Neurology douchebag - Does white count really help with seizure work up?

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Hello friends,

I got into it with the Neurology resident over this. Some background, however: he is a known case of douchebag and almost always is extremely rude on the phone. So, I consulted his service for a patient with known history of seizures who came to us for breakthrough seizure. There were no s/s that would suggest infection. I ordered electrolytes and sent off anti-seizure drug levels. I consult his service and Dr. Douchebag calls back. I tell him about the patient and then he asks, "Did you get an infective work-up?" I replied, "There are no signs or symptoms of infection." He responded (here is the douchebag part), "I didn't ask about that. I asked, did you order an infective work-up, like a CBC?" I told him, "It's not part of our work-up, but I can definitely order it for you." Then, instead of being happy with my compromise, he starts lecturing me on seizure work-up and how CBC is mandatory, etc. And of course, he did it in a demeaning and douchebag way, as is his normal style. I told him, "White counts alone rarely change your management unless they are on the extremes..." But anyways, things escalated and I just said, "Listen, I'm not going to do this dance with you every time. Come see the patient, bye."

I've been taught by my Emergency Medicine faculty that CBC in seizure work-up is useless...even BMP is hardly useful since the patient would likely still be seizing actively if something was off, i.e. hyponatremia.

Anyways, what do you guys think? Any studies to back up the uselessness of CBC?

Don't get me wrong. In the community world, I might just prophylacticly order the CBC... I don't think it's a big deal. But, I get flack from attendings at my institution if I order it or other useless tests that consultants always want (even before they see the patient).

Thoughts?

(Funny thing is: I don't even care about this topic. I don't care if you order a CBC or not. It's just how much of a douchebag this douche is.)

 

[diphenyl]

If the patient was afebile, nothing in the CBC changes the management. I would however get one prior to admission just to dot the i's and cross the t's.

 

[Rendar5]

Why was neuro even consulted, to adjust meds?? This is why I like community medicine in some ways.

 

[RustedFox]

Neurology douchebag ?

Isn't that a touch redundant ?

 

[southerndoc]

Aren't all WBC's elevated with seizures? It's elevated because of a stress response/demargination just like trauma patients.

You can have intermittent seizures with hyponatremia. I've seen it a few times. In fact, I've only seen one status from hyponatremia (sodium was 108). I'm also curious how acidotic they are and get a general idea by the CO2 in their BMP. The lower the number, the longer they were seizing.

Perhaps you should've said "request denied, you have 30 minutes before I call your attending."

I'm thankful I work in a place where I don't have to argue every admission or consult.

 

[Rendar5]

Honestly I don't usually check any labs other than seizure drugs on my patients with established seizure histories who are A&Ox3 and no longer post-ictal when they get to me. I usually reserve labs for status epi's, altered pt's, and new onset pt's. Dunno, am I missing something?

 

[Birdstrike]

Hello friends,

I got into it with the Neurology resident over this. Some background, however: he is a known case of douchebag and almost always is extremely rude on the phone. So, I consulted his service for a patient with known history of seizures who came to us for breakthrough seizure. There were no s/s that would suggest infection. I ordered electrolytes and sent off anti-seizure drug levels. I consult his service and Dr. Douchebag calls back. I tell him about the patient and then he asks, "Did you get an infective work-up?" I replied, "There are no signs or symptoms of infection." He responded (here is the douchebag part), "I didn't ask about that. I asked, did you order an infective work-up, like a CBC?" I told him, "It's not part of our work-up, but I can definitely order it for you." Then, instead of being happy with my compromise, he starts lecturing me on seizure work-up and how CBC is mandatory, etc. And of course, he did it in a demeaning and douchebag way, as is his normal style. I told him, "White counts alone rarely change your management unless they are on the extremes..." But anyways, things escalated and I just said, "Listen, I'm not going to do this dance with you every time. Come see the patient, bye."

I've been taught by my Emergency Medicine faculty that CBC in seizure work-up is useless...even BMP is hardly useful since the patient would likely still be seizing actively if something was off, i.e. hyponatremia.

Anyways, what do you guys think? Any studies to back up the uselessness of CBC?

Don't get me wrong. In the community world, I might just prophylacticly order the CBC... I don't think it's a big deal. But, I get flack from attendings at my institution if I order it or other useless tests that consultants always want (even before they see the patient).

Thoughts?

(Funny thing is: I don't even care about this topic. I don't care if you order a CBC or not. It's just how much of a douchebag this douche is.)

This is the kind of petty BS in residency which makes you get the iPhone app that counts down the days to the end of residency:


https://itunes.apple.com/us/app/countdown-to-an-event/id363735527?mt=8

How dare you not roll out the red carpet and make the on-call residents life just a touch easier, as if that's your job?

Oye vey...

As times goes on, getting angry about this kind of BS will be replaced by staring through the person, and yawning, indifferently.

Even when you're an attending though, lots of consultants will want their arses kissed and for you to make their life easier.

This is where mastering the art of "making their life easier, to make my life easier" comes in to play. There is a fine line between that, and getting walked on.

You'll figure it out.

 

[WilcoWorld]

Status epilepticus patients without infection have a leukocytosis almost as often as not.

 

[jdh71]

While I don't condone condescending douchebag treatment, on the other side of the hospital ED, we start becoming interested not in what it most likely is, but also what it is not.

You may argue that a CBC and a BMP are usually not helpful in the diagnosis, but it helps your colleagues in the hospital know that is isn't something else complicating the picture.

We're going to order the labs. Once in the hospital we have to prove it's not something else, run through the possible differential, so it does help out your in patient colleagues to order the CBC and the basic lytes. I mean we don't have to prove it's not kuru, but the basic standard of care on our side will mean we'll need to make sure we're not dealing with an infective or electrolyte abnormality.

The patient has seizures, you're going to admit them, you have your dispo . . . I mean it shouldn't kill you to order a few more labs between the time the admitting comes to see the patient and the time the patient leaves the ED if asked to.

 

[Rendar5]

While I understand that point too and will happily order requested tests that the inpatient team will use, this doesn't sound at this point like something that is being admitted, just being consulted on, possibly with simply a question of whether a seizure med change is warranated. But I'm also not sure how a normal WBC is any more useful than a high WBC. I've seen plenty of infections require admission with a normal one, including people in septic shock (though I agree that is uncommon). That said, I still order CBC and BMP on all patients being admitted, just cause people look at me weirdly if I don't. If I think I'm going to d/c them, then I only order what I feel is necessary to make a decision and a little extra if I feel that there may be a CYA issue.

 

[jdh71]

While I understand that point too and will happily order requested tests that the inpatient team will use, this doesn't sound at this point like something that is being admitted, just being consulted on, possibly with simply a question of whether a seizure med change is warranated. But I'm also not sure how a normal WBC is any more useful than a high WBC. I've seen plenty of infections require admission with a normal one, including people in septic shock (though I agree that is uncommon). That said, I still order CBC and BMP on all patients being admitted, just cause people look at me weirdly if I don't. If I think I'm going to d/c them, then I only order what I feel is necessary to make a decision and a little extra if I feel that there may be a CYA issue.

Well, even if all you are asking for is the consult, there is all the more reason to get the information that the consultant wants cooking. If the patient is liky to go home and you're waiting for the consult opinion and the consult final opinion hinges on more information and part of that information is a CBC you're just messin with your own dispo now.

 

[Birdstrike]

Now that I think of it, why did you consult neuro for a simple seizure in the first place?

 

[EM2BE]

If I have a pt with known seizure history, typical breakthrough seizure, I accucheck. No other labs unless I get from them something else has been going on. I of course get medication levels if warranted as well. Discharge with instructions to follow up with their neurologist for medication adjustment if needed. If they had several seizures throughout the day, then it's a different conversation.

People with epilepsy seize. Nothing new there.

 

[Xerxes1729]

This is where mastering the art of "making their life easier, to make my life easier" comes in to play. There is a fine line between that, and getting walked on.

You'll figure it out.

One of my seniors told me I'm too nice to consultants, but I generally try to anticipate what test they'll want and order them, even if they're clearly useless (really? you need a urine tox to figure out that the 75yo hypertensive diabetic's hemiparesis, neglect, and aphasia aren't being caused by opiates or cannabis?). By doing things to help them that I think are stupid, I like to think they're a little more willing to help me with things that they think are stupid. Your experience may vary, but it works for me.

 

[Hercules]

Now that I think of it, why did you consult neuro for a simple seizure in the first place?

+1. Your neurology resident may have been giving you some behavioral conditioning. If you consult him unnecessarily he may be ordering labs to drag out your work up and discourage future consults.

 

[Birdstrike]

One of my seniors told me I'm too nice to consultants, but I generally try to anticipate what test they'll want and order them, even if they're clearly useless (really? you need a urine tox to figure out that the 75yo hypertensive diabetic's hemiparesis, neglect, and aphasia aren't being caused by opiates or cannabis?). By doing things to help them that I think are stupid, I like to think they're a little more willing to help me with things that they think are stupid. Your experience may vary, but it works for me.

I agree. You have to play "the game" to a certain extent to make your life easier.

 

[Birdstrike]

This thread reminds me of a time when I was a resident (a long time ago, in a galaxy far, far, away), and I consulted Peds surgery for a kid we thought had an appy.

In this case, he got on my case because I did order a CBC, and started lecturing me on how useless CBCs are in an appy work up, and how stupid it is to order one; that it's a useless knee jerk order. Finally he gets off his soap box and asks, "Why did you order it?"

I told him, for one reason and one reason only, "Because the surgeons always want it."

He didn't like that too much, but it was true.

 

[BJJVP]

Well, even if all you are asking for is the consult, there is all the more reason to get the information that the consultant wants cooking. If the patient is liky to go home and you're waiting for the consult opinion and the consult final opinion hinges on more information and part of that information is a CBC you're just messin with your own dispo now.

I could be wrong but it doesn't sound like getting the CBC was much of an issue. I think the real problem was the Neuro residents attitude. There are ways of asking for things without provoking another colleague. "Could you get a CBC and I'll see the pt when I get a chance," is a lot different than, "You didn't even check him for infection? I am not seeing the pt until you do your job better and get a CBC!" ED guys have to have thick skin but at some point, esp in this work environment, you are gonna have a weak moment and then respond in a manner not conducive to good pt care.

That said, I don't think you routinely need any labs for sz's that have returned to baseline other than levels. But, I will order a CBC/BMP just so I don't run into the OPs exact situation in case the pt seizes again or something happens that warrants an admission.

I'm also wondering why the consult?

 

[UnderwaterDoc]

This is the kind of petty BS in residency which makes you get the iPhone app that counts down the days to the end of residency:

Sooooo true, 414 days!

 

[jdh71]

I could be wrong but it doesn't sound like getting the CBC was much of an issue. I think the real problem was the Neuro residents attitude. There are ways of asking for things without provoking another colleague. "Could you get a CBC and I'll see the pt when I get a chance," is a lot different than, "You didn't even check him for infection? I am not seeing the pt until you do your job better and get a CBC!" ED guys have to have thick skin but at some point, esp in this work environment, you are gonna have a weak moment and then respond in a manner not conducive to good pt care.

That said, I don't think you routinely need any labs for sz's that have returned to baseline other than levels. But, I will order a CBC/BMP just so I don't run into the OPs exact situation in case the pt seizes again or something happens that warrants an admission.

I'm also wondering why the consult?

Oh I get that the attitude puts your teeth on edge but if your consultant asks for something, my point was why not get if. If you admit a seizure to my MICU I'm going to want a CBC. All I'm saying is that perhaps it's ED practice to not need one but its not going to be the same practice of lots of your consultants. I guess I'm more responding to the notion of asking for an opinion and then not wanting to do what the guy you asked for the opinion wants. As a consultant when this occurs I find myself a bit confused. Why bother me in the first place if you think you already know everything you need to know?

 

[BJJVP]

Oh I get that the attitude puts your teeth on edge but if your consultant asks for something, my point was why not get if. If you admit a seizure to my MICU I'm going to want a CBC. All I'm saying is that perhaps it's ED practice to not need one but its not going to be the same practice of lots of your consultants. I guess I'm more responding to the notion of asking for an opinion and then not wanting to do what the guy you asked for the opinion wants. As a consultant when this occurs I find myself a bit confused. Why bother me in the first place if you think you already know everything you need to know?

I work in a community hospital and in this setting, I completely agree with you.

I do feel that in the academic setting, things are not always as straight foward. I think the more inexperienced residents can go overboard with their requests. Sometimes they don't realize that we are consulting their attending, and not them. Also, a lot of times, a "consult" is really a request to admit.

Having said that, in the OPs case, I would have no problem ordering a CBC. But, I can see how a stressed out, overworked, tired, and possibly inexperienced EM resident would refuse to do so if asked in a condescending, critical manner.

 

[gman33]

generally i'm very nice and will order pretty much anything the consultant wants.
it's not really much of a problem for me.

I guess I have an issue when I think the requests are stall tactics or things that are just looking for a reason to admit to another service.

Even if I don't agree with the tests and think they are worthless, some other service is going to be taking care of the patient.

 

[gman33]

This thread reminds me of a time when I was a resident (a long time ago, in a galaxy far, far, away), and I consulted Peds surgery for a kid we thought had an appy.

In this case, he got on my case because I did order a CBC, and started lecturing me on how useless CBCs are in an appy work up, and how stupid it is to order one; that it's a useless knee jerk order. Finally he gets off his soap box and asks, "Why did you order it?"

I told him, for one reason and one reason only, "Because the surgeons always want it."

He didn't like that too much, but it was true.

Love it.

 

[Apollyon]

Neurology douchebag ?

Isn't that a touch redundant ?

I can't pain the whole specialty with one brush - I guess I've said this a few times before now. One guy might be a douche, but I don't know that I would extrapolate that.

As to the OP, I used to argue, and, one day, an attending said, "Tell them, 'whatever you want'." I started doing that, and it got infinitely easier. You want a ceruloplasmin? Sure, I'll order it. CT the chest? Why not?

It doesn't change my dispo, and it is the path of least resistance.

 

[RustedFox]

I can't pain the whole specialty with one brush - I guess I've said this a few times before now. One guy might be a douche, but I don't know that I would extrapolate that.

As to the OP, I used to argue, and, one day, an attending said, "Tell them, 'whatever you want'." I started doing that, and it got infinitely easier. You want a ceruloplasmin? Sure, I'll order it. CT the chest? Why not?

It doesn't change my dispo, and it is the path of least resistance.

Just stirrin' the pot, man. You of all people should know. 🙂

 

[RustedFox]

besides, you think WE'RE not emm-eff'ed in every other forum on this gig ?

I mean, we already are in RL.

 

[emergentmd]

This is a battle not working. If you are asking a service to consult/admit, and they request a lab test then just do it for the most part.

When I admit a person where I work, Everyone gets a CBC, Chem, EKG, CXR, UA. I order all of this if I know someone will be admitted unless its the most straight forward reason. But I would say 90% medicine admits get this.

What you should do and what is done in practice is different. Learn this and your job will be less stressful.

Or if you want to look at it this way, more labs may increase you billing.

 

[Tiger26]

This is a battle not working. If you are asking a service to consult/admit, and they request a lab test then just do it for the most part.

When I admit a person where I work, Everyone gets a CBC, Chem, EKG, CXR, UA. I order all of this if I know someone will be admitted unless its the most straight forward reason. But I would say 90% medicine admits get this.

What you should do and what is done in practice is different. Learn this and your job will be less stressful.

Or if you want to look at it this way, more labs may increase you billing.

Like others said, this is pretty much what we do, as they're going to be taking care of them. If it's completely unreasonable and won't change immediate management, I'll ask to defer some tests though (like carotid ultrasounds) to be done on the floor.

On a slightly unrelated note, if you're having difficulty with consulting services when they're down in the ED, try to shake hands with them when they come down. It sounds kind of hokey, but most of them just melt in front of you from a state of confrontation to that of being willing to work with you. Learned this one from Jim Adams and it's made a lot of shifts more pleasant.

 

[Apollyon]

besides, you think WE'RE not emm-eff'ed in every other forum on this gig ?

I mean, we already are in RL.

Hell, I've said that many a time - no thread on SDN is complete without throwing EM under the bus. (And I write this at 0435 while working.)

 

[jdh71]

To be fair, bitchin' about the ED as on the same level as complaining about the food in the cafeteria. I don't think it's personal.

 

[The White Coat Investor]

To be fair, bitchin' about the ED as on the same level as complaining about the food in the cafeteria. I don't think it's personal.

No, but I didn't have to look at your sig to see you're still in training. I pass around the money at my community hospital. "Thank you for the appy, may I have another?" says the surgeon. "Thank you for the fracture, may I have another? " says the Orthopod. "Thank you for the seizure patient. As much as I hate it when you call me at midnight, thanks for never making me come in and for the 3 other patients you sent to follow-up with me without ever calling me in the middle of the night about them," says the neurologist.

Our two neurologists are awesome. Super nice. But I can't recall ever dragging them out of bed to come in. That just doesn't happen much in the community. Now that poor GI guy, he comes in every night at midnight to pull that steak out of someone's esophagus.

 

[jdh71]

No, but I didn't have to look at your sig to see you're still in training. I pass around the money at my community hospital. "Thank you for the appy, may I have another?" says the surgeon. "Thank you for the fracture, may I have another? " says the Orthopod. "Thank you for the seizure patient. As much as I hate it when you call me at midnight, thanks for never making me come in and for the 3 other patients you sent to follow-up with me without ever calling me in the middle of the night about them," says the neurologist.

Our two neurologists are awesome. Super nice. But I can't recall ever dragging them out of bed to come in. That just doesn't happen much in the community. Now that poor GI guy, he comes in every night at midnight to pull that steak out of someone's esophagus.

What does me still being training have to anything to do with it? If you're going to pull the "attending card", it's not really going to phase me much when I actually have more formal training than anyone who only did a single residency in either a three or four year EM program. So you'll have to pardon me if I'm not impressed - won't even bother to cover my mouth or turn my head when I yawn - when some of you guys try and flex the "attending nuts" around here.

Don't hurt your shoulder patting yourself on the back too hard being the first doc to see something that the rest of us will eventually take care of. You didn't pass any money to the surgeon, the appendix did.

It was joke. I get along with my EM colleagues and much of that is because I think I have more in common with them than probably any other specialty. So lighten the **** up. You don't have to take offense, but it's a free country (ostensibly), so you can do what you want. 🙂

 

[The White Coat Investor]

What does me still being training have to anything to do with it? If you're going to pull the "attending card", it's not really going to phase me much when I actually have more formal training than anyone who only did a single residency in either a three or four year EM program. So you'll have to pardon me if I'm not impressed - won't even bother to cover my mouth or turn my head when I yawn - when some of you guys try and flex the "attending nuts" around here.

Don't hurt your shoulder patting yourself on the back too hard being the first doc to see something that the rest of us will eventually take care of. You didn't pass any money to the surgeon, the appendix did.

It was joke. I get along with my EM colleagues and much of that is because I think I have more in common with them than probably any other specialty. So lighten the **** up. You don't have to take offense, but it's a free country (ostensibly), so you can do what you want. 🙂

It doesn't have to do with the fact you're in training so much as the fact that you're salaried and surrounded by salaried docs. It was the same in the military and in an academic center as an attending. That's all. Relax.

When everyone is salaried the ED passes out work. When everyone is fee for service they pass out money.

 

[Birdstrike]

some of you guys try and flex the "attending nuts" around here.

[begin visual]

"Attending nuts" being flexed...

[/end visual]

 

[jdh71]

It doesn't have to do with the fact you're in training so much as the fact that you're salaried and surrounded by salaried docs. It was the same in the military and in an academic center as an attending. That's all. Relax.

When everyone is salaried the ED passes out work. When everyone is fee for service they pass out money.

roger that

 

[WilcoWorld]

[begin visual]

"Attending nuts" being flexed...

[/end visual]

Yeah, but is torsion ruled out?

 

[WilcoWorld]

...

 

[TysonCook]

I don't do too many "routine" labs. When confronted, I ask what the end point would be and how it would change with that test, and if a reasonable discussion ensues, then either one of us orders it.

Another article from our press, worth a skim:
Inadequacy of temperature and white blood cell count in predicting bacteremia in patients with suspected infection
http://www.ncbi.nlm.nih.gov/pubmed/20674238

Using WBC count as a "screen" for infection is foolhardy, and wasteful. There are a multitude of reasons for a leukocytosis, including seizures (or anything stressful for that reason). Lastly, what would be your cutoff for acting on an elevated WBC? 13k, 25k, 2k, left shift, no left shift, etc.

If you are sending a multitude of studies on every patient every time, do not be surprised when your CFO comes to you asking why, or denies your requests for additional staffing as you're costing the hospital "too much" - this includes "labs requested" as the ordering MD is the one responsible for the charge.

 

[gro2001]

To quote a brilliant old timer: "The serum white count is the last resort of the intellectually destitute."

It has 2 genuine uses in the ER:
1) to diagnose neutropenia.
2) to diagnose acute leukemia.

 

[jdh71]

White count is a part of the SIRS criteria and apacheII calculations . . .

It also does tend to go up with infections and come down with appropriate treatment. I suppose perhaps I can appreciate that it's not all that helpful merely in the ED, but it has plenty of clinical utility as a marker of something needing more investigation.

 

[deleted109597]

It also does tend to go up with infections and come down with appropriate treatment. I suppose perhaps I can appreciate that it's not all that helpful merely in the ED, but it has plenty of clinical utility as a marker of something needing more investigation.

Wait, are you talking about ESR? CRP? Procalcitonin? Because there are a ton of things that tend up with infections and down with treatment.
CBC is one of those. Band count might be a little better, but I only get one about 25% of the time (not sure if they don't report "normal", or don't check, or what).

Either way, it's of almost zero use, in the seizure patient, immediately post seizure, with known seizure disorder. Just like in the trauma patient.

 

[TysonCook]

Association... I 100% agree that there are times when we can use a WBC in our workups, but to say that in a post-ictal epileptic patient, a WBC of X, would lead me down an ID workup is probably going to put more epileptics in the way of harm than good. I appreciate apache as much as the next MD, but a CR of 1.5 has twice the value of a WBC of 19k in scoring. The utility of apache in the ED has been evaluated several times, and it's utility as an *admission to the ICU* score is where it's validated (and conflicting articles at that).

I don't argue with SIRS, but remember that SIRS does not = infection. It is a sign of an inflammatory state. What the etiology of the occurring inflammation is not defined by a lab test, but an accurate history and physical.

On a completely separate topic... I personally would NEVER refer to ANY of my consultants as a D-Bag. You can throw as much evidence based medicine in their face, but if you don't show personal respect, than you will never earn respect. Just have a moment of introspection, and think prior to getting worked up with a consultant. Your best friend is being collegial, friendly, and helpful with your consultants. They will be much more receptive to your thoughts, and it will be much more of a "team" workup.

 

[TysonCook]

...why not add on the CG4 with Lactate for that matter...

 

[la gringa]

holy cow, i bet if i got a WBC + lactate on all of my seizing pts on arrival and factor in HR, they all meet SIRS criteria and need a sepsis eval! (not)

Tyson - try keeping cool when the same (insert generic hospitalist group we know well here) physician repeatedly is rude to you, insults your intelligence, and is pretty much a bully. discharges patients behind your back. screams on the phone so loud the nurses can hear it. d-bag becomes appropriate, but only behind his back (be glad he isn't at the mothership).

 

[jdh71]

Wait, are you talking about ESR? CRP? Procalcitonin? Because there are a ton of things that tend up with infections and down with treatment.
CBC is one of those. Band count might be a little better, but I only get one about 25% of the time (not sure if they don't report "normal", or don't check, or what).

Either way, it's of almost zero use, in the seizure patient, immediately post seizure, with known seizure disorder. Just like in the trauma patient.

I don't know . . . You talk to the ID guys, and following ESR, CRPs, and procalcitonin has gone out of favor.

It could be of zero use and it might not be of zero use. Would also be nice to know if the number 100 or 0.1. You don't know until you draw the lab.

My point here is that there is plenty of clinical utility of the CBC from my point of view, and I'm actually finding the whole idea that the CBC isn't a bit ironic when, while the ED might be the place where these guys show up, it definitely isn't the place where the seizure patient is more than acutely treated, and the doctors who actually manage seizure outside the ED might actually have a professional opinion on the matter that is completely valid from their perspective. Through some of the thread there has been some complaining about being "emm effed" and then after that I see plenty going on to "emm eff" the neurology expert's opinion. Heh. No one can get any respect in medicine.

 

[jdh71]

Association... I 100% agree that there are times when we can use a WBC in our workups, but to say that in a post-ictal epileptic patient, a WBC of X, would lead me down an ID workup is probably going to put more epileptics in the way of harm than good. I appreciate apache as much as the next MD, but a CR of 1.5 has twice the value of a WBC of 19k in scoring. The utility of apache in the ED has been evaluated several times, and it's utility as an *admission to the ICU* score is where it's validated (and conflicting articles at that).

I don't argue with SIRS, but remember that SIRS does not = infection. It is a sign of an inflammatory state. What the etiology of the occurring inflammation is not defined by a lab test, but an accurate history and physical.

It does all have to be taken together, doesn't? 🙂 Every piece of information is important including . . . the CBC. Heh.

I'd quibble about the etiology of of inflammation not defined by a lab test. Your etiology is almost always defined by your ultimate culture data, and at least in the case of inflammatory pulmonary disorders often on the basis of rheum markers or even final pathology opinion following a VATS. You almost never have a specific diagnosis of any inflammation outside of the the lab.

On a completely separate topic... I personally would NEVER refer to ANY of my consultants as a D-Bag. You can throw as much evidence based medicine in their face, but if you don't show personal respect, than you will never earn respect. Just have a moment of introspection, and think prior to getting worked up with a consultant. Your best friend is being collegial, friendly, and helpful with your consultants. They will be much more receptive to your thoughts, and it will be much more of a "team" workup.

A little bit of respect goes a long way in many walks of life . . .

 

[deleted109597]

I don't know . . . You talk to the ID guys, and following ESR, CRPs, and procalcitonin has gone out of favor.

Eh, the ortho and pulm guys here either don't read or don't care. I wouldn't order many of those if other people didn't request them.

It could be of zero use and it might not be of zero use. Would also be nice to know if the number 100 or 0.1. You don't know until you draw the lab.f

You're so right. In fact, we should probably check those on every single person. Daily. Otherwise we won't know.

 

[jdh71]

You're so right. In fact, we should probably check those on every single person. Daily. Otherwise we won't know.

Now you're just making a sarcastic strawman argument. I'm not telling you what you should or should not do in the ED to deal with your side of the equation - I can appreciate the point some of you are making, but to the thinking of many other physicians, most of whom are not "mickey mouse" simply because they didn't do an EM training, but rather experts in their own right, think that if you have a patient who is sick enough to show up in an ED (an ultimately be admitted) that at the very minimum an initial CBC is helpful for the entire context of the case. Something ACUTE happened, and you'd like to get to the bottom of why the acute things happened, then information is helpful - ask yourself if you'd like me taking care of your mother or your child without ever looking at a CBC following an acute change in their status from baseline, including seizure. Common things are common, but "looks like a duck, quacks like a duck, it's most likely a duck" is not simply enough from the perspective of many of us. Different styles of practice depending on where you approaching the case from doesn't seem too provocative an assessment to make.

 

[deleted109597]

Now you're just making a sarcastic strawman argument.

Nah, I'm just taking it to the absurd end.

I'm not telling you what you should or should not do in the ED to deal with your side of the equation -

The whole point of the thread is that they are telling the ED what to do, often with the BS "we won't consult until XYZ is done.

Something ACUTE happened, and you'd like to get to the bottom of why the acute things happened, then information is helpful - ask yourself if you'd like me taking care of your mother or your child without ever looking at a CBC following an acute change in their status from baseline, including seizure.

Patients with seizure disorders have seizures at baseline. This isn't terribly abnormal to us. Now, if they're having status, or something concerning, I can at least acquiesce to the concern.

Common things are common, but "looks like a duck, quacks like a duck, it's most likely a duck" is not simply enough from the perspective of many of us. Different styles of practice depending on where you approaching the case from doesn't seem too provocative an assessment to make.

EDs don't (or shouldn't) always treat common things as common. Hoofbeats mean horses upstairs, not zebras. In the ED, they're unicorns. Because they're magical, rare, and can kill. Our mindset is always a)what can kill, b)can they go home. And truthfully, I don't care what the upstairs doc wants to order once it's their patient. Sure, the CBC might be helpful to them. So might an MRI, a HIDA, and b12 levels. And they are completely allowed to order the tests they want. You can even ask me to. Just don't berate me when I disagree. I don't consult surgery to operate. I consult to evaluate the patient. They choose to operate.

 

[jdh71]

The whole point of the thread is that they are telling the ED what to do, often with the BS "we won't consult until XYZ is done.

Not really. They were telling the ED what they'd like for their consult. If the ED didn't have any questions and had this handled, why consult in the first place? Hmm?

I don't consult surgery to operate. I consult to evaluate the patient. They choose to operate.

Right. You consult to get an expert opinion above and beyond your own and when that opinion asks for an additional test, maybe . . . just maybe . . . they are thinking of something you are not. 😉

Like I said, if you got it handled hoss, don't bother me. It's good to know we've got quality dealing with shiz in the ED. 🙂