Question about ER procedure

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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?


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567WingsO'Heaven said:
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?


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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
 
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BoardingDoc said:
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
Click to expand...

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...

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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.
 
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MSmentor018 said:
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.
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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.
 
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567WingsO'Heaven said:
Do you call for a derm consult to perform the biopsy?
Click to expand...

vg6xm.jpg
 
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This is not an emergency and should not be treated in the emergency department.
 
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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.
 
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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.
 
Do you call for a derm consult to perform the biopsy? Or do you release and have them follow up with their derm?


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

 
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567WingsO'Heaven said:
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...

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Click to expand...


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.
 
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...

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sonofva said:
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...

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entitlements and expectations.....it's gone way too far
 
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southerndoc said:
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.
Click to expand...

I order ortho MRI's daily. Albeit I work out the outlier hospital.
 
sonofva said:
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...

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At that point I would have d/c and told the derm not to bother coming over.
 
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sonofva said:
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...

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"This thing can flash fry a buffalo in 5 minutes."

-"But I want it now"
 
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southerndoc said:
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.
Click to expand...
As a staff physician I had to wait 6 weeks for a Derm appointment for what I thought might be a malignant lesion.
 
Penile nerve block. Punch biopsy with 14 guage. Buy pathologist lunch from cafeteria. Dx before signout.
 
turkeyjerky said:
out of curiosity, how many of you would actually call the patients dermatologist (i.e. To arrange f/u)?
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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.
 
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.


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doctalaughs said:
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.


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Click to expand...

Nice! You're spot on with the DDx


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turkeyjerky said:
out of curiosity, how many of you would actually call the patients dermatologist (i.e. To arrange f/u)?
Click to expand...

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.
 
DrYoda said:
lettuce be serious, has anyone even seen a dermatologist in the ED before.?
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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.
 
Apollyon said:
Yes... once. Wait, twice - one time was in residency, but, if I recall, dude was just walking through.
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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.


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doctalaughs said:
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.


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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****).
 
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