High Risk EM

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TrumpetDoc

TrumpetDoc

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For those who went this week, or who have been to such a course... Wow, pretty scary.

But good course nonetheless!

Time to go scan and admit everyone 😉 Jk
 
TrumpetDoc said:
For those who went this week, or who have been to such a course... Wow, pretty scary.

But good course nonetheless!

Time to go scan and admit everyone 😉 Jk
Click to expand...

Sounds interesting--I haven't heard of this course. What kinds of cases did they review?
 
I've been to two of these over the last several years. I think they're interesting and good for cautionary examples but you can't let these outlying cases change your practice too much.

Another thing that I found with these courses is that they always suggest that you include some extra documentation on every patient of a given complaint. For example they say every seizure must have a sentence like, "Both UEs tested and found to have full ROM without pain. There is no evidence of dislocation." to ward off the occult dislocation lawsuit. I think some of these things are good ideas but too many can get overwhelming.

As I said I think these courses are valuable but you don't want to get too scared.
 
Indeed! 3page dictations for everyone.
Stubbed toe? Humpf... More like rule out DVT and embolic phenom...and could definitely by migratory symptom of acute dissection. JK

Also, really highlighted just how screwed we can be DESPITE doing everything right. Yeah!!!
 
TrumpetDoc said:
Also, really highlighted just how screwed we can be DESPITE doing everything right. Yeah!!!
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The good news is, we still win most of what goes to trial - even when we don't do everything right.

Please don't help make 3-page dictations and embolic workups for stubbed toes the standard of care. 😉
 
Oh dear lord no! 🙂 if I get to that point, I'm going into something else!

True that most cases (that actually go to trial) do go in our favor.
That
 
I was there. That was some of the most painful CME I've ever been to. 2 ten-hour days of how not to get sued. The other thing that turned me off a bit was how the presenters thought it was a "win" when the doc won the suit but the patient still had a horrible outcome. In my limited experience with claims/lawsuits etc, as much as you hate that they're suing you, what you feel the worst about is that the patient had the crappy outcome.

One decent thing I got out of it though is that almost all these suits are coming from missing just a handful of things. So your charting needs to address just a few things:

Chest pain patient: Address ACS, PE, and aortic dissection. Whether you ruled it out with H&P or labs/x-rays/scans, mention it in your notes. If you didn't rule it out, rule it out.

Abdominal pain: Address appy

Febrile infant: Address meningitis

Extremity injury: Address occult fracture

Laceration: Address nerve/tendon injury and foreign body

Altered mental status: Address sepsis

Flank pain: Address AAA

Pregnant abdominal pain: Address ectopic

Etc.

When you look at the numbers, 90+% of suits are coming from just a handful of missed diagnoses. People aren't getting sued for most of what we see. Learn to recognize a risky case and address the risk head on.

I also learned (not from the course, but from a side discussion) that it is very common for a physician in the hospital to be on the payroll of a local law firm and pass "good cases" on to them. Don't be "that guy."
 
What does this course have to say regarding timeliness of documentation?

For instance, I had a case intern year that never went to trial, but for which I met with the hospital attorney - and when I met with him to review the chart, they really focused on when each note was started, completed, and/or added to the medical record, and how it correlated with nursing notes and other documentation.

Ever since then - barring true illness emergency - when in our ER and when moonlighting, I complete the H&P in the chart immediately after seeing a patient, both so it's fresh in my mind, and for what I perceive to be important medicolegal reasons.

I see some of the other posters in other threads talking about seeing 25-35 patients in 8 to 10 hour shifts - and then spending a few hours afterwards completing charts. Was anything like that addressed in the high-risk EM course? I mean, with electronic charting you're gonna max out your PPH somewhere between 2 and 3 if you document after each patient...and if you're the only one in your group doing that, and you're an efficiency outlier....

Plus, I had an attending bitch me out last night for writing notes when while working in the zero-acuity section because patients were waiting to be seen...having waited for two hours...sound asleep on the stretcher with intermittent abdominal pain x2 weeks, currently resolved...etc. And, for the guy who runs our M&M and reams out resident charting in anonymity during conference, he was not surprisingly not receptive to my medicolegal argument....
 
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You want high risk EM? I'll give you high risk EM. A recent real case:

Male in his late 30s: chest pain. Sternal, non-radiating, non-pleuritic. Nurse notes patient is anxious. Recently incarcerated. Pain partially relieved by nitro. Given ativan. Very drowsy for one dose of ativan but comfortable. History of untreated HTN, BP 180s/90s upon arrival. BP improves also after nitro (150s/80s). Temp normal, RR normal, O2 sat normal. BP equal in both arms. CXR normal per radiologist. EKG - LVH with early repolarization. Enzymes negative. No other medical history. Exam - normal except for systolic murmur. Creatinine 2.1. Other labs unremarkable. Drug screen negative. Only history or risk factor for CAD, PE, TAD, AAA is HTN.

Patient is admitted to internist for chest pain and hypertension. Has negative stress test. Pain goes away while in hospital. Spikes some fevers, but otherwise is stable.

He dies before discharge. Why?
 
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...admitting team orders echo and stress test (on a Sat. night). Sunday a.m. the stress test is done = negative. Pt has stable vitals (except for spiking temps) and PAIN IS GONE, so trans-thoracic echo done next day (Mon.), not emergently (community hospital). Echo shows huge aortic root, suspected dissection. CT now has to be done (despite elevated Cr) and show thoracic dissection. Pt is still totally stable, is awake and alert enough give thorough consent for O.R. The repair goes fine. They go to take him off bypass and restart his heart. It won't start. He dies on the table.

The patient is in his late THIRTIES!, only risk factor is HTN, no back pain, no "tearing" pain, no BP asymmetry. No marfanoid appearance or history.

Am I supposed to CT everybody with chest pain, hypertension, equal BPs, no back pain and no other risk factors (with a creatinine of >2.0) at a hospital that doesn't do TEEs at all and won't do "routine" echos in 30 something year old's on weekends 😕
 
Hope you all don't mind what might be a stupid question, but what's the deal with the (what I presume is huge) pulse pressure and where is the systolic murmur coming from?
 
DeadCactus said:
Hope you all don't mind what might be a stupid question, but what's the deal with the (what I presume is huge) pulse pressure and where is the systolic murmur coming from?
Click to expand...

i wouldn't look at the Pulse Pressure too much. Doesn't usually provide much diagnostic value. systolic's up, but diastolic's not that low. Pretty common with a sympathetic surge (your anxiety, pain, PE, and cardiac patients).

The systolic murmur is presumably from aortic turbulence, or if it's really proximal dissection, aortic stenosis (though at that point, you're about to dissect into the pericardium and have a deadly pericardial effusion -->tamponade).

EDIT: actually, proximal dissection would normally cause aortic regurg due to widening of the aortic root. so that would not cause a systolic murmur.
 
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Birdstrike said:
...Am I supposed to CT everybody with chest pain, hypertension, equal BPs, no back pain and no other risk factors (with a creatinine of >2.0) at a hospital that doesn't do TEEs at all and won't do "routine" echos in 30 something year old's on weekends 😕
Click to expand...

Nope. It sounds like you did a pretty reasonable w/u in your ED and appropriately admitted the patient for further eval of his concerning CP. Just because he had a bad outcome doesn't mean someone did something wrong. I'm pretty sure you could defend that case as is. I'm pretty sure you would have a decent chance of defending the case even if you sent him home (provided his Cr was not elevated, you had no other smoking gun). A d-dimer would have likely picked up his dissection and resulted in a CT scan though. Even then, not sure it was indicated. I remember hearing a CT surg doc talk on EM rap about how the "standard of care" is to actually miss a dissection due to the atypical nature of presentation...don't know if I would use that as my defence, but it probably isn't far from the truth.
 
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wow, this is a tough case. i agree with the others, you did a very thorough work up and admitted him. dissection is so hard, every time i start chasing it i feel dumb (but then you find it and feel smart every once in a while).

bedside echo in the ED is helpful sometimes-obviously you can't see the whole arch, but usually you can see the aortic root (sounds like maybe in this patient that would have helped), and if there is a pericardial effusion. that might have helped in this case but bedside cardiac echo is not standard of care nationwide.

if i am considering but not highly suspicious of dissection, bedside echo and ddimer are both part of my workup. if highly suspicious, then i try to get CT scan or TEE. you could make an argument for just doing a non contrast CT i guess too, to look for a dilated proximal aorta. what do others do? would be curious to hear others address dissection.
 
emrox said:
... bedside echo and ddimer are both part of my workup. if highly suspicious, then i try to get CT scan or TEE. you could make an argument for just doing a non contrast CT i guess too, to look for a dilated proximal aorta. what do others do? would be curious to hear others address dissection.
Click to expand...

Echo was what ultimately made the diagnosis, but on the weekend at my ever so modest community hospital, this took 1 1/2 days to get done since he was "stable" and it was "elective". I don't know that I can rule out a dissection with my own bedside ultrasound reliably and consistently. I don't remember if he had a pericardial effusion or not, which would've been fairly easy to pick up by bedside ultrasound, but would likely have led to a "pericardial effusion/pericarditis" diagnosis and similar pathway. D-dimer would've been positive. But he still had a Cr of 2.1. Non-con CT scan is a great suggestion, and I've pulled that out of my "tool box" from time to time, but in patients with a GOOD STORY, ie, "tearing pain", radiating pain between the shoulder blades or anywhere in the back or migrating to abdomen, unequal arm BPs, marfanoid appearance or with risk factors other than hypertension which is probably the single most common past medical history of just about every adult patient we see.

You can't do a non-con CT chest on every chest pain patient in his or her thirties who is anxious and has hypertension, without any dissection red flags. If a murmur is the only other peculiarity, they need an echo, eventually, not necessarily in the ED. I can only imagine what would become of my ED efficiency if I'm trying to personally do echo's on every single one of my chest pain patients in the ED trying to pick up dissections even in people without any specific symptoms of such.

Bottom line: he was admitted. Went to the floor stable. Got the work up. Got diagnosed. Remained stable. Went to the OR stable. Had a bad outcome. Tough case.
 
Birdstrike said:
I don't know that I can rule out a dissection with my own bedside ultrasound reliably and consistently.
Click to expand...

The US gurus can correct me if I'm wrong, but I was taught that if the aortic root is >4cm, it is diagnostic of dissection. Granted, this doesn't rule it out if normal, but it could be helpful.

Also agree that a non-con CT can be useful if suspicious and elevated Cr, but Birdstrike is again correct that you can't do this in every CP pt with elevated BP. For the patient in whom I'm really suspicious (good story, wide mediastinum, something to really make me concerned) and an elevated creatinine, I would argue that a CTA (with contrast) is probably the lesser of two evils. Obviously, if you can get the echo that's great, but many can't, especially during off hours. This of course requires discussions with the patient, radiology, surgery, etc...but it comes down to risk of kidney injury/dialysis vs risk of death. Not an easy decision to make, and I'm certainly not advocating this for the patient that Birdstrike described. And if the CTA is normal and their kidneys crump, well, then you were an idiot (that's why I'd get others on board before doing this).

Aortic dissection is a bad disease. It's difficult to diagnose, and even when treated correctly, patients die. I had a patient in my first year out of residency that had transient abdominal pain and lightheadedness. He was older, so I did a bedside US of his aorta looking for AAA. The size was normal, but I thought for a split second that I saw a little dissection "flap." I then did a really thorough ROS and found that he'd had brief leg paresthesias earlier in the day and maybe some CP. He'd dissected his entire aorta into the iliacs. He was never symptomatic or hypertensive in the ED (his HR was 60 and BP was 110/70 the entire time). He was in the OR within 3 hours of hitting the door (probably would have been sooner if not for the 28 inch snowstorm). He died on POD 1. Like I said, it's a bad disease.
 
Hawkeye Kid said:
The US gurus can correct me if I'm wrong, but I was taught that if the aortic root is >4cm, it is diagnostic of dissection.
Click to expand...

Not an ultrasound guru, but an aortic root >4cm is certainly not diagnostic for dissesction.

Many aneruysmal aortas (even chronic) will have a root >4cm and no dissection. This is seen on CT and ultrasound.

Birdstrike is very correct in saying bedside ultrasound (excluding TEE) can not rule-out dissection - regardless of how skilled the operator...not even close.

However, running the aorta in the abdomen, TTE, and a look in the suprasternal notch has caught more than one dissection in our ED (one was caught by an ED resident in the ICU) in the last few years.

If positive, you're set. If negative, you're unchanged. I think it is definitely worth a look in many patients.

HH
 
As things are presented, it sounds like Birdstrike the absolute right thing--admitting the pt at the very least gave him some chance of survival.

It sounds like his death could be a complication (or more likely a side effect) of surgical repair for a tremendously difficult disease process both to diagnose and treat.

Although, I'm a huge ultrasound fan, I don't think it could ever be expected as standard of care to do an extensive bedside u/s in a pt without red flag sx, especially at a high-volume community hospital.
 
So, unfortunately, I had a d-dimer negative dissection earlier this year. Although, to be fair, I think it is because our lab can't do the assay correctly. I also had a PE so big it infarcted an entire lobe, and it had a negative d-dimer.
 
Dr.McNinja said:
So, unfortunately, I had a d-dimer negative dissection earlier this year. Although, to be fair, I think it is because our lab can't do the assay correctly. I also had a PE so big it infarcted an entire lobe, and it had a negative d-dimer.
Click to expand...

Which D-dimer?

HH
 
Tiger26 said:
As things are presented, it sounds like Birdstrike the absolute right thing--admitting the pt at the very least gave him some chance of survival.

It sounds like his death could be a complication (or more likely a side effect) of surgical repair for a tremendously difficult disease process both to diagnose and treat.
Click to expand...

This....

The M&M from elective repair of a thoracic aneurysm approaches 10%/50% respectively depending on your population and definition of morbidity (according to a CT surgeon I asked about it recently).

It's hard (and by hard I mean impossible) to say whether more rapid echo or sacrificing the beans for that contrast CT would have resulted in a different outcome. The management, as outlined by Birdstrike sounds both reasonable and legally defensible from top to bottom, from ED to Floor to OR.

Sometimes bad s**t happens to young and/or good people.
 
The d-dimer at my hospital is almost ALWAYS positive. It's so sensitive its almost worthless. If I had ordered it in this case, it almost certainly would have been positive and with the elevated creatinine, it probably would have forced me to order a VQ which would have been useless and sent me down the wrong pathway. I hate our d-dimer. If I'm thinking of ordering our d-dimer, I just order a CT (if I can).

Thanks for all your responses. Its a tough case. Part of being a good doc involves losing some sleep over these cases, whether you did everything right or not, so that you can become a better clinician. Each of these, and hearing about each of these, makes you a much better doc. Burn these cases into your brain.

You don't become a good doc by being able to decide who has BS chest pain, but by being able to decide which "BS chest pain" has a dissection.
 
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Birdstrike said:
Echo was what ultimately made the diagnosis, but on the weekend at my ever so modest community hospital, this took 1 1/2 days to get done since he was "stable" and it was "elective". I don't know that I can rule out a dissection with my own bedside ultrasound reliably and consistently. I don't remember if he had a pericardial effusion or not, which would've been fairly easy to pick up by bedside ultrasound, but would likely have led to a "pericardial effusion/pericarditis" diagnosis and similar pathway. D-dimer would've been positive. But he still had a Cr of 2.1. Non-con CT scan is a great suggestion, and I've pulled that out of my "tool box" from time to time, but in patients with a GOOD STORY, ie, "tearing pain", radiating pain between the shoulder blades or anywhere in the back or migrating to abdomen, unequal arm BPs, marfanoid appearance or with risk factors other than hypertension which is probably the single most common past medical history of just about every adult patient we see.

You can't do a non-con CT chest on every chest pain patient in his or her thirties who is anxious and has hypertension, without any dissection red flags. If a murmur is the only other peculiarity, they need an echo, eventually, not necessarily in the ED. I can only imagine what would become of my ED efficiency if I'm trying to personally do echo's on every single one of my chest pain patients in the ED trying to pick up dissections even in people without any specific symptoms of such.

Bottom line: he was admitted. Went to the floor stable. Got the work up. Got diagnosed. Remained stable. Went to the OR stable. Had a bad outcome. Tough case.
Click to expand...


Just to be clear, I wasn't criticizing your management at all. I completely agree with your bottom line and everyone else's comments. I also don't think, based on what you are describing, that a CT either noncon/contrast was indicated either. I was curious what others do in a general sense. AD is a really really difficult diagnosis, and people die from it even if you do everything right. It is very very possible you could have made that dx within minutes of walking in the door and he would have had the same outcome.

EP Bedside echo is specific not sensitive. It is helpful, only if it is positive. If you have a positive finding, that gives you grounds to push for a formal echo on the weekend, etc. I work in a similar situation where the entire hospital grinds to a halt on the weekend and this is a way how I have adapted. I have found things on US that changed the patient's management while in the ED and that is why I make time to do it.

I definitely don't ultrasound everyone, as you pointed out, you cannot ultrasound everyone with chest pain. That's not indicated and not practical. I usually do it based on my H&P, if I'm admitting them for their cp, and if something seems weird about the situation (read: spidey sense tingling). I have no idea how you felt about this patient in this setting, and I'm not saying I would have picked up on the dx. Bedside ultrasound just a tool I wanted to point out that wasn't mentioned previously.
 
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emrox said:
Just to be clear, I wasn't criticizing your management at all. I completely agree with your bottom line and everyone else's comments. I also don't think, based on what you are describing, that a CT either noncon/contrast was indicated either. I was curious what others do in a general sense. AD is a really really difficult diagnosis, and people die from it even if you do everything right. It is very very possible you could have made that dx within minutes of walking in the door and he would have had the same outcome.

EP Bedside echo is specific not sensitive. It is helpful, only if it is positive. If you have a positive finding, that gives you grounds to push for a formal echo on the weekend, etc. I work in a similar situation where the entire hospital grinds to a halt on the weekend and this is a way how I have adapted. I have found things on US that changed the patient's management while in the ED and that is why I make time to do it.

I definitely don't ultrasound everyone, as you pointed out, you cannot ultrasound everyone with chest pain. That's not indicated and not practical. I usually do it based on my H&P, if I'm admitting them for their cp, and if something seems weird about the situation (read: spidey sense tingling). I have no idea how you felt about this patient in this setting, and I'm not saying I would have picked up on the dx. Bedside ultrasound just a tool I wanted to point out that wasn't mentioned previously.
Click to expand...

No offense taken. The whole point of posting it was to hear different suggestions. I greatly appreciate the viewpoints. I benefit; you all benefit. There is usually more than one way to handle a case correctly within the standard of care, anyways (and an infinite number of ways to handle a case incorrectly).

Also, "standard of care" is community based, not specialty based or even a national standard. What is standard of care in one community may be significantly different from the medico-legal standard of care in another community. Also, as others have pointed out, following "the standard of care", whatever it may be, does not guarantee a good outcome. Obvious, but worth pointing out again. Thanks for the points of view.
 
Birdstrike said:
The patient is in his late THIRTIES!, only risk factor is HTN, no back pain, no "tearing" pain, no BP asymmetry. No marfanoid appearance or history.

Am I supposed to CT everybody with chest pain, hypertension, equal BPs, no back pain and no other risk factors (with a creatinine of >2.0) at a hospital that doesn't do TEEs at all and won't do "routine" echos in 30 something year old's on weekends 😕
Click to expand...

No, but I sort of keep 40 years old as a cutoff in my head. If you're over 40 with chest pain suspicious for ischemia, you get a stress test (barring prior positive stress tests, clear unstable angina that needs admission for a cath blah blah). If you're under 40 with chest pain, you get a UDS so I can look for that crack you didn't tell me about in the H&P...
 
Old_Mil said:
No, but I sort of keep 40 years old as a cutoff in my head. If you're over 40 with chest pain suspicious for ischemia, you get a stress test (barring prior positive stress tests, clear unstable angina that needs admission for a cath blah blah). If you're under 40 with chest pain, you get a UDS so I can look for that crack you didn't tell me about in the H&P...
Click to expand...

He denied drug use. I didn't believe him. His UDS was negative. I still didn't believe him and that's why I admitted him. I'm glad I did.
 
Anecdote-based practice and catching every last case of everything is costly and harmful.

As much fun as it is to tout the "great save" in an atypical patient, the cumulative harms from overtesting, overdiagnosing, and overtreating many conditions are greater than missing a few unusual presentations of an infrequent disease.
 
xaelia said:
Anecdote-based practice and catching every last case of everything is costly and harmful.

As much fun as it is to tout the "great save" in an atypical patient, the cumulative harms from overtesting, overdiagnosing, and overtreating many conditions are greater than missing a few unusual presentations of an infrequent disease.
Click to expand...

I'm going to issue a qualified "disagree" with that. I agree spamming every possible test on every patient in the hope of blindly picking up unusual presentations is BS and evil. However, ignoring your gut feeling that something is wrong with a patient leads to bad medicine also. For the patient that you are convinced is sick, overtesting and overtreating can be good things if they lead to the right diagnosis.
 
xaelia said:
Anecdote-based practice and catching every last case of everything is costly and harmful.
Click to expand...

To the system.

Not catching every last case of everything is costly and harmful to you.
 
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