Low utility tests you (usually) shouldn't order in the ER

[WilcoWorld]

Parents getting mad if you don't?

This is where the theatrical physical exam can be helpful (I'm guessing you knew that already tho).

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[WilcoWorld]

And there's the problem, at least in my experience. And it is very regional dependent. In my last job (PP) I didn't even have flu swabs because they are expensive and rarely surprise me with the results. Never got any push back on that (same with unneeded antibiotics). Moved 90 miles up the road, now everyone gets mad if they don't get either a test or a antibiotic/Tamiflu/medrol shot.

Seriously, in 2 years of PP I was an antibiotic/test nazi and lost like 5 patients in that time. 3 months here with literally the exact same practice pattern/bedside manner and getting swamped in complaints. And doing a chart review its likely because I was solo before and built the practice myself while here I took over for a zpack candyman and my current partner is the medrol shot candyman.

I’d rather just give them the tamiflu or z pack instead of wait for a chest X-ray or flu swab. Throughput is king and it trumps good medicine. I’m a discharge machine.

I sympathize, and I've been there. I found that approach burned me out even more. Now I'm back to a more judicious approach. We'll see how long that lasts...

 

[WilcoWorld]

I should add that I'm not actually a particularly stingy tester or treater. I offer my patients the moon & the stars. I just do it in such a way that most of 'em end up choosing to forego the radiation-exposing CT or the 8 hour wait-inducing (and its attendant NPO status) MRI.

 

[GeneralVeers]

I’d rather just give them the tamiflu or z pack instead of wait for a chest X-ray or flu swab. Throughput is king and it trumps good medicine. I’m a discharge machine.

I agree with the Tamiflu. I tell them: "I will prescribe Tamiflu if you want it, but it won't make you better much faster, won't reduce severity of symptoms, will be expensive, and could cause side effects. Do you still want me to prescribe it?"

I say something similar for the swabs: "We can do the swabs if you want, but you will wait 2 hours for the results, won't change anything I prescribe, and you will still be going home. Would you rather I just discharge you now?"

 

[GeneralVeers]

I should add that I'm not actually a particularly stingy tester or treater. I offer my patients the moon & the stars. I just do it in such a way that most of 'em end up choosing to forego the radiation-exposing CT or the 8 hour wait-inducing (and its attendant NPO status) MRI.

You order MRIs? I just tell them that "they" won't let me order MRI scans through the ED. If patients want to complain, I totally throw administration under the bus, and blame them for not allowing me to order it.

 

[WilcoWorld]

You order MRIs? I just tell them that "they" won't let me order MRI scans through the ED. If patients want to complain, I totally throw administration under the bus, and blame them for not allowing me to order it.

Yeah, we do MRI's in my ED. I wish we didn't. It sucks. It is very rare that I find something on MRI that I didn't already know was going on based on my H&P.

Unfortunately, my ED gets a lot of transfers from critical access hospitals ostensibly for MRI-warranting concerns (epidural abscess, dural sinus thrombosis, spinal osteomyelitis, stroke within the intravascular procedure window (don't get me started on that one, please)).

We can't admit all of these people. Since many of them do not have the disease that they were sent to us for we do MRI's in the ED. Then send them on their 3 hour drive home, where the nearest provider is an NP staffing a clinic 45 minutes away.

 

[VA Hopeful Dr]

I sympathize, and I've been there. I found that approach burned me out even more. Now I'm back to a more judicious approach. We'll see how long that lasts...

My current view point that let's me sleep at night is to help those that want my help and get everyone else out of my office as fast as I can without major harm/negligence.

 

[Perfect Hair Day]

- CK-MB (even if the patient had an MI a week ago)
- BNP
- ABG rather than VBG in majority of ER patients
- Abdominal X-rays (if you're concerned about obstruction, get the appropriate imaging)
- RSV for any child, including sick (bronchiolitis is bronchiolitis, regardless of whether it's RSV+)
- Utox
- Ammonia levels

What about Ammonia level for lethargic neonate?

 

[RoyBasch]

I've definitely given up on good medicine. If something will not actively harm the patient and won't jeopardize my licence/livelihood, I just don't care anymore.

Yeah this is where I am at. The powers that be have made it clear that satisfaction is very important. Even a relatively small number of complaints are taken seriously and have significant repercussions. A lot of patients seem to expect pointless tests and if they are minimally harmful I don't have a big problem with ordering them.

 

[RoyBasch]

I've definitely given up on good medicine. If something will not actively harm the patient and won't jeopardize my licence/livelihood, I just don't care anymore.

Yeah this is where I am at. The powers that be have made it clear that satisfaction is very important. Even a relatively small number of complaints are taken seriously and have significant repercussions. A lot of patients seem to expect pointless tests and if they are minimally harmful I don't have a big problem with ordering them.

 

[qwerty89]

PGY-3 radiology resident here

Panorex plain films looking for periapical lucencies/dental abscess. If the concern is dental abscess just go straight for the CT Maxillofacial w/ contrast.

 

[GeneralVeers]

PGY-3 radiology resident here

Panorex plain films looking for periapical lucencies/dental abscess. If the concern is dental abscess just go straight for the CT Maxillofacial w/ contrast.

How about no imaging, discharging them home with RX for PCN and have them follow up with a DENTIST?

 

[Zebra Hunter]

How about no imaging, discharging them home with RX for PCN and have them follow up with a DENTIST?

Agreed, I've lost count of the number of times I've argued with an attending about how a CT was going to change our management of an obvious, uncomplicated dental abscess.

Me: "What do you think we are going to find?"
Attending: "Well, um, you just never know."
Me: "With that reasoning, I should put everyone through the donut of truth. What do you expect is a reasonable possibility of what we might find that will change our management?"
Attending: "Zebra Hunter, why do you always have to be so difficult? Just order the damn scan."

Thankfully there are only 3 more months of residency for me.

 

[Siggy]

Agreed, I've lost count of the number of times I've argued with an attending about how a CT was going to change our management of an obvious, uncomplicated dental abscess.

Me: "What do you think we are going to find?"
Attending: "Well, um, you just never know."
Me: "With that reasoning, I should put everyone through the donut of truth. What do you expect is a reasonable possibility of what we might find that will change our management?"
Attending: "Zebra Hunter, why do you always have to be so difficult? Just order the damn scan."

Thankfully there are only 3 more months of residency for me.

It's like that on the inpatient side.

:: picks up patient in the morning::

Oh, look, another syncope where the overnight NP decided that syncope needed a neuro consult AND carotid Dopplers. What fun.

 

[RoyBasch]

It's like that on the inpatient side.

:: picks up patient in the morning::

Oh, look, another syncope where the overnight NP decided that syncope needed a neuro consult AND carotid Dopplers. What fun.

Yeah I've never understood the knee-jerk neuro consult for syncope, if it really is syncope and not a seizure I'm not sure what the suspected neuro etiology that requires neurology consult could be. That being said when I follow up my syncope admits a lot of them do get neuro consults, so maybe the hospitalists know something I don't.

Of course there are some situations where it is quite unclear what the actual "episode" was if it was seizure, or syncope, or something else due to poor/No collateral history and patient unable to clarify the peri-episode events well.

ACEP has a position statement on the very low yield of CT head (and I would argue by extension MRI brain) in syncope with a normal and non-focal neuro exam. That being said if the patient is relatively old, some kind of head imaging (even in the absence of reported head trauma) with these patients appears to be de rigeur.

 

[Siggy]

Yeah I've never understood the knee-jerk neuro consult for syncope, if it really is syncope and not a seizure I'm not sure what the suspected neuro etiology that requires neurology consult could be. That being said when I follow up my syncope admits a lot of them do get neuro consults, so maybe the hospitalists know something I don't.

Of course there are some situations where it is quite unclear what the actual "episode" was if it was seizure, or syncope, or something else due to poor/No collateral history and patient unable to clarify the peri-episode events well.

ACEP has a position statement on the very low yield of CT head (and I would argue by extension MRI brain) in syncope with a normal and non-focal neuro exam. That being said if the patient is relatively old, some kind of head imaging (even in the absence of reported head trauma) with these patients appears to be de rigeur.

The problem is that people throw the term "syncope" around like it's a generic term of loss of consciousness. It's defined as (and stealing from UpToDate) " a transient loss of consciousness, associated with loss of postural tone, with spontaneous return to baseline neurologic function requiring no resuscitative efforts. The underlying mechanism is global hypoperfusion of both the cerebral cortices or focal hypoperfusion of the reticular activating system."

There are a lot of things that cause loss of consciousness. If someone thinks that the loss of consciousness is a stroke, mass, or a seizure, then they shouldn't be calling it syncope. If seizure is on the list, then by all means, consult neuro and get an EEG, but it's not syncope and they shouldn't be calling it such. If the patient has focal symptoms, then it's not syncope. All neuro consults and carotid dopplers do in syncope is waste money.

I can use the same rant for encephalopathy and confusion or altered mental status. Brain tumors don't cause encephalopathy. Chemo can. Tumors can't.

 

[slurpy15]

Yeah I've never understood the knee-jerk neuro consult for syncope, if it really is syncope and not a seizure I'm not sure what the suspected neuro etiology that requires neurology consult could be. That being said when I follow up my syncope admits a lot of them do get neuro consults, so maybe the hospitalists know something I don't.

Of course there are some situations where it is quite unclear what the actual "episode" was if it was seizure, or syncope, or something else due to poor/No collateral history and patient unable to clarify the peri-episode events well.

ACEP has a position statement on the very low yield of CT head (and I would argue by extension MRI brain) in syncope with a normal and non-focal neuro exam. That being said if the patient is relatively old, some kind of head imaging (even in the absence of reported head trauma) with these patients appears to be de rigeur.

Sigh. I recently had a young man with recurrent syncope. I scanned him. Tumor wrapped around the medulla. Transferred him to neuro at the big house. Was intubated and transferred to the unit within hours.

 

[GeneralVeers]

Sigh. I recently had a young man with recurrent syncope. I scanned him. Tumor wrapped around the medulla. Transferred him to neuro at the big house. Was intubated and transferred to the unit within hours.

You sure it wasn't a Zebra wrapped around the medulla?

 

[Fox800]

You sure it wasn't a Zebra wrapped around the medulla?

 

[RoyBasch]

Sigh. I recently had a young man with recurrent syncope. I scanned him. Tumor wrapped around the medulla.

I'll concede that a medullary tumor is not typically on my syncope differential diagnosis.

 

[slurpy15]

I'll concede that a medullary tumor is not typically on my syncope differential diagnosis.

I've been doing this awhile, and never say never, and put everything in context. Medullary tumor guy had syncopized multiple times- not normal in a 30 y o male. Of course no CT necessary in a different patient. But he needed an answer.

 

[slurpy15]

You sure it wasn't a Zebra wrapped around the medulla?

Lol. You have to know when to look for the zebra, right?

 

[TooMuchResearch]

Yeah I've never understood the knee-jerk neuro consult for syncope, if it really is syncope and not a seizure I'm not sure what the suspected neuro etiology that requires neurology consult could be. That being said when I follow up my syncope admits a lot of them do get neuro consults, so maybe the hospitalists know something I don't.

Of course there are some situations where it is quite unclear what the actual "episode" was if it was seizure, or syncope, or something else due to poor/No collateral history and patient unable to clarify the peri-episode events well.

ACEP has a position statement on the very low yield of CT head (and I would argue by extension MRI brain) in syncope with a normal and non-focal neuro exam. That being said if the patient is relatively old, some kind of head imaging (even in the absence of reported head trauma) with these patients appears to be de rigeur.

Then again the people I know that do medical malpractice work tell me you had better he damn sure it is a 100% normal neuro exam. Not even a whiff of post-ictal drowsiness at time of discharge.

 

[Old_Mil]

Fusobacterium causes Lemierre's which can have some horrifying consequences.

Here's the problem with "don't treat ear infections", "don't treat sore throats", "don't run strep tests" and much of this choosing wisely stuff: The people who make these recommendations aren't practicing as front line physicians. They are working as public health officials and making statistical recommendations based on saving the resources of the system. As such, they can safely say "don't treat ear infections" or "don't run a strep test" because they aren't personally subjecting themselves or their patients to the complications caused by doing nothing.

You are not a public health official. You are a hippocratic physician. You deal in retail, not wholesale. Let the system save itself. That is not your job.

 

[Siggy]

Here's the problem with "don't treat ear infections", "don't treat sore throats", "don't run strep tests" and much of this choosing wisely stuff: The people who make these recommendations aren't practicing as front line physicians. They are working as public health officials and making statistical recommendations based on saving the resources of the system. As such, they can safely say "don't treat ear infections" or "don't run a strep test" because they aren't personally subjecting themselves or their patients to the complications caused by doing nothing.

You are not a public health official. You are a hippocratic physician. You deal in retail, not wholesale. Let the system save itself. That is not your job.

I'm making the "don't run the strep test" not because of saving money, but because it's useless. If the patient's sick or scores a few points on Centor, then I would make the argument to treat. If Centor score is like a zero or one, then don't treat. My concern for the Strep Test is the false negative rate when using it to say that it's viral... despite the bacteria that the Strep A test doesn't test for.

 

[GeneralVeers]

I agree with Siggy. Assuming I believed antibiotics have any impact on Strep (which I don't). I would just Centor them out, and treat/not treat based on that. What is the possible down-side to a missed diagnosis?

 

[Brigade4Radiant]

Then again the people I know that do medical malpractice work tell me you had better he damn sure it is a 100% normal neuro exam. Not even a whiff of post-ictal drowsiness at time of discharge.

Even if you think its a seizure give them seizure precautions and tell them to f/u with Neuro.

Also if someone has Fusiform bacteria throat infection they will be SICK. That's why you tell them to return to the ER if you see it early how would you even know it's Lemierre syndrome?

That patient will have a bad outcome thats what gets you sued and being a jerk.

 

[Instatewaiter]

-
- Blood cultures pretty much all the time

WAT?

 

[siliso]

You get me my blood cultures before you give antibiotics . If you want them admitted, I mean. Sending out? Fine skip them, if you really think they might have a bloodstream infection they wouldn’t be going out right?

 

[Instatewaiter]

On a tangent, I still just don't get how IM people can't "get it" that not everyone with an MI will be showing you Levine's sign. Old women that are nauseated can really be having a true cardiac issue.

And the cardiologists just don't get why you would order troponin on 90% of people that get them in the ED. Every IM person in the world knows nausea is an anginal equivalent. It is actually the myriad of other reasons troponins are ordered that they complain about. A few of the troponin gems from the last week:

- AMS in a 98 year old with dysuria- apparently heart attacks cause foul smelling urine.
- Obvious sepsis- the fever of 102 was the MI.
- Obvious zoster rash on the chest. Apparently never interviewed or examined the patient.

 

[Apollyon]

And the cardiologists just don't get why you would order troponin on 90% of people that get them in the ED. Every IM person in the world knows nausea is an anginal equivalent. It is actually the myriad of other reasons troponins are ordered that they complain about. A few of the troponin gems from the last week:

- AMS in a 98 year old with dysuria- apparently heart attacks cause foul smelling urine.
- Obvious sepsis- the fever of 102 was the MI.
- Obvious zoster rash on the chest. Apparently never interviewed or examined the patient.

You do you. I don't know about the cases you mention. However, what I name has been said on SDN for YEARS, about IM people ****ting on EM. But, you do you.

 

[lucid_leprechaun]

And the cardiologists just don't get why you would order troponin on 90% of people that get them in the ED. Every IM person in the world knows nausea is an anginal equivalent. It is actually the myriad of other reasons troponins are ordered that they complain about. A few of the troponin gems from the last week:

- AMS in a 98 year old with dysuria- apparently heart attacks cause foul smelling urine.
- Obvious sepsis- the fever of 102 was the MI.
- Obvious zoster rash on the chest. Apparently never interviewed or examined the patient.

And yet even if the patient does not have ACS, the troponin still provides prognostic information. Just because you know one thing a troponin can mean doesn’t mean that others can’t interpret it in other contexts.

 

[Zebra Hunter]

And the cardiologists just don't get why you would order troponin on 90% of people that get them in the ED. Every IM person in the world knows nausea is an anginal equivalent. It is actually the myriad of other reasons troponins are ordered that they complain about. A few of the troponin gems from the last week:

- AMS in a 98 year old with dysuria- apparently heart attacks cause foul smelling urine.
- Obvious sepsis- the fever of 102 was the MI.
- Obvious zoster rash on the chest. Apparently never interviewed or examined the patient.

I've never seen a single 90+ year old that has ever complained of dysuria. I'm sure it happens occasionally, I've just never seen it. People that old generally just don't have the mental capacity or the peripheral nerve function to complain about or feel the sensation of "dysuria". More likely, this was a 98 year old who presented to the ER w/ unspecified encephalopathy, had shotgun labs ordered because literally anything could be wrong with an encephalopathic 98 year old, got urine obtained 2 hours into their admission that was "foul smelling" and suddenly the ER doctor is an idiot for getting a troponin.

 

[TooMuchResearch]

And the cardiologists just don't get why you would order troponin on 90% of people that get them in the ED. Every IM person in the world knows nausea is an anginal equivalent. It is actually the myriad of other reasons troponins are ordered that they complain about. A few of the troponin gems from the last week:

- AMS in a 98 year old with dysuria- apparently heart attacks cause foul smelling urine.
- Obvious sepsis- the fever of 102 was the MI.
- Obvious zoster rash on the chest. Apparently never interviewed or examined the patient.

To be fair, foul smelling urine has been shown unreliable in predicting UTI.

And unless we're incredibly slow, when working in the big ED, I have labs back on lots of patients before I see them. I'm not typically ordering them, triage protocol orders.

 

[Psai]

I've never seen a single 90+ year old that has ever complained of dysuria. I'm sure it happens occasionally, I've just never seen it. People that old generally just don't have the mental capacity or the peripheral nerve function to complain about or feel the sensation of "dysuria". More likely, this was a 98 year old who presented to the ER w/ unspecified encephalopathy, had shotgun labs ordered because literally anything could be wrong with an encephalopathic 98 year old, got urine obtained 2 hours into their admission that was "foul smelling" and suddenly the ER doctor is an idiot for getting a troponin.

Urine is often foul smelling

 

[siliso]

Unspecified puniness is the primary presenting symptom of every elderly UTI but also every other elderly disease state. Throw the book at them, saves me time admitting.

The only time I’ve been mad that the ED doc got a troponin was on an 88m with AML, no treatment options, on hospice. It was positive. What do you want me to do, get him a cath? I sent him home out of the ED with pain meds and instructions to call the hospice nurse with future uncontrolled symptoms = patient satisfaction.

I understand the medicolegal use of head CT for everyone confused. But if they’re confused and febrile with belly pain can you please go ahead and scan the part that’s actually probably causing the delirium too? They’re going to the scanner anway...

 

[EMDOC17]

And the cardiologists just don't get why you would order troponin on 90% of people that get them in the ED. Every IM person in the world knows nausea is an anginal equivalent. It is actually the myriad of other reasons troponins are ordered that they complain about. A few of the troponin gems from the last week:

- AMS in a 98 year old with dysuria- apparently heart attacks cause foul smelling urine.
- Obvious sepsis- the fever of 102 was the MI.
- Obvious zoster rash on the chest. Apparently never interviewed or examined the patient.

I often get the question why did you order the troponin in an obviously septic patient? I just don’t get it. Why do we get LFT’s or a bun/cr? I can’t keep up with the monthly updates to sepsis but isn’t one of them end organ damage? Or even multi-organ failure? Isn’t the heart an organ? Sure if the patient is septic and their troponin is elevated I likely won’t start heparin but if you don’t check that then why check the kidney function? The reversal is obviously the AKI is causing the fever of 102.

 

[Siggy]

I often get the question why did you order the troponin in an obviously septic patient? I just don’t get it. Why do we get LFT’s or a bun/cr? I can’t keep up with the monthly updates to sepsis but isn’t one of them end organ damage? Or even multi-organ failure? Isn’t the heart an organ? Sure if the patient is septic and their troponin is elevated I likely won’t start heparin but if you don’t check that then why check the kidney function? The reversal is obviously the AKI is causing the fever of 102.

Well, for renal function tests, if the renal function sucks you might have to renal dose your antibiotics. I've yet to have to adjust med dosing for a type 2 NSTEMI.

 

[Instatewaiter]

Me thinks the ladies doth protest too much! Truly, If you all were really checking troponins for risk stratification as many of you claimed, you wouldnt consult me in the ER for the positive troponins when it shouldnt have been checked in the first place.

Now its not just the ER that is guilty of this. IM does it too and surgery rarely.

 

[Instatewaiter]

And yet even if the patient does not have ACS, the troponin still provides prognostic information. Just because you know one thing a troponin can mean doesn’t mean that others can’t interpret it in other contexts.

Thats rich for the medical student to lecture the cardiologist about what troponins mean...

 

[TooMuchResearch]

Me thinks the ladies doth protest too much! Truly, If you all were really checking troponins for risk stratification as many of you claimed, you wouldnt consult me in the ER for the positive troponins when it shouldnt have been checked in the first place.

Now its not just the ER that is guilty of this. IM does it too and surgery rarely.

I only call cardiology about a troponin if I think the patient needs the cath lab now, it's late afternoon and I think a trip to the cath Lab probably needs to happen in the next 1-2 days and maybe they want to do it before they go home, I have a question about someone I'm discharging, or the hospitalist asked me to call you but I don't really have a question.

 

[Janders]

Do I live in some bizzaro universe from the rest of ya'll?

I DO routinely get troponin in my septic shock patients, and in my elderly TRULY lethargic / ill patients.

I find these useful, both for prognostic information, and for the occasional elderly person with a troponin of 2 who has ZERO anginal symptoms and a baseline LBBB or benign appearing EKG who really had an NSTEMI two days ago I failed to ascertain from the history...

I also can't remember the last time I called a cardiologist from the ED about an elevated troponin in a septic patient?! Like, if my 89yoF with a Cr of 2 and a need for low-dose levophed from her post-flu pneumonia septic shock, and her troponin is 0.22 with an EKG that has no ST changes and she denies ongoing pain... I just chart that, and note likely type 2 MI / myocardial dysfunction due to septic shock, no indication for emergent cath lab referral, etc. I'm sure cards gets consulted in-house... but isn't that how they pay the bills? Isn't this elevated troponin somewhat useful for stratification, just like the lactate I ordered (and the platelet count! perhaps the most predictive of mortality due to sepsis!)?

I've honestly never had a hospitalist question why i would get a troponin, or a cardiologist complain... we all seem to be on the same page that elderly people present atypically, and mild/moderate troponin elevations occur in multiple disease states that do NOT require emergent cath lab / heparin / cardiology consultation.

Guess occasional the grass is greener on my side of the fence!

 

[NITRAS]

The documentation people like us document NSTEMI type 2 cause it effects expected LOS.

I’ve never been bothered by shotgun tests by ED. It’s a lot easier to sort it out in the next morning.

And you get my **** blood cultures early, not after they’ve been on Vanc and Zosyn for three hours. Thanks.

 

[siliso]

Someone who springs a troponin leak every time they get a hangnail is objectively sicker and higher risk than someone who doesn’t and probably deserves the upcode/case mix index adjustment (and a cardiac workup at some point if they haven’t had one, most have).

 

[lucid_leprechaun]

Thats rich for the medical student to lecture the cardiologist about what troponins mean...

No problem, happy to help

 

[Psai]

Someone who springs a troponin leak every time they get a hangnail is objectively sicker and higher risk than someone who doesn’t and probably deserves the upcode/case mix index adjustment (and a cardiac workup at some point if they haven’t had one, most have).

That's why I get ddimers on everyone. Because you never know when you will miss a pe and most patients could use a pulmonary workup.

 

[siliso]

You don’t need a pulm workup for an elevated ddimer . I’m just sayin, a shotgun trop out of the ED that happens to be elevated doesn’t break my own internist heart even if I maybe wouldn’t have ordered it myself (except on the hospice guy, wth) and might be productive for my patient or biller or both. The definition of type 2 nstemi is elevated markers and “ischemic symptoms” - a broad net for the puny person who hurts all over and is weak/dyspneic.

But if you’re gonna get the ddimer then just go ahead and get my scan while they’re down there when it’s elevated. Maybe I’ll get additional evidence for their pneumonia or lack thereof as a bonus. Low dose radiation therapy for all! My wtf moments are only when the ed doc has decided it’s worthwhile to send the ddimer but not worthwhile to follow up on it when it’s high - in that case really why send. Ima look stupid in front of the peer review committee explaining why I had the info and ignored it.

 

[Janders]

That's why I get ddimers on everyone. Because you never know when you will miss a pe and most patients could use a pulmonary workup.

Weak analogy is weak

Like I said, I a liberal getting troponin testing on the critically ill and high risk poor historians. Not on hospice patients of course.

I almost never get a DDIMER in this population Just buzz the chest if you have actual concern... *the sound of a million radiologists screaming**

 

[TooMuchResearch]

That's why I get ddimers on everyone. Because you never know when you will miss a pe and most patients could use a pulmonary workup.

That's not the same thing. But you knew that.

 

[TooMuchResearch]

You don’t need a pulm workup for an elevated ddimer . I’m just sayin, a shotgun trop out of the ED that happens to be elevated doesn’t break my own internist heart even if I maybe wouldn’t have ordered it myself (except on the hospice guy, wth) and might be productive for my patient or biller or both. The definition of type 2 nstemi is elevated markers and “ischemic symptoms” - a broad net for the puny person who hurts all over and is weak/dyspneic.

But if you’re gonna get the ddimer then just go ahead and get my scan while they’re down there when it’s elevated. Maybe I’ll get additional evidence for their pneumonia or lack thereof as a bonus. Low dose radiation therapy for all! My wtf moments are only when the ed doc has decided it’s worthwhile to send the ddimer but not worthwhile to follow up on it when it’s high - in that case really why send. Ima look stupid in front of the peer review committee explaining why I had the info and ignored it.

Every once in a while, I find something else that makes way more sense than a PE, and I might not order the CT, but typically I don't shotgun dimers.