Don't Do This

[Strength&Speed]

2 things

From a colleague:
Him: Oh, he has a new pleural effusion and an echo showed he had an EF of 30% with an apical thrombus.
Me: did you tap it?
Him: no, he has CHF so it's probably due to that. There's no need to tap.

decub film later showed a consolidation with parapnuemonic effusion

#2.
From the ER. This patient is saying she needs to be admitted for daytime sleepiness, but her 02 sat is 94%, and when i told her she wouldnt be admitted, she jumped up and left. So she's not sleepy when she doesnt want to be, so I have no reason to admit her.

later, a cxr shows pnuemonia, a utox shows cocaine, and her sats drop into the lower 80's

---

Members don't see this ad.

 

[EMCC]

I am confused... Are there parts of each story that you left out? Otherwise, I am not sure what you are trying to get at... Pleae elaborate...

 

[Strength&Speed]

emcc, i didnt give all the information on the case mainly because i was venting. i was just illustrating two points. a new onset pleural effusion with chf is not necessarily chf. this other physician was going to chalk it up to pleural effusion...and would have missed a pna and parapneumonic effusion.

On #2, the ER physician (not dogging er here...they are usually quite good) was dissuaded by a normal 02 saturation in a patient with severe daytime sleepiness...which would have included an ABG for C02 retention, and an xray for pnuemonia/other lung pathology which could contribute to abnormal blood gases.

Just venting a bit b/c they both happened in same day and both patients would have been possibly affected by these incorrect decisions.

 

[Monkeyguts]

2 things

From a colleague:
Him: Oh, he has a new pleural effusion and an echo showed he had an EF of 30% with an apical thrombus.
Me: did you tap it?
Him: no, he has CHF so it's probably due to that. There's no need to tap.

decub film later showed a consolidation with parapnuemonic effusion

#2.
From the ER. This patient is saying she needs to be admitted for daytime sleepiness, but her 02 sat is 94%, and when i told her she wouldnt be admitted, she jumped up and left. So she's not sleepy when she doesnt want to be, so I have no reason to admit her.

later, a cxr shows pnuemonia, a utox shows cocaine, and her sats drop into the lower 80's

Don't do what? Make mistakes?

So you should tap every pleural effusion in someone with known CHF? Chest x-ray and some supporting labs with history and physical to see if there is some other cause.

People miss things dude and you should give your colleagues the benefit of the doubt because you too will be in the same position one of these days where your work up wasn't necessarily sufficient.

 

[Strength&Speed]

Don't do what? Make mistakes?

So you should tap every pleural effusion in someone with known CHF? Chest x-ray and some supporting labs with history and physical to see if there is some other cause.

People miss things dude and you should give your colleagues the benefit of the doubt because you too will be in the same position one of these days where your work up wasn't necessarily sufficient.

Oh, I do make mistakes, I'm not saying that. Im saying that in the case of a 42 yo with no previously known chf to call a new pleural effusion "chf" is poor decision making. i dont think you'll find anyone who'll argue with that. Also, the second case was also poor decision making--this patient had come to the ER multiple times in the same day, and not recieved any workup, at all. And an IM consult was called, to essentially get the patient to leave the ER. shyt happens, but it doesnt have to happen that bad.

 

[Soundwave]

I don't know about the first case. A pleural effusion in a patient with an ef of 30% is probably going to be secondary to chf. The second case is challenging as well. Drug users are difficult to read, its not that uncommon that they present with atypical symptoms and are less then forthcoming in their history when they have something real going on. It can be quite frustruating because they are obstructing the physicians who are just trying to do whats best for them. When you do miss something like pneumonia by not checking a cxr for nonspecific symptoms, you can get sued. There was a case a case not too long about with some drug user who went to some er every other day or so with one complaint or another, typically wanting narcotics. One day they presented with a hx of cough and fever and a cxr had been done the previous day that was clear so no repeat cxr was ordered and the patient was sent home without anything. Some bad outcome occurred, I think that the patient may have died from pneumonia, and the er physician was sued successfully for a large sum.

 

[ekydrd]

I think the point here was not to ask for opinions from others... S&S just wanted to vent and apparently didn't have a safe audience to vent to.

 

[Trifling Jester]

emcc, i didnt give all the information on the case mainly because i was venting. i was just illustrating two points. a new onset pleural effusion with chf is not necessarily chf. this other physician was going to chalk it up to pleural effusion...and would have missed a pna and parapneumonic effusion.

If you see a pleural effusion on CXR how do you miss the pneumonia? And was it a B/L or unilateral effusion?

-The Trifling Jester

 

[Strength&Speed]

the pneumonia was hiding behind the pleural effusion. it was only seen after a lateral decub was ordered. and it was unilateral.