I hate derm.

[Old_Mil]

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I mean, I would probably like Derm if I did that for a living.

I hate Derm when people come into the ER with their longstanding dermatological issues.

Like this one.

Autoimmune Progesterone Dermatitis
Autoimmune progesterone dermatitis (APD) occurs as a result of an allergic reaction to a woman's own progesterone. Symptoms typically occur anywhere from 3 to 10 days prior to the onset of menses, and begin to resolve within 1 to 2 days after the onset of menstruation.

WTF.

 

[Old_Mil]

Or this one.

Catamenial Anaphylaxis
Catamenial anaphylaxis is another condition that is related to the menstrual cycle. Woman who have this condition experience symptoms of anaphylaxis as soon the menstrual flow begins, and symptoms continue until the menses flow stops. Unlike APD, however, catamenial anaphylaxis is not an allergic condition, but rather is caused by prostaglandins released from the lining of the uterus (endometrium), which may be absorbed into the bloodstream. The diagnosis is usually made on a clinical basis, as allergy testing to progesterone (and other hormones) is negative. Treatment of catamenial anaphylaxis has been successful with the use of non-steroidal anti-inflammatory medications (NSAIDs), such as Indocin (indomethacin). Surgical removal of the ovaries and uterus is required in severe cases of catamenial anaphylaxis when medications are unable to control the symptoms.

Talk about being allergic to yourself.

 

[Angry Birds]

I think it's sometimes very hard to diagnose rash in the ER, and it's annoying that patients are annoyed at this.

 

[dchristismi]

I tell people point-blank that I know the 5 rashes that kill you, and it isn't one of those, but the others are a lot harder for us.

I also routinely do "rash rounds" and grab some colleagues if I can to poll the proverbial audience. But unless it's hand-foot-mouth or some other really obvious one, I'm not a big fan.

Exception made for toxic-appearing patient... saw a staphylococcal scalded skin once, and even though we weren't 100% sure, the admission (or in this case, transfer to a hospital with a burn unit), was obvious. Ironically, this kid had been seen at an urgent care and told "oh, it's just measles. It'll run its course in a few days..." (JUST measles??? Aside from the public health ramifications, I still shudder recalling this case.)

 

[erdoc00]

Back when the ER was used for actual emergencies, dealing with rashes wasn't that hard. If it wasnt one of the deadly rashes the pt got brief counseling and told to follow up with derm.

Now everyone who doesn't want to wait the 4 months to see derm or the month to see their pcp comes to the ER expecting a definitive diagnosis with biopsy and treatment.

These are the same patients who are surprised when I tell them I don't freeze warts off in the ER.

 

[deleted109597]

Exception made for toxic-appearing patient... saw a staphylococcal scalded skin once, and even though we weren't 100% sure, the admission (or in this case, transfer to a hospital with a burn unit), was obvious. Ironically, this kid had been seen at an urgent care and told "oh, it's just measles. It'll run its course in a few days..." (JUST measles??? Aside from the public health ramifications, I still shudder recalling this case.)

Maybe they meant German Measles? Either way, WTF.

 

[hundreddaysoff]

Back when the ER was used for actual emergencies, dealing with rashes wasn't that hard. If it wasnt one of the deadly rashes the pt got brief counseling and told to follow up with derm.

Now everyone who doesn't want to wait the 4 months to see derm or the month to see their pcp comes to the ER expecting a definitive diagnosis with biopsy and treatment.

These are the same patients who are surprised when I tell them I don't freeze warts off in the ER.

Given the real lack of dermatologists, I'm curious whether any FSEDs/urgent cares have expanded their services to wart-freezing and biopsies. Are there reimbursement issues for non-dermatologists?

 

[RustedFox]

I hate endocrinology in a similar fashion. Its just... esoteric and bizarre. T3 or T4 ? No.... FREE T4.... No? REVERSE T3 ? TSH = LOLZ.

 

[GeneralVeers]

If it's wet, dry it. If it's dry, wet it. If you don't know then give steroids.

 

[deltamed]

Aw guys, but rashes presenting to the ED are sometimes fun! Not that I get called very often to the ED (or would want to) but some of the coolest cases go there first so you get a higher chance to see them. I think my favorites are:
- ten/sjs
- dress
- disseminated zoster
- eczema herpeticum
- deep fungal infxn in onc patient
- sweets sydrome
- acute vasculitis disorders
- thrombotic emboli to skin
- warfarin necrosis
- pemphigus
- staph scalded skin

Beyond that not too much probably matters to you guys.



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[gutonc]

If it's wet, dry it. If it's dry, wet it. If you don't know then give steroids.

Mixed with an anti-fungal.

 

[Mad Jack]

If it's any consolation, when I've seen my dermatologist and ask them wtf this or that thing is I get a *shrug* it's probably a clogged oil gland. Or it probably isn't cancer. Or that's probably a cherry angioma but I really can't tell but it probably won't kill you so whatever. Just let me know if any of the things on your grows or itches, and come back if they do.

 

[Old Grunt]

Aw guys, but rashes presenting to the ED are sometimes fun! Not that I get called very often to the ED (or would want to) but some of the coolest cases go there first so you get a higher chance to see them. I think my favorites are:
- ten/sjs
- dress
- disseminated zoster
- eczema herpeticum
- deep fungal infxn in onc patient
- sweets sydrome
- acute vasculitis disorders
- thrombotic emboli to skin
- warfarin necrosis
- pemphigus
- staph scalded skin

Beyond that not too much probably matters to you guys.



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Wait. Are you a mercenary, I mean dermatologist? Because if so, I think you inadvertently demonstrated why we hate derm with this statement:

Not that I get called very often to the ED (or would want to)

. I am sure we would all love derm a whole bunch more if we could actually talk to someone at 2 AM (because that's when rashes come in) on the scary looking rash on a 3 year old that we aren't quite sure is a manifestation of some underlying lethal pathology that needs a full sepsis work up or transfer to a burn center versus some benign skin hiccup that the parents are freaking out about. I mean, for every other organ system, I can generally raise someone on the phone to at least discuss the case with them. Even at 2 AM.

In the day and age of cell phones, I am surprised that Tele-Derm isn't a bigger thing.

 

[Old_Mil]

IJust let me know if any of the things on you grow or itch, and come back if they do.

Best discharge instruction ever.

 

[dchristismi]

Jinxed myself by replying.

Erythema multiformae today. (One of the few I can nail as long as I can find a damned target lesion in the mess.) Oh, and an opthalmic zoster, but that was a textbook presentation.

The ONLY time I have ever called for an emergent-ish derm consult, it turned out to be Sweet syndrome, which I had never heard of. Looked awful.
Tele-derm would be awesome. Not that we'd use it all that often honestly, but as mentioned above, we can call pretty much every other specialty at any hour for help/input.

And FWIW, I had a patient ask me if I could amputate his foot for him today. I pulled out the trauma shears and gave him the WTF look. They think we truly do it all...

 

[deltamed]

Wait. Are you a mercenary, I mean dermatologist? Because if so, I think you inadvertently demonstrated why we hate derm with this statement: . I am sure we would all love derm a whole bunch more if we could actually talk to someone at 2 AM (because that's when rashes come in) on the scary looking rash on a 3 year old that we aren't quite sure is a manifestation of some underlying lethal pathology that needs a full sepsis work up or transfer to a burn center versus some benign skin hiccup that the parents are freaking out about. I mean, for every other organ system, I can generally raise someone on the phone to at least discuss the case with them. Even at 2 AM.

In the day and age of cell phones, I am surprised that Tele-Derm isn't a bigger thing.

Eh- I'm totally fine with looking at a picture at 2am to tell you if it's something bad or not (I've done it before). Or coming in if really needed. However - how often do you call the allergist, or rheumatologist at 2am?

Also, if you "can't" send a picture or consult to derm maybe it's because your hospital hasn't arranged coverage? (which is somewhat understandable given the extremely low volume but not our fault).

I think the reason telederm hasn't taken off all over is the lack of widespread ability to bill or be compensated for these types of consults, not lack of willingness.



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[gutonc]

Eh- I'm totally fine with looking at a picture at 2am to tell you if it's something bad or not (I've done it before). Or coming in if really needed. However - how often do you call the allergist, or rheumatologist at 2am?

Also, if you "can't" send a picture or consult to derm maybe it's because your hospital hasn't arranged coverage? (which is somewhat understandable given the extremely low volume but not our fault).

I think the reason telederm hasn't taken off all over is the lack of widespread ability to bill or be compensated for these types of consults, not lack of willingness.



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I won't argue with you that the inability to bill for telemedicine is a major problem, because it clearly is.

But, as a subspecialist, I probably bill 10-20% (at most) of the "consults" I get from the ED at night and on weekends. And most of those happen in the light of (the next) day, when the patient is stable and on the floor. In my mind, being available to answer those questions in the middle of the night is the price I pay for referrals in the morning.

 

[deltamed]

I won't argue with you that the inability to bill for telemedicine is a major problem, because it clearly is.

But, as a subspecialist, I probably bill 10-20% (at most) of the "consults" I get from the ED at night and on weekends. And most of those happen in the light of (the next) day, when the patient is stable and on the floor. In my mind, being available to answer those questions in the middle of the night is the price I pay for referrals in the morning.

Sure I get it. If the hospital has arranged coverage with you and you are on call, there is no excuse - you should answer pages at 2am and be helpful.

But in derm (unlike many subspecialties) 60% of patients are self-referred, 35% are PCP referrals, 5% are from other specialties and 0.001% came from the ED or inpatient route. So its not exactly a "good" way to get business. I personally enjoy doing an occasional inpatient or ED consult but I don't kid myself that its for profit. Most private practice derms don't take hospital call at all which is why the perception is probably that we are unavailable. But if you think about it there is an economic reason why -the system has been setup to make it undesirable.

If photo consults could be reimbursed, it might be a better situation because the hospital could more easily arrange a coverage person (if they even tried to begin with - derm isn't exactly their priority).


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[RustedFox]

Jinxed myself by replying.

Erythema multiformae today. (One of the few I can nail as long as I can find a damned target lesion in the mess.) Oh, and an opthalmic zoster, but that was a textbook presentation.

The ONLY time I have ever called for an emergent-ish derm consult, it turned out to be Sweet syndrome, which I had never heard of. Looked awful.
Tele-derm would be awesome. Not that we'd use it all that often honestly, but as mentioned above, we can call pretty much every other specialty at any hour for help/input.

And FWIW, I had a patient ask me if I could amputate his foot for him today. I pulled out the trauma shears and gave him the WTF look. They think we truly do it all...

I had a kiddo today with e.multiforme. Claaaasic target lesions with confluence. Cute kid. That's what happens when pediatricians shower children with beta-lactams for "colds".

 

[Old Grunt]

Eh- I'm totally fine with looking at a picture at 2am to tell you if it's something bad or not (I've done it before). Or coming in if really needed. However - how often do you call the allergist, or rheumatologist at 2am?

Also, if you "can't" send a picture or consult to derm maybe it's because your hospital hasn't arranged coverage? (which is somewhat understandable given the extremely low volume but not our fault).

I think the reason telederm hasn't taken off all over is the lack of widespread ability to bill or be compensated for these types of consults, not lack of willingness.



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Agree with you. Just being a little sardonic. I've actually called the allergist at 2 AM several times for follow up issues (ours want to be called for follow up).

 

[Old Grunt]

I had a kiddo today with e.multiforme. Claaaasic target lesions with confluence. Cute kid. That's what happens when pediatricians shower children with beta-lactams for "colds".

Or maybe it was just caused by the virus, idiopathic, the alignment of Jupitor in the 3rd Qaudrant, Trump winning Michigan, or ........

 

[gman33]

I love derm.

Sorry I don't know what this is.
D/c

 

[RustedFox]

I love derm.

Sorry I don't know what this is.
D/c

Best post of 2016 to date right there.

 

[deltamed]

I love derm.

Sorry I don't know what this is.
D/c

I cant really disagree. It probably should be more like "you dont have fevers, purple spots or disseminated blisters?" I don't know/care what this is - D/c. You don't belong in the ED right now.


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[deltamed]

My favorite consult in the last year from the ED was a guy with hiv slightly AMS and a truncal /hand rash/ some low grade fevers. After I saw it I told the resident and nurse it was secondary syphillis, possibly neurosyphillis too. They had a fit (mostly the nurses) because they had shook the patient's hands without gloves. I think the attending had some sort of gut feeling because he didn't touch. Luckily, its not very contagious that way


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[Hair Police]

As long as we're bragging, I had a bullosis diabeticorum and a levamisole-associated vasculitis with purpura in the last two weeks.

 

[WilcoWorld]

My favorite consult in the last year from the ED was a guy with hiv slightly AMS and a truncal /hand rash/ some low grade fevers. After I saw it I told the resident and nurse it was secondary syphillis, possibly neurosyphillis too. They had a fit (mostly the nurses) because they had shook the patient's hands without gloves. I think the attending had some sort of gut feeling because he didn't touch. Luckily, its not very contagious that way


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Also, penicillin.

 

[d2305]

Saw a case of imported Hansen's disease which didn't look impressive. Not something one wants to touch with an ungloved hand.

 

[dchristismi]

I saw a guy at 2 am because he slept with someone with leprosy and was worried he'd catch it. Which takes the above somewhat-derm-related post and makes it completely the realm of EM.

So yeah. We had a little chat about not sleeping with random people, and perhaps he should use the big head more than the little head in future decision making.

 

[Tenk]

Macular papular bull****.

 

[Angry Birds]

Macular papular bull****.

Hahaha I would give you props if you actually put that down on the chart. It reminds me of this: