High Risk Dispos?

[RustedFox]

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Yeah, widespread problem. Ironic how a new technology gets instituted, ostensably for improved patient flow, and leads to the exact opposite.

Personally, I think you're fine if you document that presentation was non-cardiac in nature, HS-trops were ordered for unclear reasons and are stable w/o a trend to suggest ACS or an absolute level concerning for Type II MI. On an insituitonal level, this should get dealt with by department leadership to disencourage people from indiscriminate ordering.

So, so many cardiac presentations are non cardiac in nature.

 

[The kitchen sink]

Just as a word of caution, absence of RV dysfunction does not mean a PE has been ruled out.

Absolutely correct, however it does rule out a hemodynamically significant PE.

So hypothetically, in the right clinical scenario, lets say you have a preggers pt, normal CXR, negative lower extremity venous duplex, normal POCUS (negative TAPSE), would you consider sending the pt for an outpatient V/Q since although you have ruled out a hemodynamically significant PE, the patient could still have a small PE somewhere?

 

[BoardingDoc]

Absolutely correct, however it does rule out a hemodynamically significant PE.

So hypothetically, in the right clinical scenario, lets say you have a preggers pt, normal CXR, negative lower extremity venous duplex, normal POCUS (negative TAPSE), would you consider sending the pt for an outpatient V/Q since although you have ruled out a hemodynamically significant PE, the patient could still have a small PE somewhere?

No? Because the argument against doing a CTA on a preggers patient is that they're preggers and radiation is bad for a fetus. A CTA is less rads to the fetus than a VQ. Order the CTA if you're worried about a PE.

 

[thegenius]

Absolutely correct, however it does rule out a hemodynamically significant PE.

So hypothetically, in the right clinical scenario, lets say you have a preggers pt, normal CXR, negative lower extremity venous duplex, normal POCUS (negative TAPSE), would you consider sending the pt for an outpatient V/Q since although you have ruled out a hemodynamically significant PE, the patient could still have a small PE somewhere?

Our radiologist says a CT PE study on a pregnant woman who is properly shielded is less radiation than a V/Q study

 

[The kitchen sink]

Our radiologist says a CT PE study on a pregnant woman who is properly shielded is less radiation than a V/Q study

True

 

[dadaddadaBATMAN]

No? Because the argument against doing a CTA on a preggers patient is that they're preggers and radiation is bad for a fetus. A CTA is less rads to the fetus than a VQ. Order the CTA if you're worried about a PE.

Not based on any literature just a truism from residency, but my understanding is that the ct is a higher dose exposure for mom with actively dividing breast tissue that actually has a link to future breast cancer. Not a huge one, but way more real than the usual spiel.

Vq is higher exposure to fetus, but not breast.

99% of the time if mom is willing to get study they’ll go ctpa based On above , esp as it’s a better study anyway

 

[lucid_leprechaun]

Not based on any literature just a truism from residency, but my understanding is that the ct is a higher dose exposure for mom with actively dividing breast tissue that actually has a link to future breast cancer. Not a huge one, but way more real than the usual spiel.

Vq is higher exposure to fetus, but not breast.

99% of the time if mom is willing to get study they’ll go ctpa based On above , esp as it’s a better study anyway

Just was reading a good review article on radiation in pregnancy. It’s true that the main concern is radiation to breast tissue rather than radiation to fetus, thought to be more sensitive during pregnancy. Both studies well below any threshold for fetal harm. Less than the 9 months of radiation exposure just living on Earth in utero. Here’s the article if anyone is interested

CT in pregnancy: Risks and benefits

 

[WilcoWorld]

Not based on any literature just a truism from residency, but my understanding is that the ct is a higher dose exposure for mom with actively dividing breast tissue that actually has a link to future breast cancer. Not a huge one, but way more real than the usual spiel.

Vq is higher exposure to fetus, but not breast.

99% of the time if mom is willing to get study they’ll go ctpa based On above , esp as it’s a better study anyway

I would guess the change are more cell hypertrophy, rather than cell multiplication...but that's a total guess

 

[turkeyjerky]

Not based on any literature just a truism from residency, but my understanding is that the ct is a higher dose exposure for mom with actively dividing breast tissue that actually has a link to future breast cancer. Not a huge one, but way more real than the usual spiel.

Vq is higher exposure to fetus, but not breast.

99% of the time if mom is willing to get study they’ll go ctpa based On above , esp as it’s a better study anyway

I don’t know if the last part is necessarily true…

 

[wamcp]

“At first, Xavier Ortiz wasn't too worried about his headache and sensitivity to noise, which set in one day last April. He was 20 years old and healthy, and suppressed his discomfort enough to play basketball with his friends.
But on the court, a few of the pals, who are nurses, noticed Ortiz's drifting eye and urged him to go the ER. While there, he complained of a severe headache, light sensitivity, blurry vision, dizziness, and numbness on one side of his body, according to his girlfriend Natasha Sanchez, who had driven Ortiz there.

"He wanted all the lights off, he was covering his eyes, he was like, 'My head's killing me,'" Sanchez remembers.

According to Sanchez, the clinician told them it was a migraine, gave Ortiz an IV and pain meds, and sent him on his way.
Sanchez and Ortiz's mom, who had joined them by that point, had to carry him out to the car. "I was like, 'How is this normal?'" Sanchez told Insider.

It wasn't: The next day, Sanchez awoke to Ortiz seizing in bed. She called an ambulance, but says the EMTs didn't share her urgency. One said, "it's probably just a cold,'" Sanchez said.

At the hospital, clinicians suspected drugs, but Ortiz doesn't use drugs or drink, his stepmom Jackie Ortiz said. They thought it was a reaction to the COVID-19 vaccine, but Ortiz hadn't gotten one yet. It wasn't until the next day when a second neurologist looked at Ortiz's brain scans that the family learned he'd had a serious stroke and had only a 3% chance of survival.”

Doctors diagnosed a 20-year-old's stroke symptoms as a migraine and sent him home. The next day, he had a seizure and was given a 3% chance to live.

Xavier Ortiz went to the ER with a headache, a drifting eye, and poor coordination. The next day he had a seizure and was in a coma for months.

www.yahoo.com

So what happened here? Rads miss?

 

[Angry Birds]

“At first, Xavier Ortiz wasn't too worried about his headache and sensitivity to noise, which set in one day last April. He was 20 years old and healthy, and suppressed his discomfort enough to play basketball with his friends.
But on the court, a few of the pals, who are nurses, noticed Ortiz's drifting eye and urged him to go the ER. While there, he complained of a severe headache, light sensitivity, blurry vision, dizziness, and numbness on one side of his body, according to his girlfriend Natasha Sanchez, who had driven Ortiz there.

"He wanted all the lights off, he was covering his eyes, he was like, 'My head's killing me,'" Sanchez remembers.

According to Sanchez, the clinician told them it was a migraine, gave Ortiz an IV and pain meds, and sent him on his way.
Sanchez and Ortiz's mom, who had joined them by that point, had to carry him out to the car. "I was like, 'How is this normal?'" Sanchez told Insider.

It wasn't: The next day, Sanchez awoke to Ortiz seizing in bed. She called an ambulance, but says the EMTs didn't share her urgency. One said, "it's probably just a cold,'" Sanchez said.

At the hospital, clinicians suspected drugs, but Ortiz doesn't use drugs or drink, his stepmom Jackie Ortiz said. They thought it was a reaction to the COVID-19 vaccine, but Ortiz hadn't gotten one yet. It wasn't until the next day when a second neurologist looked at Ortiz's brain scans that the family learned he'd had a serious stroke and had only a 3% chance of survival.”

Doctors diagnosed a 20-year-old's stroke symptoms as a migraine and sent him home. The next day, he had a seizure and was given a 3% chance to live.

Xavier Ortiz went to the ER with a headache, a drifting eye, and poor coordination. The next day he had a seizure and was in a coma for months.

www.yahoo.com

So what happened here? Rads miss?

This is so scary. It would be so easy to do the same.
Also, in this case, the ER doc actually did the CT scan, right???

 

[southerndoc]

This is so scary. It would be so easy to do the same.
Also, in this case, the ER doc actually did the CT scan, right???

Headache + numbness = CT for most of us. Many times I do a CTA. I've been surprised at the number of dissections, occlusions, significant stenoses, etc. I've found with CTAs (head/neck). I realize not all facilities have this luxury to do a CTA.

I love how they said "at the hospital, clinicians suspected drugs." They paint the pictures (and I'm sure plaintiff's counsel will or has done the same) that they waited for the drug screen to come back and then said "oh crap, it's not drugs!" More than likely, patient had a workup, was in the process of being admitted, and the hospitalist requested it or the ER doc ordered it with a shotgun approach initially.

 

[DrSnips]

I love how they said "at the hospital, clinicians suspected drugs." They paint the pictures (and I'm sure plaintiff's counsel will or has done the same) that they waited for the drug screen to come back and then said "oh crap, it's not drugs!" More than likely, patient had a workup, was in the process of being admitted, and the hospitalist requested it or the ER doc ordered it with a shotgun approach initially.

Reminds me of something said to me during residency:

Attending: Did you train at Hopkins by any chance?
Me: No. Why? (thinking he must find me to be a solid clinician)
Attending: You just always want a Utox on everyone.
Me: Ah, that.

 

[The Knife & Gun Club]

Headache + numbness = CT for most of us. Many times I do a CTA. I've been surprised at the number of dissections, occlusions, significant stenoses, etc. I've found with CTAs (head/neck). I realize not all facilities have this luxury to do a CTA.

I love how they said "at the hospital, clinicians suspected drugs." They paint the pictures (and I'm sure plaintiff's counsel will or has done the same) that they waited for the drug screen to come back and then said "oh crap, it's not drugs!" More than likely, patient had a workup, was in the process of being admitted, and the hospitalist requested it or the ER doc ordered it with a shotgun approach initially.

What do you do for the otherwise asymptomatic subjective numbness? Like I can touch it and they can still do 2 point discrimination or pain, but say it feels funny or heavy.

That’s got to be one of my least favorite complaints.

 

[Clean7795]

This is so scary. It would be so easy to do the same.
Also, in this case, the ER doc actually did the CT scan, right???

Presumably the patient had a hyperdense basilar artery on CT, which is fairly subjective in most cases and related to artifact. Pretty much impossible to prospectively call if it is on an older scanner. The times I've seen it called, there was an acute infarct in the cerebellum which lowered the threshold to call a hyperdense basilar artery.

I've seen strokes in pediatric patients without an initially known thrombophilic disorder, so basically if you get unlucky enough to be the first doctor that saw them, you get to be the one who misses the dx.

 

[TheComebacKid]

What do you do for the otherwise asymptomatic subjective numbness? Like I can touch it and they can still do 2 point discrimination or pain, but say it feels funny or heavy.

That’s got to be one of my least favorite complaints.

You discharge them. Numbness without any specific neurological distribution, that is not reproducible on exam (document the hell out of it), is something that I don't waste time on. You can really go down the rabbit hole and I have found that it rarely leads to anything of significance.

Numbness + headache, numbness + chest pain etc is more nefarious and requires more of a workup.

Also patients use the phrase "numb" to mean a lot of different things. The average person understands that "numb" means absence or decrease of sensory input. But many people still use this phrase to describe paresthesias, pain/discomfort, weakness. Patients often times use the phrase "numb" to describe how they feel "weird" or "off". Again these complaints can be really nonsensical, and if you do a full motor/sensory exam, the patient is walking normally, you document as much as possible and send them on their way.

I had a patient two shifts ago who said his R foot was numb. I did a full exam, and lone behold, his right lower extremity was pulseless. The only way I dodged that land mine was literally by doing the most basic of exams. If he had a pulse in his leg, he would have also been sent home. Objective data will always reign supreme over subjective complaints.

To this day I have yet to see a neurologist recommend TPA for a patient with isolated numbness (even unilaterally) without any other obvious deficits. I am though very fortunate to work at a facility with 24/7 MRI capability so if there is any every question, I can get bailed out, but still I try to avoid it because if we get an MRI on every patient with numbness I might lose my mind.

I have found in EM that when patients really give you a crazy story, with lots of "red flag" symptoms that don't seem to make sense i.e. "worst headache of my life, by the way, can I get a sandwich and do you have a charger for my phone?" you have to rely on physical exam much more, otherwise you will be pushed to pursue completely unnecessary workups.

 

[BoardingDoc]

.

You discharge them. Numbness without any specific neurological distribution, that is not reproducible on exam (document the hell out of it), is something that I don't waste time on. You can really go down the rabbit hole and I have found that it rarely leads to anything of significance.

Numbness + headache, numbness + chest pain etc is more nefarious and requires more of a workup.

Also patients use the phrase "numb" to mean a lot of different things. The average person understands that "numb" means absence or decrease of sensory input. But many people still use this phrase to describe paresthesias, pain/discomfort, weakness. Patients often times use the phrase "numb" to describe how they feel "weird" or "off". Again these complaints can be really nonsensical, and if you do a full motor/sensory exam, the patient is walking normally, you document as much as possible and send them on their way.

I had a patient two shifts ago who said his R foot was numb. I did a full exam, and lone behold, his right lower extremity was pulseless. The only way I dodged that land mine was literally by doing the most basic of exams. If he had a pulse in his leg, he would have also been sent home. Objective data will always reign supreme over subjective complaints.

To this day I have yet to see a neurologist recommend TPA for a patient with isolated numbness (even unilaterally) without any other obvious deficits. I am though very fortunate to work at a facility with 24/7 MRI capability so if there is any every question, I can get bailed out, but still I try to avoid it because if we get an MRI on every patient with numbness I might lose my mind.

I have found in EM that when patients really give you a crazy story, with lots of "red flag" symptoms that don't seem to make sense i.e. "worst headache of my life, by the way, can I get a sandwich and do you have a charger for my phone?" you have to rely on physical exam much more, otherwise you will be pushed to pursue completely unnecessary workups.

Agree with basically all of this.

FYI: it's "Lo and behold"