Ovarian cyst rupture case - thoughts?

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I am an ER PA and had an ovarian cyst rupture case that concerned me. I can’t find a ton of literature on life threatening hemorrhage associated with this so I wanted to get some opinions. A few weeks ago I had a 30 year old female come in with an acute onset of abdominal and chest pain radiating into the shoulders, pleuritic in nature. When I saw her she was tachycardic (120), pale, diaphoretic, moaning. I barely grazed her abdomen and she screamed, guarded, and seemed near syncopal. The presentation gave me chills. I immediately told my attending, got her rushed to CT, notified radiologist to start looking for her scan, started fluids, hydromorphone, and cardiac monitoring. EKG confirmed sinus tachycardia. I CTed her chest (angiogram), abdomen and pelvis. While waiting for CT she passed out on a walk to the bathroom. CT showed free fluid in the pelvis and upper abdomen that looked like hemorrhage. Radiologist said ovarian cyst rupture most likely. Called GYN, she was in disbelief that all this blood could be from a cyst... she said “it could be from the stomach” (no free air noted on the CT) and asked for a pelvic US. Consulted surgery, they said this definitely sounded like an ovarian cyst and advised continued consultation with GYN. US confirmed a ruptured ovarian cyst with lots of likely blood in the pelvis. Good flow to ovaries. The patient’s hemoglobin dropped from 12.5 to 9.0 in two hours (I know serial H and H are sometimes not useful, however). She continued to be very tender. Called GYN, they evaluated her and said she was no longer tender (“her abdomen was benign” and wanted to go home. (?!) this surprised me because on six or seven abdominal examinations including one 15 minutes prior the patient was wincing, guarding, crying out. OB said this was typical of ovarian cysts. When I went back in the room she said she felt better and wanted to go home and eat food, and she was definitely tender. Still guarding and wincing/moaning when I pressed anywhere on her belly. Told GYN I was still concerned... brought her and my attending back in the room to show her my patient was still wincing in pain, GYN said if the patient didn’t want to stay she could go home. So did attending. I said I was concerned about the initial tachycardia, syncope in the department and continued peritoneal type tenderness despite multiple doses of narcotics, and that I was also concerned of continued bleeding. GYN laughed, said they all present this way and then they all the sudden look great. For the first time ever in my PA career I didn’t just listen to the attending and specialist (I know I know) and went back in the room and really tried to get the patient to stay just for observation. I did not yet feel comfortable sending her home. She continued to decline, saying she wanted to go and eat (usually a positive sign). I discharged her with strict return precautions and Percocet. On the way out she nearly passed out from severe recurrence of pain and vomited all over. Then asked to be admitted. I called GYN back and they were PISSED and basically said “this could have been prevented” although she wouldn’t clarify when asked what she meant.

When I went home and read up on this (surprisingly my usual Pepid, EMRAP, Medscape and Tintinalli don’t have as much info as I would like though) lead me to believe that significant life threatening hemorrhage from a ruptured ovarian cyst is uncommon, and that patients do often present like they’re dying with acute surgical abdomens like in this case. Question is, was I right to advocate for admission or was the OBGYN correct in this case? I only know a small fraction of what OBGYN and my ER attending know - they are physicians after all - but this is one of those cases that didn’t settle right in my gut.

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I am an ER PA and had an ovarian cyst rupture case that concerned me. I can’t find a ton of literature on life threatening hemorrhage associated with this so I wanted to get some opinions. A few weeks ago I had a 30 year old female come in with an acute onset of abdominal and chest pain radiating into the shoulders, pleuritic in nature. When I saw her she was tachycardic (120), pale, diaphoretic, moaning. I barely grazed her abdomen and she screamed, guarded, and seemed near syncopal. The presentation gave me chills. I immediately told my attending, got her rushed to CT, notified radiologist to start looking for her scan, started fluids, hydromorphone, and cardiac monitoring. EKG confirmed sinus tachycardia. I CTed her chest (angiogram), abdomen and pelvis. While waiting for CT she passed out on a walk to the bathroom. CT showed free fluid in the pelvis and upper abdomen that looked like hemorrhage. Radiologist said ovarian cyst rupture most likely. Called GYN, she was in disbelief that all this blood could be from a cyst... she said “it could be from the stomach” (no free air noted on the CT) and asked for a pelvic US. Consulted surgery, they said this definitely sounded like an ovarian cyst and advised continued consultation with GYN. US confirmed a ruptured ovarian cyst with lots of likely blood in the pelvis. Good flow to ovaries. The patient’s hemoglobin dropped from 12.5 to 9.0 in two hours (I know serial H and H are sometimes not useful, however). She continued to be very tender. Called GYN, they evaluated her and said she was no longer tender (“her abdomen was benign” and wanted to go home. (?!) this surprised me because on six or seven abdominal examinations including one 15 minutes prior the patient was wincing, guarding, crying out. OB said this was typical of ovarian cysts. When I went back in the room she said she felt better and wanted to go home and eat food, and she was definitely tender. Still guarding and wincing/moaning when I pressed anywhere on her belly. Told GYN I was still concerned... brought her and my attending back in the room to show her my patient was still wincing in pain, GYN said if the patient didn’t want to stay she could go home. So did attending. I said I was concerned about the initial tachycardia, syncope in the department and continued peritoneal type tenderness despite multiple doses of narcotics, and that I was also concerned of continued bleeding. GYN laughed, said they all present this way and then they all the sudden look great. For the first time ever in my PA career I didn’t just listen to the attending and specialist (I know I know) and went back in the room and really tried to get the patient to stay just for observation. I did not yet feel comfortable sending her home. She continued to decline, saying she wanted to go and eat (usually a positive sign). I discharged her with strict return precautions and Percocet. On the way out she nearly passed out from severe recurrence of pain and vomited all over. Then asked to be admitted. I called GYN back and they were PISSED and basically said “this could have been prevented” although she wouldn’t clarify when asked what she meant.

When I went home and read up on this (surprisingly my usual Pepid, EMRAP, Medscape and Tintinalli don’t have as much info as I would like though) lead me to believe that significant life threatening hemorrhage from a ruptured ovarian cyst is uncommon, and that patients do often present like they’re dying with acute surgical abdomens like in this case. Question is, was I right to advocate for admission or was the OBGYN correct in this case? I only know a small fraction of what OBGYN and my ER attending know - they are physicians after all - but this is one of those cases that didn’t settle right in my gut.

I think you did everything right, up until you argued for something that neither the patient nor the consultant wanted.

At that point, I would have said something like "Thanks for coming to see the patient. I'm glad that you feel the patient has improved enough to be safe for discharge. I'd just like to make sure she can ambulate and tolerate PO before sending her out. Sound reasonable?" Then, if the patient fails her discharge trial, the consultant would likely have been more amenable. As it played out in your case, GYN probably felt like you scared the patient into the admission, even though it's clear to me that you were simply trying to do what you thought was best for the patient.
 
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When I went home and read up on this (surprisingly my usual Pepid, EMRAP, Medscape and Tintinalli don’t have as much info as I would like though) lead me to believe that significant life threatening hemorrhage from a ruptured ovarian cyst is uncommon, and that patients do often present like they’re dying with acute surgical abdomens like in this case. Question is, was I right to advocate for admission or was the OBGYN correct in this case? I only know a small fraction of what OBGYN and my ER attending know - they are physicians after all - but this is one of those cases that didn’t settle right in my gut.
Hell yes, you were right to advocate for admission in this case. Although you say you only "know a small fraction of what OB/GYN and your ER attending know," apparently you know how to diagnose obvious impending death from hemorrhagic shock, unlike them. Pat yourself on the back, you did a great job. Good job sticking to your guns, and continue to do so in the future, when your instincts speak to you.
 
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I am an ER PA and had an ovarian cyst rupture case that concerned me. I can’t find a ton of literature on life threatening hemorrhage associated with this so I wanted to get some opinions. A few weeks ago I had a 30 year old female come in with an acute onset of abdominal and chest pain radiating into the shoulders, pleuritic in nature. When I saw her she was tachycardic (120), pale, diaphoretic, moaning. I barely grazed her abdomen and she screamed, guarded, and seemed near syncopal. The presentation gave me chills. I immediately told my attending, got her rushed to CT, notified radiologist to start looking for her scan, started fluids, hydromorphone, and cardiac monitoring. EKG confirmed sinus tachycardia. I CTed her chest (angiogram), abdomen and pelvis. While waiting for CT she passed out on a walk to the bathroom. CT showed free fluid in the pelvis and upper abdomen that looked like hemorrhage. Radiologist said ovarian cyst rupture most likely. Called GYN, she was in disbelief that all this blood could be from a cyst... she said “it could be from the stomach” (no free air noted on the CT) and asked for a pelvic US. Consulted surgery, they said this definitely sounded like an ovarian cyst and advised continued consultation with GYN. US confirmed a ruptured ovarian cyst with lots of likely blood in the pelvis. Good flow to ovaries. The patient’s hemoglobin dropped from 12.5 to 9.0 in two hours (I know serial H and H are sometimes not useful, however). She continued to be very tender. Called GYN, they evaluated her and said she was no longer tender (“her abdomen was benign” and wanted to go home. (?!) this surprised me because on six or seven abdominal examinations including one 15 minutes prior the patient was wincing, guarding, crying out. OB said this was typical of ovarian cysts. When I went back in the room she said she felt better and wanted to go home and eat food, and she was definitely tender. Still guarding and wincing/moaning when I pressed anywhere on her belly. Told GYN I was still concerned... brought her and my attending back in the room to show her my patient was still wincing in pain, GYN said if the patient didn’t want to stay she could go home. So did attending. I said I was concerned about the initial tachycardia, syncope in the department and continued peritoneal type tenderness despite multiple doses of narcotics, and that I was also concerned of continued bleeding. GYN laughed, said they all present this way and then they all the sudden look great. For the first time ever in my PA career I didn’t just listen to the attending and specialist (I know I know) and went back in the room and really tried to get the patient to stay just for observation. I did not yet feel comfortable sending her home. She continued to decline, saying she wanted to go and eat (usually a positive sign). I discharged her with strict return precautions and Percocet. On the way out she nearly passed out from severe recurrence of pain and vomited all over. Then asked to be admitted. I called GYN back and they were PISSED and basically said “this could have been prevented” although she wouldn’t clarify when asked what she meant.

When I went home and read up on this (surprisingly my usual Pepid, EMRAP, Medscape and Tintinalli don’t have as much info as I would like though) lead me to believe that significant life threatening hemorrhage from a ruptured ovarian cyst is uncommon, and that patients do often present like they’re dying with acute surgical abdomens like in this case. Question is, was I right to advocate for admission or was the OBGYN correct in this case? I only know a small fraction of what OBGYN and my ER attending know - they are physicians after all - but this is one of those cases that didn’t settle right in my gut.

Funny you mention this. I had rather similar case taking care of a local medical student about 2-3 months ago (first termer, what a way to start).
Looked BAD, ended up being a big nothing but a bad-ass ovarian cyst.
What happened with the course of hospitalization? I too, would have obs'ed her for a bit.
 
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Thank you guys for your responses. So here’s the thing… The gynecologist kept telling me that “the patient doesn’t want to be admitted” but she was more “offering admission” more than anything which drives me nuts. If you think the patient might need to be admitted to the hospital, you have to explain to them why. I hate when I see in the charts that admission was offered, like it is some sort of option on the menu. That doesn’t offer protection for you at all if the patient goes home and croaks. They need to understand why you offer admission, the risk and benefits of staying and going home, and they need to demonstrate adequate decision-making capacity. And all of that has to be documented. This was never done by the ER attending or OBGYN. So I felt I owed it to the patient to explain to her why was offered her in the first place so that she could make in informed decision. All I said was: Look, I understand you are feeling a little bit better now and the specialist came to see you and said you want to go home. I’m glad you’re feeling better. You have some pretty significant bleeding from this ruptured cyst, and the risk is that you could continue to bleed if you go home. I think admission to the hospital just to watch you overnight is reasonable, but if you want to go home that it is OK by the specialist, as long as you understand the risks.” She said she wished to go home because she “felt like eating” ... Then she changed her mind when she stood up and vomited everywhere and nearly passed out again.

Thank you guys for your responses. This is the first time ever as a PA that I did not feel comfortable sending home a patient that was evaluated by both my attending and a specialist. I was really, truly worried about her, even if just from the pain control standpoint. But there are obviously some other concerning variables going on.
 
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In my 10 years of practice, I've never seen a ruptured ovarian cyst that caused hemoperitoneum, hemorrhagic shock, and a trip to the OR... until this year. Saw two cases in spring. One came in by EMS with a BP of 60 and another tanked her pressure after getting back from ultrasound. Both had positive FAST exams.

Think about it: the ovary is a vascular structure. If a ruptured ectopic can cause you to bleed to death, so can a ruptured hemorrhagic cyst. It's not that common. I probably won't see another case for 10 more years.
 
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Simple vs complicated hemorrhagic cyst rupture. This one is obviously complicated. Yes, these can bleed quite briskly and on occassion require a trip to the OR, cystectomy and even oophorectomy. It's uncommon, but not uncommon enough that I haven't had a few cases over the years. In my experience, it's really a 50/50 crap shoot on how Gyn handles these depending on the surgeon. Obs with serial crits until the bleeding stops with early surgery if VS become unstable or if HCT continues to drop is not unreasonable and usually what I push for given an exam like you describe. On occassion I will have a new surgeon that rushes these to the OR and usually ends up with cystectomy or the entire ovary taken out with the belly washed out. If you obs most of these the bleeding actually does stop though it takes weeks for the hemoperitoneum to resolve and they will obviously have technical peritoneal signs. I think your management sounds solid and you were just trying to take care of the pt and had every right to be alarmed.

Don't sweat it, it's not like you're going to get peer reviewed for not sending the hemoperitoneum pt home fast enough. How dare you! ;)
 
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I have also seen exactly one of these, but I'll never forget it. Presented like a ruptured ectopic, 80/40, syncopized, belly full of blood. Got the preg back and was neg which threw us, but went to the OR anyway due to her crappy vitals and hemoperitoneum.
 
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The mere fact you post something like this to an ER forum indicates that about 100% of the responses would be in support of your case. There's a bias name for this, can't remember the name. :)

Of course you were right in thinking this patient could be critically ill. She was potentially critically ill, nobody knows which direction she is going to go in the first 24 hours.

I can't tell from your original post whether the your ER attending was helping you with the discussions with Gyn. Did he/she play a passive role in this? For what its worth, MDs tend to have more clout with other MDs (as opposed to MLP and an MD).

It's times like this that I consider talking about legal stuff, "how is it going to look on a chart review a month later that we discharged someone with intraabdominal bleeding with recurrent fainting and vomiting?" "How can anyone justify this?" "What good is it to her, and us, when she goes home, faints, hits her head and then comes back in with a 3 cm forehead laceration that I have to repair? Let alone the small possibility she cracked her skull or gets an IPH?" Sometimes consultants change their minds

I probably would have, in this scenario, said

"GYN consultant...the patient has been here for x hours. Let's come up with a discharge plan. I will keep here here another 2 hours, and am willing to discharge her if she has none of the following:
- hypotension
- tachycardia
- Hg is stable or rising
- can tolerate PO
- no fainting
if she has any of the above, it's simply not a safe discharge and request you admit her."



Sorry man, sorry you had to go through this! At the end of the day.....it is safer for the patient to stay in the ER vs going home.
 
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BTW, sometimes....actually often.....patients make stupid decisions about their health. You have to be clear what the likely bad outcomes would be and not necessarily the worst outcomes. Once patients visualize what their life will be like over the next 24 hours, they often change their mind.

"your pain will get worse and worse, despite taking percocet, you will be rolled up into a ball on your bed crying in pain."
"you get up and faint, and hit the side of your bed, and you get a laceration on your forehead"
"you faint while on the toilet, fall over and hit your head."
"you feel like you are going to die."

Why did she want to go home? Afraid of the cost? What was it?


Lots of good responses on this board!
 
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My attending was passively involved in the case. I immediately notified him after my initial examination to see if he agreed with my work up, and also just because any unstable patient I feel needs to have the MD in the loop. I kept updating him throughout the shift but he seemed to think I had it under control. Didn't evaluate the patient or talk much if at all to the specialist. I am certain that if he had seen her from beginning to end like I had he would have pushed the gynecologist harder for admission. Her presentation was so severe initially that it seemed the entire department including nurses and rad techs were spooked, Mom was in the room sobbing, etc.

The patient wanted to go home because "my pain is a little better and I just wanna eat." That was literally her response. Little did she know that in twenty minutes she would try to get out of bed and scream out in intense pain, nearly pass out and vomit everywhere. But like I had told her before that happened, I didn't think she needed to even try to get up and get out of bed in the first place.

Observing her in the ER for a few hours could have been an option but I didn't feel that it was a long enough period of observation. There were plenty of reasons to admit - intraperitoneal hemorrhage from the ruptured ovarian cyst, symptomatic anemia, syncope, intractable pain, rapidly dropping H+H. That is why I thought it was so weird that the docs thought that this patient was okay to go home just because for twenty minutes she said her pain went away and she wanted to eat.

Sometimes I think about "If this patient died within 24 hours how would my care be scrutinized?" I would be scrutinized for sending home a patient with intraperitoneal hemorrhage, syncope, symptomatic anemia who was (initially) pale, diaphoretic, tachycardic, involuntarily guarding...who's not to say the second she gets home her pain is going to return ten fold? Or that she passes out again, this time suffering a head injury? Or if she just goes to sleep on her narcs and never wakes up (obviously very unlikely)? At the very least, the selfish reasons besides fear of lawsuits - I considered the opinions of the other docs in the ER whose opinions I respect so much - what would they think when they looked at all of that on paper and saw that I sent that patient home?
 
I am an ER PA and had an ovarian cyst rupture case that concerned me. I can’t find a ton of literature on life threatening hemorrhage associated with this so I wanted to get some opinions. A few weeks ago I had a 30 year old female come in with an acute onset of abdominal and chest pain radiating into the shoulders, pleuritic in nature. When I saw her she was tachycardic (120), pale, diaphoretic, moaning. I barely grazed her abdomen and she screamed, guarded, and seemed near syncopal. The presentation gave me chills. I immediately told my attending, got her rushed to CT, notified radiologist to start looking for her scan, started fluids, hydromorphone, and cardiac monitoring. EKG confirmed sinus tachycardia. I CTed her chest (angiogram), abdomen and pelvis. While waiting for CT she passed out on a walk to the bathroom. CT showed free fluid in the pelvis and upper abdomen that looked like hemorrhage. Radiologist said ovarian cyst rupture most likely. Called GYN, she was in disbelief that all this blood could be from a cyst... she said “it could be from the stomach” (no free air noted on the CT) and asked for a pelvic US. Consulted surgery, they said this definitely sounded like an ovarian cyst and advised continued consultation with GYN. US confirmed a ruptured ovarian cyst with lots of likely blood in the pelvis. Good flow to ovaries. The patient’s hemoglobin dropped from 12.5 to 9.0 in two hours (I know serial H and H are sometimes not useful, however). She continued to be very tender. Called GYN, they evaluated her and said she was no longer tender (“her abdomen was benign” and wanted to go home. (?!) this surprised me because on six or seven abdominal examinations including one 15 minutes prior the patient was wincing, guarding, crying out. OB said this was typical of ovarian cysts. When I went back in the room she said she felt better and wanted to go home and eat food, and she was definitely tender. Still guarding and wincing/moaning when I pressed anywhere on her belly. Told GYN I was still concerned... brought her and my attending back in the room to show her my patient was still wincing in pain, GYN said if the patient didn’t want to stay she could go home. So did attending. I said I was concerned about the initial tachycardia, syncope in the department and continued peritoneal type tenderness despite multiple doses of narcotics, and that I was also concerned of continued bleeding. GYN laughed, said they all present this way and then they all the sudden look great. For the first time ever in my PA career I didn’t just listen to the attending and specialist (I know I know) and went back in the room and really tried to get the patient to stay just for observation. I did not yet feel comfortable sending her home. She continued to decline, saying she wanted to go and eat (usually a positive sign). I discharged her with strict return precautions and Percocet. On the way out she nearly passed out from severe recurrence of pain and vomited all over. Then asked to be admitted. I called GYN back and they were PISSED and basically said “this could have been prevented” although she wouldn’t clarify when asked what she meant.

When I went home and read up on this (surprisingly my usual Pepid, EMRAP, Medscape and Tintinalli don’t have as much info as I would like though) lead me to believe that significant life threatening hemorrhage from a ruptured ovarian cyst is uncommon, and that patients do often present like they’re dying with acute surgical abdomens like in this case. Question is, was I right to advocate for admission or was the OBGYN correct in this case? I only know a small fraction of what OBGYN and my ER attending know - they are physicians after all - but this is one of those cases that didn’t settle right in my gut.

First off in general, I think you did everything right.

I would say its uncommon, but I have seen it about once every 2 years where a pt with a ruptured ovarian cyst has a MASSIVE hemoperitoneum. I emphatically disagree with your gynecology colleague that "this never happens." Plain and simple, they are inexperienced or wrong.

That being said, only one of these patients I had emergently went to the OR for hemorrhage control. Most are observed non operatively and the hemorrhage resolves. Some have gone to the OR urgently the next day or two simply for evacuation of the hemoperitoneum just because it is causing the patient lots of pain, even tho their hgb and hemodynamics have stabilized. The ones whose symptoms are controlled can be managed expectantly IN the hospital.

I would never allow for this patient to be discharged. I would sooner transfer to a different hospital as a last resort if all consultants unwilling to do the right thing.

I have encountered similar situations where a specialist will not operate and also will not see or admit the patient.

Here is my approach:

First, insist on a consultation. I cannot blame a proceduralist who will not do a procedure AFTER seeing and examining the patient in full consultation. That being said, it is not acceptable for them not to consult. Every hospital has bylaws that stipulate a consultant must see emergent consults within a usually fairly short time interval if explicitly requested by the emergency staff. Be clear the consult is emergent, and you are invoking this bylaw if they push back. Make it clear this is not just a phone call drive by.

If the consultant won't operate after seeing the patient; fine. That is their prerogative. That being said I will still admit this patient for observation for serial hgb/hct and tele monitoring. At this point you can usually admit the patient to the hospitalist service.

I have had patients admitted to the hospitalist after the initial surgeon would not operate, and then as the patient continued to deteriorate inpatient, they were urgently operated on in the next 48 hours. Invariably this same consultant recommended discharge from the ER initially.
 
Thank you guys for your responses. So here’s the thing… The gynecologist kept telling me that “the patient doesn’t want to be admitted” but she was more “offering admission” more than anything which drives me nuts.

In my mind there are three somewhat distinct situations:

"admitting" the patient.

"Recommending admission" to the patient.

"Offering admission" to the patient.

These are in descending order of risk. If a patient has a confirmed high risk diagnosis or situation, anything other than "admitting" the patient is not acceptable. You are the patients physician, it is your job to determine their level of risk and make the decision.

In this case a massive hemoperitoneum with dropping hemoglobin and unstable vitals is an unequivocally high risk situation. It is not appropriate to do "shared decision making" with the patient. The patient is at risk of imminent death. They only safe location is the hospital. The only appropriate medical recommendation is admission. Therefore a "shared decision making discussion" taking the patient's preferences into account is not appropriate. Their preference here is immaterial. If the patient does not want to be admitted, I would have them sign out AMA with iron clad documentation and--no joke--multiple witnesses to the conversation documented.

"Recommending admission" would be for a relatively low risk situation but an outpatient workup on an urgent basis is acceptable. Example: Syncope in a middle age patient with negative testing in the ER. I think 24 hours of tele obs is always reasonable. It is difficult to exclude at the point of care that they suffered a self-terminating arrhythmia. But if the patient would rather follow up outpt; its not crazy. I don't think they need to sign out AMA. This is a case where with a reasonable patient, a shared decision making discussion of risks and benefits is acceptable.

"Offering admission" is for a patient who is in a very low risk situation medically and really just needs symptom control. For example, a kidney stone that is probably passable (say 3mm) with no other concerning features (acute kidney injury, h/o solitary kidney, sepsis with UTI, etc.) but you are concerned about their level of pain control. If patient is content with pain control with PO agents and would like to try to go home and follow up with urology outpatient, that is definitely OK. I make clear to these patients this is not a binding decision and I emphasize return precautions if outpatient treatment fails.
 
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Beware of common things presenting uncommonly.

I had a young woman present in shock, one time. CT scan showed an abdomen full of blood but no source. I consulted general surgery with the thought that maybe she fell and ruptured her spleen or something and we just weren't seeing that on the scan, for some reason. Fortunately, they didn't insanely try to send her home or pass the buck. They did the right thing and admitted her to do an emergency ex-lap. What they found was a little artery pumping away on her ovary from a ruptured ovarian cyst. The only risk factor we could ever dig up, was that she was taking ibuprofen. If the scan had come back "Hemoperitoneum from ruptured ovarian cyst" instead of "hemoperitoneum source unknown," then I probably would have had to deal with the same "that's not possible" garabage, the OP had to deal with, along with all the associated gaslighting.

For those of you new to EM, be aware that you will see things in your career that consultants will try to tell you "don't happen" or aren't possible, then they'll try to talk you out of what your eyes, ears and instincts are telling you. There are all kinds of different types of bias that lead to that, but suffice it to say, that it will happen, and not infrequently.
 
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For those of you new to EM, be aware that you will see things in your career that consultants will try to tell you "don't happen" or aren't possible, then they'll try to talk you out of what your eyes, ears and instincts are telling you. There are all kinds of different types of bias that lead to that, but suffice it to say, that it will happen, and not infrequently.

Seems like this happens almost weekly.
 
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Here’s the thing, I strongly considered having this patient sign out against medical advice (when I was originally told to DC her). But it was the medical opinion of the OB/GYN and my attending (who has the false mentality that “if the specialist sees them and says they can go home we are off the hook” ) she could go home. So while I thought about having her sign the paperwork, ultimately I didn’t do it because it would be like “you’re signing out against the medical advice of the lowly PA but the board certified EM doctor and expert gynecologist say you can go home if you want.” I also didn’t want to undermine and disrespect my superiors. What I did do is document that I personally strongly advised her to stay in the hospital due to the risks and that she understood the risks and still wanted to go home. It was LUCKY that she puked everywhere and screamed in pain when she got up to leave because then I had an excuse to admit her - thank the LORD (LOL). Anyway! This is where being a PA can be tricky - in almost every single case I have deferred to my attending and specialist, them telling me I can send someone home reassures me and I can get on with it. This time I couldn’t get on board - with my limited knowledge and experience at least compared to that of of board certified docs, I have little to stand on when trying to subtly convince a patient PLEASE STAY. in this case, it was extra tricky having a cavalier attending who rarely seems to get very worried about any patient and thinks “if the specialist says it’s OK we aren’t responsible” an OBGYN who clearly needed sleep and didn’t want to come into the hospital at 11 PM, and clearly exaggerated that “the repeat examination was COMPLETELY benign.”
 
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apparently you know how to diagnose obvious impending death from hemorrhagic shock, unlike them

I think that you've made a leap here. The patient "almost fainted" but that does not equate to impending death. @ERCAT - did she end up requiring a transfusion or an operative intervention?

That said, I'm not arguing with the admission. I would've recommended an Obs admission, and if GYN pushed back I would've pulled out my best tricks to make it go my way.

I'm just saying that we need to know more about the case to say that there was "impending death". If so, you should raise a stink or at least request an administrative case review. But if not, you should probably let this one go.
 
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I think that you've made a leap here. The patient "almost fainted" but that does not equate to impending death. @ERCAT - did she end up requiring a transfusion or an operative intervention?

That said, I'm not arguing with the admission. I would've recommended an Obs admission, and if GYN pushed back I would've pulled out my best tricks to make it go my way.

I'm just saying that we need to know more about the case to say that there was "impending death". If so, you should raise a stink or at least request an administrative case review. But if not, you should probably let this one go.
He said "tachycardic at 120, pale and diaphoretic" due to blood emptying into the belly. That’s hemorrhagic shock. I haven't seen much good come to ER docs that send that home.
 
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Sometimes I think about "If this patient died within 24 hours how would my care be scrutinized?" I would be scrutinized for sending home a patient with intraperitoneal hemorrhage, syncope, symptomatic anemia who was (initially) pale, diaphoretic, tachycardic, involuntarily guarding.
"H" "E" to the "double L" yes, you’d be scrutinized and you’d have no leg to stand on. Furthermore, the defense, “I knew the patient was critically ill, but I let 2 lazy consultants who didn’t want to do their jobs convince me to do something I knew was stupid and dangerous,” does not sell well.

You were right. They were wrong. Period.
 
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"H" "E" to the "double L" yes, you’d be scrutinized and you’d have no leg to stand on. Furthermore, the defense, “I knew the patient was critically ill, but I let 2 lazy doctors who didn’t want to do their jobs convince me to do something I knew was stupid and dangerous,” does not sell well.

You were right. They were wrong. Period.

This would not only be breach of standard of care, but would likely be viewed by most as grossly negligent.
 
She did "syncopize" in the ER right in front of the nurse and had to be carried back to bed. When she got up and tried to go home at the end of the night that’s when she had the near syncope and another attack of pain.

She ended up being discharged the next day by the OB. Surgery was "offered but the patient declined" and was feeling better. Last Hgb was 8.5 at discharge.
 
She ended up being discharged the next day by the OB. Surgery was "offered but the patient declined" and was feeling better. Last Hgb was 8.5 at discharge.
The best case scenario is that the bleeding stops during a period of close, medical observation, on someone else's watch.

Admit that 100 out of 100 times.

Notice they're still very weakly hedging in their note, with no confidence whatsoever. "Offered surgery but declined" is like saying, "If the patient goes home and dies, it's not my fault. There's obviously something bad enough going on, I 'offered' her surgery, but I don't even care enough to actually recommend it, document why it's recommended, or type the words that document I explained the risks to her. I don't even care enough to have her sign an AMA form. I'm just tired, don't care, and want to go home."
 
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This is not a midlevel case. Acute symptomatic hemoperitoneum rarely (?never) is.
Nice catch, ERCAT.
Next step: transfer to the EM doc.

HH
 
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This is not a midlevel case. Acute symptomatic hemoperitoneum rarely (?never) is.

Why not? He handled it the same way you would have, maybe even better than his attending would have.
 
And yet sounds like he handled it well and ensured the patient got appropriate care.

MLPs can handle asshat consultants as well.
 
It sure as hell was a mid level case! I am so relived I didn’t hand it off. Both the specialist and attending ER doc told me to send her home, while I was squeamish with discomfort. Thank God I was able to talk to the patient privately to tell her it was a bad idea and thank god she became symptomatic again in the ER and then asked to be admitted based on my advice.
 
***So I am in IM in primary care

You sound like a patient advocate, just the king of person I would want working in an ED

I’d be curious to see if anyone disagrees with this, but I would not have discharged pt with Percocet ... pt might have changed their mind about wanting to be discharged if no Percocet given, plus I wouldnt want to mask the pain in this pt if symptoms worsen at home
 
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***So I am in IM in primary care

You sound like a patient advocate, just the king of person I would want working in an ED

I’d be curious to see if anyone disagrees with this, but I would not have discharged pt with Percocet ... pt might have changed their mind about wanting to be discharged if no Percocet given, plus I wouldnt want to mask the pain in this pt if symptoms worsen at home

If someone wants to leave against medical advice, you are still responsible to provide them with reasonable medical care to the best of your ability. However I do agree with you that Percocet or another narcotic pain reliever is not necessarily in that category. Withholding not in a patient leaving AMA may be a bargaining chip to get them to agree to a more appropriate care. Just don’t try to use a similar tactic as a bargaining chip in another situation such as with antibiotics
 
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It sure as hell was a mid level case! I am so relived I didn’t hand it off. Both the specialist and attending ER doc told me to send her home, while I was squeamish with discomfort. Thank God I was able to talk to the patient privately to tell her it was a bad idea and thank god she became symptomatic again in the ER and then asked to be admitted based on my advice.

Either your ER attending is an utter baffoon with an IQ of a soap dish, or he wasn’t really listening to your presentation. Every doc here says admit. And your ER doc said go home?!?!
 
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And yet sounds like he handled it well and ensured the patient got appropriate care.

MLPs can handle asshat consultants as well.

I didn't mean to suggest that they can't. Rather, that one of the things attendings are getting paid for is to deal with this crap.
 
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It sure as hell was a mid level case! I am so relived I didn’t hand it off. Both the specialist and attending ER doc told me to send her home, while I was squeamish with discomfort. Thank God I was able to talk to the patient privately to tell her it was a bad idea and thank god she became symptomatic again in the ER and then asked to be admitted based on my advice.
It may not have been a "midlevel case" but it sure was a case for this mid-level. Good job.
 
I am just amazed that the gyn didn't try to claim patient had an appendicitis (because an appendix floating in blood is probaby going to a little prominent). I can't tell you how often I have had to deal with these ruptured cyst patients because the gyn punted to me and I see no reason to refuse to do this kind of consult (even if all the imaging is pointing to gyn origin). I have seen them with significant hemorrhage requiring surgical intervention (and not an appendectomy but I always let gyn know I will come pull out the appendix if they think it needs to come out after they deal with their problem) or just needing pain meds and serial exams. Every time the gyn acts like it is case report rare when clearly that can't be the case if I have my own case series as a general surgeon. But at least by calling me the em doc or pa gets someone supporting an admission and then gyn and I can duke it out. Same goes for the tuboovarian abscess patients that aren't chandelier-ing enough and gyn decides it can't possible be pid.
 
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I’ve seen one bad ovarian cyst. Usually these are large cysts that hemorrhage and rupture (this is the fairly common part that the OBGYN was talking about) but keep bleeding (uncommon). Most ruptured ovarian cysts clot off and very few continue to bleed. The key difference is like you said: clinical. I don’t think you did anything wrong but I agree with the above. If some specialist says some stuff you don’t agree with: road test!!! I always road test these patients and usually when I’m right they fail miserably and I get to call back whoever with a big grin on my face.
 
I’m a urogyn fellow and I would have 100% admitted this patient based on initial presentation if not immediately scoped her. Ruptured corpus luteum cysts are one of the top gynecologic emergencies up there with torsion and ruptured ectopic and while most of the time the bleeding will stop on it’s own, in the case you describe with tachycardia, hypotension and free fluid many of the gyn surgical subspecialists (onc, uro, mis, rei) would take her to the OR. Even if you do a scope and there is no active bleeding you’d still do her some good by evacuating the hemoperitoneum. At my institution we’ve had this issue come up. It got to be such an issue the point that now only fellows and the surgical specialty attendings get called about ER consults that may require surgery. Out of curiosity what time of day did this case come in and what ended up happening with the patient?
 
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I've had plenty of rare gyn cases before but luckily have had good ob/gyn's as consultants who will watch the pt and take to the OR if needed. I've never had a hemorrhagic cyst need surgery but have had partners who've needed it. I have had 3 ovarian torsions with normal flow on u/s but clinically suspicious for torsion and the ob/gyn all came in and helped me out, in addition to a incomplete miscarriage in hemorrhagic shock and someone come in w/ a BP of 60's from a minor deep vaginal lac from an overly agressive masturbator w/ I think von Willebrand's
 
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So, the patient got admitted because she almost passed out again, vomited everywhere, etc. This was like around 11:00 PM and the OB/GYN had coming to the hospital from home so she was very unhappy when I called her and said she would need to come back. The hospitalist refused the admission because she said it was a purely gynecological issues, and so did surgery, so the OB/GYN had this all on her own. She discharged the patient the next day about 12 hours later here in her note mentions that she “offered surgery in court but there was no indication of why it was offered in the note, and then she said the patient declined... That was it. At this point the hemoglobin was 8, on discharge, and the OB/GYN note said the patient had no pain at this point. I called the patient the next day and she said she was still having some pain and lightheadedness but was doing better than she had been in the hospital. I gave her strict return precautions and that was the last time I called her.
 
The other odd thing is that the OB/GYN kept saying that the presentation did not bother her too much because “they always present like this.” I’ve seen a lot of ruptured ovarian cysts but have never thought twice about sending them home because of their benign presentation.
 
I’m a urogyn fellow and I would have 100% admitted this patient based on initial presentation if not immediately scoped her. Ruptured corpus luteum cysts are one of the top gynecologic emergencies up there with torsion and ruptured ectopic and while most of the time the bleeding will stop on it’s own, in the case you describe with tachycardia, hypotension and free fluid many of the gyn surgical subspecialists (onc, uro, mis, rei) would take her to the OR. Even if you do a scope and there is no active bleeding you’d still do her some good by evacuating the hemoperitoneum. At my institution we’ve had this issue come up. It got to be such an issue the point that now only fellows and the surgical specialty attendings get called about ER consults that may require surgery. Out of curiosity what time of day did this case come in and what ended up happening with the patient?

I love the fact that a urogyn fellow actually is reading an ER forum!!!

Thanks for your opinion, nice to hear from the specialty itself on this topic.
 
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I love the fact that a urogyn fellow actually is reading an ER forum!!!

Thanks for your opinion, nice to hear from the specialty itself on this topic.

I peruse all the forums, keeps me in the know of other specialties and sometimes I come across a relevant topic. Not to mention the OB forum is dead and you guys have the best stories.
 
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The other odd thing is that the OB/GYN kept saying that the presentation did not bother her too much because “they always present like this.” I’ve seen a lot of ruptured ovarian cysts but have never thought twice about sending them home because of their benign presentation.

Clearly she did not want to operate. I think you did the right thing by the patient and your hands were tied. Sometimes it’s the luck of the draw, another attending may have taken this patient back immediately, as I probably would have.
 
I've really enjoyed this thread. I wish we had more posts like this one with discussions of complex management of more uncommon variations of patient diseases and presentations.
 
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I’ve seen a lot of ruptured ovarian cysts but have never thought twice about sending them home because of their benign presentation.

You have?
Are you that experienced?
This is the kind of thinking that produces suspicious responses from the EM docs like those above. This kind of thinking is what scares me about midlevels.
I wouldn't make the kind of comment quoted, and I highly suspect I have way more emergency medicine experience than you do.
There is just no way you have seen that many cases of ruptured ovarian cysts unless you have been practicing in the ED at the nearest Women's Hospital...and even then...no. Just no.
HH
 
You have?
Are you that experienced?
This is the kind of thinking that produces suspicious responses from the EM docs like those above. This kind of thinking is what scares me about midlevels.
I wouldn't make the kind of comment quoted, and I highly suspect I have way more emergency medicine experience than you do.
There is just no way you have seen that many cases of ruptured ovarian cysts unless you have been practicing in the ED at the nearest Women's Hospital...and even then...no. Just no.
HH

Sorry to bump a (nearly) dead thread, but this is an interesting comment. I suspect that ERCAT meant that s/he has seen many cases of pelvic pain with an ovarian cyst noted on ultrasound. Most ovarian cysts we diagnose are incidental to the presenting complaint.

In 6.5 years of ED practice, I haven't seen hemorrhagic shock from from a ruptured cyst. I've seen a handful of cases of peritonitis from a ruptured cyst--they present quite dramatically (just as the consultant noted), but typically they just need pain control (and sometimes a night in the hospital for it).

Sometimes I think we're too quick to dismiss the recommendations of consultants and come in here to **** on them. In this case, with the benefit of hindsight, the consulting obgyn ended being right. The patient did fine, stopped bleeding and was discharged the next day. Based on the OP, I (and I think the majority of EM docs) would probably have admitted the patient, but to act s/he saved the patient from being murdered by a bloodthirsty buffoonish obygn is obviously incorrect.
 
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Sometimes I think we're too quick to dismiss the recommendations of consultants and come in here to **** on them. In this case, with the benefit of hindsight, the consulting obgyn ended being right. The patient did fine, stopped bleeding and was discharged the next day. Based on the OP, I (and I think the majority of EM docs) would probably have admitted the patient, but to act s/he saved the patient from being murdered by a bloodthirsty buffoonish obygn is obviously incorrect.

I followed this thread with interest as I have only seen one case of a ruptured ovarian cyst with significant hemorrhage and it was not nearly as dramatic as the case above. I definitely agree with you that we can be overly or inappropriately critical of consultants. However, I don't think that the OP was really looking for hero points as much as reassurance that his/her actions were not unreasonable given the push back from the OB/GYN. In my mind, just because the pt didn't need surgery doesn't mean that the OB/GYN was correct. The pt was tachycardic, passed out, and was in what sounds like severe pain with a concerning exam. I think the correct move would have been admit regardless of the ultimate outcome. We admit TIAs and syncope all the time. Just because most of them do well doesn't mean they never should've been admitted.
 
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Sorry to bump a (nearly) dead thread, but this is an interesting comment. I suspect that ERCAT meant that s/he has seen many cases of pelvic pain with an ovarian cyst noted on ultrasound.

...except that ERCAT didn't say -- or do I suspect meant to say -- she had seen many incidental findings of ovarian cysts on ultrasound.

In ERCAT's own words (my emphasis):


I’ve seen a lot of ruptured ovarian cysts but have never thought twice about sending them home because of their benign presentation.

That distinction and the air of experience ERCAT's post implies is what generated my response.

Self-delusion is so dangerous in these situations...and only support my previous post:

This is not a midlevel case. Acute symptomatic hemoperitoneum rarely (?never) is.
Nice catch, ERCAT.
Next step: transfer to the EM doc.

HH

HH
 
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Can’t believe this thread is still going! I meant to say in my post that I have seen a lot of pelvic pain secondary to ovarian cysts. I have only seen ovarian cyst ruptures a few times. Those times the patients were sent home. This was the only time I had to admit someone.
 
I meant to say in my post that I have seen a lot of pelvic pain secondary to ovarian cysts. I have only seen ovarian cyst ruptures a few times.

I am even less confident in your experience now.
And this statement is in complete contradiction to what you said before.
Please acknowledge your limits in knowledge and experience when working in the ED. This will go a long way for patient safety.
HH
 
I am even less confident in your experience now.
And this statement is in complete contradiction to what you said before.
Please acknowledge your limits in knowledge and experience when working in the ED. This will go a long way for patient safety.
HH

You make a hell of a lot of assumptions based on an instance where I mistyped and later clarified what I meant! I do acknowledge my limits which is why I consulted both my attending and the specialist in this case.
 
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Dont worry about it ERCat. Just like in the real world, there are a couple of people here who constantly need to make themselves feel better about their situation in life by constantly pointing out their superiority over others.
 
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