SDN members see fewer ads and full resolution images. Join our non-profit community!

Question about ER procedure

Discussion in 'Emergency Medicine' started by 567WingsO'Heaven, Apr 10, 2017.

  1. SDN is made possible through member donations, sponsorships, and our volunteers. Learn about SDN's nonprofit mission.
  1. 673441

    673441 Guest

    549
    436
    Feb 20, 2015
    ~ Lost In Translation ~
    Patient admitted with anxiety regarding a nonspecific skin lesion localized to the genital region. There is no pain or erythema. The lesion is localized to the glans penis and is appears purple. Light shone at the lesions reveals whitish streaks. The patient has state insurance Medicaid, and you wish to perform a biopsy to rule out cancer. The patient stated he has to wait 3-5 weeks to obtain a derm appointment, however is very anxious about the lesion. Do you call for a derm consult to perform the biopsy? Or do you release and have them follow up with their derm?


    Sent from my iPhone using SDN mobile
     
  2. SDN Members don't see this ad. About the ads.
  3. BoardingDoc

    BoardingDoc Don't worry. I've got my towel. Physician 7+ Year Member

    724
    871
    Feb 23, 2010
    Outpatient. This is not an ED workup. If I called derm to do a biopsy in the ED they would almost certainly refuse and they would be right to do so.

    If you're looking to be nice, page derm and see if they can see him sooner as an outpatient than his existing appointment
     
  4. 673441

    673441 Guest

    549
    436
    Feb 20, 2015
    ~ Lost In Translation ~
    So referral! Cool. Bonus points if you can get the DDx ;)

    (It doesn't say, fyi)

    I have an idea but I'd like to see what a doc says...

    Sent from my iPhone using SDN mobile
     
    Last edited: Apr 10, 2017
  5. MSmentor018

    MSmentor018 Hooah! Physician Faculty SDN Advisor 10+ Year Member

    1,187
    214
    Jul 9, 2007
    it's always hot!
    I work in a comm hosp without derm. I don't think derm even know where the hospital is located? refer to tertiary care center and/or call his derm if you can get a number to express your concern and boost up the appt time. I don't think I am (or any ED doc) has creds to do a biopsy.
     
    shoal007 and 567WingsO'Heaven like this.
  6. TooMuchResearch

    TooMuchResearch i'm goin' to Kathmandu... Lifetime Donor Classifieds Approved 7+ Year Member

    4,602
    1,008
    Oct 20, 2008
    Townsville, USA
    I don't think I can get derm to come to my large referral center residency hospital.

    On the plus side, there is a new derm group in town offering next day appointments as they grow their base.

    The differential includes non-emergent dermatologic concern.
     
  7. goodoldalky

    goodoldalky Member 10+ Year Member

    520
    328
    Jul 6, 2006
    [​IMG]
     
    WheezyBaby, smq123 and racerwad like this.
  8. 673441

    673441 Guest

    549
    436
    Feb 20, 2015
    ~ Lost In Translation ~
    Well, you know... zero clinical experience here


    Sent from my iPhone using SDN mobile
     
  9. alpinism

    alpinism Give Em' the Jet Fuel 5+ Year Member

    This is not an emergency and should not be treated in the emergency department.
     
  10. southerndoc

    southerndoc life is good Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    11,419
    304
    Jun 6, 2002
    Atlanta
    The ED is not the solution to Medicaid's problems, despite what the public may perceive.

    Having said that, any insured patient would have to wait nearly a month to get into a dermatologist. My wife and I have excellent insurance, and it took 3 weeks to get her MRI's scheduled after the insurance approved and I waited 2 months for a GI consult and another 6 weeks for my EGD.
     
    irJanus, WilcoWorld and turkeyjerky like this.
  11. EMDOC17

    EMDOC17

    57
    76
    Oct 12, 2016
    Etomidate, sux, 8.0 ETT and derm can see in the am. Literally the only way I'm getting derm to look at this in the hospital.
     
  12. sum dude

    sum dude MD Physician 7+ Year Member

    136
    84
    Jun 16, 2009
    Do you call for a derm consult to perform the biopsy? Or do you release and have them follow up with their derm?


    Sent from my iPhone using SDN mobile[/QUOTE]

    Always ask yourself, would Dr Cox do this? Then YES!

     
    SpacemanSpifff likes this.
  13. EMDOC17

    EMDOC17

    57
    76
    Oct 12, 2016

    Dermatitis NOS. Really it does not matter. This is not a life threatening disease and I will not diagnose it in the ED. Im not a dermatologist nor care to be one. If it is not the few life threatening rashes I will do my best but I'm not a dermatologist. The ED is not a one stop shop for everything that ails you which is the talk I have for many patients daily.
     
  14. sonofva

    sonofva 7+ Year Member

    1,037
    366
    Aug 31, 2009
    Im in a military residency. Had some woman come in with her boy for a rash and some oral burning after starting doxy. Not a life threatening rash, but the military is socialized medicine, so i figure what the hell. It was just weird looking enough so i call derm to see if they could walk him in same day. Derm said that he would come eval IN THE ED. "Holy crap,"I thought. I go tell the woman the good news, and she gets super salty because the consultant will be taking an hour to arrive...

    Sent from my SM-G930V using SDN mobile
     
    HooliganSnail and surely like this.
  15. MSmentor018

    MSmentor018 Hooah! Physician Faculty SDN Advisor 10+ Year Member

    1,187
    214
    Jul 9, 2007
    it's always hot!
    entitlements and expectations.....it's gone way too far
     
    evilbooyaa, sonofva and shoal007 like this.
  16. fahimaz7

    fahimaz7 10+ Year Member

    3,251
    193
    Jul 18, 2004
    Colorado
    I order ortho MRI's daily. Albeit I work out the outlier hospital.
     
  17. gman33

    gman33 Moderator Emeritus 10+ Year Member

    2,180
    475
    Aug 18, 2007
    At that point I would have d/c and told the derm not to bother coming over.
     
    smq123 and sonofva like this.
  18. Arcan57

    Arcan57 Junior Member 10+ Year Member

    2,729
    1,026
    Nov 21, 2003
    "This thing can flash fry a buffalo in 5 minutes."

    -"But I want it now"
     
    sonofva, surely and WilcoWorld like this.
  19. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

    2,748
    1,238
    Nov 2, 2004
    As a staff physician I had to wait 6 weeks for a Derm appointment for what I thought might be a malignant lesion.
     
  20. Groove

    Groove Member Physician 10+ Year Member

    1,120
    278
    May 3, 2004
    Non emergent. Derm referral. Call derm for definitive f/u if you are feeling nice and/or want to buff the chart. Discharge. Next pt.
     
  21. witzelsucht

    witzelsucht 5+ Year Member

    446
    642
    Jun 20, 2012
    Penile nerve block. Punch biopsy with 14 guage. Buy pathologist lunch from cafeteria. Dx before signout.
     
  22. Apollyon

    Apollyon Screw the GST Physician Lifetime Donor Classifieds Approved 10+ Year Member

    18,211
    2,127
    Nov 24, 2002
    SCREW IT!
    Whiney McWimperson. Walk it off!

    (Kidding, dude!)
     
  23. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

    2,748
    1,238
    Nov 2, 2004
    Actinic keratosis with inflammatory changes, maybe I shoulda lopped it off myself.
     
  24. Apollyon

    Apollyon Screw the GST Physician Lifetime Donor Classifieds Approved 10+ Year Member

    18,211
    2,127
    Nov 24, 2002
    SCREW IT!
    And then sent yoself a bill!
     
  25. turkeyjerky

    turkeyjerky Physician 7+ Year Member

    1,666
    64
    Sep 27, 2008
    out of curiosity, how many of you would actually call the patients dermatologist (i.e. To arrange f/u)?
     
  26. TrumpetDoc

    TrumpetDoc 7+ Year Member

    344
    51
    Sep 17, 2009
    I'm pretty positive our dermatologists don't have phones:)

    All kidding aside, I have tried in the past and never had one return an ER call.
     
  27. doctalaughs

    doctalaughs Member 10+ Year Member

    628
    441
    Jul 9, 2003
    Sounds like lichen planus. I'm a derm btw, so cheating. But in any case if it's the worst melanoma or aggressive SCC in the world it's fairly unlikely 5 weeks will make a difference.

    I am usually fairly happy to come to the ED or hospital if another doc asks (last few time very appropriate rule-out SJS or DRESS syndrome) but usually in a case like this would ask if it's ok to arrange an overbooked appointment the next day or so. Because whatever takes me 10 minutes in the office would take me 2 hours in the hospital.


    Sent from my iPhone using SDN mobile
     
  28. DrYoda

    DrYoda Space Cowboy Physician 7+ Year Member

    13,800
    75
    Jun 22, 2008
    Dagobah System
    lettuce be serious, has anyone even seen a dermatologist in the ED before.?
     
    gro2001, Dr.McNinja and shoal007 like this.
  29. 673441

    673441 Guest

    549
    436
    Feb 20, 2015
    ~ Lost In Translation ~
    Nice! You're spot on with the DDx


    Sent from my iPhone using SDN mobile
     
  30. Apollyon

    Apollyon Screw the GST Physician Lifetime Donor Classifieds Approved 10+ Year Member

    18,211
    2,127
    Nov 24, 2002
    SCREW IT!
    Yes... once. Wait, twice - one time was in residency, but, if I recall, dude was just walking through.
     
    567WingsO'Heaven likes this.
  31. smq123

    smq123 John William Waterhouse Administrator Physician SDN Advisor 10+ Year Member

    13,097
    1,906
    Jan 9, 2006
    I saw a patient once who had gone to the ER for a rash; the ER called derm to arrange next-day outpatient follow up, and the dermatologist actually agreed! (This was in a pretty high-dollar, frou-frou part of town; the dermatologist also had a Medi-spa and took care of the hospital CEO, etc etc etc.)

    Good thing, too. Because the dermatologist took one look at the patient and instantly diagnosed her with secondary syphilis.
     
  32. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner Moderator Physician Faculty 10+ Year Member

    8,569
    4,077
    Aug 2, 2006
    Texas
    Yeah, because his kid had leukemia.
    But not in a clinical role.


    I did see a rheumatologist once, and he tapped a finger in the ED. I simply called the clinic for followup, and he answered the phone and was like "I'll be right over." And then this guy that was basically the black equivalent of Emmett Brown arrived. It was mind boggling.
     
  33. doctalaughs

    doctalaughs Member 10+ Year Member

    628
    441
    Jul 9, 2003
    Ha. Yeah I recall a few EM docs cracking jokes when I've showed up; one joked he wanted to take a photo.

    But seriously - I do a ED or hospital consult maybe 5 times a year, but more often look at a photograph sent by an inpatient doctor friend (way more efficient model), and I think a dermatologist can really make a positive difference in hospital patient care. The problem is that most hospitals don't bother to arrange dermatology coverage because it's so infrequently needed and therefore not essential like other services. In addition, it's a money-losing proposition for any dermatologist to do consults at a hospital so few bother.

    I think hospitals arranging a full coverage teledermatology service makes more sense.


    Sent from my iPhone using SDN mobile
     
  34. Apollyon

    Apollyon Screw the GST Physician Lifetime Donor Classifieds Approved 10+ Year Member

    18,211
    2,127
    Nov 24, 2002
    SCREW IT!
    I just wish I had a dermie friend to bounce things off of occasionally. One o' mah grate friends is a neuroradiologist, and she is a godsend on occasion (otherwise, just a great pal with whom to bull****).
     
  35. gro2001

    gro2001 SOCMOB Physician Faculty 10+ Year Member

    807
    419
    Jul 4, 2006
    the desert
    I've called derm consults about 4 times, at a hospital with a derm residency. They showed up every time and were very helpful. Two were for r/o SJS (one ruled in, one did not), 1 for no good reason, and 1 for a VIP type patient.
     

Share This Page