DVT R-O at night

[Groove]

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Do you guys have 24h availability? If so, what is the annual volume of your ED?

Is anyone actually in an environment where they are forced to administer lovenox to elderly patients who are high fall risk with scheduled morning DVT studies?

We're having to re-visit this battle with our vascular surgery department who is trying to cut out US services for DVTs at night, in a 60K ED no less.

 

[jw3600]

Bedside POCUS. Formal study follow up in 1 week. Standard of care met.

 

[GeneralVeers]

I'm never sure why these "DVT rule outs" are emergencies to begin with. Most of them should be managed with scheduled outpatient US, and PCP follow up. Does starting these patients on Eliquis a day or two earlier really make a big difference in outcomes?

That being said, I wouldn't work in a place where I couldn't get basic 24 hr US.

 

[GonnaBeADoc2222]

Bedside POCUS. Formal study follow up in 1 week. Standard of care met.

I don't think this is really standard of care.

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[GonnaBeADoc2222]

I'm never sure why these "DVT rule outs" are emergencies to begin with. Most of them should be managed with scheduled outpatient US, and PCP follow up. Does starting these patients on Eliquis a day or two earlier really make a big difference in outcomes?

That being said, I wouldn't work in a place where I couldn't get basic 24 hr US.

The best is when they actually DO get study outpatient, it is positive, and then the patient is sent to the ED cause the PMD can't be bothered to order eliquis.

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[thegenius]

My part time job I have no US at night. What I do:

1) low risk DVT - I just do my own ultrasound. I’m assuming a pretest probability of like < 5%. Basically I do it to appease the patient because I know it’s going to be negative.

2) medium risk DVT - I’ll order an US for them first thing in the AM. I tell them they can either go home and come back in the AM to the US suite, or they can hang out in the ED until the AM. Most just go home. Most of the time I do not give lovenox. Note that they are not coming back to the ED and they are getting their study done as an outpatient (I’m able to do this, which is nice)

3) high risk DVT, same as #2 but I give lovenox and usually kind of convince them they should stay, but if they go I’m ok with that.

Can’t we use the Wells score for DVT and just get a d-dimer? How come we rarely do that? Are the testing characteristics for DVT poor?

 

[thegenius]

The best is when they actually DO get study outpatient, it is positive, and then the patient is sent to the ED cause the PMD can't be bothered to order eliquis.

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Yup. I get so angry with that but it’s technically easy money.

No wonder insurance companies spend so much time refusing to pay ER bills. We get nonsense like that every day.

 

[KGflyboy]

I see patients routinely who had an outpatient d-dimer ordered, which was positive, so they get sent to the ED to the ultrasound. I don't understand.

If someone is willing to order the d-dimer, he or she should be willing to order the follow up test if it's positive as opposed to sending them to the ED.

I have 24 US availability, but dvt studies are fairly straight forward and easy for those willing to try or learn it. I think I would be ok doing it myself if need be on most patients, but I'm glad it's not needed.

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[bravotwozero]

Where I did my residency was arguably the busiest ED in the state at 120k visits per year. Unbelievably, they did not have US at night! I would offer the patient a lovenox shot and dc home to return in the morning, or observation with a morning ultrasound. Here at our shop that sees a fraction of that many ED visits, we have 24/7 US. Go figure.

Sending people on xarelto doesn’t always work. Had a bounce back on my shift because their stupid insurance won’t pay. I guess the *****s thought a hospital stay would be somehow cheaper.


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[Groove]

I'm never sure why these "DVT rule outs" are emergencies to begin with.

It's not the DVTs I'm usually worried about, it's their evolution into one of the leading causes of cardiovascular death worldwide. In fact, depending on which study you quote, 40-50% of DVTs have concomitant PEs. If I could accurately predict which DVTs will kill and which ones won't do anything....I'd be rich...sitting on some island drinking scotch and tossing dollars at cabana girls.

What's so frustrating are these small studies put out by vascular surgeons or SDMS claiming no bad outcomes and increased job satisfaction for sonographers with increased retention rates when they put up roadblocks for the ED during after hours. I get the business economics of it all, but talk about providing two standards of care in the emergency room. I feel the same way about our "prelim" radiology reads at night. Completely two standards of care. God forbid we inconvenience anybody who took on a job to take care of live human patients.

 

[DrGasPasser]

My part time job I have no US at night. What I do:

1) low risk DVT - I just do my own ultrasound. I’m assuming a pretest probability of like < 5%. Basically I do it to appease the patient because I know it’s going to be negative.

2) medium risk DVT - I’ll order an US for them first thing in the AM. I tell them they can either go home and come back in the AM to the US suite, or they can hang out in the ED until the AM. Most just go home. Most of the time I do not give lovenox. Note that they are not coming back to the ED and they are getting their study done as an outpatient (I’m able to do this, which is nice)

3) high risk DVT, same as #2 but I give lovenox and usually kind of convince them they should stay, but if they go I’m ok with that.

Can’t we use the Wells score for DVT and just get a d-dimer? How come we rarely do that? Are the testing characteristics for DVT poor?

I’ve used to pull a shift or two per month at one of our smaller community hospitals that didn’t have vascular US after 11 PM. I’d say this is pretty reasonable if you are doing proper compression views every 2 cm along the entire thigh and documenting them (Qpath, hard copies, etc.). A similar strategy was described by Jacob Avila on EMRAP last month. For low-medium risk and below, a negative D-dimer is also reasonable to discharge to PCP with no US.

I stopped using Lovenox for the high-risk when the Xerelto bunny put 30-day starter packs in our Pixis...

 

[DrGasPasser]

Where I did my residency was arguably the busiest ED in the state at 120k visits per year. Unbelievably, they did not have US at night! I would offer the patient a lovenox shot and dc home to return in the morning, or observation with a morning ultrasound. Here at our shop that sees a fraction of that many ED visits, we have 24/7 US. Go figure.

Sending people on xarelto doesn’t always work. Had a bounce back on my shift because their stupid insurance won’t pay. I guess the *****s thought a hospital stay would be somehow cheaper.


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You really need to start going to more pharm rep dinners. If you do and remember to keep smiling and nodding your head despite the wine, the Xarelto bunny will put 30-day starter packs in your Pixis. Ahh, the lengths that I’ll go to for my patients...😉

 

[Groove]

Departmental politics plays a huge factor into these policies also. I wouldn't even be having this discussion if radiology hadn't turfed DVT studies to vascular surgery. I have zero issues with any radiological study ordered 24/7 whereas it's an act of congress to get vascular to send one of their techs in to do an US.

Yes, I'm trained to do my own peripheral DVTs. I did one today even, but I'm typically only doing those on my low risk pt's, much like @thegenius

But c'mon....we all know it's easier, more efficient and better in every way to have a formal study. Hell, I used to read my own wet preps in residency and do my own transvaginal ultrasoud exams but you don't see me begging to do those anymore. Plus, talk about killing your flow.

 

[thegenius]

It's not the DVTs I'm usually worried about, it's their evolution into one of the leading causes of cardiovascular death worldwide. In fact, depending on which study you quote, 40-50% of DVTs have concomitant PEs. If I could accurately predict which DVTs will kill and which ones won't do anything....I'd be rich...sitting on some island drinking scotch and tossing dollars at cabana girls.

I guess we need to study whether delaying treatment for a DVT by 6-12 hours actually makes a lick of difference. Patient oriented outcomes: death, cardiac arrest w/ ROSC, requiring vasopressors, development of at least moderate, permanent pHTN (via RVSP or PAP measurements).

My guess waiting 6-12 hours probably doesn’t matter at all.

If one has normal vitals and no overt thoracic complaints, I don’t really care if they have a PE.

 

[thegenius]

I’ve used to pull a shift or two per month at one of our smaller community hospitals that didn’t have vascular US after 11 PM. I’d say this is pretty reasonable if you are doing proper compression views every 2 cm along the entire thigh and documenting them (Qpath, hard copies, etc.). A similar strategy was described by Jacob Avila on EMRAP last month. For low-medium risk and below, a negative D-dimer is also reasonable to discharge to PCP with no US.

I start at the inguinal crease and go to just below the popliteal fossa, like 2-3 cm below.

I’m not confident in my skills....so again it’s only low pretest probability. Like those who come in because their foot is mildly swollen and they don’t have any leg pain or calf pain or calf asymmetry. In someone with no established risk factors for DVT and a benign exam like that, that’s when I do the US.

I could probably just do a d-diner though which would take less time.

 

[cyanide12345678]

Do you guys have 24h availability? If so, what is the annual volume of your ED?

Is anyone actually in an environment where they are forced to administer lovenox to elderly patients who are high fall risk with scheduled morning DVT studies?

We're having to re-visit this battle with our vascular surgery department who is trying to cut out US services for DVTs at night, in a 60K ED no less.

20k volume. I'll often give the lovenox and they get a scheduled early morning US. If the person is some ridiculous fall risk, then i may hold off, the ultrasonographers usually do the study by 9 am for my referred patients.

 

[TooMuchResearch]

Even at our 6k site, US tech will come in overnight to do a study. They tried to cut overnight coverage at one of our sites, we told them it wasn't our community standard, so they continued on call coverage.

 

[gamerEMdoc]

Proximal dvts (the ones that embolize) are not hard to find. You may miss a calf dvt, but who cares, we dont even have evidence they should even be treated.

DVT US to rule out a proximal DVT is very easy, and very accurate in the hands of an EM doc. Add to that the ability to get a next day followup US, and you definitely have a safe system IMO.

And dont forget the Ddimer. Negative ddimer, no point in getting the US in the first place.

If you arent comfortable with your US skills, Id suggest:

1. Age adjusted ddimer. If negative, you are done, followup with pcp.
2. If positive, give a dose of lovenox and get a next day dvt US.

 

[Groove]

Proximal dvts (the ones that embolize) are not hard to find. You may miss a calf dvt, but who cares, we dont even have evidence they should even be treated.

While I agree that proximal DVTs are of the greatest concern...they all have risk of embolization.

Playing Devil's Advocate, here's a small study that I found of PEs with isolated calf DVTs. 3 patients had submassive PE and 3 had massive PE. It can happen.

The prevalence of isolated calf deep vein thrombosis in patients with pulmonary embolism - PubMed

Our results reflected the prevalence of PE at presentation, which was high and included severe cases. Though, as reported, PE during surveillance was the most precisely way to reflect PE in isolated calf DVT, but such a risk of PE at presentation should not just be ignored and its importance...

www.ncbi.nlm.nih.gov

 

[GeneralVeers]

Patient's want "something done" so I put all the DVTs on Eliquis, or admit them. I've given up arguing with people, or even trying to quote them evidence.

 

[AlmostAnMD]

We have 24/7 vascular so I've stopped writing for US in the morning and a dose of xarelto that evening like I did in residency (if it was positive they'd come back to the ED for the rest of the xarelto starter pack)

We also have 24/7 everything so I'm just watching my skills atrophy lol

 

[Groove]

Even at our 6k site, US tech will come in overnight to do a study. They tried to cut overnight coverage at one of our sites, we told them it wasn't our community standard, so they continued on call coverage.

That's the direction I'm going to take... I've got a meeting with our CMO and vascular surgeon. Our current director seems neutral on the issue and doesn't seem to want to cause any waves but when he brought it up to the group in a recent meeting we all felt pretty strongly about it. So, I got volunteered to represent the rest of the group. We'll see if it does any good. I just called around to a few of my buddies in town that work at other hospitals and all of them have night time US availability. Even a smaller 12K? ED an hour away has the service. Regardless of the arguments, it's clearly not a local standard of care if every other hospital but ours offers the service during night hours.

The problem is politics... Vascular surgery brings in $$$, and we don't. Vascular surgery is pissed because their US techs are quitting and complaining of having to be on call, so CMO probably wants to pacify him and we end up suffering because of it. I'm probably being called in to be the one to piss someone off so my director doesn't have to do it. Wonderful.

I fail to see how being on call as a sonographer would be a significant cause of attrition when their own website states that 40% nationwide jobs take call and over 60% hospital jobs have on call requirements.

 

[Groove]

We have 24/7 vascular so I've stopped writing for US in the morning and a dose of xarelto that evening like I did in residency (if it was positive they'd come back to the ED for the rest of the xarelto starter pack)

We also have 24/7 everything so I'm just watching my skills atrophy lol

ED volume?

 

[AlmostAnMD]

Our SDG services several hospitals that we rotate through. All have pretty amazing support, except for the FSEDs, understadably.

Flagship is north of 100k

 

[RoyBasch]

Can’t we use the Wells score for DVT and just get a d-dimer? How come we rarely do that? Are the testing characteristics for DVT poor?

I think a low risk for DVT Wells score with negative d dimer rules out DVT and meets standard of care.

The problem is DVT is one of those diseases that kind of actually "exists" in the mind of the lay public (similar to appendicitis) and a lot of people believe they "must" have an ultrasound. Perhaps this is just my experience an affluent suburb outside a major city in Texas.

Similarly, I've had many surgeons, PCPs, and OB/GYNs specifically refer patients to the ER for "an ultrasound to rule out blood clots." Why they don't sack up and order the test as an urgent outpt and follow it up themselves and manage accordingly--I don't know. Suffice to say I probably see at least one of these "ER referral" patients per week.

So if someone comes in to the ER expecting an ultrasound (particularly if a physician they know and trust like their surgeon or OB tells them they need one) and you only do a blood test, they leave upset. You're in a situation of weighing the patient satisfaction against the sonographer satisfaction (particularly if they are homecall and not on site). I know playing into patient or ancillary staff satisfaction doesn't go over well on this board, especially with resident and student posters, but I think it's something to be considered in the decision-making. It's not the only factor, but it is A factor.

 

[RuralEDDoc]

Patient's want "something done" so I put all the DVTs on Eliquis, or admit them. I've given up arguing with people, or even trying to quote them evidence.

You admit DVTs? Or, just rule out DVTs awaiting testing?
Regardless, I am fascinated that this is a possibility for you.
(With the caveat that massive DVTs with perfusion problems and other issues should of course be admitted)

 

[gamerEMdoc]

While I agree that proximal DVTs are of the greatest concern...they all have risk of embolization.

Playing Devil's Advocate, here's a small study that I found of PEs with isolated calf DVTs. 3 patients had submassive PE and 3 had massive PE. It can happen.

The prevalence of isolated calf deep vein thrombosis in patients with pulmonary embolism - PubMed

Our results reflected the prevalence of PE at presentation, which was high and included severe cases. Though, as reported, PE during surveillance was the most precisely way to reflect PE in isolated calf DVT, but such a risk of PE at presentation should not just be ignored and its importance...

www.ncbi.nlm.nih.gov

Fair point. However, we dont know if treating calf vein dvt is beneficial. You can find a few that lead to PE. You can also find a few people who had devestating bleeding from anticoagulation. There’s always a risk benefit of any intervention, and with calf vein dvt, its still an uncertain area of medicine if we should be treating them. One of the recommended strategies is waiting and watching for progression. And if guidelines say its appropriate to wait and watch, then I certainly think waiting a few hrs for a confirmatory US is more than reasonable if you are confident a proximal dvt does not exist.

 

[Janders]

35k ED. No U/S from 2200-->0800.

I do basically as above.

Low risk patient with history that sounds nothing like a DVT but THEY want it ruled out? I do my own U/S, and when negative d/c home with strong recommendation to have a formal U/S via radiology with the "big machine" in the next 1-2 days, or come back to the ED in the AM and we'll arrange it.

Low/moderate risk patient with a history that makes me want to rule out DVT? Wells score, DDimer, my own bedside u/s. If all negative, same as above.

Moderate/High Risk patient with a history where I think they HAVE a DVT? I do my own scan. If positive treat. If negative but still super concerned, offer Lovenox x1 and come back in the AM, or hang out in an ED bed 'til AM. Frankly these are rather infrequent.

 

[GeneralVeers]

You admit DVTs? Or, just rule out DVTs awaiting testing?
Regardless, I am fascinated that this is a possibility for you.
(With the caveat that massive DVTs with perfusion problems and other issues should of course be admitted)

I ultrasound all of the swollen/painful legs regardless of Wells criteria, and don't waste my time dimering them. It's a whole lot faster than spending 20 min in the room persuading them they don't need the US that their doctor convinced them they need.

When negative they get discharged. If positive they can go down one of two pathways: Discharge home with prescription for Eliquis, as we have a coupon for 30-day supply we give them. If I can't get them on the PO meds due to finances, insurance, etc. I just admit them and have the case management and hospitalist figure out the appropriate regimen.

 

[RoyBasch]

I ultrasound all of the swollen/painful legs regardless of Wells criteria, and don't waste my time dimering them. It's a whole lot faster than spending 20 min in the room persuading them they don't need the US that their doctor convinced them they need.

When negative they get discharged. If positive they can go down one of two pathways: Discharge home with prescription for Eliquis, as we have a coupon for 30-day supply we give them. If I can't get them on the PO meds due to finances, insurance, etc. I just admit them and have the case management and hospitalist figure out the appropriate regimen.

Agree this is one of the few situations where I really get to the bottom of the patient's financial situation. If they do not have money or/and insurance DOACs are not going to be viable. I admit these patients for either heparin bridge to coumadin or the case managers/SW in the hospital find some special coupons or program to get the patient a DOAC.

 

[GonnaBeADoc2222]

While we're on the subject of ultrasound, what about things like r/o torsion? I wonder who is going down when the patient loses an ovary cause the tech takes 2 hours to come in or you have to transfer for a u/s.

 

[gamerEMdoc]

Well to be fair, your first call to someone when you truly have a suspected torsion should he the specialist, not US. Someone with a clearly torsed testicle should not require an US. And US isnt good enough to rule out ovarian torsion. The sensitivity is not good. Its all about suspician. I had seen exactly two ovarian torsions in my career. Both had known adnexal masses. One went to the OR without an US, the other had a no torsion, went to the OR anyways based on her pain out of porportion and had a torsion.

I have ordered IDK how many US’s to “rule out torsion” on people with pelvic pain, but have yet to see one where the clinical suspician wasnt pretty obvious. Not saying it cant happen. But in a decade I just havent seen it.

 

[gamerEMdoc]

For those that say why ddimer, I would argue that its because it is a more definitive test in ruling out the disease. It has a higher sensitivity than US. If negative, it more effectively rules out a dvt than an US.

 

[deleted836128]

In our ER which is probably the third largest volume in town, we don’t have vascular US at night past 7:00 PM. Only way they’ll come in is for an arterial study that the vascular surgeon on call has to approve first. So the protocol is to get a D-Dimer. If positive, Lovenox and outpatient US in twelve hours. If negative, no Lovenox and the patient still gets an order for an outpatient US. There is supposed to be a comment on the order that says “If positive for DVT, send patient to ER.”

 

[GonnaBeADoc2222]

Sad that we have to give potentially dangerous tx to pts cause hospital doesnt want to pay for us coverage or upset a vascular surgeon

I wonder who's on the hook if patient gets in MVA on drive home after shot of lovenox and has SDH

 

[KGflyboy]

Sad that we have to give potentially dangerous tx to pts cause hospital doesnt want to pay for us coverage or upset a vascular surgeon

I wonder who's on the hook if patient gets in MVA on drive home after shot of lovenox and has SDH

I agree. I suspect your question is somewhat rhetorical, because we all know if the hammer drops in that situation it will land on the physician who ordered the lovenox and not the hospital mandating that protocol.

It's not fair, but it's true.

 

[gamerEMdoc]

Sad that we have to give potentially dangerous tx to pts cause hospital doesnt want to pay for us coverage or upset a vascular surgeon

I wonder who's on the hook if patient gets in MVA on drive home after shot of lovenox and has SDH

To me its sad that we tout ourselves as a specialty who is at the forefront of US in medicine, yet the majority of us don't do DVT US's despite it being considered a core US of EM and one of the easiest ones to do.

But to clarify on your post:

- You wouldn't be liable. The standard of care in court is regionally defined. The standard thus changes based on the size, scope, and resources of the given hospital. So if the standard has been established at your hospital to give a dose of lovenox and get an AM US, then its hard to find you personally at fault for this. They could go after the hospital, but I'd find it hard to believe the doc would be held liable for following the hospitals policy.

There is virtually no reason to practice this all or nothing way of just treating every patient with lovenox anyways.

- Ddimer negative, don't treat, don't get a next day US
- Ddimer positive, but still with a low likelihood based on gestalt. Do a bedside US. If negative, the chance of that patient having a DVT is very low. IMO, its more than reasonable to wait, get a followup US in the AM
- Ddimer positive, higher risk by gestalt but negative bedside US. Consider risk discussion with patient about lovenox / factor Xa inhibitor prior to getting a next day US. Shared decision making.
- Ddimer positive, bedside US positive. Treat with a single dose of lovenox or factor Xa inhibitor. This isn't that many patients.

You could just cut out the Ddimer if you want and just do the bedside US, but I think the ddimer gives people who are less confident in their US skill a feeling of reassurance, and completely negates the need for a next day US when negative.

 

[GonnaBeADoc2222]

To me its sad that we tout ourselves as a specialty who is at the forefront of US in medicine, yet the majority of us don't do DVT US's despite it being considered a core US of EM and one of the easiest ones to do.

But to clarify on your post:

- You wouldn't be liable. The standard of care in court is regionally defined. The standard thus changes based on the size, scope, and resources of the given hospital. So if the standard has been established at your hospital to give a dose of lovenox and get an AM US, then its hard to find you personally at fault for this. They could go after the hospital, but I'd find it hard to believe the doc would be held liable for following the hospitals policy.

There is virtually no reason to practice this all or nothing way of just treating every patient with lovenox anyways.

- Ddimer negative, don't treat, don't get a next day US
- Ddimer positive, but still with a low likelihood based on gestalt. Do a bedside US. If negative, the chance of that patient having a DVT is very low. IMO, its more than reasonable to wait, get a followup US in the AM
- Ddimer positive, higher risk by gestalt but negative bedside US. Consider risk discussion with patient about lovenox / factor Xa inhibitor prior to getting a next day US. Shared decision making.
- Ddimer positive, bedside US positive. Treat with a single dose of lovenox or factor Xa inhibitor. This isn't that many patients.

You could just cut out the Ddimer if you want and just do the bedside US, but I think the ddimer gives people who are less confident in their US skill a feeling of reassurance, and completely negates the need for a next day US when negative.

I don't think we are at the forefront of US. I trained at a place that pushed US hard but I got little bedside teaching in it. We do not have the skill of a trained ultrasonographer who does 10 DVT ultrasounds a day.

Yes I have done a DVT US. But nowhere near the number where I would feel comfortable making a solid decision on it.

The ultrasound machine at the places I've been post residency are the equivalent of an iPad on a stick.

Hospitals should not be absolved of not providing basic services at night and leaving us on the hook.

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[gamerEMdoc]

We are on the forefront of physician trained US as a specialty compared to other physician specialties. It's a major part of EM training. There are studies that show EM docs can be very accurate in ruling out DVT at the bedside. It's honestly probably the easiest US to do IMO.

We also aren't trained to read ECGs as much as an electrophysiologist. And yet, we act on that information all the time. We don't demand we have a cardiologist read all our ECGs in real time.

The fact is in EM, there's always someone better than us at virtually everything we do. We are the masters at putting out fires, and being the next best person at just about everything. Optho is better at plucking out corneal FBs than me. Ortho is better at resetting fractures. ENT is better at posterior nosebleeds. And yet, we still do all of these things because 24 hours a day we don't have someone readily available to come in for the basic cases. In my opinion, this vascular US issue is no different.

 

[GonnaBeADoc2222]

We are on the forefront of physician trained US as a specialty compared to other physician specialties. It's a major part of EM training. There are studies that show EM docs can be very accurate in ruling out DVT at the bedside. It's honestly probably the easiest US to do IMO.

We also aren't trained to read ECGs as much as an electrophysiologist. And yet, we act on that information all the time. We don't demand we have a cardiologist read all our ECGs in real time.

The fact is in EM, there's always someone better than us at virtually everything we do. We are the masters at putting out fires, and being the next best person at just about everything. Optho is better at plucking out corneal FBs than me. Ortho is better at resetting fractures. ENT is better at posterior nosebleeds. And yet, we still do all of these things because 24 hours a day we don't have someone readily available to come in for the basic cases. In my opinion, this vascular US issue is no different.

Then why have vascular ultrasound in the ed at all?

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[gamerEMdoc]

Then why have vascular ultrasound in the ed at all?

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Why have orthopedics, ENT, opthalmology, etc. For backup.

Because we do need confirmatory studies. Its just not time urgent. In the end, the workup for MOST dvts is an outpatient workup with outpatient treatment. PCPs should be able to handle this. A PCP can see these patients and order outpatient USs that are done and get followed up hours later. There is zero reason this needs to be an emergent test at 3am if you don't have overnight vascular coverage. These patients don't need transferred. This is an outpatient workup.

 

[betamale]

Do you guys have 24h availability? If so, what is the annual volume of your ED?

Is anyone actually in an environment where they are forced to administer lovenox to elderly patients who are high fall risk with scheduled morning DVT studies?

We're having to re-visit this battle with our vascular surgery department who is trying to cut out US services for DVTs at night, in a 60K ED no less.

Sucks. We have 24 hr US but DVT studies are done by our regular US techs, however, they don't look below popliteal which is weird. I worked at a place where people are transferred for US. Another where US is only done emergently if D-dimer is positive.

 

[betamale]

Why have orthopedics, ENT, opthalmology, etc. For backup.

Because we do need confirmatory studies. Its just not time urgent. In the end, the workup for MOST dvts is an outpatient workup with outpatient treatment. PCPs should be able to handle this. A PCP can see these patients and order outpatient USs that are done and get followed up hours later. There is zero reason this needs to be an emergent test at 3am if you don't have overnight vascular coverage. These patients don't need transferred. This is an outpatient workup.

I don't think you can argue that as "standard of care" in a litigation

 

[gamerEMdoc]

I don't think you can argue that as "standard of care" in a litigation

Yeah you can. You've met the standard of care. Workup for DVT US as a risk stratification with ddimer, bedside US, obtaining confirmatory studies, etc. That's a completely defensible approach.

Also, what litigation are we referring to. Is there a case where someone had a DVT missed on bedside ED US in the middle of the night, didn't get treated, only to embolize in the few hours before they could get the confirmatory US just a few hours later? We aren't talking about delaying workup by a week, just a couple hours.

If so, then all leg pain is a time sensitive emergency. No one should ever wait in the waiting room with calf pain, and all primary care doctors should immediately send all calf pain patients to the ED for an emergent study.

You have to be found to have not met the standard of care in a suit. If your hospital defines the standard of care, and you meet it, then IDK how you can be held liable. If anything, the hospital would if their standard of care was considered "substandard". But in this case, I don't think it is.

 

[alpinism]

Really??

Since when is the immediate diagnosis and treatment of a non emergency condition in the emergency department the standard of care?

 

[alpinism]

DVTs are not in any way shape or form emergencies and can be managed by the patient’s primary care physician.

 

[betamale]

DVTs are not in any way shape or form emergencies and can be managed by the patient’s primary care physician.

Wow, I hope I don't end up at your hospital if I ever have a DVT. Jeez.

Wasn't so long ago that I took care of a patient who had the DVT travel to his lung and coded -> anoxic brain injury -> dead. I do consider DVTs as an emergency and I sincerely hope most people do

 

[Porfirio]

50k volume ED

24 hr US
24 hr MRI (ct techs are cross trained for MRI)
24 X-ray reads (I still read all my xrays - amazing what radiologist miss or what I miss)
No Peds US (sadly)

 

[GonnaBeADoc2222]

It really doesn't matter what standard of care is.all that matters is what a jury of your non-peers will smoke you for.

Sent from my Pixel 3 using SDN mobile

 

[emergentmd]

60K an no 24h U/S tech?

Everywhere I work at, the U/S tech does everything - belly/Vascular/soft tissue.

I never knew there were techs does everything but vascular, odd.