Quick question from the ED.

[EMDOC17]

Want to get the opinion of my Opthalmology colleagues. Do you expect the ED physician to do a dialated eye exam? I had a patient that I had a high suspecion of a retinal detachment. Had decently classic symptoms and a visual field cut. I did a quick bedside US which was concerning.

When I called my Opthalmologist (granted at 1 am.) I got reamed for not doing a dialated eye exam. I have done them before but very very infrequently. I did it and was still at the point of “yea I think they have a retinal detachment”. I was just surprised that I got flack for not doing the exam. Do you all expect that out of the ED?

---

Members don't see this ad.

 

[MstaKing10]

Absolutely not. That’s ridiculous. The call at 1am is probably what did it. Is there a way to set up a system where patient can follow up the next day in the office and let the doc and his/her staff know about it in the morning?

 

[EyeGuy15]

Agreed. You are not at fault. I don't know any ophthalmologist who expects an ED physician to be performing a dilated exam and definitively diagnose a retinal detachment. If they are the on call ophthalmologist, they should not be angry that they got called at 1 am. That is what happens when someone is on call. This isn't even being lazy because the ophthalmologist would not have even had to come in at 1 am. A competent ophthalmologist would have said something like "Ok, have them come to my office(or another associate who is available) when the office opens in the morning. Tell them not to eat/drink anything from now until they are seen. Here is the office information to give to the patient etc." There is no issue in care if the patient is seen in the office in the morning to make a diagnosis and treat accordingly. It's embarrassing to our profession when ophthalmologists act like this. Not your fault at all. Send the patient to another ophthalmologist if possible.

 

[cubsrule4e]

Agreed. The key here is that with a midnight presentation of an RD, nothing is going to be done until the next day anyway... but medicolegally from the ED standpoint you should probably have the ophtho consult documented. No offense, but honestly what can the average ER doc even appreciate on a dilated exam? An RD is obvious to anyone with eye experience, but most of the ER guys i deal with have no clue what that would even look like sans a google search, and even then, are you confident enough to just say RD, follow up with retina specialist in AM? Its definitely worth the call on your end even if im pissed you woke me up. The fact that you did a B scan ultrasound is already much more in depth than most of the information i get on a call.

Another pearl: If you are suspecting a patient has an RD and their visual acuity is relatively unchanged from their baseline, thats a more urgent situation, and you should definitely make the consult call. If their vision went completely out already then you have more time to coordinate follow up care even if you cant find any immediately.

 

[EMDOC17]

Agreed. The key here is that with a midnight presentation of an RD, nothing is going to be done until the next day anyway... but medicolegally from the ED standpoint you should probably have the ophtho consult documented. No offense, but honestly what can the average ER doc even appreciate on a dilated exam? An RD is obvious to anyone with eye experience, but most of the ER guys i deal with have no clue what that would even look like sans a google search, and even then, are you confident enough to just say RD, follow up with retina specialist in AM? Its definitely worth the call on your end even if im pissed you woke me up. The fact that you did a B scan ultrasound is already much more in depth than most of the information i get on a call.

Another pearl: If you are suspecting a patient has an RD and their visual acuity is relatively unchanged from their baseline, thats a more urgent situation, and you should definitely make the consult call. If their vision went completely out already then you have more time to coordinate follow up care even if you cant find any immediately.

Thanks everyone for the replies and I was kind of figuring this. I usually try to have a good exam done when calling to be prepared especially at night. Pressures, visual acuity, good slit lamp exam ect. Also no offense taken on the fact that I probably don’t know what I’m looking at. That’s pretty much my point. Sure I can do a dilated exam but do I really trust my exam? No I’m just not qualified or have the experience to do it.

Opthalmology I do think is a weak point of our residency training though. I feel like we are good at the really straight foreword easy thinks like abrasions, foreign bodies, ect. Past that I swear when I do call I often get a “that’s classic for x disease” that sometimes I’ve never even heard of.

Either way that’s for the reaffirmation that I’m not incompetent.