So, doing EM this month. It seems to me that in our ER, the min you see the patient, you put in all orders. We had this obese guy with subjective fevers for 3 days, non-septic, non-toxic looking. We did a full septic work up to cover our bases - never mind the guy had no findings on physical exam except symmetric weakness on finger grip test. Is it just me or are we trained wrong in the med school to go by the physical exam findings, not just subjective hx. Everything was neg and he went home on Tylenol. Patient was puzzled while his wifie, who is a nurse (was grinning and happy with all the work up we did.) Oh yeah, he is hypertensive and diabetic and we told him to go to his PCP(both have nothing to do with his "fevers"). My original plan to just do a CBC/BMP combined with his vitals would have led us to the same conclusion.
ER way of doing things
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It's hard to say the way you presented the case whether the attending was being overly defensive because wife was a nurse or not. Just because the workup was negative doesn't mean it wasn't warranted. Did you ask your attending why he did a full septic workup? What was the guys glucose level? What was his actual temperature? Are you sure your attending didn't find any other neurological findings? If you are confused as to why something was done, why didn't you speak with your attending about it?
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You wait to see the patient to put in all the orders? Too slow...
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LOL! So true. That's what happens when you have EMR pre-made orders for common conditions.
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Arggh. First, I'll echo that if you have questions about the work up of a particular patient you should ask your attending or supervising resident. Second, the diagnosis of plenty of diseases are based off of subjective findings or as you may know it better - the history of present illness. Febrile seizures, TIAs, hx of rigors in ESRD patients, unstable angina, suicidal ideation, etc. While it would be nice from a medmal standpoint if we were only held to the standard of not missing diseases with obvious physical exam findings, everyone expects better us to be better than that. Based on some combination of clinical gestalt and formalized risk stratification, we decide what tests need to be ordered to rule out the worst-case scenario for whatever the patient's presenting complaint happens to be.
Obese (especially if morbid) diabetics are not renowned for their ability to effectively clear bacterial infections and depending on the level of obesity, the diagnostic value of the physical exam will be degraded by body habitus. If the patient isn't sick, it doesn't really matter what work-up you do (including not doing any) so in a very real way you don't get points for suggesting a more minimalistic work-up for this patient. The problem arises in the patient that could be sick. Your initial work-up features a test with relatively poor AUC for most diseases (assuming you're looking for WBC count on the CBC) and a reasonable screen for significant electrolyte abnormalities (although with B hand weakness you could considering adding on a phosphorous). Since you're not giving me an indication that the patient/wife had a hidden agenda in coming to the ED (work-note, avoiding incarceration, drug-seeking, etc.), I'd want to know what the guy (or more likely his wife) was worried about. Playing the odds right now it's a viral illness, but with B hand weakness and reported fever it could be something as dangerous as early cord compression from an epidural abscess. I'm not saying the guy needed an MRI, but it's possible your attending went hunting to find a more benign cause for the patient's symptoms while buying time to observe the guy for progression of symptoms.
In terms of ordering everything in one go, it's actually relatively uncommon in medicine to systematically hunt down diseases in a serial fashion. Most medicine specialties will have some version of a shotgun work-up that they order initially (GI chasing elevated LFTs, heme/onc working up anemia, rheumatology going after an autoimmune disease, etc .) even in the face of convincing evidence for a particular cause of the disease. A lot of intern year is spent figuring out what to load the shotgun with depending on the service you're rotating through. In the ED, ordering multiple rounds of tests sometimes is necessary because of changing patient conditions or new history (family arrives and says grandma's face was drooping for 30 min). In general though, most of our testing pattern in based off of the fact that many of our patients' pre-test probability of disease is in an intermediate zone and that unremarkable basic labs may not be sufficiently sensitive to drop the post-test probability low enough to rule out the disease.
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agree, although there are good reasons for this- it can cost a lot in physician/bed time to order one set of labs, go over the results, and then order a 2nd and maybe 3rd set of labs. I
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Order first, ask questions later
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Yup...totally agree with the shotgun lab approach. Anemia, coagulopathy and clotting are great examples. Sure, I could order one or two labs, get the results, have them come back to see me, get a couple more labs, lather, rinse, repeat. To the tune of 4 or 5 patient co-pays and a savings of a couple (maybe) "unnecessary" lab tests. Or I can just get the 5 or 10 labs that are most likely to define the issue at hand, make a f/u phone call when they come back and be done with it. Shotgunning labs in the ED based on nursing protocols is, by necessity less precise than the labs I shotgun, but that's what you get when people present with undifferentiated "feeling bad".
It's easy to Monday morning QB this kind of stuff when you're used to dealing with medicine inpatients who aren't going anywhere anyway so what harm is there in doing 1 test at a time. But in the real world, in and out of the ED, we break a few lab eggs to make a quick diagnosis omelette.
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It's fine to ask questions first but since so many people are idiots, liars, or both, the endpoint will ultimately be the same.Order first, ask questions later
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All other fields of medicine are fields of specificity... what is wrong with the patient
EM is a field of sensitivity... what isn't wrong. The goal of EM is to rule out life threats.
So yes, every other field will look at a 25yr old with 3 days of chest pain after lifting weights and say "it's probably just costochondritis, here's your ibuprofen". EM people will say "well.. it's probably costochondritis... but... first let me get an EKG and maybe some inflammatory markers or cardiac enzymes depending on the patient's family/social history... oh, and could this be a PE? Was he vomiting a lot recently? Maybe he needs a chest xray."
It's because of the medicolegal burdens placed on the ER. It's not necessarily a good thing. And it's not that ED people are dumb and don't have a good handle on what's really going on with the patient. We can walk into the room and within seconds know if the person is really sick or not. We run a lot of tests to pick up a small amount of pathology.
Sometimes though we know something's wrong, and we do a lot of tests in order to rapidly identify or exclude the lifethreatening pathology and then admit them for evaluation of less than lifethreatening but still serious problems.
EM is a field of sensitivity... what isn't wrong. The goal of EM is to rule out life threats.
So yes, every other field will look at a 25yr old with 3 days of chest pain after lifting weights and say "it's probably just costochondritis, here's your ibuprofen". EM people will say "well.. it's probably costochondritis... but... first let me get an EKG and maybe some inflammatory markers or cardiac enzymes depending on the patient's family/social history... oh, and could this be a PE? Was he vomiting a lot recently? Maybe he needs a chest xray."
It's because of the medicolegal burdens placed on the ER. It's not necessarily a good thing. And it's not that ED people are dumb and don't have a good handle on what's really going on with the patient. We can walk into the room and within seconds know if the person is really sick or not. We run a lot of tests to pick up a small amount of pathology.
Sometimes though we know something's wrong, and we do a lot of tests in order to rapidly identify or exclude the lifethreatening pathology and then admit them for evaluation of less than lifethreatening but still serious problems.
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