TooMuchResearch

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Our poison center and local toxicologists not only recommend 4-6 hours, but they distribute this information to us so we're aware of it, so I do it. They generally leave within 1-2 hours, and I don't hear about it until 10 minutes after they walk out.
Well, virtually any EM text is going to recommend 4-6 hours of observation (Same as most poison centers if you happened to call them for an opiod overdose though most of us never do). Personally, for the ones that are significant opiod overdoses....I've been watching them 2 hours. That has always made sense to me given narcan half life combined with potential for extended release narcotic ingestions, co-ingestions that they might not be reporting, etc.. Anecdotally though, there are a few I've discharged after an hour and I've always felt that with a reassuring exam, their risk was very low for any sort of adverse effect barring that they did not go back out and overdose again. Until now, all we've had is the St. Paul derivation study from 2000. Now we have a validation study and in my opinion, more of a leg to stand on if we discharge patients after an hour of observation. With all the practice patterns I've observed over the years, I'd say 1 hour obs is hyper aggressive for most EM docs. What I usually run into is that I recommend 2 hour obs and they virtually never stick around. Most sign out AMA.

For myself, 1 hour obs is a little aggressive for my historical comfort level, but I think the data is decent and seems to indicate that most traditional guidelines are probably overly conservative.
 
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Ottawa ankle rules....:rolleyes: Man, I haven't used those since residency. Do any of you really have patients that don't test positive who are coming in for an "ankle injury"? I mean, look at all the places you are pressing. I don't think I've ever had a patient who didn't say it "hurt" when I pressed somewhere in the zone. Especially the mid foot. They all go "Ow", even the fakers who are there for a work note. It's so much easier to just image the ankle.
 

TooMuchResearch

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Order X-ray first. See patient once x-ray results. Push on foot to make you don't need to send them back for foot x-ray. Discharge.
Ottawa ankle rules....:rolleyes: Man, I haven't used those since residency. Do any of you really have patients that don't test positive who are coming in for an "ankle injury"? I mean, look at all the places you are pressing. I don't think I've ever had a patient who didn't say it "hurt" when I pressed somewhere in the zone. Especially the mid foot. They all go "Ow", even the fakers who are there for a work note. It's so much easier to just image the ankle.
 

GeneralVeers

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Order X-ray first. See patient once x-ray results. Push on foot to make you don't need to send them back for foot x-ray. Discharge.
Exactly. I don't waste my time with non-critical decision rules on knees and ankles. It's just easier to X-ray all of them than it is to explain why you are not. Patients expect X-rays, and this is low on the harm list for patient satisfiers.
 

RustedFox

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Exactly. I don't waste my time with non-critical decision rules on knees and ankles. It's just easier to X-ray all of them than it is to explain why you are not. Patients expect X-rays, and this is low on the harm list for patient satisfiers.

Yep. Forget trying to practice good medicine. That ship has sailed. Far easier to waste money than do the right thing.
It sounds like I'm being sarcastic, but I'm not.
 

TimesNewRoman

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So what I’m hearing is that many of you are psuedo-legally kidnapping patients who accidentally OD on heroin......seems.....less than ideal.
 

southerndoc

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So what I’m hearing is that many of you are psuedo-legally kidnapping patients who accidentally OD on heroin......seems.....less than ideal.
Georgia has a specific involuntary hold ("2013") that deals with substance addicted individuals. So a physician has legal authority to hold a substance abuser against his or her will.
 

TimesNewRoman

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Georgia has a specific involuntary hold ("2013") that deals with substance addicted individuals. So a physician has legal authority to hold a substance abuser against his or her will.
It seems like if someone is held against their will and raised a federal suit, they could probably argue that well. That being said, most heroin users aren’t the type to lawyer up.
 

TooMuchResearch

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I just played the "don't order useless tests" game with a patient the clinic sent for me to evaluate who really did not need a CT. The clinic note said "to ED for CT" after I told the clinic doc on the phone it didn't sound like the patient needed a CT. The patient didn't want a CT and was irritated he was going to get an ED bill for something his clinic could have done. I didn't CT him. Worked again 2 days later, he calls the clinic, they say "we can't see you, you better go to the ED to get the CT." CT shows "incidental finding needing follow-up" and nothing related to the initial reason he was sent in. Now the patient gets 2 ED bills and if he follows up, specialty follow-up. The best part: This clinic absolutely can obtain same day/visit CT, so the doc could have ordered their own incidental finding CT the patient didn't need.
Yep. Forget trying to practice good medicine. That ship has sailed. Far easier to waste money than do the right thing.
It sounds like I'm being sarcastic, but I'm not.
 

Birdstrike

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I'm not at all joking or being hyperbolic when I say all of our textbooks and journals are frauds. Why? Because none of them have the statement, "You must not order unnecessary tests and treatments, in order to save money, and at the same time you must order unnecessary tests and treatments to satisfy patients." Any textbook or journal that doesn't have that statement, which is Medicine in 2019 in a nutshell, is a lie and a fraud.
 

GeneralVeers

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I'm not at all joking or being hyperbolic when I say all of our textbooks and journals are frauds. Why? Because none of them have the statement, "You must not order unnecessary tests and treatments, in order to save money, and at the same time you must order unnecessary tests and treatments to satisfy patients." Any textbook or journal that doesn't have that statement, which is Medicine in 2019 in a nutshell, is a lie and a fraud.
That's why I find it hysterical that all these people get published for "Ottawa Ankle Rules" and "Canadian C-spine rules". I understand in socialist systems like Canada they need to document why they can't get test X. In America these rules are laughable, and it's a waste of time for me to even think about them.
 
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That's why I find it hysterical that all these people get published for "Ottawa Ankle Rules" and "Canadian C-spine rules". I understand in socialist systems like Canada they need to document why they can't get test X. In America these rules are laughable, and it's a waste of time for me to even think about them.
I think they are good rules for students and residents to know about. We should at least be attempting to teach them good medicine before they are thrust into the toxic pit of despair that is Medicine 2019.

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