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So you have an extremely old person who's out the window for tpa. Head CT without any intracranial hemorrhage. He's so old he likely would not be a candidate for endarterectomy. Vitals are stable. Is there a point in admitting this person to the hospital? I'm always attempting to understand the benefit of all of my admits.
 

Raryn

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So you have an extremely old person who's out the window for tpa. Head CT without any intracranial hemorrhage. He's so old he likely would not be a candidate for endarterectomy. Vitals are stable. Is there a point in admitting this person to the hospital? I'm always attempting to understand the benefit of all of my admits.
Gets him evaluated by PT/OT/Speech therapy in the acute setting and appropriate followup there arranged.
 
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USCDiver

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I think it depends a lot on how profound the deficits are. Like Raryn mentioned, you might need PT/Speech to evaluate the patient to make sure they can swallow safely and get around the house.

Also you said 'likely would not be a candidate for endarterectomy'. Are you making that decision for the patient or are you willing to discuss risk benefits and alternatives yourself?
 

Birdstrike

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Strokes can progress and worsen. They may have a correctable cause (carotid, afib, valve vegitation, carotid/vertebral dissection) not obvious on routine ED testing. A certain percentage may have delayed bleeds into the ischemic area, depending on what the stroke affected. They may have trouble walking, talking, swallowing, or any number of things that are essential for independent daily life. Often there's uncontrolled hypertension.

If you think someone in front of you whom you've slapped the label of "CVA" on, is well enough to go home from your ED, you're either missing something, you don't respect/understand how serious strokes are/can be, or maybe you shouldn't be putting the CVA diagnosis on their chart.

There's just too much that can go wrong with CVAs, and too much pathology leading up to the CVA having caused it, to blow one off and send one home barring something out of the ordinary (hospice, AMA refusal, etc). Rarely should you get any real resistance from admitting teams asked to admit an actual acute CVA of any variety.
 

doctorFred

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head of bed up, swallow eval, PT/OT eval, stroke unit admission, carotid u/s, MRI, medication optimization, social work c/s, home safety eval, etc etc etc.
 
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So I actually agree with all of the responses. I actually thought it was a no brainer, but when I called to admit the patient I got resistance from the hospitalist stating not much to do except aspirin and she's not a candidate for anything. I was wondering if I was being unreasonable or "behind the times" in the management of these folks by requesting an admit.
 

erdoc00

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So I actually agree with all of the responses. I actually thought it was a no brainer, but when I called to admit the patient I got resistance from the hospitalist stating not much to do except aspirin and she's not a candidate for anything. I was wondering if I was being unreasonable or "behind the times" in the management of these folks by requesting an admit.
Ah yes, the old hospitalist punt.. "There's nothing much to do..."

Just ask the hospitalist to come down and discharge them from the ER, then... seems like a pretty straightforward process based on their work-avoidance behavior.

And not to highjack the thread, but I'm convinced internists and family practice physicians learn a different form of medicine than emergency physicians. I have never seen such a lack of concern for pathology as I do when dealing with these admitting services. "65 y/o diabetic chest pain with normal EKG and first trop normal... they've clearly got costochonditis" "80 y/o acute CVA... ASA and home, nothing else to do..."

And I'm so tired of hearing about "saving the system money" as if our job is to solve the spending crisis. This becomes especially entertaining when the reason for the patient visit is "sent in from PMDs office..."

Sorry for the rant, but this is such routine stupidity, I had to get it out of the way. You are 100% correct in what you did. Stop overthinking it and realize that hospitalists are trying to avoid as much work as possible and hoping you're too weak to press the issue. Just make sure not to forget that they have their best interest and not yours or the patient's best interest in mind.
 

erdoc00

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Also, one thing that can help is getting a case manager involved whenever there is any dispute. If they meet for admission criteria, tell the admitting team they meet criteria and need to be admitted and that's the final word. Don't let these fools jerk you around and don't feel badly about it.
 

e30ftw

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there are times when I've discharged (back to snf usually) a patient presenting with "new" neuro symptoms. Usually it's recurrence of symptoms of prior ischemic stroke. When a pt who had an MCA stroke which has partially improved after long rehab comes in with mild recurrence of symptoms (ie, my R arm feels weaker today than normal but it's usually weak..) and is already on maximal medical therapy w/ recent appropriate stroke work up and family is comfortable with plan to DC back to rehab I will send these patients back after discussion with neurology. In that case there's really nothing more to do. Of course if family wants them admitted no problem.
 

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I'm surprised you guys get push back admitting acute CVAs. I can also get MRIs so patient's outside of the window who look like strokes and have normal BP, awake and alert, I go to MRI first. If there are things pushing me toward being concerned about hemorrhage (mostly if they're on coumadin and I can do something about it or they have AMS) I'll get a CT first. I think getting the MRI maybe helps seal the deal with the hospitalist, they're not sending someone with an abnormal MRI home.
 

Raryn

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I have a hospitalist that won't admit chest pain. I **** you not.
Chest pain in a patient who had an absolutely clean cath last week and just got a negative CTPA? ;)
 
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Chest pain in a patient who had an absolutely clean cath last week and just got a negative CTPA? ;)
Tell ya what... You come down and discharge them so we can both save our breath in a discursive conversation over plaque composition, the fallacies of luminal stenosis as an absolute predictor of plaque rupture --> ACS, the irrelevance of things such as recent stress tests and let's definitely not talk about coronary vasospasm or troponinemias of "insignificance" or the 100 other "chest pain" pt's I discharged in the last week. Just come down, listen to the patient and discharge them yourself.

We both know it's not about the "absolutely clean cath last week" but more about the "LAST WEEK" part that everyone cares about (administrators, cardiology, etc..) Re-admit < 30d? No CHEESE. Much wrist slapping from hospital administration and gnashing of teeth.
 
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Groove

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So I actually agree with all of the responses. I actually thought it was a no brainer, but when I called to admit the patient I got resistance from the hospitalist stating not much to do except aspirin and she's not a candidate for anything. I was wondering if I was being unreasonable or "behind the times" in the management of these folks by requesting an admit.
That's ridiculous. If you truly are getting push back over a CVA admission, just call the neurologist first and ask them if it's ok to put them down as a floor consult. (emphatic "YE$") Then, use that to buff your admission though I would rarely think that necessary most of the time.
 

Birdstrike

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Chest pain in a patient who had an absolutely clean cath last week and just got a negative CTPA? ;)
Agree with Groove. What is an "absolutely clean" cath? What a cardiologist considers "negative cath" may just mean there was no plaque or stenosis bad enough to stent. I've seen this before, where there is a plaque that is, let's say 40% stenotic, and they say, "The cath was 'fine.'" The 40% lesion is not worthy of stenting, and maybe is not the source of pain during the previous episode, but can't that still undergo acute plaque rupture and thrombosis, unrelated to whatever was going on the previous week when the cath was done?

Ask a cardiologist to answer that question. I bet you they'll say, "Well, it's unlikely, but...."

Of course it can. Acute MIs are acute events. Is it likely? Well, maybe not, but Ebola walking into your ED isn't likely,beither. Neither is meningiococcemia, and you're there to pick that needle out of a haystack, too. "Likely" doesn't mean a damn thing if it's the one, does it?

Now if the cath is truly "normal coronaries," (which is actually not that many patients > age 40) then the odds obviously are greatly in your favor. Unless it's vasospasm, of course. I've seen STEMI in a 28 yr old with that before. When you hear that "normal cath" comment, it's worth taking a look at the actual report, and making your own judgement. That's all I'm saying.
 
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Raryn

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Agree with Groove. What is an "absolutely clean" cath? What a cardiologist considers "negative cath" may just mean there was no plaque or stenosis bad enough to stent. I've seen this before, where there is a plaque that is, let's say 40% stenotic, and they say, "The cath was 'fine.'" The 40% lesion is not worthy of stenting, and maybe is not the source of pain during the previous episode, but can't that still undergo acute plaque rupture and thrombosis, unrelated to whatever was going on the previous week when the cath was done?

Ask a cardiologist to answer that question. I bet you they'll say, "Well, it's unlikely, but...."

Of course it can. Acute MIs are acute events. Is it likely? Well, maybe not, but Ebola walking into your ED isn't likely,beither. Neither is meningiococcemia, and you're there to pick that needle out of a haystack, too. "Likely" doesn't mean a damn thing if it's the one, does it?

Now if the cath is truly "normal coronaries," (which is actually not that many patients > age 40) then the odds obviously are greatly in your favor. Unless it's vasospasm, of course. I've seen STEMI in a 28 yr old with that before. When you hear that "normal cath" comment, it's worth taking a look at the actual report, and making your own judgement. That's all I'm saying.
Sometimes the chance of that acute MI is such an unlikely event that it's an absolutely absurd call. I'm thinking frequent fliers who have gotten the million dollar workup the last five times they came in with the same presentation. Mind you, if I get the call for chest pain, I'll admit them, but that's mostly because I don't think it's worth my time to argue. It's faster for me to simply put the H&P in and d/c them a few hours later once my attending comes in. Hell, it's actually better for me because it's a joke of an admit that takes me 15 minutes that brings me closer to my cap.
 

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I hate those arguments against admission. I've seen actual, honest to God MIs in patients with a "negative" cath a month ago, or a "negative" stress last week. I've had push back on admitting people with CABG in the past year because "those bypass grafts are pristine!" Our job in the ED is finding the needle in the haystack with a 0% miss rate, and frankly, if they have a good story, I don't care what their history is or how many recent admissions they have, unless they want to go home, they're getting admitted with their negative troponin and normal ECG.
 

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Chest pain in a patient who had an absolutely clean cath last week and just got a negative CTPA? ;)
No, try 5 risk factors, with pain resolved by nitro, good story, but no EKG changes or troponin bump. What I should have done was call the cardiologist at the big house (as we don't have any cards in the community hospital). I am just deliriously happy that the patient didn't come back in cardiac arrest.
 

Groove

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Sometimes the chance of that acute MI is such an unlikely event that it's an absolutely absurd call. I'm thinking frequent fliers who have gotten the million dollar workup the last five times they came in with the same presentation. Mind you, if I get the call for chest pain, I'll admit them, but that's mostly because I don't think it's worth my time to argue. It's faster for me to simply put the H&P in and d/c them a few hours later once my attending comes in. Hell, it's actually better for me because it's a joke of an admit that takes me 15 minutes that brings me closer to my cap.
<Yawn> I don't even know where to start. We need another thread for this one. Part of your problem is that you still see consults, admissions and work ups through the eyes of a medicine resident. You definitely don't have enough respect for atypical ACS presentations. Nor do you have any idea about ruling it out in the ED. (We see a lot more undifferentiated chest pain than you do.) Your practice patterns, insight, professionalism (or lack thereof) will likely change once you graduate and find yourself in private practice. Love it or hate it, chest pain admissions are a part of your future. If you absolutely can't stand it, then look for a hospitalist gig where the ED has their own CPU.

That is, unless you plan on pursuing a fellowship... Cardiology, perhaps?
 

Groove

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No, try 5 risk factors, with pain resolved by nitro, good story, but no EKG changes or troponin bump. What I should have done was call the cardiologist at the big house (as we don't have any cards in the community hospital). I am just deliriously happy that the patient didn't come back in cardiac arrest.
Any reason why you didn't escalate the issue? I'm sure you have hospital bylaws for formal consults to the ED (<30 mins, etc..) where you could have forced him to come down and write a note or dc. Hell, you could have called hospital administration if he refused. I'm not saying anybody likes to play those types of cards but I'd have little patience for an admitting doc who both refused admission and refused to see the pt in the ED.
 

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Sorry to bring back to the initial topic, but I had a patient a few months ago with recent ischemic stroke. He had the typical inpatient workup after getting tPA, had some carotid disease that was going to be medically managed. He was discharged and two days later came back with some recurrent symptoms that had resolved. I find this to be a challenging situation. Maybe he's having some hypoperfusion of affected area, or maybe new ischemia. But what are we going to do for him in the hospital? There is no operative intervention etc, he can't get tPA again (thank god). Who admits this guy? Who discharges?
 

ThoracicGuy

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Sorry to bring back to the initial topic, but I had a patient a few months ago with recent ischemic stroke. He had the typical inpatient workup after getting tPA, had some carotid disease that was going to be medically managed. He was discharged and two days later came back with some recurrent symptoms that had resolved. I find this to be a challenging situation. Maybe he's having some hypoperfusion of affected area, or maybe new ischemia. But what are we going to do for him in the hospital? There is no operative intervention etc, he can't get tPA again (thank god). Who admits this guy? Who discharges?
Have they considered a carotid stent?