Pelvic Exams

[thegenius]

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FOBTs are non-emergent screening for colon cancer. The evaluation of anemia is an inpatient or outpatient evaluation. Our job in the ED is to resuscitate the obviously bleeding patient. Somehow our field has overcomplicated this and misconstrued FOBT with our role as rescucitationists. Trying to catch people in a lie about whether or not they are bleeding from their butthole isn’t our job.

Boy I was diggin this answer until the last sentence.

 

[thegenius]

I don’t understand not doing FOBTs. Besides the fact the entire thing takes under a minute, I can’t tell you how many times I’ve had newly anemic patients say they aren’t bleeding when they are, or patients who present for dark black stool and worry they’re bleeding, when they aren’t. So easy to sort out. Am I understanding that those who defer these are going to punt most of these to a PCP who can fit them in sometime next month?

The reality is a DRE with knowledge + or - from a card gives the ED good information to help the patient. I do DRE's and will often (but not always) want to know if there is blood in the stool, regardless of the color.

 

[Zebra Hunter]

Patients anemic, no significant risk factors, reports bleeding or melena, but negative FOBT? Patient still getting admitted for scope.

Patient not anemic, no significant risk factors, reports bleeding or melena, but negative FOBT? Patient gets discharged with GI f/u.

Patient not anemic, no significant risk factors, reports bleeding or melena, no gross blood or melena on exam, but FOBT positive? Patient gets discharged with GI f/u.

Patient markedly and acutely anemic, no significant risk factors, no reported melena or bleeding, FOBT negative? Admission and likely scope.

Patient markedly and acutely anemic, no significant risk factors, no reported bleeding or melena, FOBT positive? Admission and likely scope.

How is FOBT changing your management?

Edit to add more scenarios:

Mildly anemic, no risk factors, reports melena or bleeding, negative FOBT? Review risk factors thoroughly, maybe repeat hgb, and shared decision making.

Mildly anemic, no risk factors, reports melena or bleeding, no gross blood or melena, positive FOBT? Review risk factors thoroughly, maybe repeat hgb, and shared decision making.

 

[Apollyon]

And a turd can have an HCT of 25% and still be brown.

 

[Jabbed]

I try to spot avoid all pelvics, but DREs yield way more information as @Pinner Doc mentioned. I may not use the FOBT card, but seeing melena vs blood vs normal stool gives you a lot of information. @Tiger26 the ED cure for diarrhea is to order a stool sample. It’s painful enough getting a urine collection that I can’t imagine waiting for stool samples to dispo.

Also pretty much all anorectal diagnoses require looking at the patient’s dingus. Anal fissure, hemorrhoid, perianal abscess, Fournier’s.

 

[Jabbed]

Patients anemic, no significant risk factors, reports bleeding or melena, but negative FOBT? Patient still getting admitted for scope.

Patient not anemic, no significant risk factors, reports bleeding or melena, but negative FOBT? Patient gets discharged with GI f/u.

Patient not anemic, no significant risk factors, reports bleeding or melena, no gross blood or melena on exam, but FOBT positive? Patient gets discharged with GI f/u.

Patient markedly and acutely anemic, no significant risk factors, no reported melena or bleeding, FOBT negative? Admission and likely scope.

Patient markedly and acutely anemic, no significant risk factors, no reported bleeding or melena, FOBT positive? Admission and likely scope.

How is FOBT changing your management?

Edit to add more scenarios:

Mildly anemic, no risk factors, reports melena or bleeding, negative FOBT? Review risk factors thoroughly, maybe repeat hgb, and shared decision making.

Mildly anemic, no risk factors, reports melena or bleeding, no gross blood or melena, positive FOBT? Review risk factors thoroughly, maybe repeat hgb, and shared decision making.

Patient not anemic, significant risk factors, on eliquis/coumadin, reports “dark stools”— DRE would help your dispo.

Patient anemic, hypotensive, suspected GIB— BRBPR vs melena would dictate getting a CTA for lower GI embo target vs EGD.

I’m not a huge fan of FOBT, but it does help distinguish melena vs pseudo-melena from pepto/iron supplements. I also once had a kid with what looked like BRBPR but ended up being side effect from cefdinir— red diarrhea.

In contrast to pelvic exams there’s not really any great options for diagnostic testing that will give you the same information.

 

[Zebra Hunter]

Patient not anemic, significant risk factors, on eliquis/coumadin, reports “dark stools”— DRE would help your dispo.

Patient anemic, hypotensive, suspected GIB— BRBPR vs melena would dictate getting a CTA for lower GI embo target vs EGD.

I’m not a huge fan of FOBT, but it does help distinguish melena vs pseudo-melena from pepto/iron supplements. I also once had a kid with what looked like BRBPR but ended up being side effect from cefdinir— red diarrhea.

In contrast to pelvic exams there’s not really any great options for diagnostic testing that will give you the same information.

I’m not arguing utility of DRE which has its place in very select patient presentations as you describe, but there is zero utility for FOBT in an emergency department outside of convincing anxious parents that their child on cefdinir isn’t bleeding out. An FOBT result has never changed management decisions for me and there is a ton of literature and recommendations on this exact subject that state the same.

 

[Apollyon]

One of the Peds attendings when I was a resident did a yearly lecture on "Doctor, my baby's poop is red", ranging from ate a red crayon and drank cherry Kool Aid to cefdinir to intussusception to heme to blood.

 

[DocEspana]

Patient not anemic, significant risk factors, on eliquis/coumadin, reports “dark stools”— DRE would help your dispo.

Patient anemic, hypotensive, suspected GIB— BRBPR vs melena would dictate getting a CTA for lower GI embo target vs EGD.

I’m not a huge fan of FOBT, but it does help distinguish melena vs pseudo-melena from pepto/iron supplements. I also once had a kid with what looked like BRBPR but ended up being side effect from cefdinir— red diarrhea.

In contrast to pelvic exams there’s not really any great options for diagnostic testing that will give you the same information.

ct angios of the abdomen exist, just saying. This tremendous tool in the "i actually do think youre bleeding" workup that essentially tells you discharge vs admission vs straight to IR suite.

 

[Jabbed]

ct angios of the abdomen exist, just saying. This tremendous tool in the "i actually do think youre bleeding" workup that essentially tells you discharge vs admission vs straight to IR suite.

Yes, but they are not the most sensitive for GIB and are really only indicated for LGIB, which again requires a DRE to set your pre-test probability of UGIB vs LGIB. It’s also worth acknowledging that most ill GIB patients also have significant enough AKI that precludes contrast-enhanced scans. Sure I might do it anyway and the risk the CIN, but are you really going to do all that without properly examining the patient?

 

[maxxor]

Yes, but they are not the most sensitive for GIB and are really only indicated for LGIB, which again requires a DRE to set your pre-test probability of UGIB vs LGIB. It’s also worth acknowledging that most ill GIB patients also have significant enough AKI that precludes contrast-enhanced scans. Sure I might do it anyway and the risk the CIN, but are you really going to do all that without properly examining the patient?

The nephrologists on the CIN grift need to be sanctioned. ACR has come out questioning even if this exists.

Know what else causes a creatinine bump in an inpatient? A high vanc trough. Don’t hear about vanco induced nephropathy as a reason to avoid giving vanco…

CTA for intestinal bleed does work. It just takes too long to scrutinize for the ER rad setting to have any hope for good sensitivity. You do have higher yield when it’s active BRBPR.

 

[TooMuchResearch]

Yes, but they are not the most sensitive for GIB and are really only indicated for LGIB, which again requires a DRE to set your pre-test probability of UGIB vs LGIB. It’s also worth acknowledging that most ill GIB patients also have significant enough AKI that precludes contrast-enhanced scans. Sure I might do it anyway and the risk the CIN, but are you really going to do all that without properly examining the patient?

Yes.

 

[thegenius]

One of the Peds attendings when I was a resident did a yearly lecture on "Doctor, my baby's poop is red", ranging from ate a red crayon and drank cherry Kool Aid to cefdinir to intussusception to heme to blood.

Never knew that.

We don't prescribe cefdinir all that much around here.

 

[DocEspana]

Yes, but they are not the most sensitive for GIB and are really only indicated for LGIB, which again requires a DRE to set your pre-test probability of UGIB vs LGIB. It’s also worth acknowledging that most ill GIB patients also have significant enough AKI that precludes contrast-enhanced scans. Sure I might do it anyway and the risk the CIN, but are you really going to do all that without properly examining the patient?

There is no such thing as this. (I'm not denying that people believe it. I'm repeating the actual ACR comments on this which flat out says there is no contraindication for IV contrast based on renal function, the only contraindication is allergy)

 

[Apollyon]

The nephrologists on the CIN grift need to be sanctioned. ACR has come out questioning even if this exists.

Not trying to argue, but just to clarify: is this just a matter of dose of contrast? I mean, I'm 20 years from residency, but, Duke Cards would tell pts, "this is your last pee, because the contrast in your cath will finish off the last part of your kidneys". These were NC rural types with Cr 3 or 3.5 or 4. They would get the cath, including a ventriculogram, and, sure enough, after that, they became oligo- to anuric, with a Cr of 8, or more, and went on HD.

 

[maxxor]

Not trying to argue, but just to clarify: is this just a matter of dose of contrast? I mean, I'm 20 years from residency, but, Duke Cards would tell pts, "this is your last pee, because the contrast in your cath will finish off the last part of your kidneys". These were NC rural types with Cr 3 or 3.5 or 4. They would get the cath, including a ventriculogram, and, sure enough, after that, they became oligo- to anuric, with a Cr of 8, or more, and went on HD.

Intra arterial doses of the high concentration stuff used for cardiology can cause renal toxicity.

The low concentration iso osmolar venous doses we use for diagnostic imaging does not.

 

[thegenius]

There is no such thing as this. (I'm not denying that people believe it. I'm repeating the actual ACR comments on this which flat out says there is no contraindication for IV contrast based on renal function, the only contraindication is allergy)

https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Contrast-Manual/ACR-Manual-on-Contrast-Media.pdf#page=38

Page 38

I think if the ACR truly believes the statement above, they would just write it. There's always caveats and nuance with this stuff.

 

[DocEspana]

Not trying to argue, but just to clarify: is this just a matter of dose of contrast? I mean, I'm 20 years from residency, but, Duke Cards would tell pts, "this is your last pee, because the contrast in your cath will finish off the last part of your kidneys". These were NC rural types with Cr 3 or 3.5 or 4. They would get the cath, including a ventriculogram, and, sure enough, after that, they became oligo- to anuric, with a Cr of 8, or more, and went on HD.

As someone else said, the stuff that we use for CT studies is low osmolality and it definitely causes a transient shift in GFR that seems to be reversible in everyone. The stories of kidneys that never came back seem to be limited to anecdotes which have many confounding variables rather than actual percentage chances. The way to take a weak kidney and finish it off seems or be the IR and interventional cards contrast not the stuff we use for CTs nowadays.

But because before 2000ish we used high osmolarity contrast in CTs and because there is a transient GFR shift, the ghost of CIN will never be vanquished totally. Plus as @thegenius points out, ACR is getting so close to having an actual stance but then waters it down with lots of caveats (In this case saying there is no kidney related reason to ever clinically withhold contrast if it is needed for a study, But then saying that they don't think the data is vigorous enough to be 100% certain that there isn't some hypothetical risk in the wrong patient population and caveat emptor you're on your own if someone wants to blame you for it).

 

[gutonc]

As someone else said, the stuff that we use for CT studies is low osmolality and it definitely causes a transient shift in GFR that seems to be reversible in everyone. The stories of kidneys that never came back seem to be limited to anecdotes which have many confounding variables rather than actual percentage chances. The way to take a weak kidney and finish it off seems or be the IR and interventional cards contrast not the stuff we use for CTs nowadays.

My rural CAH (part of a large regional system) just lost their local rads group because 2 of the 3 radiologists who had been practicing for 30+ years retired. We're now covered by the regional quarternary center's rads group (including on-site coverage, not just remote) and literally overnight, now everyone can get contrast regardless of renal function and every single CT A/P doesn't need to be done with oral contrast regardless of indication.

It's amazing what happens when people pay attention to current data.

 

[Apollyon]

My rural CAH (part of a large regional system) just lost their local rads group because 2 of the 3 radiologists who had been practicing for 30+ years retired. We're now covered by the regional quarternary center's rads group (including on-site coverage, not just remote) and literally overnight, now everyone can get contrast regardless of renal function and every single CT A/P doesn't need to be done with oral contrast regardless of indication.

It's amazing what happens when people pay attention to current data.

True story: in my EM career, I never once did oral contrast. As an attending told me, "if they need oral contrast, they're not an ED pt!"

 

[xaelia]

True story: in my EM career, I never once did oral contrast. As an attending told me, "if they need oral contrast, they're not an ED pt!"

Triple contrast. 💪

 

[Apollyon]

Triple contrast. 💪

Right up the highway!!

 

[Janders]

Gosh I’m coming into this late—
(1) I’ve dropped my hemoccult usage 95% since residency. I mostly still use it for old / anticoagulated patients who report scary dark stools but are stable and hg is OK. Dark heme negative goes home, dark heme positive stays over.
(2) if CTa was that good at seeing mild GIB I would find it useful. Instead it just increases ED LoS and adds minimal info. It they are dying from rapid rectal bleeding (shocker) it is positive and I have to find them IR.
(3) I LOVE CT. I consider myself very good at reading CT. I do find oral contrast helpful about 1x a month. Enough that I’m trying to get it properly programmed in our EMR. It is niche, but can be super helpful.

 

[AlmostAnMD]

True story: in my EM career, I never once did oral contrast. As an attending told me, "if they need oral contrast, they're not an ED pt!"

Maybe this is just an anecdote, but I had always been told super thin people need it for appendicitis.

I had a resident order a ct w iv contrast on a very obviously thin patient that looked like classic appendicitis. He did it as part of his workup and told me he was surprised it was negative.

I saw patient looked like Christine Bale in The Machinist. I suggested repeating it with oral contrast and suddenly a massive appendix appeared

You could also say, why didn't you just consult surgery after the first ct and a convincing history? And the answer is I don't do clinical EM anymore loooooool

 

[pkwraith]

Speaking of utility (or lack of) FOBT, I'm noticing an annoying trend of nurses telling me they guac'd the vomiter and it was positive as if implying they have a UGIB. I don't have a ****. You throw up enough times, your vomit will have a positive FOBT and has no clinical significance. Please stop doing that.

 

[maxxor]

Maybe this is just an anecdote, but I had always been told super thin people need it for appendicitis.

I had a resident order a ct w iv contrast on a very obviously thin patient that looked like classic appendicitis. He did it as part of his workup and told me he was surprised it was negative.

I saw patient looked like Christine Bale in The Machinist. I suggested repeating it with oral contrast and suddenly a massive appendix appeared

You could also say, why didn't you just consult surgery after the first ct and a convincing history? And the answer is I don't do clinical EM anymore loooooool

Thin people have relatively less intra abdominal fat which acts as a negative contrast and can provide secondary signs of inflammation (fat stranding etc).

In those cases, oral contrast is helpful because if you opacify the bowel loops, the blocked appendix sticks out as it shouldn’t have contrast by virtue of being blocked.

The whole abomination of doing rectal contrast for appendicitis was to help with throughput: get the contrast to the appendiceal orifice faster! Turns out all the rest of the drama with getting the rectal contrast into the patient is slower than telling them to just drink.

 

[DocEspana]

Speaking of utility (or lack of) FOBT, I'm noticing an annoying trend of nurses telling me they guac'd the vomiter and it was positive as if implying they have a UGIB. I don't have a ****. You throw up enough times, your vomit will have a positive FOBT and has no clinical significance. Please stop doing that.

Did they put..... Stool .... On the card? Or vomit? I forget exactly why, but they're not calibrated to detect blood in vomit. There is some fancy vomit "guaiac" card on the market

Also, I am just noticing now that you wrote guac. Which is obviously a typo but makes that sentence even better.

 

[Powdermonkey]

Did they put..... Stool .... On the card? Or vomit? I forget exactly why, but they're not calibrated to detect blood in vomit. There is some fancy vomit "guaiac" card on the market

Also, I am just noticing now that you wrote guac. Which is obviously a typo but makes that sentence even better.

There is a specific gastrocult card for the stomach contents. It's something about the acidity od the comments that causes a false positive on the hemocult cards, or so I've been told.

 

[DocEspana]

There is a specific gastrocult card for the stomach contents. It's something about the acidity od the comments that causes a false positive on the hemocult cards, or so I've been told.

Yeah I've been told the same but I like (for me personally) to avoid repeating what the nurses tell me if I haven't checked on it myself. The positive predictive value on what they tell me often approaches 50/50

 

[AlmostAnMD]

Yeah I've been told the same but I like (for me personally) to avoid repeating what the nurses tell me if I haven't checked on it myself. The positive predictive value on what they tell me often approaches 50/50

Consult quarter

 

[Janders]

E

There is a specific gastrocult card for the stomach contents. It's something about the acidity od the comments that causes a false positive on the hemocult cards, or so I've been told.

It’s actually that the acidity of stomach contents LOWERS the sensitivity of the hemocult card, making false negatives. Hence the Gastroccult card with buffered solution. Check the box, the fold out pamphlet actually shows the data for this—>

 

[Rendar5]

I don’t understand not doing FOBTs. Besides the fact the entire thing takes under a minute, I can’t tell you how many times I’ve had newly anemic patients say they aren’t bleeding when they are, or patients who present for dark black stool and worry they’re bleeding, when they aren’t. So easy to sort out. Am I understanding that those who defer these are going to punt most of these to a PCP who can fit them in sometime next month?

1. Newly anemic patients get a scope regardless of FOBT results and may need admission.
2. I still perform FOBT ONLY when I can’t tell if the discoloration is blood or not and it is grossly discolored. If I know it’s not blood I tell the patient and they’re happy without the test.

 

[gro2001]

How many ED physicians are on this quality review team? Pelvic exams are a quality metric at your hospital now? Ha...that's an email I'd delete before ever opening every time. Colleagues that crucify me are more than welcome to go do pelvic exams on my patients when I don't feel they are indicated.

The scary thing is that this in an ER quality review team, so they are ALL currently practicing emergency physicians.

Pelvics are thankfully not a quality metric, but it is the opinion of the quality people (and therefore the department leadership) that pelvics are necessary. So if a case of a woman of with a potentially pelvic CC goes sideways in some ways, people will criticize you for not having done a pelvic exam.

 

[JacobMcCandles]

The scary thing is that this in an ER quality review team, so they are ALL currently practicing emergency physicians.

Pelvics are thankfully not a quality metric, but it is the opinion of the quality people (and therefore the department leadership) that pelvics are necessary. So if a case of a woman of with a potentially pelvic CC goes sideways in some ways, people will criticize you for not having done a pelvic exam.

Sounds like they need to put together a Code Pelvic and when it's called the people on that committee can come take care of it while everyone else continues to provide necessary care.