if you think we are useless. I guess the next time a surgeon doesn't want to go to the hospital to deal with their floor patients b/c they have a lac they want me to repair, a fistula that doesn't stop bleeding, a central line they want me to place; I will tell him that this monkey is too useless to care for his problem. Let me put that on my things to do.

In all seriousness, if you had surgeons work in the ED and only dealt with abdominal pain, you would say the same thing to your surgical colleagues. I am also very sure that they would have about the same success, order the same amount of test, consult the same amount of times as an ED doc. Surgeons like you think abdominal pain evaluation is some mythical skill. Trust me, I know. I can teach a medical student in 1 wk how to evaluate abdominal pain as well as the best surgeons I know. Trust me.... and I am not kidding about this.

Anyhow, I wish you took call for my shop. If you had this same attitude, and gave me lip every time I called you.... things would change very fast. Surgeons think that somehow they can make ED docs lives difficult. I can tell you with certainty, I hold your quality of life with a much stronger grip than you every bother my life. If you gave me lip like that over the phone, you would get calls at 2am for a consult, 15 min bf your shift ends. You attitude would change very quickly.

But I am sure your one of those guys that can talk tough on the internet but a sheep when the ED calls you.

My bad, I thought I was being nice. Good thing I didn't give my whole rant.
Anyway, if you're a good ER doc good for you! Most of your colleagues suck. I don't know why they suddenly suck after getting the same grades etc. culture? Personality drawn to the soecialty? Who knows.

And Im sure you could teach a great abdominal exam. It's not hard. It's not magical. But strangely, it actually requires that you set foot in the patients room. Again, maybe you do. But a lot of you don't.

Bottom line. Across about 7 hospitals now my experience is that most ER docs are happy to be glorified triage nurses. It's a sweeping generalization and I know, I know I'm not supposed to make those here but it's a broadly held sweeping generalization for a reason. You can yell at me, give me crap consults, call and wake me up, egg my car, call me an Internet tough guy, whatever.
But in the end, and it's happening allready, unless you fix your own specialty you'll be relegated to a minority position of oversite for practice extenders and you'll have nobody to blame but yourself for making yourself and your specialty reliably replaceable.
People come to the ER regardless. You don't draw dollars. Not to be mean but you're a cog and you can chose to have that be a very good hard to replace cog or you guys can keep doing what you ON AVERAGE do and become a easily replaced cog.

 

[emergentmd]

My bad, I thought I was being nice. Good thing I didn't give my whole rant.
Anyway, if you're a good ER doc good for you! Most of your colleagues suck. I don't know why they suddenly suck after getting the same grades etc. culture? Personality drawn to the soecialty? Who knows.

And Im sure you could teach a great abdominal exam. It's not hard. It's not magical. But strangely, it actually requires that you set foot in the patients room. Again, maybe you do. But a lot of you don't.

Bottom line. Across about 7 hospitals now my experience is that most ER docs are happy to be glorified triage nurses. It's a sweeping generalization and I know, I know I'm not supposed to make those here but it's a broadly held sweeping generalization for a reason. You can yell at me, give me crap consults, call and wake me up, egg my car, call me an Internet tough guy, whatever.
But in the end, and it's happening allready, unless you fix your own specialty you'll be relegated to a minority position of oversite for practice extenders and you'll have nobody to blame but yourself for making yourself and your specialty reliably replaceable.
People come to the ER regardless. You don't draw dollars. Not to be mean but you're a cog and you can chose to have that be a very good hard to replace cog or you guys can keep doing what you ON AVERAGE do and become a easily replaced cog.

I will not chose to argue most of your points. But from what you are posting, I am sure you are one unhappy doctor. From your point of view, I am sure ER docs are triage nurses. I am sure Hospitalists can be replaced with PAs (I mean, all they do is consult anyhow). I am sure Radiologists can be replaced by Rad Techs (I mean, you guys read your own studies and they overread anyhow). I get all of that. In my 15 yrs as an attending, I hear specialties dog each other all of the time. I hear your surgical ortho docs called every other name b/c they don't want to touch anything unless its bony.

I do find it quite laughable, that Surgeons couldn't treat 90% of medical issues while these ER triage nurses (like myself) could care for 99% of medical issues. I also bet when you come to the ER, the first person you would like to treat you/your family are ER docs. I am sure if a PA or even a godly surgeon came in when you were having chest pain or hypertensive emergency, you would be one unhappy person. I guess next time your need conscious sedation in the ED, you will order your own meds and manage the airway.

But I will go to my little hole and make my $3-500/hr triaging the next pt. I will comfort myself knowing that I will be pulling in close to 500k this year working 15 dys a month or 140 hrs a week. Not too bad of a gig as a triage nurse and never touching a pager again.

 

[dynx]

I will not chose to argue most of your points. But from what you are posting, I am sure you are one unhappy doctor. From your point of view, I am sure ER docs are triage nurses. I am sure Hospitalists can be replaced with PAs (I mean, all they do is consult anyhow). I am sure Radiologists can be replaced by Rad Techs (I mean, you guys read your own studies and they overread anyhow). I get all of that. In my 15 yrs as an attending, I hear specialties dog each other all of the time. I hear your surgical ortho docs called every other name b/c they don't want to touch anything unless its bony.

I do find it quite laughable, that Surgeons couldn't treat 90% of medical issues while these ER triage nurses (like myself) could care for 99% of medical issues. I also bet when you come to the ER, the first person you would like to treat you/your family are ER docs. I am sure if a PA or even a godly surgeon came in when you were having chest pain or hypertensive emergency, you would be one unhappy person. I guess next time your need conscious sedation in the ED, you will order your own meds and manage the airway.

But I will go to my little hole and make my $3-500/hr triaging the next pt. I will comfort myself knowing that I will be pulling in close to 500k this year working 15 dys a month or 140 hrs a week. Not too bad of a gig as a triage nurse and never touching a pager again.

LOL, I wish more ER docs were sure of so many things! Did you need to consult someone to come to those conclusions?
Anyway, your point about hypertensive emergency is a good one. That's a real head scratcher. Amazingly mismanaged most of the time in the ER before they call me to fix the aorta.
I like your last paragraph. It's exactly my point. You may have missed it as it soared over your head. Either way, enjoy your chosen profession, whatever you do don't reflect on criticism.

 

[vhawk]

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.

Sure, I hear you, I put "I'm naive" like 5 words into my post for a reason, I'm not trying to be clueless. and I'm sure I'll have the same perspective as you when I'm a little further along. It won't make me right then. Future me will have more experience, but he will also have different incentives and have made different compromises, so his judgment can't be taken at face value. The idea that we all become disillusioned and less "naive" as go through the grinding process doesn't have much at all to say about whether we become more "right."

 

[deleted547339]

LOL, I wish more ER docs were sure of so many things! Did you need to consult someone to come to those conclusions?
Anyway, your point about hypertensive emergency is a good one. That's a real head scratcher. Amazingly mismanaged most of the time in the ER before they call me to fix the aorta.
I like your last paragraph. It's exactly my point. You may have missed it as it soared over your head. Either way, enjoy your chosen profession, whatever you do don't reflect on criticism.

Were you not held enough as a child?

 

[deleted547339]

LOL, I wish more ER docs were sure of so many things! Did you need to consult someone to come to those conclusions?
Anyway, your point about hypertensive emergency is a good one. That's a real head scratcher. Amazingly mismanaged most of the time in the ER before they call me to fix the aorta.
I like your last paragraph. It's exactly my point. You may have missed it as it soared over your head. Either way, enjoy your chosen profession, whatever you do don't reflect on criticism.

Additionally, it shows your glaring bias and poor insight by making sweeping generalizations like that. If I notice a trend where everyone does something differently than I do, my first thought isn't (and shouldn't be) "wow, everyone else is really dumb....they're lucky they have me to teach them." If you think all of the EM docs are doing it wrong, maybe it's you.

You are showing your lack of understanding of EM as a specialty and your inability to step away from your selection bias. The overwhelming majority of patients that show up to the ED are treated and discharged. The vast majority of abd pain and headache does not get a CT. The one's that get admitted to you have a diagnosis (for the most part), when they show up to the ED they simply had a complaint. Further, you have the benefit of longitudinal care and being the same person to follow up your patients. EM is unique in that the next doctor to see the patient will almost never be me. 90% of the errors you make, you catch and no one else knows about it. 90% of the errors I make are found by someone else.

I am proud of the job that I do and the service I provide to society. I don't need your respect, nor do I need the respect of anyone else (get your loving at home); all I care about is you evaluating the patient when I call. That being said I have tremendous respect for surgeons. But I will say that in the past month or two I've had about a half dozen residents or fellows call, text or came to me in the ED and ask if I will take a look at them, their spouse or their child because they trust me. Traumatic MSK complaint, child with a fever and rash, pregnant wife spotting, father with TIA - these are just the ones that immediately come to mind.

You may be an all-knowing expert of all specialties, but one day your kid's going to have a febrile and not be eating well, or your wife's going to have abdominal pain during pregnancy, or your brother is going to have a traumatic pneumothorax from an MVC and need a chest tube, or your mom's going to be septic and need resuscitation and intubation.

To the rest of the surgeons on this board - thanks. I appreciate what I've learned about the practice of real-world medicine. If we can get back to the previous discussion, that would be great.

 

[DrBowtie]

I tried to do a lit search but could not answer my specific question.
What is the complication rate for whatever operation you would call taking the patient to the OR and finding a normal appendix (laparoscopy?) under GA.

 

[deleted547339]

I tried to do a lit search but could not answer my specific question.
What is the complication rate for whatever operation you would call taking the patient to the OR and finding a normal appendix (laparoscopy?) under GA.

My 100% guess is that the risk of anesthesia would overshadow the risk of a negative laparoscopy.

 

[SLUser11]

Sure, I hear you, I put "I'm naive" like 5 words into my post for a reason, I'm not trying to be clueless. and I'm sure I'll have the same perspective as you when I'm a little further along. It won't make me right then. Future me will have more experience, but he will also have different incentives and have made different compromises, so his judgment can't be taken at face value. The idea that we all become disillusioned and less "naive" as go through the grinding process doesn't have much at all to say about whether we become more "right."

Not all of our philosophical changes occur from burnout or expatriatism. Once you've seen things go South a few times, see what works and what doesn't, what is sustainable and what is not....but most importantly, once you see that there is a huge disconnect between textbooks/board exams and real life, you simply make a different, measured choice. For example, the literature changes constantly, and basically swings back and forth like a pendulum, so I'm less convinced of things that I previously believed to be absolute truths, and I trust my own personal, anecdotal experience more than the big trials that maybe were biased or had subtle, tragic flaws that limit their accuracy. I also occasionally make choices that I'm not sure will benefit the patient, but are definitely not harmful to the patient, that I believe will make me sleep easier at night....those choices ultimately make me a better, more focused surgeon.

That being said, I'm not a grey-haired veteran, and I generally share your idealism. I'm relatively new in practice, and since I train residents I am up to date and evidence-driven, but I have been absolutely amazed at my own changes in philosophy during the last 4 years.

 

[dpmd]

I tried to do a lit search but could not answer my specific question.
What is the complication rate for whatever operation you would call taking the patient to the OR and finding a normal appendix (laparoscopy?) under GA.

I would guess the same risk of appendectomy since most surgeons i know would still take out the appy on the chance there is some less obvious inflammation occurring. I am not just going to do a diagnostic laparoscopy and leave the appy unless i find a contraindication to taking it.

 

[DrBowtie]

My 100% guess is that the risk of anesthesia would overshadow the risk of a negative laparoscopy.

My guess is that it outweighs the negative effects of a singular CT scan.

 

[dynx]

I forgot how much fun this is!

Additionally, it shows your glaring bias and poor insight by making sweeping generalizations like that. If I notice a trend where everyone does something differently than I do, my first thought isn't (and shouldn't be) "wow, everyone else is really dumb....they're lucky they have me to teach them." If you think all of the EM docs are doing it wrong, maybe it's you.

I agree your first thought is correct. For other people like me...I'm actually right. It's a subtle difference but important. Anyway, your completely off base point is recognized and recognized as stupid. Your supposition is that my disagreement with them as a specialist consult is off base and outside the standard of care? I should learn from them how to order the wrong test? How to fail to order coags in a bleeding patient? I'll work on that.
Again, this may not be you. But from what I've seen in multiple states in multiple hospitals it is the majority of your colleagues. So for sure, YOUR first thought shouldn't be everyone is really dumb, at least you recognize that...it's a start.

You are showing your lack of understanding of EM as a specialty and your inability to step away from your selection bias. The overwhelming majority of patients that show up to the ED are treated and discharged. The vast majority of abd pain and headache does not get a CT. The one's that get admitted to you have a diagnosis

Yes because I make sure they have a diagnosis before they get admitted to me. Luckily at this point I'm mostly shielded from the ER by specialist physicians that have a clue what they're doing. Cardiology takes the brunt of the stupidity and God bless them for it.

pray tell what are you treating and discharging from the ER that a nurse couldn't handle? I'd really like to know what medical miracles you're performing down there? Do you cure cancer and discharge them?
I'd like to know what medical issues you've treated without consultation that resulted in a discharge from the ER that a nurse couldn't handle. Diarrhea? A stubbed toe? This could be a learning opportunity for me so please let me know.
Now, total those up and ask yourself....could my entire ER be run by nurses at a tremendous cost savings with a tenth as many ER docs (we can still keep the fraction that actually know what they're doing) to handle the real urgent interventions and oversee the nurses assuring the fat lady her stomach hurts because of the 82 tacos she ate?
If you're not at USC or Miami the answer is truthfully, yes. And I'm not just saying this, I'm seeing this. It's happening. I don't make the decision. But I agree with it.

(for the most part), when they show up to the ED they simply had a complaint. Further, you have the benefit of longitudinal care and being the same person to follow up your patients. EM is unique in that the next doctor to see the patient will almost never be me. 90% of the errors you make, you catch and no one else knows about it. 90% of the errors I make are found by someone else.

The percent doesn't matter. it's the absolute number and the consequences.

I am proud of the job that I do and the service I provide to society. I don't need your respect, nor do I need the respect of anyone else (get your loving at home); all I care about is you evaluating the patient when I call. That being said I have tremendous respect for surgeons. But I will say that in the past month or two I've had about a half dozen residents or fellows call, text or came to me in the ED and ask if I will take a look at them, their spouse or their child because they trust me. Traumatic MSK complaint, child with a fever and rash, pregnant wife spotting, father with TIA - these are just the ones that immediately come to mind.

I don't need your respect....here's why you should respect me.

You may be an all-knowing expert of all specialties, but one day your kid's going to have a febrile and not be eating well, or your wife's going to have abdominal pain during pregnancy, or your brother is going to have a traumatic pneumothorax from an MVC and need a chest tube, or your mom's going to be septic and need resuscitation and intubation.

And a pediatrician, an ob gyn, a surgeon and an anesthesiologist will respectively take care of them. I wouldn't let an ER doc put a chest tube in my worst enemy. I will say for the most part you guys can intubate.
If it makes you feel better to portray me as claiming to be an expert of all specialties that's great. I'm glad it helps your ego. Please point out where I ever claimed anything close to that.

To the rest of the surgeons on this board - thanks. I appreciate what I've learned about the practice of real-world medicine. If we can get back to the previous discussion, that would be great.

That would be wouldn't it!

 

[deleted547339]

I forgot how much fun this is!



I agree your first thought is correct. For other people like me...I'm actually right. It's a subtle difference but important. Anyway, your completely off base point is recognized and recognized as stupid. Your supposition is that my disagreement with them as a specialist consult is off base and outside the standard of care? I should learn from them how to order the wrong test? How to fail to order coags in a bleeding patient? I'll work on that.
Again, this may not be you. But from what I've seen in multiple states in multiple hospitals it is the majority of your colleagues. So for sure, YOUR first thought shouldn't be everyone is really dumb, at least you recognize that...it's a start.

Yes because I make sure they have a diagnosis before they get admitted to me. Luckily at this point I'm mostly shielded from the ER by specialist physicians that have a clue what they're doing. Cardiology takes the brunt of the stupidity and God bless them for it.

pray tell what are you treating and discharging from the ER that a nurse couldn't handle? I'd really like to know what medical miracles you're performing down there? Do you cure cancer and discharge them?
I'd like to know what medical issues you've treated without consultation that resulted in a discharge from the ER that a nurse couldn't handle. Diarrhea? A stubbed toe? This could be a learning opportunity for me so please let me know.
Now, total those up and ask yourself....could my entire ER be run by nurses at a tremendous cost savings with a tenth as many ER docs (we can still keep the fraction that actually know what they're doing) to handle the real urgent interventions and oversee the nurses assuring the fat lady her stomach hurts because of the 82 tacos she ate?
If you're not at USC or Miami the answer is truthfully, yes. And I'm not just saying this, I'm seeing this. It's happening. I don't make the decision. But I agree with it.



The percent doesn't matter. it's the absolute number and the consequences.


I don't need your respect....here's why you should respect me.


And a pediatrician, an ob gyn, a surgeon and an anesthesiologist will respectively take care of them. I wouldn't let an ER doc put a chest tube in my worst enemy. I will say for the most part you guys can intubate.
If it makes you feel better to portray me as claiming to be an expert of all specialties that's great. I'm glad it helps your ego. Please point out where I ever claimed anything close to that.


That would be wouldn't it!

Cool story, bro.

 

[dynx]

Cool story, bro.

*drops the mic*

 

[emergentmd]

LOL, I wish more ER docs were sure of so many things! Did you need to consult someone to come to those conclusions?
Anyway, your point about hypertensive emergency is a good one. That's a real head scratcher. Amazingly mismanaged most of the time in the ER before they call me to fix the aorta.
I like your last paragraph. It's exactly my point. You may have missed it as it soared over your head. Either way, enjoy your chosen profession, whatever you do don't reflect on criticism.

I feel dirty just even discussing any point with you. I will just end this by saying that I hope somehow you find peace in your life b/c its painful to see someone live in such persistent turmoil.

 

[dynx]

I feel dirty just even discussing any point with you. I will just end this by saying that I hope somehow you find peace in your life b/c its painful to see someone live in such persistent turmoil.

You sure that's not appendicitis?
Just kidding. Anyway you too. Take care.