My most recent NP referral...

[wareagle726]

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completely agree. I see meningitis like once/year. It's pretty rare. I can't remember the last time I had a confirmed case of meningitis.

Actually I do! It was an 8 day old with a fever 38.5, it was unfortunately a bloody LP but CSF grew enterovirus.

It's so funny how people who look great and are well appearing can be thought by a mildly educated health care professional to have a dangerous and deadly disease causing brain dysfunction.

I have actual "concern" for meningitis once/year. I can't tell you the last time I actually had an adult with meningitis. At least not bacterial. I'm sure I've missed a few viral. I think I've seen maybe 3 through training and real job and I'm pretty sure on all 3 I walked in the room and was instantly like "this person is sick AF."

 

[thegenius]

I have actual "concern" for meningitis once/year. I can't tell you the last time I actually had an adult with meningitis. At least not bacterial. I'm sure I've missed a few viral. I think I've seen maybe 3 through training and real job and I'm pretty sure on all 3 I walked in the room and was instantly like "this person is sick AF."

I honestly cannot remember the last time I did an LP for meningitis and the CSF cultured bacteria.

And yet this person who is walking, talking, and playing tennis somehow has meningitis.

"Doc, maybe it's the beginning of meningitis and it will get worse!"

"That's right...this is the beginning 10 minutes of your disease and three days from now you'll be in the ICU on pressors and multiple antiepileptics."

Sometimes you can't win. I agree with others I routinely say bad stuff about other midlevels if they send in nonsense.

 

[DocEspana]

I've had some good referrals from NPs, lately.

"I dont know whats going on. Referring out for some clarity"

 

[BoardingDoc]

I have actual "concern" for meningitis once/year. I can't tell you the last time I actually had an adult with meningitis. At least not bacterial. I'm sure I've missed a few viral. I think I've seen maybe 3 through training and real job and I'm pretty sure on all 3 I walked in the room and was instantly like "this person is sick AF."

I distinctly remember mine because I missed it.

About 1 yr ago some guy came in altered. Daily drinker. Last drink 3 days ago per the wife at the bedside. Very confused. Not answering anything appropriately. Frequently getting agitated. Tachy, but otherwise normal vitals. Afebrile. Labs showed a +WBC and some elevated LFTs with a ~ 2:1 AST/ALT elevation. I called it DTs and phenobarbed him and admitted to the ICU. For whatever miracle of a reason, the ICU doc asked if I thought it was meningitis. I said I didn't think so and that this screamed DTs. She said she'd probably just LP him when he got upstairs. Boom. Bacterial meningitis on the LP. Guy got his abx and did fine.

I still don't know what made her think to LP the dude. I also read up on it a lot afterwards and saw that the biggest prognostic factor for MISSING meningitis (and with increased mortality) is absence of fever.

 

[Dantrolene FC]

Hey, I’m from the anesthesia world. I’ve noticed spinal kits at my place have 20G cutting needles. Do y’all see a lot of post dural puncture headaches? Although you probably wouldn’t see it yourself, so you may not recognize it.

If so, you could use a smaller non-cutting needle like we do.

 

[BoardingDoc]

Hey, I’m from the anesthesia world. I’ve noticed spinal kits at my place have 20G cutting needles. Do y’all see a lot of post dural puncture headaches? Although you probably wouldn’t see it yourself, so you may not recognize it.

If so, you could use a smaller non-cutting needle like we do.

Someone came to the em forum not long ago to say something similar.

Edit: my response at the time is here: Someone please start an academic discussion.

The long and short of it is that the ED is nowhere near as resource rich as other depts seem to think it is. If the OR asks for a non cutting spinal needle, they probably get it. The ED does not stock those, and if we want to go get one from upstairs we frequently get yelled at for touching things that don't belong to us.

Also, we review all of our bounce back cases to the ED. I can't remember the last time a patient who had an LP subsequently came back to the ED for a HA that ostensibly could be due to a post LP HA. That said, that obviously doesn't capture everyone.

 

[ScepticSkeksis]

I was forced to work the Pedi-ED side this week (don't ask) and got a transfer from an urgent care for "Paraphimosis". Jenny had terrifed the parents that this kid had a life-threatening penile condition and had to be seen at our ED immediately. The only problem is that the kid was circumcised and just had balanitis.

 

[thegenius]

Hey, I’m from the anesthesia world. I’ve noticed spinal kits at my place have 20G cutting needles. Do y’all see a lot of post dural puncture headaches? Although you probably wouldn’t see it yourself, so you may not recognize it.

If so, you could use a smaller non-cutting needle like we do.

Yes they all have cutting needles, and I wished they swapped them out. But not for a flimsy 22g needle. I find it hard to guide the needle exactly where I want it to go because they bend at the first site of resistance.

Our ER does a handful of blood patches / year. So yea we do see them! In the community, every possible symptom bypasses primary care and goes straight to the ER.

 

[Dantrolene FC]

Yes they all have cutting needles, and I wished they swapped them out. But not for a flimsy 22g needle. I find it hard to guide the needle exactly where I want it to go because they bend at the first site of resistance.

Our ER does a handful of blood patches / year. So yea we do see them! In the community, every possible symptom bypasses primary care and goes straight to the ER.

In anesthesia, we use 25G non cutting needles for our spinals. It’s requires a 20G cutting introducer needle.

 

[Arch Guillotti]

The ED does not stock those, and if we want to go get one from upstairs we frequently get yelled at for touching things that don't belong to us.

So get some and stock them. It isn't that hard. Who is "yelling" at you anyway?

 

[gutonc]

So get some and stock them. It isn't that hard. Who is "yelling" at you anyway?

Nurses...obvi

 

[BoardingDoc]

So get some and stock them. It isn't that hard. Who is "yelling" at you anyway?

The idea that I can effect this level of change in the emergency department makes it readily apparent that you don't work in one.

Case in point. I have been asking for them to restock the aluminum finger splints for over a year. Multiple conversations about this. Nothing. This is an item I'm already supposed to have. The idea that I can simply "get some and stock them" is not rooted in reality.

And yes, nursing supervisor is generally the one telling us to stay in the Ed and keep our hands off of supplies in the parts of the hospital that actually make the hospital money.

 

[RustedFox]

The idea that I can effect this level of change in the emergency department makes it readily apparent that you don't work in one.

Case in point. I have been asking for them to restock the aluminum finger splints for over a year. Multiple conversations about this. Nothing. This is an item I'm already supposed to have. The idea that I can simply "get some and stock them" is not rooted in reality.

And yes, nursing supervisor is generally the one telling us to stay in the Ed and keep our hands off of supplies in the parts of the hospital that actually make the hospital money.

Replace "aluminum finger splints" with "working otoscope/ophthalmoscope" and same.

 

[RustedFox]

Agree. Although, I can’t remember the last time those things ever really mattered for emergent management. I don’t look at retinas anymore with an otoscope. Almost every otitis is viral. Cerumen isn’t an emergency. Ear foreign bodies - I guess… Mainly just ranting that I have to see these complaints as they aren’t emergencies. The physical exam is largely antiquated other than pushing on a belly. Even then I’m over all of the people and their fake guarding. Just enjoy the Haldol/Droperidol and let me enjoy my wine/scotch.

Here in seniorcitizenland, retinal pathology is very, very common.

 

[WilcoWorld]

Here in seniorcitizenland, retinal pathology is very, very common.

What clinical decisions are you making with an ophthalmoscope these days?

 

[ScepticSkeksis]

Just use the non-working otoscope/ophthalmoscope anyway. It's a dog-and-pony show. A bit of razzle dazzle for the masses that mean nothing to me. I pretend to look in well children's ears because the parents expect it.

 

[thegenius]

So get some and stock them. It isn't that hard. Who is "yelling" at you anyway?

Sure it can be added to the list of things we need in our ER.
It would end up somewhere around #32, give or take a few.

 

[thegenius]

The idea that I can effect this level of change in the emergency department makes it readily apparent that you don't work in one.

Case in point. I have been asking for them to restock the aluminum finger splints for over a year. Multiple conversations about this. Nothing. This is an item I'm already supposed to have. The idea that I can simply "get some and stock them" is not rooted in reality.

And yes, nursing supervisor is generally the one telling us to stay in the Ed and keep our hands off of supplies in the parts of the hospital that actually make the hospital money.

Right and the number of finger splints you need / year is orders of magnitude greater than the number of LP use each year.

 

[thegenius]

Replace "aluminum finger splints" with "working otoscope/ophthalmoscope" and same.

Yup

 

[thegenius]

Agree. Although, I can’t remember the last time those things ever really mattered for emergent management. I don’t look at retinas anymore with an ophthalmoscope. Almost every otitis is viral. Cerumen isn’t an emergency. Ear foreign bodies - I guess… Mainly just ranting that I have to see these complaints as they aren’t emergencies. The physical exam is largely antiquated other than pushing on a belly. Even then I’m over all of the people and their fake guarding. Just enjoy the Haldol/Droperidol and let me enjoy my wine/scotch.

No no no no no.......
You need light to look in a lot of ENT nooks and crannies. If you have your own penlight, then great. I should get one. Any good ones out there? I'm willing to spend a few bucks for a good one.

Without a penlight, need the light on the otoscope. I'm not shining my iPhone light into someone's nasty meth ridden mouth.

 

[DocEspana]

No no no no no.......
You need light to look in a lot of ENT nooks and crannies. If you have your own penlight, then great. I should get one. Any good ones out there? I'm willing to spend a few bucks for a good one.

Without a penlight, need the light on the otoscope. I'm not shining my iPhone light into someone's nasty meth ridden mouth.

Get a streamlight stylus. It's the LED light of God, so bright you can almost do a bedside anoscopy with it alone. Definitely bright enough to work as a malginering detector in the supposedly unresponsive. Plus its damn near indestructible. The only thing I would say is that it's a good bit more expensive than a random penlight of ****ty quality, so make sure you're not going to lose it

 

[RustedFox]

What clinical decisions are you making with an ophthalmoscope these days?

When to call ophtho vs when to tell grandma to eff off.

CRAO and CRVO, retinal detachment.

It's litigious. Your defense can't be "I didn't do an eye exam."

 

[WilcoWorld]

No no no no no.......
You need light to look in a lot of ENT nooks and crannies. If you have your own penlight, then great. I should get one. Any good ones out there? I'm willing to spend a few bucks for a good one.

Without a penlight, need the light on the otoscope. I'm not shining my iPhone light into someone's nasty meth ridden mouth.

I was about to reply "I use my iPhone"...and then I finished reading your post.

 

[WilcoWorld]

When to call ophtho vs when to tell grandma to eff off.

CRAO and CRVO, retinal detachment.

It's litigious. Your defense can't be "I didn't do an eye exam."

Sounds like your retinal exam skills are far superior to mine.

 

[Brigade4Radiant]

When to call ophtho vs when to tell grandma to eff off.

CRAO and CRVO, retinal detachment.

It's litigious. Your defense can't be "I didn't do an eye exam."

CRAO vs CRVO? If they have an acute loss of vision, they need an ophthalmology evaluation. And I don’t dilate anyone’s eyes so my exam is worthless. Also, I can diagnose a retinal detachment with an ultrasound, but that doesn’t matter since ophthalmology doesn’t care what I do with the ultrasound.

Other than the visual acuity, they really don’t care about our eye exam is (they would be foolish to), unless it’s something that can be visualized grossly. The standard of care for an eye exam is to dilate the eye if you’re doing fundoscopy or if you’re using the slit lamp.

98 times out of 10. They’ll just tell you to have them follow up in their office since they have way more equipment to deal with it in their office anyway.

 

[thegenius]

Get a streamlight stylus. It's the LED light of God, so bright you can almost do a bedside anoscopy with it alone. Definitely bright enough to work as a malginering detector in the supposedly unresponsive. Plus its damn near indestructible. The only thing I would say is that it's a good bit more expensive than a random penlight of ****ty quality, so make sure you're not going to lose it

You mean this one?
https://a.co/d/asn1SyD

 

[xaelia]

CRAO vs CRVO? If they have an acute loss of vision, they need an ophthalmology evaluation. And I don’t dilate anyone’s eyes so my exam is worthless. Also, I can diagnose a retinal detachment with an ultrasound, but that doesn’t matter since ophthalmology doesn’t care what I do with the ultrasound.

Other than the visual acuity, they really don’t care about our eye exam is (they would be foolish to), unless it’s something that can be visualized grossly. The standard of care for an eye exam is to dilate the eye if you’re doing fundoscopy or if you’re using the slit lamp.

98 times out of 10. They’ll just tell you to have them follow up in their office since they have way more equipment to deal with it in their office anyway.

Pretty much the "can I see the back of the retina and do they look the same" level of exam with an undilated pupil; it's not reliable enough to diagnose or exclude anything specific, but it never hurts to add a wee bit of potential credibility to the phone consultation.

 

[RustedFox]

CRAO vs CRVO? If they have an acute loss of vision, they need an ophthalmology evaluation. And I don’t dilate anyone’s eyes so my exam is worthless. Also, I can diagnose a retinal detachment with an ultrasound, but that doesn’t matter since ophthalmology doesn’t care what I do with the ultrasound.

Other than the visual acuity, they really don’t care about our eye exam is (they would be foolish to), unless it’s something that can be visualized grossly. The standard of care for an eye exam is to dilate the eye if you’re doing fundoscopy or if you’re using the slit lamp.

98 times out of 10. They’ll just tell you to have them follow up in their office since they have way more equipment to deal with it in their office anyway.

Yeah, I guess my situation is a bit unique.
We have a "retired" ophtho who, out of the goodness of his heart - will take my phone calls at 2 am and such.
He loves to B.S. about military history and such, too. We're buddies.
Guy must have more money than God. He operates an indigent care center near the hospital.
I try to make that phone call as easy as possible, so I do the thing.
If not for him, an ophtho emergency would be a pain in the ass to transfer and find coverage for and such. Even still, he can't "do it all", so he needs to know what I can see so he can say: "not this one; transfer it 3 counties away"

 

[Ho0v-man]

My ED pan scans the OPs patient at least 5 times a day.

 

[skougess]

When to call ophtho vs when to tell grandma to eff off.

CRAO and CRVO, retinal detachment.

It's litigious. Your defense can't be "I didn't do an eye exam."

I literally haven’t used an ophthalmoscope since med school. My algorithm for painless vision loss is:

Bedside ultrasound for vitreous/retinal detachment:

- positive? > determine vitreous vs retinal > retinal? > mac on or mac off? > mac on? Ophthalmology emergency, transfer, all others discharged with rapid follow up

- negative? > move to stroke work up. If in TPA window, call stroke alert and let neuro decide if it’s in their practice pattern to TPA. Otherwise just admit after CTAs.

 

[RustedFox]

I literally haven’t used an ophthalmoscope since med school. My algorithm for painless vision loss is:

Bedside ultrasound for vitreous/retinal detachment:

- positive? > determine vitreous vs retinal > retinal? > mac on or mac off? > mac on? Ophthalmology emergency, transfer, all others discharged with rapid follow up

- negative? > move to stroke work up. If in TPA window, call stroke alert and let neuro decide if it’s in their practice pattern to TPA. Otherwise just admit after CTAs.

You made it simple.
Even "rapid follow up" would be a problem in my neck of the woods.

 

[skougess]

You made it simple.
Even "rapid follow up" would be a problem in my neck of the woods.

Fair enough. Different practice environments. But then are you transferring vitreous detachments? Seems aggressive.

 

[DocEspana]

You mean this one?
https://a.co/d/asn1SyD

Yes.

 

[BoardingDoc]

My ED pan scans the OPs patient at least 5 times a day.

Your ED pan scans 5 patients a day who present with total body pain from a minor mechanism car accident the previous day?

If not sarcasm you guys need to seriously reassess who you have working there.

 

[RustedFox]

Fair enough. Different practice environments. But then are you transferring vitreous detachments? Seems aggressive.

Not those; but even getting follow-up requires the patient to commit to a hour+ drive after you make a phone call, if anyone answers that call.

 

[TooMuchResearch]

The idea that I can effect this level of change in the emergency department makes it readily apparent that you don't work in one.

Case in point. I have been asking for them to restock the aluminum finger splints for over a year. Multiple conversations about this. Nothing. This is an item I'm already supposed to have. The idea that I can simply "get some and stock them" is not rooted in reality.

And yes, nursing supervisor is generally the one telling us to stay in the Ed and keep our hands off of supplies in the parts of the hospital that actually make the hospital money.

We seem to be able to get new ultrasound machines and disposable fiberoptic scopes for the large monitor glidescope while also being unable to stock enough supplies to close a laceration without digging through three carts.

 

[Ho0v-man]

Your ED pan scans 5 patients a day who present with total body pain from a minor mechanism car accident the previous day?

If not sarcasm you guys need to seriously reassess who you have working there.

Like everywhere else, we have NPs who were triaged this patient.

 

[CoolDoc1729]

Someone came to the em forum not long ago to say something similar.

Edit: my response at the time is here: Someone please start an academic discussion.

The long and short of it is that the ED is nowhere near as resource rich as other depts seem to think it is. If the OR asks for a non cutting spinal needle, they probably get it. The ED does not stock those, and if we want to go get one from upstairs we frequently get yelled at for touching things that don't belong to us.

Also, we review all of our bounce back cases to the ED. I can't remember the last time a patient who had an LP subsequently came back to the ED for a HA that ostensibly could be due to a post LP HA. That said, that obviously doesn't capture everyone.

We’re definitely the red haired step child of our hospital too but I just grab the kit and also grab a non cutting needle. The needles on our kits are annoying anyway because even the end of the needle is metal so you can’t see “flash” before it starts dripping out .. why don’t they put the good (~22 whitacre) needles in the LP kits though in the first place?

 

[BoardingDoc]

Like everywhere else, we have NPs who were triaged this patient.

I guess I have the benefit of working in a group that controls our own staffing. We don't hire NPs. Period. We have a few PAs who are all solid and would never pull this crap. Nor, obviously, would any of the docs.

 

[Dantrolene FC]

We’re definitely the red haired step child of our hospital too but I just grab the kit and also grab a non cutting needle. The needles on our kits are annoying anyway because even the end of the needle is metal so you can’t see “flash” before it starts dripping out .. why don’t they put the good (~22 whitacre) needles in the LP kits though in the first place?

My understanding is that opening pressure is standardized to a 20 gauge cutting needle, but I could be very, very wrong.

If you use a smaller needle, you’ll be standing around for ages to let it drip out. But, if you don’t really need serial tube samples, you can just aspirate out the CSF. To aspirate 10 mL of CSF from a 25 gauge needles takes like 30 seconds. It would probably take what seems like 15 minutes to let it drip out, unless your patient actually has meningitis with high opening pressure.

And smaller needles are probably less likely for a bloody tap.

 

[WildEMDoc]

Biggest recent pet peeve of these NPs is leg pains sent in for r/o DVT

Recently had one sent in for bilateral shin pain after mowing their lawn the day before, “acute onset bilateral pain, send to ER for EMERGENT blood clot rule out”. Exam normal. Literally had to spend in excess of 15min discussing why no ultrasound will be done.

Since when is DVT such a lights an sirens emergency and why do people think bilateral sudden DVTs from things like overuse are a thing?

 

[bravotwozero]

I’d consider DVTs, or the suspicion of one, based on PROPER clinical judgment, to be something that requires an emergent workup. Because there’s also a possibility that the person may also have a concurrent PE. I’ve seen some asymptomatic patients with normal vitals with significant PEs.

But again, proper clinical judgement is key. That’s not the scenario above.

 

[ScepticSkeksis]

I’d consider DVTs, or the suspicion of one, based on PROPER clinical judgment, to be something that requires an emergent workup. Because there’s also a possibility that the person may also have a concurrent PE. I’ve seen some asymptomatic patients with normal vitals with significant PEs.

But again, proper clinical judgement is key. That’s not the scenario above.

Why is DVT emergent? In most cases, there is literally nothing emergent to be done about it. Putting them on blood thinners will gradually allow them to dissolve the clot, but likely won't change PE risk in the first couple of days. DVT should be urgent outpatient evaluation, not an ER referral.

 

[WildEMDoc]

I’d consider DVTs, or the suspicion of one, based on PROPER clinical judgment, to be something that requires an emergent workup. Because there’s also a possibility that the person may also have a concurrent PE. I’ve seen some asymptomatic patients with normal vitals with significant PEs.

But again, proper clinical judgement is key. That’s not the scenario above.

I don't look for PE's in asymptomatic patients for a PE when I find a DVT because doing so changes nothing. They still go home on a DOAC. Never have seen a PE needing IR interventions asymptomatic.

A few ERs I have worked at in the past don't even have the ability to do DVT US at night. Its a lovenox shot and discharge for an outpatient US the PCP could have ordered anyway. I don't think delaying an US for <48hours in someone who walks and talks into the clinic is going to suddenly develop a massive PE.

 

[thegenius]

Why is DVT emergent? In most cases, there is literally nothing emergent to be done about it. Putting them on blood thinners will gradually allow them to dissolve the clot, but likely won't change PE risk in the first couple of days. DVT should be urgent outpatient evaluation, not an ER referral.

If you search online for "medical malpractice and DVT" you will find countless attorneys happy to represent patients who have had delayed DVT diagnoses or PE's as a result of a delay in diagnosis.

As long as this kind of thing overhangs the medical community, every single DVT study will be performed by ER docs nationwide. It's more work, but you'll make $150/chart and about 2-4% of the time will Rx a DOAC.

 

[TooMuchResearch]

Biggest recent pet peeve of these NPs is leg pains sent in for r/o DVT

Recently had one sent in for bilateral shin pain after mowing their lawn the day before, “acute onset bilateral pain, send to ER for EMERGENT blood clot rule out”. Exam normal. Literally had to spend in excess of 15min discussing why no ultrasound will be done.

Since when is DVT such a lights an sirens emergency and why do people think bilateral sudden DVTs from things like overuse are a thing?

This is one I don't fight. Sent in for DVT ultrasound? Order from triage.

Sent in for inappropriate whole body CT or MRi? Not doing that one.

 

[TooMuchResearch]

If you search online for "medical malpractice and DVT" you will find countless attorneys happy to represent patients who have had delayed DVT diagnoses or PE's as a result of a delay in diagnosis.

As long as this kind of thing overhangs the medical community, every single DVT study will be performed by ER docs nationwide. It's more work, but you'll make $150/chart and about 2-4% of the time will Rx a DOAC.

I think it's a waste of patient and system money, but I'll see these patients and order the non-emergent emergent ultrasound every time.

 

[TooMuchResearch]

With a smile on my face.

 

[TooMuchResearch]

https://media.tenor.com/94Hsw36edPsAAAAM/awkward-smile.gif