How to deal with bad outcomes

[ACal]

About a year and half out of residency, had a few bad outcomes since working, mostly things that I had no control over. Mainly 2 patients which were discharged. One was a young pt that came in intoxicated and sobered up and had no real complaints, discharged, ended up having a head bleed, did okay otherwise.
I'm usually fairly middle of the pack in terms of amount of CTs and workup, but now I feel like I'm scanning anyone and everyone that comes in. I think most of the anxiety comes from missing something like that again, and risk of litigation or problems with re-credentialing by the medical staff.
(Side note, how often have you guys seen significant PEs in pepole with a normal dimer? Otherwise low/medium risk per Wells?)
Any advice on how to come back to practicing more reasonably after outcomes like these?
Especially for you minimalists out there, how do you prevent bad outcomes from affecting your practice? Or do you?

---

Members don't see this ad.

 

[WilcoWorld]

You are titrating your practice. It's normal to start testing more after a scary case, and you'll return closer to baseline as time passes.

As for clinically significant PE with a negative d dimer and low to moderate risk? Never seen one.

 

[WildEMDoc]

I am very much on the minimalist end in our group honestly to the point sometimes I have altered my practice to be more in line with the group even though sometimes it isn't really what my approach would be. Cohesion is important in terms of shielding yourself from liability. If you are an significant outlier on either side you are putting yourself at risk.

Bad outcomes are part of being in EM. When you evaluate a patient, a thorough evaluation doesn't mean CT imaging their whole body or doing an entire sepsis workup on every fever; a thorough evaluation is a combination of YOUR history/exam/clinical gestalt and those additional tests. No amount of testing will prevent bad outcomes, and there is harm that comes from over testing. The more you dwell on misses the more it will impact your practice causing errors in judgement and eventually harm to patients. When a bad outcome happens, asking yourself honestly whether or not you could have done anything different is important and if there was a result of M&M due to your miss. For example with your first case, it doesn't sound like there was any reason to suspect trauma, the patient neurologically improved, and you dispositioned appropriately and his outcome was the same either way no willful harm was done and the patient is sounds like had no morbidity associated with the missed diagnosis.

FWIW I don't think I've done a PE CT on someone with a negative dimer who was low/mod risk because I'm not sure why I would order a study if I already ruled it out. The scenario you describe would be a significant outlier and should not change your approach to medicine.

 

[wareagle726]

So I can give input as someone almost 3yrs out. I feel you. Been there and done that. You are learning more right now than you ever did in residency. In the real world you're going to have some bad outcomes. I know I have had some that made me scan everything that sneezed for a few weeks then I died down. I think it's normal. You are developing your clinical practice dependent on your work environment. Learn from the people around you, especially if they are EM boarded. I have some close friends that will scan everything and some that will scan hardly anything. It's all relative. At the end of the day do what you think is best for the patient and if anyone faults you at least you can sleep knowing you did what you thought was right.

 

[GonnaBeADoc2222]

No reason not to test n' scan lots of stuff (within some threshold of reason).

No admin will ever congratulate you for not scanning someone. They will all crucify you for missing anything.

 

[Birdstrike]

how do you prevent bad outcomes from affecting your practice? Or do you?

What’s happened to you and your reaction, are normal. You shouldn’t go back to practicing like you did, when you had less experience. You have more experience now and have adjusted your practice based on that experience. That’s what you’re supposed to do. Don’t talk yourself out of it. Go with it.

You know now you need to order more tests in certain situations. So do it. Don’t apologize for it and don’t feel guilty. You’re an expert in this and your expertise will grow with experience. Trust that experience.

 

[NYEMMED]

No reason not to test n' scan lots of stuff (within some threshold of reason).

No admin will ever congratulate you for not scanning someone. They will all crucify you for missing anything.

Phrase I’ve learned.

“Nobody cares about the scan you did do, everyone cares about the scan you didn’t do”

 

[Clean7795]

I have never seen a clinically significant PE with negative D-dimer in low-med risk. If you talk to radiologists you realize that there's a lot of possible artifact in the segmental/subsegmental vasculature, so if you order a PE scan after a negative dimer you're just exposing the patient to a possible over call.

 

[kumatie]

About a year and half out of residency, had a few bad outcomes since working, mostly things that I had no control over. Mainly 2 patients which were discharged. One was a young pt that came in intoxicated and sobered up and had no real complaints, discharged, ended up having a head bleed, did okay otherwise.
I'm usually fairly middle of the pack in terms of amount of CTs and workup, but now I feel like I'm scanning anyone and everyone that comes in. I think most of the anxiety comes from missing something like that again, and risk of litigation or problems with re-credentialing by the medical staff.
(Side note, how often have you guys seen significant PEs in pepole with a normal dimer? Otherwise low/medium risk per Wells?)
Any advice on how to come back to practicing more reasonably after outcomes like these?
Especially for you minimalists out there, how do you prevent bad outcomes from affecting your practice? Or do you?

I think the most important aspect is recognizing when you made a mistake (I’m not saying you even did in the examples that you gave.) These cases are just the price of doing business. A Bad outcome does not equal bad physician.
The Most dangerous thing I see in physicians is the inability to self correct or adjust their practice with time, Based on the real life feedback from years of practicing.

 

[RustedFox]

About a year and half out of residency, had a few bad outcomes since working, mostly things that I had no control over. Mainly 2 patients which were discharged. One was a young pt that came in intoxicated and sobered up and had no real complaints, discharged, ended up having a head bleed, did okay otherwise.
I'm usually fairly middle of the pack in terms of amount of CTs and workup, but now I feel like I'm scanning anyone and everyone that comes in. I think most of the anxiety comes from missing something like that again, and risk of litigation or problems with re-credentialing by the medical staff.
(Side note, how often have you guys seen significant PEs in pepole with a normal dimer? Otherwise low/medium risk per Wells?)
Any advice on how to come back to practicing more reasonably after outcomes like these?
Especially for you minimalists out there, how do you prevent bad outcomes from affecting your practice? Or do you?

So, you're normal.

Bad outcomes are all over. I've had a jackpot lawsuit, and it hasn't affected credentialing.

Significant PE in people with a normal dimer? Sure. Just last week.

 

[johhnybgood]

So, you're normal.

Bad outcomes are all over. I've had a jackpot lawsuit, and it hasn't affected credentialing.

Significant PE in people with a normal dimer? Sure. Just last week.

Really?
Why the scan w a negative dimer?
What’s prompting the further look?

I’ve never seen anything significant w negative dimer personally.

 

[RustedFox]

Really?
Why the scan w a negative dimer?
What’s prompting the further look?

I’ve never seen anything significant w negative dimer personally.

Yeah, last week was a good week. Or something.

30-something female. Tachy to like 110. SaO2 is 98%. Dimer negative. What tipped me off? She's smart and looks uncomfortable. Too smart to come to the ER for something dumb. Big enough PE for them to consider EKOS.

Same shift: 71 year old female "chronic back pain" because she was acting squirrely in triage. Sure, she's had joint injections before. "Touch me where it hurts". She runs her finger right up and down my T-spine. Type-B aortic dissection; pretty well-contained.

To the OP: Just scan 'em, amigo. Don't be an ostrich and scan everything, but you're developing your sixth sense of "this just doesn't fit well enough; better look further".

 

[Mr. Vandemar]

30-something female. Tachy to like 110. SaO2 is 98%. Dimer negative. What tipped me off? She's smart and looks uncomfortable. Too smart to come to the ER for something dumb. Big enough PE for them to consider EKOS.

Same shift: 71 year old female "chronic back pain" because she was acting squirrely in triage. Sure, she's had joint injections before. "Touch me where it hurts". She runs her finger right up and down my T-spine. Type-B aortic dissection; pretty well-contained.

Dammit, I knew I should not have opened this thread because people would post terrifying anecdotes and yet here I am...

 

[RustedFox]

Dammit, I knew I should not have opened this thread because people would post terrifying anecdotes and yet here I am...

Truth is stranger than fiction; and the textbooks (and even residency) teaches us "this is what this normally looks like, this is how this normally happens"

Except we don't work in the normal department. In normal world.

This gal with the PE; it really bears repeating that what tipped me off was that she "was too smart to be here for a dumb reason".

The TAD... she just "looked vasculopathic". Sure, she quit smoking a decade ago, she says... but she had that "brittle vessel look". You know it. We all know it. Try putting it into adjectives. It's HARD to do so. When you try, you end up reading what you just wrote and deciding "nope; that sounds crazy".

This gal? She looked... dry in the eyes, a little droopy on the cheeks but stiff in the neck, with skin that was tight around the hands but firmer than it should be for a woman of her age, like you could break it... the way one breaks creme brulee with a spoon. It was like she had been "conditioned"... not with the lotion of "skin conditioner", but the way a gym bro's hands are conditioned... but she wasn't an athlete of any variety by glance.

Does that sound insane? Yep. Absolutely. If this wordsmith has difficulty with it; you know it can't be easy.

 

[JacobMcCandles]

Yeah, last week was a good week. Or something.

30-something female. Tachy to like 110. SaO2 is 98%. Dimer negative. What tipped me off? She's smart and looks uncomfortable. Too smart to come to the ER for something dumb. Big enough PE for them to consider EKOS.

Same shift: 71 year old female "chronic back pain" because she was acting squirrely in triage. Sure, she's had joint injections before. "Touch me where it hurts". She runs her finger right up and down my T-spine. Type-B aortic dissection; pretty well-contained.

To the OP: Just scan 'em, amigo. Don't be an ostrich and scan everything, but you're developing your sixth sense of "this just doesn't fit well enough; better look further".

Was Well's PE criteria applied accurately? It's easy to look into the rearview mirror but there is some subjectivity to the criteria. If you use the two-tier model (which ACEP supports) of Well's PE criteria then you could make an argument that she is 4.5 points (HR>100, PE is #1 diagnosis or equally likely) making PE 'likely' and recommending CTA chest without d-dimer testing.

To the OP, if you see patients then you're going to have bad outcomes. There's no way to avoid it. The risk of getting sued has NOTHING to do with being a good or bad doctor. The more patients you see the higher your risk of a lawsuit in EM is. That's all there is to it. It affects us all in a bad way and I wish there was an easier way to get through it. Keep your head up and trust in your training.

 

[Birdstrike]

-Decision rules all have pitfalls.

-But gold-standard tests, are gold.

 

[Groove]

About a year and half out of residency, had a few bad outcomes since working, mostly things that I had no control over. Mainly 2 patients which were discharged. One was a young pt that came in intoxicated and sobered up and had no real complaints, discharged, ended up having a head bleed, did okay otherwise.
I'm usually fairly middle of the pack in terms of amount of CTs and workup, but now I feel like I'm scanning anyone and everyone that comes in. I think most of the anxiety comes from missing something like that again, and risk of litigation or problems with re-credentialing by the medical staff.
(Side note, how often have you guys seen significant PEs in pepole with a normal dimer? Otherwise low/medium risk per Wells?)
Any advice on how to come back to practicing more reasonably after outcomes like these?
Especially for you minimalists out there, how do you prevent bad outcomes from affecting your practice? Or do you?

You're human and we've all been there. Yes, it's normal to over test following a bad case, peer review, suit, whatever... It's usually transient and you'll return to baseline soon.

It seems like I've always worked with at least 1 colleague who claims they diagnosed a PE with a normal dimer but in 14 years of practice I've never found one. I'm sure it's a real entity, I've just never seen it.

 

[The Knife & Gun Club]

Not out of residency yet so can’t comment on the titrating of practice since being alone sounds scary as hell lol.

That said re:negative dimer PEs - I had one maybe 6 months ago. Scared the living crap out of me. We admitted and I spoke with our heme docs about it because they were very excited. Their suspicion was that it was an old chronic DVT that somehow dislodged and migrated. But that event is basically one in a million and shouldn’t change your practice because you’ll probably never see it again.

 

[RustedFox]

Was Well's PE criteria applied accurately? It's easy to look into the rearview mirror but there is some subjectivity to the criteria. If you use the two-tier model (which ACEP supports) of Well's PE criteria then you could make an argument that she is 4.5 points (HR>100, PE is #1 diagnosis or equally likely) making PE 'likely' and recommending CTA chest without d-dimer testing.

To the OP, if you see patients then you're going to have bad outcomes. There's no way to avoid it. The risk of getting sued has NOTHING to do with being a good or bad doctor. The more patients you see the higher your risk of a lawsuit in EM is. That's all there is to it. It affects us all in a bad way and I wish there was an easier way to get through it. Keep your head up and trust in your training.

Wells criteria is so 1996.
It's PERC or nothing (it's NERF! or it's nothing).
Dimer negative.

 

[JacobMcCandles]

Wells criteria is so 1996.
It's PERC or nothing (it's NERF! or it's nothing).
Dimer negative.

Maybe so but it's nice to have something objective on the chart that deems the patient low risk so you can use PERC besides 'physician gestalt'.

 

[RustedFox]

Maybe so but it's nice to have something objective on the chart that deems the patient low risk so you can use PERC besides 'physician gestalt'.

I dimer'ed her, which means she failed PERC.

 

[Janders]

Dammit, I knew I should not have opened this thread because people would post terrifying anecdotes and yet here I am...

Had a fun one a while ago. Overnight shift. Got things settled in around 0330AM.
Old guy comes in, Right side “chest pain”. Like a pinch stab. Woke him up but went away.
Says actually he’s not sure if its chest or belly, its like right low anterior ribs and a pinch pleuritic.

I’m futzing around with the POCUS machine anyway, wheeled it in with me.
EKG is Afib at 105 (known, on anti-coag).
Lung US? No Pneumo, ?infiltrate R base
ECHO just out of curiosity? Normal looking Afib.

So we get the labs and trop and X-ray and all.

Portable X-ray classic RLL pneumonia. Something a MS1 would pick up. WBC is a pinch up. He gets briefly hypotensive (90s SBP), comes up with a liter.

Give him the abx, decide to bring him in the hospitalist with the pain and soft BP but he looks good.

Hospitalist (good dude) comes and sees him, is like “hey, his LFTs are up (like AST 58….), will you POCUS his RUQ just to be safe?”

Sure bro, POCUS is fun, its 0500 and I’m yawning… Holy crap, look at that, an immobile gallstone and a thick as GB wall! Like 1cm thick!

Huh, so broaden the abx, call the surgical PA to take a look (no formal US ‘til AM).

Patient is smiling, then has another brief hypotensive burst, again resolves as soon as we start fluids.

Surgical PA is like yeah man, seems he has acute chole AND pneumonia. Weird.

My spider sense finally says screw this, scan him stem to stern.

Rads calls, he’s like what black cloud do you have??
(1) Classic thick RLL pnuemonia
(2) Severe, perhaps becoming gangrenous, cholecystitis
(3) Short-segment Type A dissection with blood flowing into the pericardium w/ signs of tamponade.

Well **** boys and girls. Back in room. POCUS echo again, now I see an effusion. Stat Xfer to the city for the fancy repair boys; they manage to repair him but he develops triple-pressor shock, DIC, succumbs rapidly. Not before 4/4 bottles of blood cx grow out positive from my visit in 12hr.

Moral of the story? Good question. Hickam’s dictum? Diagnostic anchoring? Or my own personal saying— squirrels get shotguns, meaning if in your experience the entire history and story is squirrelly and makes you raise an eyebrow, keep doing tests. Didn’t manage to save this guy but we gave him a chance.

 

[thegenius]

About a year and half out of residency, had a few bad outcomes since working, mostly things that I had no control over. Mainly 2 patients which were discharged. One was a young pt that came in intoxicated and sobered up and had no real complaints, discharged, ended up having a head bleed, did okay otherwise.
I'm usually fairly middle of the pack in terms of amount of CTs and workup, but now I feel like I'm scanning anyone and everyone that comes in. I think most of the anxiety comes from missing something like that again, and risk of litigation or problems with re-credentialing by the medical staff.
(Side note, how often have you guys seen significant PEs in pepole with a normal dimer? Otherwise low/medium risk per Wells?)
Any advice on how to come back to practicing more reasonably after outcomes like these?
Especially for you minimalists out there, how do you prevent bad outcomes from affecting your practice? Or do you?

Yea this **** is going to happen. You can't ever be 100% correct in whether to scan or not scan these people. I have that exact fear that one day I'll be managing a drunk guy in the ED and it will be MTF. However the pt never MTFs and 10 hours later gets a CT and it's full of blood.

 

[thegenius]

Wells criteria is so 1996.
It's PERC or nothing (it's NERF! or it's nothing).
Dimer negative.

It's still part of the workflow put forth by the academy of thoracic chest-thumping dinguses who make 1M/year.

So I still WELLS. WELLS/PERC take like 6 neurons in my brain to process.

Also...apparently physician gestalt is as sensitive as WELLS. just sayin'

 

[RustedFox]

It's still part of the workflow put forth by the academy of thoracic chest-thumping dinguses who make 1M/year.

So I still WELLS. WELLS/PERC take like 6 neurons in my brain to process.

Also...apparently physician gestalt is as sensitive as WELLS. just sayin'

I remember that paper: "Who would win: Wells or Gestalt?" for those who speak meme: (Choose your Fighter: Sum Criteria or A Fine Boi)

After that, I only used PERC to document why I wasn't ordering a dimer.
Anything else got dimer'ed, and if hard negative, went home.
This one was like .489 or something. I CT'ed her. Boom.

 

[RustedFox]

Yea this **** is going to happen. You can't ever be 100% correct in whether to scan or not scan these people. I have that exact fear that one day I'll be managing a drunk guy in the ED and it will be MTF. However the pt never MTFs and 10 hours later gets a CT and it's full of blood.

We have an autotext to explain why we're not CT-ing drunks and just MTFing. It at least makes me feel better.

 

[JacobMcCandles]

I dimer'ed her, wh

I remember that paper: "Who would win: Wells or Gestalt?" for those who speak meme: (Choose your Fighter: Sum Criteria or A Fine Boi)

After that, I only used PERC to document why I wasn't ordering a dimer.
Anything else got dimer'ed, and if hard negative, went home.
This one was like .489 or something. I CT'ed her. Boom.

Hopefully you’re documenting the patient is low risk or why you think the patient is low risk since PERC is only for low risk patients.

 

[emergentmd]

Back to OP. You are a mythical baseball hitter. Good MLB hitters do .300, you are probably doing .999

Great job, pat yourself on the back.

 

[cyanide12345678]

Phrase I’ve learned.

“Nobody cares about the scan you did do, everyone cares about the scan you didn’t do”

Yeah i don’t care about CT scans now. I’ve had around a 25-30 percent CT scan rate in my discharged adult patients. Most people in my group are around 20. My dispositions and length of stays are still one of the fastest.

Nobody has ever said anything to me about it. That’s just how i feel comfortable. I don’t like to be sued and I’ve been through one as a resident.

I’m very liberal with my d dimer as well, though I’ve never scanned a negative D dimer, but I’ve gotten a few d dimers on perc negative patients. Sometimes these 20 year olds who can’t tolerate pain at all come out looking absolutely miserable that I’ll dimer them.

Either way, if you order a few extra CT scans, nobody cares. And you know what? Patients LOVE tests. They feel like something was done. The less you do the more they complain. The only metric that matters is the patient satisfaction score depending on your work environment 😂😂

 

[RustedFox]

Hopefully you’re documenting the patient is low risk or why you think the patient is low risk since PERC is only for low risk patients.

We have an autotext for that. If they're moderate or high risk by history or by smell, they get dimer'ed out of the gate.

 

[JacobMcCandles]

We have an autotext for that. If they're moderate or high risk by history or by smell, they get dimer'ed out of the gate.

If they’re high risk then they shouldn’t get a d-dimer at all, they should be getting a CTA instead.

 

[RustedFox]

If they’re high risk then they shouldn’t get a d-dimer at all, they should be getting a CTA instead.

I agree, because you're gonna spin 'em anyways. Good catch; my ass was being lazy.

 

[GonnaBeADoc2222]

Either way, if you order a few extra CT scans, nobody cares. And you know what? Patients LOVE tests. They feel like something was done. The less you do the more they complain. The only metric that matters is the patient satisfaction score depending on your work environment 😂😂

This right here. It avoids the "i WeNT tO tHe Er AnD tHeY DiD nOtHiNgGgGgGgGg!!!!"

 

[wareagle726]

I'm with RF. PERC out or dimer/CTA. Well's doesn't cut it anymore.

Had a 16yo last week, completely healthy kid. L sided CP and cough. L calf pain after 3 day wrestling camp. He was a "VIP" as mom was one of the surgeon's clinic admins. Came in at 2200. She said she had a PE in her 30s(on OCPs at the time). HR in 70s, o2 98%. Seemed uncomfortable. She was convinced. I was not. Talked her into a dimer ONLY because she was a VIP. PERC doesn't apply to < 18 mind you(I don't think). It was 7.8. CTA showed multiple segmental PEs. Eff me and the clinical portion of this. The game is rigged.

 

[RustedFox]

I'm with RF. PERC out or dimer/CTA. Well's doesn't cut it anymore.

Had a 16yo last week, completely healthy kid. L sided CP and cough. L calf pain after 3 day wrestling camp. He was a "VIP" as mom was one of the surgeon's clinic admins. Came in at 2200. She said she had a PE in her 30s(on OCPs at the time). HR in 70s, o2 98%. Seemed uncomfortable. She was convinced. I was not. Talked her into a dimer ONLY because she was a VIP. PERC doesn't apply to < 18 mind you(I don't think). It was 7.8. CTA showed multiple segmental PEs. Eff me and the clinical portion of this. The game is rigged.

Yep, bro. - I don't play silly hypothetical games anymore.

 

[WorkNoteEmergency]

As my career has advanced I order way fewer labs, more CT's, although still one of lower CT utilizers in the group.

Lots of weird ****e out there and we're expected to catch it all. Not too long ago the anxious lady who was crying and pointing and saying the name of a recently deceased relative over and over that turned out to be MCA occlusion and she was crying because she was aphasic and could only say that one word. Medic said something, I forget what now, that tipped me to order a CTA without code stroking her.

They tell us we order too many CT's then chastise us for missing stuff and it's taken for granted when we find the needle in the haystack. I'm sure we can all tell multiple stories of the patient that looks and sounds like unstable angina with an elevated troponin that doesn't quite look right and we find the saddle PE.

Don't beat yourself up OP, it has happened to everyone.

 

[TooMuchResearch]

Had a fun one a while ago. Overnight shift. Got things settled in around 0330AM.
Old guy comes in, Right side “chest pain”. Like a pinch stab. Woke him up but went away.
Says actually he’s not sure if its chest or belly, its like right low anterior ribs and a pinch pleuritic.

I’m futzing around with the POCUS machine anyway, wheeled it in with me.
EKG is Afib at 105 (known, on anti-coag).
Lung US? No Pneumo, ?infiltrate R base
ECHO just out of curiosity? Normal looking Afib.

So we get the labs and trop and X-ray and all.

Portable X-ray classic RLL pneumonia. Something a MS1 would pick up. WBC is a pinch up. He gets briefly hypotensive (90s SBP), comes up with a liter.

Give him the abx, decide to bring him in the hospitalist with the pain and soft BP but he looks good.

Hospitalist (good dude) comes and sees him, is like “hey, his LFTs are up (like AST 58….), will you POCUS his RUQ just to be safe?”

Sure bro, POCUS is fun, its 0500 and I’m yawning… Holy crap, look at that, an immobile gallstone and a thick as GB wall! Like 1cm thick!

Huh, so broaden the abx, call the surgical PA to take a look (no formal US ‘til AM).

Patient is smiling, then has another brief hypotensive burst, again resolves as soon as we start fluids.

Surgical PA is like yeah man, seems he has acute chole AND pneumonia. Weird.

My spider sense finally says screw this, scan him stem to stern.

Rads calls, he’s like what black cloud do you have??
(1) Classic thick RLL pnuemonia
(2) Severe, perhaps becoming gangrenous, cholecystitis
(3) Short-segment Type A dissection with blood flowing into the pericardium w/ signs of tamponade.

Well **** boys and girls. Back in room. POCUS echo again, now I see an effusion. Stat Xfer to the city for the fancy repair boys; they manage to repair him but he develops triple-pressor shock, DIC, succumbs rapidly. Not before 4/4 bottles of blood cx grow out positive from my visit in 12hr.

Moral of the story? Good question. Hickam’s dictum? Diagnostic anchoring? Or my own personal saying— squirrels get shotguns, meaning if in your experience the entire history and story is squirrelly and makes you raise an eyebrow, keep doing tests. Didn’t manage to save this guy but we gave him a chance.

It's sounds like the universe decided it was this guy's day. Yikes.

 

[PianoMedic]

As my career has advanced I order way fewer labs, more CT's, although still one of lower CT utilizers in the group.

Lots of weird ****e out there and we're expected to catch it all. Not too long ago the anxious lady who was crying and pointing and saying the name of a recently deceased relative over and over that turned out to be MCA occlusion and she was crying because she was aphasic and could only say that one word. Medic said something, I forget what now, that tipped me to order a CTA without code stroking her.

They tell us we order too many CT's then chastise us for missing stuff and it's taken for granted when we find the needle in the haystack. I'm sure we can all tell multiple stories of the patient that looks and sounds like unstable angina with an elevated troponin that doesn't quite look right and we find the saddle PE.

Don't beat yourself up OP, it has happened to everyone.

That unstable angina was my first aortic dissection. Initial trop negative. Exertional pain with dyspnea, known CAD with prior stents, felt very similar to prior MI, including the radiation to back, improved initially with nitro. Called her cardiologist after first trop, he admitted with plan to cath later that afternoon. He was so convinced he accepted admit himself, he never admitted anyone usually. D-dimer that we ordered as we couldn’t perc came back above reference range. Initial contrast bolus refluxed backwards off calcified aortic valve, but rads compared to prior CTA and aortic root was more dilated. Repeat dissection protocol worked and showed the flap heading up the ascending part of the arch. Went to CT surgery emergently, did well. I was a resident at the time, felt bad calling that early after the d-dimer resulted, but we kept following up on all of the results so it worked out.

To OP: bad outcomes happen. Even if you look for the bad things, sometimes you don’t find anything bad. Had a patient die within 5 minutes of me discharging them. Literally didn’t even make it to their car. Normal high sensitivity troponin, but was found to be in V fib. Was DNR/DNI. Found on the floor by their bed at home which prompted the visit. They thought they rolled out of bed. We all did. They might have and the v fib was coincidence.

Had another patient code on me during a sedation. Had three ketamine induced laryngospasms that I’ve managed to break. Had to get a STAT path consult (didn’t know this could be done or to ask for it, heme tech called and asked for it) on a slide that ended up being APML (Josh farkas and his online icu book explain this disease well), couldn’t save the patient.

I’ve had more bad crap happen in my short attendinghood (closing in on two years out) than I think I will ever be able to recall. Just gotta keep plugging through. If you received good training, are good at procedures, and know when to appropriately ask for help, you will do fine. I call for assistance when I feel I need it, this comes with time. I’m still learning every shift, hopefully we all continue to learn as medicine advances.

I don’t think I’m a minimalist, but I definitely don’t scan as liberally as some do. I use a lot of shared decision making regarding scans when appropriate. Your comfort level will fluctuate with time, recency bias, and your growing experience. I try to see myself as an educator, so I will teach my patients and explain what I’m thinking. I feel like this helps me determine their risk tolerance with uncertainty and knowing when I will not get someone out without that CT scan, and when trialing treatment first is a good option. Remember the bad things for each chief complaint, consider them (don’t have to test for them), and then move on. If you think it’s extremely low likelihood, then it probably is. Doesn’t mean it isn’t there. Emergency medicine is filled with landmines. Eventually you’ll run into one, trying to find it is tough. Not getting upset when it explodes in your face is tougher.

 

[RustedFox]

I've heard of this "Ketamine associated laryngospasm". How does one break it? Benzos? Paralytics for RSI?

 

[JacobMcCandles]

I'm with RF. PERC out or dimer/CTA. Well's doesn't cut it anymore.

Had a 16yo last week, completely healthy kid. L sided CP and cough. L calf pain after 3 day wrestling camp. He was a "VIP" as mom was one of the surgeon's clinic admins. Came in at 2200. She said she had a PE in her 30s(on OCPs at the time). HR in 70s, o2 98%. Seemed uncomfortable. She was convinced. I was not. Talked her into a dimer ONLY because she was a VIP. PERC doesn't apply to < 18 mind you(I don't think). It was 7.8. CTA showed multiple segmental PEs. Eff me and the clinical portion of this. The game is rigged.

You don't use Well's on its own. In order to PERC them out then they have to be low risk whether that is by 'physician gestalt' or other objective criteria (such as Well's). If they're high risk (by Well's or other criteria) then there's no use getting a d-dimer because they need a CTA. Well's and PERC are still useful but they need to be used correctly.

 

[BoardingDoc]

I've heard of this "Ketamine associated laryngospasm". How does one break it? Benzos? Paralytics for RSI?

Jaw thrust with lots of pressure on the laryngospasm notch.

Push hard. If you have a hard time visualizing where it is, feel around on yourself and find the spot that hurts really bad where you apply pressure. That's it.

BVM them with a bag that has a peep valve on it.

If that doesn't work, push propofol and sux and intubate them.

 

[GonnaBeADoc2222]

I had a case of this once early in my attending career. **** my pants.

Youngish person in substance induced agitated delirium. Spitting, kicking, yelling, you know the things.

Gave ketamine IM.

Came back 10 min later.

Nurse "He is doing better!"

Patient is head down, drooling, doing the "hiccup...HICCUP" breathing noise thing.

I stood bedside for 45 minutes jaw thrusting; suctioning; even gave a little atropine for secretions.

Thank god the outcome was good and the family was understanding that this result was secondary to their child's poor behavior.

I still use lots of ketamine FYI.

 

[RustedFox]

You don't use Well's on its own. In order to PERC them out then they have to be low risk whether that is by 'physician gestalt' or other objective criteria (such as Well's). If they're high risk (by Well's or other criteria) then there's no use getting a d-dimer because they need a CTA. Well's and PERC are still useful but they need to be used correctly.

Thanks for this as a summary. Man, I'm frigging bad at articulating my thoughts these past few days.

 

[Birdstrike]

Decision rules, even the good ones, are on shaky ground Here's why:

-They are based on studies with patient populations with strict inclusion and exclusion criteria. When's the last time you read those critieria on the study where your decision rule was formulated? (Never, or if you did, you can't remember what they are). Does your patient fit the criteria?

-They are designed to be useful when you're uncertain with your clinical judgement. But they all have a poison pill that says something to the effect that "physician judgement" or "clinical gestalt" is required to make the rule work. The rule is essentially telling you, "If you're not sure, I'm not sure either." What good is that?

-Decision rules nearly always have some sort of cutoff that allows them to absolve them of responsibility when you use them and miss. "Might miss 1.8%" Sound familiar? How much confidence do you want to place in a rule that tells you 1 out of 55 of your patients you were pretty sure didn't have a PE are going to have one, even when you used their rule!?

If you have enough of a suspicion to pull out a decision rule, you probably should ordering a test, in my humble opinion.

 

[PianoMedic]

Decision rules, even the good ones, are on shaky ground Here's why:

-They are based on studies with patient populations with strict inclusion and exclusion criteria. When's the last time you read those critieria on the study where your decision rule was formulated? (Never, or if you did, you can't remember what they are). Does your patient fit the criteria?

-They are designed to be useful when you're uncertain with your clinical judgement. But they all have a poison pill that says something to the effect that "physician judgement" or "clinical gestalt" is required to make the rule work. The rule is essentially telling you, "If you're not sure, I'm not sure either." What good is that?

-Decision rules nearly always have some sort of cutoff that allows them to absolve them of responsibility when you use them and miss. "Might miss 1.8%" Sound familiar? How much confidence do you want to place in a rule that tells you 1 out of 55 of your patients you were pretty sure didn't have a PE are going to have one, even when you used their rule!?

If you have enough of a suspicion to pull out a decision rule, you probably should ordering a test, in my humble opinion.

The tests aren’t perfect either. The reported miss rate of a PE on CTA in the studies the decision rules were based on was 2%. This is likely lower now. The rules used that as their endpoint, essentially trying to get you to a fairly similar miss rate so that whether you order the test or not, you’re still going to miss 2% or so of PEs.

Other points are well taken, but I’d look at the external validation studies for their inclusion/exclusion criteria and compare results to the original studies.

 

[Birdstrike]

The tests aren’t perfect either.

No gold standard test is perfect. But no decision rule is the gold standard, for anything.

 

[futureapppsy2]

Does/how does the risk of radiation exposure from CT scans enter into your decision making WRT ordering CT scans or not?

 

[RustedFox]

Does/how does the risk of radiation exposure from CT scans enter into your decision making WRT ordering CT scans or not?

Lol.

 

[Rekt]

In my experience, other physicians vastly romanticize and embelish their "subtle" PE presentations when in reality it's pretty obvious. If you're using a Dimer appropriately, there is absolutely no reason to get a CTA (for PE).

 

[BoardingDoc]

Does/how does the risk of radiation exposure from CT scans enter into your decision making WRT ordering CT scans or not?

Despite rusteds giggle at this comment, I absolutely take it into account. The 3rd trimester pregnant lady who was sent in with a positive dimer because some idiot NP ordered it for the chest pain that she had with coughing? Didn't scan. Yeah, dimer is positive but I'm not in good conscience going to cta this woman because of a positive dimer that I never would have ordered.

I documented the hell out of that visit and spent a solid 30 min in the room with the patient but we were all very much on the same page at the end of it.

Also, to address birdstrike's comment, I definitely use decision rules. PECARN springs to mind as something I will always reach for. If the argument is "you should be ordering a test" in those cases, I think we have a fundamentally different way of practicing medicine.

Over age 50? Radiation concerns vanish entirely.