Recurrent Performance Problems

[Ruh-roh]

I'm a PGY-1, and with half of the year done and about 2 months of total actual EM time done, I'm noticing some pretty big recurrent problems. I was hoping to get some advice on how to deal.

Firstly, I have a really bad habit of anchoring to diagnoses. Fairly often I'll get a strong bias towards whatever diagnosis seems most likely initially. The other day, a lady with history of kidney stones came in with colicky groin pain and couldn't get comfortable in any position. I got the workup right for the kidney stones, but got embarrassed when my attending had to remind me to do a pelvic exam.

I also some times don't dive into the charts deeply enough. I always look at the med list and PMH, but a lot of times there will be a relevant recent discharge, and I won't be aware of it until my attending tells me later.

Another big one is my anxiety around really sick patients. I'm in the MICU now, and particularly today I had a crashing patient. MAP in the toilet, desatting bad. I got them the treatments they needed and knew when they had to be intubated, but my anxiety slowed me down and gave me a lot of brain fog when I really needed clarity. This kind of thing has happened a couple times before.

The first two problems I think are related to my poor attention span. I've had anxiety and attention problems since middle school at least. Whether or not I've got a couple undiagnosed psychiatric problems, I dunno. I'm gonna see a shrink soon, but in the mean time, has anyone here had to deal with problems like this? Any tips?

---

Members don't see this ad.

 

[Porfirio]

You will be fine. This is normal. This is why you are in residency. Make the mistakes now and learn from them, so you don’t make the same mistakes as an attending.

 

[emergentmd]

if I went back to residency, and given my current practice after 18 yrs; I would have attending a yell me so forgot something which I know is FOS looking for zebras. I will look into zebras after my horses are ruled out.

Sorry, no way I do a pelvic until my kidney stone horse has been ruled out.

if your attending was my resident, I would be - wtf are u doing a pelvic and wasting time.

 

[southerndoc]

Pelvic exams are performed for one purpose: to remove foreign bodies. Seriously, I can't tell you when I've gathered useful information from a pelvic exam. Even STI's can be screened through urine tests or self-swabs. Vaginal bleeding? No use unless you expect a laceration. Pregnant? Thankfully my ultrasonographers tell me if the os is closed or not. Kidney stone or rule out torsion? Nope, won't give me any info. It's either a CT or ultrasound.

 

[CajunMedic]

I’m an EM PGY-1 after a transitional year. I had the same problems (and still do sometimes). Here’s what works for me and will depend on your EHR.

Charts: I can see who’s in the waiting room on the tracker and can figure out who’s likely to get roomed and I’ll pick up. I start with their previous notes: glance at their last ED visit, admission, etc. This also gives me a rough estimate of PMHx and meds. I can see vitals on the tracker and what’s been ordered while they’re in the waiting room; along with what’s resulted before I even go in to see them.

Diagnosis Anchoring: guilty as charged. There are some (I.e. your kidney stone patient) where things seem to be relatively clear-cut. Those have been hard to think of Zebra’s when they’re telling me “feels like my previous stones”

I pause for about 30 seconds after I walk out of the room and try to think of as many as I can, or that I might have missed with my H&P. Where I’m at is OK with carrying a notepad, so I’ll write the list down and discuss why or why not during my presentation.

For a purely academic exercise on a slow off-service rotation. I took a notebook and wrote a chief complaint at the top of a page and listed everything possible underneath. Went down the list and asked “how would I ask this in an ROS”, what’s the relevant workup, and what workup overlaps. Seemed to help during the next ED month




Sent from my iPhone using SDN

 

[Rekt]

Pelvic exams are performed for one purpose: to remove foreign bodies. Seriously, I can't tell you when I've gathered useful information from a pelvic exam. Even STI's can be screened through urine tests or self-swabs. Vaginal bleeding? No use unless you expect a laceration. Pregnant? Thankfully my ultrasonographers tell me if the os is closed or not. Kidney stone or rule out torsion? Nope, won't give me any info. It's either a CT or ultrasound.

I tend to agree, but the argument is some people may not know they have a FB. Also, what about missing an obvious cancer? Especially post-menopause. Many of them haven't had someone look in a dozen years. Genuine question.

 

[Birdstrike]

I'm a PGY-1, and with half of the year done and about 2 months of total actual EM time done, I'm noticing some pretty big recurrent problems. I was hoping to get some advice on how to deal.

Firstly, I have a really bad habit of anchoring to diagnoses. Fairly often I'll get a strong bias towards whatever diagnosis seems most likely initially. The other day, a lady with history of kidney stones came in with colicky groin pain and couldn't get comfortable in any position. I got the workup right for the kidney stones, but got embarrassed when my attending had to remind me to do a pelvic exam.

I also some times don't dive into the charts deeply enough. I always look at the med list and PMH, but a lot of times there will be a relevant recent discharge, and I won't be aware of it until my attending tells me later.

Another big one is my anxiety around really sick patients. I'm in the MICU now, and particularly today I had a crashing patient. MAP in the toilet, desatting bad. I got them the treatments they needed and knew when they had to be intubated, but my anxiety slowed me down and gave me a lot of brain fog when I really needed clarity. This kind of thing has happened a couple times before.

The first two problems I think are related to my poor attention span. I've had anxiety and attention problems since middle school at least. Whether or not I've got a couple undiagnosed psychiatric problems, I dunno. I'm gonna see a shrink soon, but in the mean time, has anyone here had to deal with problems like this? Any tips?

All of these things will likely improve drastically in the next 2 1/2 years. Keep grinding.

 

[TheSingularity]

You're fine bro! Just the self awareness about these "problems" (they're not problems, they're opportunities for growth) shows that you are committed to improving. The problem residents are the ones that have no self awareness.

Also pelvic exams are largely useless. I will do in limited situations as described above and in post menopausal women to look for obvious mass.

 

[AlmostAnMD]

I tend to agree, but the argument is some people may not know they have a FB. Also, what about missing an obvious cancer? Especially post-menopause. Many of them haven't had someone look in a dozen years. Genuine question.

She spent years getting that cancer, she can wait a week and follow up. I'll document she is supposed to, up to her to do so.

 

[southerndoc]

I tend to agree, but the argument is some people may not know they have a FB. Also, what about missing an obvious cancer? Especially post-menopause. Many of them haven't had someone look in a dozen years. Genuine question.

We aren't doing Pap smears to detect cancer in the ED.

 

[dchristismi]

I can count on one hand the times a pelvic exam gave me very good information that did not involve a foreign body. (Which can be completely asymptomatic for a shockingly long time.)

Vaginal arterial bleeds. Seen 2. There is obviously something wrong, so you look, especially when they're post-menopausal or post abortion (spontaneous or therapeutic.) Along those lines, POC stuck in the os can cause some pretty impressive vagal hypotension...

And my total WTF which turned out to be a Post-hyst cuff dehiscence. This was just a couple of weeks ago, but since gyn onc sent her in and were en route, I let them do the exam. Sort of wished I'd taken a look... I've never seen bowel at the end of the speculum before. (And this gal looked great, FWIW. Would have had a raging peritonitis in another 12-24 hours, but damn that was a benign belly.)

If you are looking for (and see) an obvious cancer, that horse is not only out of the barn, it's in the next county.

OP, you're doing fine. And if you think about it, you've only spent 8 weeks in the ED. Of course you're anxious and inefficient. That's why you are in training.
I'd worry more if you figured you knew everything already and didn't have this self awareness. Just hang in there... this is always a hard time of year.

 

[thegenius]

For the first 3 of my 4 years in residency, I was really scared to see two things
- seizures
- shortness of breath with tachypnea (like RR > 40)

I don't know why seizures scared me. I felt like they were difficult to handle, difficult to manage an airway, difficult to do things like stop it in those who had poor or no IV access, etc. etc.

SOB also worried me...what can you actually do to reduce someone breathing >= 40 times a minute? Without intubating them? If it was pneumonia, they aren't going to get better in the next 30 minutes. Flash Pulm Edema was the only "fun" thing to treat because with proper interventions you can bring the 40 down to 22 in about 1 hour. And patients feel so much better they sleep.

I still (5 years out as an attending) sometimes get heebejeebies when I hear ambulance sirens, especially when I'm not working.

OP, all this stuff you are feeling is normal and you will get better, principally because you are aware of it. Force yourself to expand your differential.

Regarding to anchoring, consider doing the following. For every complaint you see, come up with 5 potential diagnoses. No matter how easy or hard or straightforward they are. I got this advice once from an attending when I was a resident, and I still come up with them to this day. It forces me to think about cases. It allowed me to catch an oddball aortic dissection once and saved this guys life.

An example MDM:
32 yo woman p/w severe LLQ pain for the past 6 hours. Normal vitals and she is minimally tender
DDx:
1. renal colic
2. acute cystitis
3. ectopic pregnancy
4. ovarian torsion
5. diverticulitis

It helps guide your workups.

Sometimes it seems silly...but do it for easy stuff too.

45 yo man p/w laceration to the left finger while cutting steak.
DDx:
1. finger lac
2. extensor tendon lac
3. flexor tendon lac
4. phalanx fracture
5. dislocation

But at least above it reminds you to do proper finger flex/ex exam passively and against resistance, and your documentation improves.

Sometimes this seems stupid. But if you do it enough, it's like putting on a seatbelt when you get into the car. You'll do it every time even if you are driving 100 feet down the road.

And sometimes you don't have to test for what you put in the DDx, or you can exclude it simply with the H&P. Like ectopic pregnancy is basically impossible if a woman has had a b/l TAH/BSO.

 

[ShockIndex]

The fact that you are concerned is good - it means that you are likely conscious and self-aware. Here are a couple of specific strategies that may help you:

1) Look only at the triage CC and vitals before seeing each patient as an intern. Try not to do a chart biopsy until after you have taken your own history and exam. While the recent history is important, doing a detailed chart review ahead of seeing the patient is a quick way to anchor on prior visits/diagnosis at the expense of the current visit. So, focus on those vitals, see the patient for yourself, then compare what you see to what has recently happened in the chart before you present to an attending. Pay special attention to how the vitals on that visit compare to prior well visits.

2) Introduce yourself and ask an open-end question of, “What are your symptoms and concerns that brought you to see us today.” Then, let them go uninterrupted for at least 90 seconds. Use that time to do an inventory of potentially life-threatening complaints. Then, go back and clarify/develop the complaints that seem concerning. Yes, many can’t communicate, so use this technique with surrogate historians.

3) Develop a ddx list of 4 things for each complaint. Be able to explain why you do or do not plan to test for those entities in you presentation.

4) For every major illness that you consider, try and think if there is a validated decision rule that will help you establish a pre-test probability. If you cannot think of one, simply Google “disease X decision rule” and things like HEART Score, Canadian Syncope Score, PERC Rule, etc. will appear when you google the disease. While it’s true that most rules preform about as good as an experienced gestalt, you don’t have that yet. Plus, these decision rules will help reinforce the signs and symptoms that are most predictive of various diseases.

5) If a patient seems to have something bizarre and you can’t figure it out, don’t forget to check their medication list. A lot of badness comes from what our colleagues prescribe. Plus, a med list can tell you a lot about someone...remember that before you get married.

 

[thegenius]

The fact that you are concerned is good - it means that you are likely conscious and self-aware. Here are a couple of specific strategies that may help you:

1) Look only at the triage CC and vitals before seeing each patient as an intern. Try not to do a chart biopsy until after you have taken your own history and exam. While the recent history is important, doing a detailed chart review ahead of seeing the patient is a quick way to anchor on prior visits/diagnosis at the expense of the current visit. So, focus on those vitals, see the patient for yourself, then compare what you see to what has recently happened in the chart before you present to an attending. Pay special attention to how the vitals on that visit compare to prior well visits.

Excellent advice
Another piece of advice I got very early in residency (actually as an M4) is the best ER doctors go right into the room and see the patient...they don't do a chart review. Absolutely it anchors on diagnoses.

5) If a patient seems to have something bizarre and you can’t figure it out, don’t forget to check their medication list. A lot of badness comes from what our colleagues prescribe. Plus, a med list can tell you a lot about someone...remember that before you get married.

 

[Tenk]

I have never in my life performed a pelvic on a woman with confirmed kidney stones and I think your attending is a ***** for telling you that you should.

Like wtf???? What are you going to do? Bimanual massage the stone out or some ****?

 

[ShockIndex]

I have never in my life performed a pelvic on a woman with confirmed kidney stones and I think your attending is a ***** for telling you that you should.

Like wtf???? What are you going to do? Bimanual massage the stone out or some ****?

I was about to make a David Neuman joke, but figured @DrMcNinja would ban me for life.

Oh well, my wife would be proud that my frontal cortex continues to recover after years spent in the army with overgrown children and guns.

 

[Tenk]

I was about to make a David Neuman joke, but figured @DrMcNinja would ban me for life.

Oh well, my wife would be proud that my frontal cortex continues to recover after years spent in the army with overgrown children and guns.

It’s not even a joke though. That is borderline perverted useless crap with like zero medical indication.

This stuff always pisses me off because this poor intern thinks they are doing something wrong when the attending is completely off base.

 

[TheSingularity]

Have seen two hypotensive vaginal lacerations secondary to intercourse. **** my pants. Personally brought one of them up to the OR to hand patient off to the surgeon.

Have also seen post hyst cuff dehisence as described above. GYN consultant was equally blown away.

Point is, there's usually some indication that keys you into "hmm maybe I should do a pelvic exam here" (lower abdominal pain without a source plus fever is another), instead of just doing them on all comers for "completion."

Sent from my Pixel 3 using SDN mobile

 

[RoyBasch]

I'm a PGY-1, and with half of the year done and about 2 months of total actual EM time done, I'm noticing some pretty big recurrent problems. I was hoping to get some advice on how to deal.

Firstly, I have a really bad habit of anchoring to diagnoses. Fairly often I'll get a strong bias towards whatever diagnosis seems most likely initially. The other day, a lady with history of kidney stones came in with colicky groin pain and couldn't get comfortable in any position. I got the workup right for the kidney stones, but got embarrassed when my attending had to remind me to do a pelvic exam.

I also some times don't dive into the charts deeply enough. I always look at the med list and PMH, but a lot of times there will be a relevant recent discharge, and I won't be aware of it until my attending tells me later.

Another big one is my anxiety around really sick patients. I'm in the MICU now, and particularly today I had a crashing patient. MAP in the toilet, desatting bad. I got them the treatments they needed and knew when they had to be intubated, but my anxiety slowed me down and gave me a lot of brain fog when I really needed clarity. This kind of thing has happened a couple times before.

The first two problems I think are related to my poor attention span. I've had anxiety and attention problems since middle school at least. Whether or not I've got a couple undiagnosed psychiatric problems, I dunno. I'm gonna see a shrink soon, but in the mean time, has anyone here had to deal with problems like this? Any tips?

I think you're at where you need to be for your level. Suspecting you have psychiatric problems yourself here seems to be a disproportionate response.

It's good to aspire to be better, but nobody expects PGY-1s to land the plane with a crashing hypotensive, hypoxic, resus patient. These moments are good for you as a learner to focus on how you would do it better in the future, but at the same time you don't need to berate yourself too hardly in this situation. There is a reason in an academic program there should always be more senior residents or staff immediately available in these situations. The only TRUE mistake you can make in these situations is trying to be a hero and try to resuscitate the patient without notifying seniors and staff.

Learning how to balance the right amount of time mining the patient's old charts but not being too thorough and expending too much time on research and comprehensive review beyond what is necessary is a long-term skill to be developed in EM.

A reasonable balance between using gestalt/heuristics to quickly diagnose and start down the pathway for common problems (i.e. kidney stone) vs. knowing when to step back a little bit and consider/exclude the zebra (AAA with pending rupture) is again a long-term skill to be developed in EM.

Many diagnostic errors are committed by anchoring and pre-mature closure on cases. At the same time common things are common. EM is defined by uncertainty. You will miss some in your career. It's just the nature of the beast. There will be some weird 20 year old with an unknown, undiagnosed underlying disease that has a catastrophic problem presenting with a seemingly benign presentation. But unfortunately, this does not merit super aggressive workups of 1000s of other patient's with similar presentations who will ultimately have benign diagnoses.

Bear in mind that the way a lot of academic attendings practice (and I should know because I split my practice between academic and true single coverage high efficiency community EM) is not effective or very compatible with community practice. They are aware of the fact that they have significant resources in terms of consultants, staff, and manpower (i.e. you the residents). They can afford to do a pelvic on EVERY female patient with flank or abdominal pain.

But I can tell you in the real world, a pelvic is a huge efficiency time sink, have to find a female RN to chaperone (I am male) who is free a the same time as me, find the pelvic bed (usually can't be found), find the gyn cart (always somewhere else), etc. If the pelvic exam is suspected to be very low yield diagnostically--I don't do it. If the patient sounds like a kidney stone, that's what I work them up for, and if your diagnosis is right, you're done and you've saved yourself a lot of time efficiency. I can tell you the patient will be happy to that you didn't do a pointless pelvic on them. We forget some times these sensitive exams are uncomfortable and embarrassing for patients and if not necessary, they should be avoided. But if your investigation for kidney stone turns up negative, you do not need to be able to go back to the drawing board and PIVOT back to different diagnostic considerations and think about what moves need to be done next, such as possibly a pelvic exam (or more likely something else).

 

[deleted109597]

I was about to make a David Neuman joke, but figured @DrMcNinja would ban me for life.

Oh well, my wife would be proud that my frontal cortex continues to recover after years spent in the army with overgrown children and guns.

Nah. #Newmanitis jokes are still valid, mainly because they're making fun of him and not the victims.
Because **** him.

 

[SamtheWise]

Pelvics for kidney stones: I feel like there's no real right answer, it's all about risk tolerance, aka are you okay missing the 1 time in 1000 that presentation is torsion. One kind of easy and not at all evidence based thing I'll do is if I get a CT KUB I'll look at the adnexa and as long as there's not a huge mass with associated swelling feel better. From some brief literature searches i've done it seems like CTs are really pretty decent for adnexal masses and I feel like there's decent evidence that if your pre-test prob is low you can effectively rule out torsion with a CT (well an IV contrasted CT).

 

[TooMuchResearch]

I can't diagnose ovarian torsion on pelvic exam.

Pelvics for kidney stones: I feel like there's no real right answer, it's all about risk tolerance, aka are you okay missing the 1 time in 1000 that presentation is torsion. One kind of easy and not at all evidence based thing I'll do is if I get a CT KUB I'll look at the adnexa and as long as there's not a huge mass with associated swelling feel better. From some brief literature searches i've done it seems like CTs are really pretty decent for adnexal masses and I feel like there's decent evidence that if your pre-test prob is low you can effectively rule out torsion with a CT (well an IV contrasted CT).

 

[TheSingularity]

Pelvics for kidney stones: I feel like there's no real right answer, it's all about risk tolerance, aka are you okay missing the 1 time in 1000 that presentation is torsion. One kind of easy and not at all evidence based thing I'll do is if I get a CT KUB I'll look at the adnexa and as long as there's not a huge mass with associated swelling feel better. From some brief literature searches i've done it seems like CTs are really pretty decent for adnexal masses and I feel like there's decent evidence that if your pre-test prob is low you can effectively rule out torsion with a CT (well an IV contrasted CT).

There is a right answer.

Don't do it.

 

[RoyBasch]

I can't diagnose ovarian torsion on pelvic exam.

I agree with you 100%; however, it seems like a bad look if you miss an ovarian torsion and you didn't do a pelvic exam. Let's be real its an eminently missable diagnosis because it's a "clinical" diagnosis without 100% sensitive imaging options (US with doppler is only 80-90% sensitive). I promise you the gynecologist who peer reviews your case of missed torsion (same person who won't come in to do a diagnostic laparoscopy when your clinical suspicion is high but the doppler is negative or equivocal) will ream you out and say if you had done the pelvic, you would have appreciated the torsion.

 

[SamtheWise]

I agree with you 100%; however, it seems like a bad look if you miss an ovarian torsion and you didn't do a pelvic exam. Let's be real its an eminently missable diagnosis because it's a "clinical" diagnosis without 100% sensitive imaging options (US with doppler is only 80-90% sensitive). I promise you the gynecologist who peer reviews your case of missed torsion (same person who won't come in to do a diagnostic laparoscopy when your clinical suspicion is high but the doppler is negative or equivocal) will ream you out and say if you had done the pelvic, you would have appreciated the torsion.

Yeah totally, I feel like documenting 'no adnexal tenderness or masses' will go a long way towards protecting you even if you don't pursue imaging.

 

[SamtheWise]

There is a right answer.

Don't do it.

I mean I get it, I don't pelvic every kidney stone, but I feel like you should at least consider it and come up with a reason for not. Pelvics are annoying, but why deprive yourself of additional information that may not be perfectly sensitive or specific, but is free, quick, and risk free to the patient.

 

[cyanide12345678]

I'm a PGY-1, and with half of the year done and about 2 months of total actual EM time done, I'm noticing some pretty big recurrent problems. I was hoping to get some advice on how to deal.

Firstly, I have a really bad habit of anchoring to diagnoses. Fairly often I'll get a strong bias towards whatever diagnosis seems most likely initially. The other day, a lady with history of kidney stones came in with colicky groin pain and couldn't get comfortable in any position. I got the workup right for the kidney stones, but got embarrassed when my attending had to remind me to do a pelvic exam.

I also some times don't dive into the charts deeply enough. I always look at the med list and PMH, but a lot of times there will be a relevant recent discharge, and I won't be aware of it until my attending tells me later.

Another big one is my anxiety around really sick patients. I'm in the MICU now, and particularly today I had a crashing patient. MAP in the toilet, desatting bad. I got them the treatments they needed and knew when they had to be intubated, but my anxiety slowed me down and gave me a lot of brain fog when I really needed clarity. This kind of thing has happened a couple times before.

The first two problems I think are related to my poor attention span. I've had anxiety and attention problems since middle school at least. Whether or not I've got a couple undiagnosed psychiatric problems, I dunno. I'm gonna see a shrink soon, but in the mean time, has anyone here had to deal with problems like this? Any tips?

Most of this is normal.

Anchoring you just need to be aware about, and I've been taught that if it's a female with lower abdominal pain then you always have to do a pelvic and consider pelvic pathologies.

Not going a thorough chart dive is normal for interns, they are not efficient. It will take you a lot of time to do things, you will be slow and often you will find yourself not having done a chart review. I've started to make the habit of quickly looking through meds, encounters, and pmh before i see patients. I maybe spend 30s to 1 minute doing it.

Anxiety around sick patients is normal. Let's face it. You are an intern, you shouldn't be comfortable around normal patients, let alone sick patients. A pgy2 Midway through residency starts feeling better. I work single coverage in a 20k volume hospital. When there are 18-20 patients in the department with a couple of sick ones, i sometimes still feel anxious (I'm only 6 months out). I've had several moments when I've thought to myself that I'm being stretched and if one more critical patient arrived then I'm screwed basically lol. It is the nature of the beast that is Emergency medicine.

 

[ShockIndex]

I mean I get it, I don't pelvic every kidney stone, but I feel like you should at least consider it and come up with a reason for not. Pelvics are annoying, but why deprive yourself of additional information that may not be perfectly sensitive or specific, but is free, quick, and risk free to the patient.

Painful and highly unlikely to yield additional information in a known stone former with symptoms consistent with renal colic (the situation we are discussing) are probably better descriptions.

I have no problem with pelvic exams being a best practice in patients having undifferentiated lower abdominal pain, especially if they are of childbearing age and using those organs. However, I’ve never recommended one when a female stone former experiences symptoms consistent with renal colic unless there are other, unrelated GU complaints.

 

[deleted109597]

I mean I get it, I don't pelvic every kidney stone, but I feel like you should at least consider it and come up with a reason for not. Pelvics are annoying, but why deprive yourself of additional information that may not be perfectly sensitive or specific, but is free, quick, and risk free to the patient.

Pelvics are not free, often not quick in many departments, and do have risk. Especially in rape victims, women who aren't sexually active, post menopausal women, and others.

If you don't have to do one, don't do it. We don't have to do them very often. In fact, we could probably get away with close to zero.

 

[thegenius]

This whole thing about pelvicing a stone is ridiculous. Are people honesty suggesting doing a pelvic exam either before or after the diagnoses of kidney stone is made?

So....you get a UA positive for blood, and imaging (CT or US/KUB) shows ureterolithiasis with hydronephrosis. And kidney stone was high, if not #1 on your differential. Your done! Why in heavens name are you going to test for CMT or adnexal tenderness which nobody can feel anyway?

This is absurd.

 

[TooMuchResearch]

I've done at least two on sexually active young women and have the nurse tell me afterwards the patient is crying and embarrassed and has never had a pelvic exam before. So yes, not without risk and discomfort.

Pelvics are not free, often not quick in many departments, and do have risk. Especially in rape victims, women who aren't sexually active, post menopausal women, and others.

If you don't have to do one, don't do it. We don't have to do them very often. In fact, we could probably get away with close to zero.

 

[TooMuchResearch]

A better test for adnexal tenderness is probably the US tech mashing it with the probe...if only there was a sonographic Murphy's sign of the adnexa.

This whole thing about pelvicing a stone is ridiculous. Are people honesty suggesting doing a pelvic exam either before or after the diagnoses of kidney stone is made?

So....you get a UA positive for blood, and imaging (CT or US/KUB) shows ureterolithiasis with hydronephrosis. And kidney stone was high, if not #1 on your differential. Your done! Why in heavens name are you going to test for CMT or adnexal tenderness which nobody can feel anyway?

This is absurd.

 

[ShockIndex]

Pelvics are not free, often not quick in many departments, and do have risk. Especially in rape victims, women who aren't sexually active, post menopausal women, and others.

If you don't have to do one, don't do it. We don't have to do them very often. In fact, we could probably get away with close to zero.

I recently changed my practice in some patients to forgoing a speculum exam, and offering only a bi-manual exam along with a couple of swabs for the patient to collect their own specimens. I only recommend the speculum if there is bleeding or concern for a FB. I’m surprised at how many still want me to look up there with a speculum.

 

[ShockIndex]

This whole thing about pelvicing a stone is ridiculous. Are people honesty suggesting doing a pelvic exam either before or after the diagnoses of kidney stone is made?

So....you get a UA positive for blood, and imaging (CT or US/KUB) shows ureterolithiasis with hydronephrosis. And kidney stone was high, if not #1 on your differential. Your done! Why in heavens name are you going to test for CMT or adnexal tenderness which nobody can feel anyway?

This is absurd.

I think the overwhelming consensus is no - not routinely needed or useful in any way.

 

[thegenius]

What is this thread about again? Let's get back on topic.

OP. You are fine. You're going to OK. Some residents don't even have the insight to know what the problem is. I'm not gonna worry about you. Just start making changes and you'll notice a difference after the next 2-4 clinical months.

 

[bky3c]

OP, there was a story circulating in my residency program about an intern who went to see a patient, discovered that she was just beginning to deliver a baby, and went tearing out of the room and down the hall screaming for "a doctor." (This is someone who, like the rest of us, did numerous deliveries as a medical student.) He is now an excellent attending EP.

We've all done (at least in our own heads) the same kind of thing numerous times. It's totally normal for an intern, and we keep stories like the above circulating because it reminds all of us that we're not alone when we feel like we're in over our heads sometimes. If you're thinking about this stuff, then you're doing fine. It's the cocky "I've been a doctor for six whole months" types who get themselves into trouble and never learn.

 

[emergentmd]

Again, Your attending are ridiculous. Many Attendings are ridiculous esp when all they do is read books and latch on to what "best practice is". If your attending was my intern, he would get a low grade doing pelvics on all abd pain. If I was his intern, I would get a bad grade b/c I will walk in to do my pelvic thinking, "another wasted pelvic exam"

Everyone will have their own way of practicing and 99% of the time, it is reasonable.

OP, nothing you did was wrong.

As you become your own attending, you will start to do stuff or not do stuff that was persistently flogged during residency.

Things I do very little of or refuse to do as an attending

1. Rectal exams on all abd pts. Unless I am looking for blood or hemmoroids, my fingers will never touch a butt again
2. LPs - Unless I am thinking Meningitis. No more LPS for "worse headache of my life" looking for blood. NEVER AGAIN
3. Pelvic exams - Unless I am looking for something specific that will change management, NEVER again

I would say I do a rectal/pelvic exam once every month. LP once a yr.

 

[thegenius]

Again, Your attending are ridiculous. Many Attendings are ridiculous esp when all they do is read books and latch on to what "best practice is". If your attending was my intern, he would get a low grade doing pelvics on all abd pain. If I was his intern, I would get a bad grade b/c I will walk in to do my pelvic thinking, "another wasted pelvic exam"

Everyone will have their own way of practicing and 99% of the time, it is reasonable.

OP, nothing you did was wrong.

As you become your own attending, you will start to do stuff or not do stuff that was persistently flogged during residency.

Things I do very little of or refuse to do as an attending

1. Rectal exams on all abd pts. Unless I am looking for blood or hemmoroids, my fingers will never touch a butt again
2. LPs - Unless I am thinking Meningitis. No more LPS for "worse headache of my life" looking for blood. NEVER AGAIN
3. Pelvic exams - Unless I am looking for something specific that will change management, NEVER again

I would say I do a rectal/pelvic exam once every month. LP once a yr.

ya similar to me. Although I probably do a few pelvics / month. I do about 5 LP's a year. And I rectalize people every other shift.

Probably too much.




For the OP, the only acceptable thing here re: pelvics is that if you have a woman with lower abdominal pain, right or left, and your differential includes ovarian torsion as #1 or #2, you better work that up first. So get the pelvic US. If ovarian torsion is on the differential but low (like no. 4 or 5), then work the others up first. Like "this is my 6th kidney stone in my R flank area with pain in my groin", then you can likely safely work that up first.