Question about ER procedure

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

  1. 673441

    673441 Guest

    Joined:
    Feb 20, 2015
    Messages:
    549
    Likes Received:
    441
    Status:
    Medical Student
    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. Thread continues after this sponsor message. SDN Members do not see this ad.

  3. BoardingDoc

    BoardingDoc Don't worry. I've got my towel.
    Physician

    Joined:
    Feb 23, 2010
    Messages:
    850
    Likes Received:
    1,090
    Status:
    Attending Physician
    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

    Joined:
    Feb 20, 2015
    Messages:
    549
    Likes Received:
    441
    Status:
    Medical Student
    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
     
    #3 673441, Apr 10, 2017
    Last edited: Apr 10, 2017
  5. MSmentor018

    MSmentor018 Hooah!
    Physician Faculty SDN Advisor

    Joined:
    Jul 9, 2007
    Messages:
    1,198
    Likes Received:
    236
    Status:
    Attending Physician
    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

    Joined:
    Oct 20, 2008
    Messages:
    4,753
    Likes Received:
    1,132
    Status:
    Resident [Any Field]
    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

    Joined:
    Jul 6, 2006
    Messages:
    546
    Likes Received:
    357
    Status:
    Attending Physician
    [​IMG]
     
    WheezyBaby, smq123 and racerwad like this.
  8. 673441

    673441 Guest

    Joined:
    Feb 20, 2015
    Messages:
    549
    Likes Received:
    441
    Status:
    Medical Student
    Well, you know... zero clinical experience here


    Sent from my iPhone using SDN mobile
     
  9. alpinism

    alpinism Give Em' the Jet Fuel

    Joined:
    Nov 6, 2011
    Messages:
    2,977
    Likes Received:
    2,570
    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

    Joined:
    Jun 6, 2002
    Messages:
    11,553
    Likes Received:
    469
    Status:
    Attending Physician
    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

    Joined:
    Oct 12, 2016
    Messages:
    68
    Likes Received:
    82
    Status:
    Resident [Any Field]
    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

    Physician

    Joined:
    Jun 16, 2009
    Messages:
    148
    Likes Received:
    99
    Status:
    Attending Physician
    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

    Joined:
    Oct 12, 2016
    Messages:
    68
    Likes Received:
    82
    Status:
    Resident [Any Field]

    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

    Joined:
    Aug 31, 2009
    Messages:
    1,045
    Likes Received:
    381
    Status:
    Attending Physician
    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

    Joined:
    Jul 9, 2007
    Messages:
    1,198
    Likes Received:
    236
    Status:
    Attending Physician
    entitlements and expectations.....it's gone way too far
     
    evilbooyaa, sonofva and shoal007 like this.
  16. Thread continues after this sponsor message. SDN Members do not see this ad.

  17. fahimaz7

    Joined:
    Jul 18, 2004
    Messages:
    3,269
    Likes Received:
    203
    Status:
    Attending Physician
    I order ortho MRI's daily. Albeit I work out the outlier hospital.
     
  18. gman33

    Moderator Emeritus

    Joined:
    Aug 18, 2007
    Messages:
    2,188
    Likes Received:
    489
    Status:
    Attending Physician
    At that point I would have d/c and told the derm not to bother coming over.
     
    smq123 and sonofva like this.
  19. Arcan57

    Arcan57 Junior Member

    Joined:
    Nov 21, 2003
    Messages:
    2,769
    Likes Received:
    1,103
    Status:
    Attending Physician
    "This thing can flash fry a buffalo in 5 minutes."

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

    WilcoWorld Senior Member

    Joined:
    Nov 2, 2004
    Messages:
    2,832
    Likes Received:
    1,418
    As a staff physician I had to wait 6 weeks for a Derm appointment for what I thought might be a malignant lesion.
     
  21. Groove

    Groove Member
    Physician Lifetime Donor Classifieds Approved

    Joined:
    May 3, 2004
    Messages:
    1,186
    Likes Received:
    380
    Status:
    Attending Physician
    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.
     
  22. witzelsucht

    Joined:
    Jun 20, 2012
    Messages:
    462
    Likes Received:
    678
    Status:
    Resident [Any Field]
    Penile nerve block. Punch biopsy with 14 guage. Buy pathologist lunch from cafeteria. Dx before signout.
     
  23. Apollyon

    Apollyon Screw the GST
    Physician Lifetime Donor Classifieds Approved

    Joined:
    Nov 24, 2002
    Messages:
    18,930
    Likes Received:
    3,137
    Whiney McWimperson. Walk it off!

    (Kidding, dude!)
     
  24. WilcoWorld

    WilcoWorld Senior Member

    Joined:
    Nov 2, 2004
    Messages:
    2,832
    Likes Received:
    1,418
    Actinic keratosis with inflammatory changes, maybe I shoulda lopped it off myself.
     
  25. Apollyon

    Apollyon Screw the GST
    Physician Lifetime Donor Classifieds Approved

    Joined:
    Nov 24, 2002
    Messages:
    18,930
    Likes Received:
    3,137
    And then sent yoself a bill!
     
  26. turkeyjerky

    Physician

    Joined:
    Sep 27, 2008
    Messages:
    1,688
    Likes Received:
    79
    Status:
    Resident [Any Field]
    out of curiosity, how many of you would actually call the patients dermatologist (i.e. To arrange f/u)?
     
  27. TrumpetDoc

    Joined:
    Sep 17, 2009
    Messages:
    344
    Likes Received:
    52
    Status:
    Attending Physician
    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.
     
  28. doctalaughs

    doctalaughs Member

    Joined:
    Jul 9, 2003
    Messages:
    654
    Likes Received:
    492
    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
     
  29. DrYoda

    DrYoda Space Cowboy
    Physician

    Joined:
    Jun 22, 2008
    Messages:
    13,818
    Likes Received:
    107
    Status:
    Attending Physician
    lettuce be serious, has anyone even seen a dermatologist in the ED before.?
     
    gro2001, Dr.McNinja and shoal007 like this.
  30. 673441

    673441 Guest

    Joined:
    Feb 20, 2015
    Messages:
    549
    Likes Received:
    441
    Status:
    Medical Student
    Nice! You're spot on with the DDx


    Sent from my iPhone using SDN mobile
     
  31. Apollyon

    Apollyon Screw the GST
    Physician Lifetime Donor Classifieds Approved

    Joined:
    Nov 24, 2002
    Messages:
    18,930
    Likes Received:
    3,137
    Yes... once. Wait, twice - one time was in residency, but, if I recall, dude was just walking through.
     
    567WingsO'Heaven likes this.
  32. smq123

    smq123 John William Waterhouse
    Administrator Physician SDN Advisor

    Joined:
    Jan 9, 2006
    Messages:
    13,412
    Likes Received:
    2,505
    Status:
    Attending Physician
    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.
     
  33. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner
    Moderator Physician Faculty

    Joined:
    Aug 2, 2006
    Messages:
    8,976
    Likes Received:
    4,635
    Status:
    Attending Physician
    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.
     
  34. doctalaughs

    doctalaughs Member

    Joined:
    Jul 9, 2003
    Messages:
    654
    Likes Received:
    492
    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
     
  35. Apollyon

    Apollyon Screw the GST
    Physician Lifetime Donor Classifieds Approved

    Joined:
    Nov 24, 2002
    Messages:
    18,930
    Likes Received:
    3,137
    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****).
     
  36. gro2001

    gro2001 SOCMOB
    Physician Faculty

    Joined:
    Jul 4, 2006
    Messages:
    840
    Likes Received:
    470
    Status:
    Attending Physician
    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