Today's Pet Peeve...

[RustedFox]

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Feel free to add/delete/criticize/flame/whatever...

Here's what I want to scream at around half of my patient populous:

"ATTENTION, ALL FATTY BOOM-BAHS:"

"When you come to the ED and tell me that you have chest pain... and that you felt dizzy... and maybe a little short of breath... but it all went away after you sat down and you feel fine now... THEN EXPECT TO BE ADMITTED."

I just had one of those shifts where every obese late 40-something gave me that story, then looked at me as if I was a lunatic when I tell them I want to admit them... because THEY couldn't POSSIBLY have CAD.

Here's the real kicker: One said to me - "But... I just wanted to come and get 'checked out'." I replied - "Yep. I checked you out. The danger is clear and present. You're staying in the hospital."

*Facepalm*.

 

[Pinner Doc]

Feel free to add/delete/criticize/flame/whatever...
Here's the real kicker: One said to me - "But... I just wanted to come and get 'checked out'." I replied - "Yep. I checked you out. The danger is clear and present. You're staying in the hospital."

This is an excellent line. I may have to steal it from you.👍

 

[beanbean]

It was "chest pain day" at my shop too. However, all were very very happy to be admitted and did not seem to think I was a lunatic 🙂

Except one who was horrified that I suggested she might try the electronic cigarette to help stop smoking:

"I'll never smoke one of those. They but all sorts of bad chemicals in there that aren't FDA approved"

Ah, yes! Silly me! Cigarettes are healthy and FDA approved....by all means keep smoking them.

 

[OccupyTheED]

I had a patient and his family get upset with me today because I wouldn't send him home after one set of negative cardiac enzymes. Never mind your uncontrolled diabetes, uncontrolled hypertension, morbid obesity and the episode of SOB and diaphoresis that brought you in today.

 

[RustedFox]

The thing that probably makes it extra difficult for me is that I'm 31 and look like I'm 21. I break the news to them, and then they look at me with that sharp eye as if to say - "Ehh... what do you know anyways, boy?"

The other line that they break out is: "But... I *KNOW* my body... there's no way this is the heart."

I want to say: "Nope, you don't know your body. Not at all. If you did, you'd go fix yourself, and not be here in the ED, being evaluated for chest pain."

What I actually say is: "This may not be the big one... but this is a warning shot. One that I hope that you don't ignore for any longer."

 

[deleted109597]

My recent pet peeve was a likely similar fatty getting upset at me personally because my CT scanner isn't big enough for her.
As if I called GE and told them to cut it off at 450lbs.

 

[keeping-it-real]

The whole "just want to get checked out" thing irks me as well. The one thing you can do to avoid problems, though, is address an admission right at the beginning of the visit. After you examine the patient, tell them that you'll be doing a work-up, but that they can expect to be admitted.

If you set the expectation early, you're less likely to run into a problem. And if they do want to go home, you can start filling out the AMA paperwork sooner rather than later, and document your discussion instead of waiting until later.

 

[GeneralVeers]

The whole "just want to get checked out" thing irks me as well. The one thing you can do to avoid problems, though, is address an admission right at the beginning of the visit. After you examine the patient, tell them that you'll be doing a work-up, but that they can expect to be admitted.

If you set the expectation early, you're less likely to run into a problem. And if they do want to go home, you can start filling out the AMA paperwork sooner rather than later, and document your discussion instead of waiting until later.

I've been doing this too, which helps me start the AMA or Admission paperwork, depending on what the patient wants. I personally don't care if they go home AMA. Since they "know their bodies" and are "just here to get checked out", they will obviously know when they have a real problem and come back via ambulance.

 

[The White Coat Investor]

You admit them ALL? What's the point of you being there?

I'd say I discharge the majority of my chest pain patients. The STEMIs go to the cath lab. The high risk ones go to tele. The low risk ones go home and get a stress test tomorrow, usually after two sets of enzymes and EKGs and a few hours of being pain free.

Working with your cardiologists to ensure you can reliably get next-day stress tests improves your life, your cardiologists' lives, and your patients' lives.

What exactly do you think the risk is of a patient who has been pain-free for hours and had two negative troponins and EKGs over several hours in the ED having a fatal arrythmia in the 12-18 hours from the time you discharge them until they walk in for the stress test? It seems to me you're more likely to miss an MI in a patient without chest pain.

Don't get me wrong. I offer all these guys admission. But when I explain the real risk they're running by going home (especially versus the risks and costs of hospitalization), they all choose to run it. I document the conversation and off they go. The cardiology office calls them at 8 am and schedules the test.

Too many emergency docs don't know what the cardiologists consider "high-risk". Here's a link to their guidelines:

http://circ.ahajournals.org/content/102/10/1193/T1.expansion.html

Prior MI or stroke, age over 70, abnormal EKG, positive troponins, physical exam abnormalities, syncope, typical pain (most of the pain we see isn't) etc.

Notice there's no discussion of hyperlipidemia, DM, HTN etc.

You don't have to admit someone with some type of vague chest pain who happens to have hyperlipidemia "just in case." What you do have to do is be a doctor, determine his risk level, be cautious and conservative, have a real discussion of his risks, and treat him like you'd treat your family member.

 

[The White Coat Investor]

More from their guidelines:

1. The history, physical examination, 12-lead ECG, and initial cardiac marker tests should be integrated to assign patients with chest pain to 1 of 4 categories: a noncardiac diagnosis, chronic stable angina, possible ACS, and definite ACS. (Level of Evidence: C)
2. Patients with definite or possible ACS but whose initial 12-lead ECG and cardiac marker levels are normal should be observed in a facility with cardiac monitoring (eg, chest pain unit), and a repeat ECG and cardiac marker measurement should be obtained 6 to 12 hours after the onset of symptoms. (Level of Evidence: B)
3. If the follow-up 12-lead ECG and cardiac marker measurements are normal, a stress test (exercise or pharmacological) to provoke ischemia may be performed in the ED, in a chest pain unit, or on an outpatient basis shortly after discharge. Low-risk patients with a negative stress test can be managed as outpatients. (Level of Evidence: C)
4. Patients with definite ACS and ongoing pain, positive cardiac markers, new ST-segment deviations, new deep T-wave inversions, hemodynamic abnormalities, or a positive stress test should be admitted to the hospital for further management. (Level of Evidence: C)

My interpretation: Possible ACS with a negative trop and EKG at 6 hours after onset (usually easily doable in a 2-6 hour ED visit since many don't come right in) can get a stress test in the next day or two.

I set expectations this way- Right after the exam I tell them I'm going to be running some tests, but that I know some of the tests aren't very accurate for a few more hours, so I'll have to repeat them in (I give them an exact time based on onset of symptoms) and then we'll talk about whether we should put you in the hospital or let you go home and get a stress test in the next day or two. So they're prepped for a 4 or 5 hour ED stay and they spend that whole time hoping they can go home. So when I offer the option to stay in the hospital overnight and get a stress test or sleep in their bed overnight and get a stress test they usually choose to go home, despite a very slightly higher risk of arrythmia and a much lower risk of acquiring a hospital-associated infection or getting the wrong medication.

 

[8654Marine]

Agreed.

 

[GeneralVeers]

Agreed, but you work in an idyllic system where an outpatient stress is a reality. In my city, a patient would be lucky if they got a stress test within the next week. The only ones I ever send home are ones who have a cardiologist who has agreed to see in the office the next day.

 

[southerndoc]

You admit them ALL? What's the point of you being there?

The low risk ones go home and get a stress test tomorrow, usually after two sets of enzymes and EKGs and a few hours of being pain free.

Working with your cardiologists to ensure you can reliably get next-day stress tests improves your life, your cardiologists' lives, and your patients' lives.

What exactly do you think the risk is of a patient who has been pain-free for hours and had two negative troponins and EKGs over several hours in the ED having a fatal arrythmia in the 12-18 hours from the time you discharge them until they walk in for the stress test? It seems to me you're more likely to miss an MI in a patient without chest pain.

We have a policy that if they're risky enough to deserve a second set of enzymes, then they get admitted to an observation unit for serial enzymes. There's no reason to tie up your ED bed for 4-6 hours for a second set of enzymes. I can have a CP admitted and out of the ED within 30-45 minutes of arrival thanks to I-STAT's. I would rather clear out the ED bed and see the next patient than keep that patient in the ED for 4-6 hours to check the second enzyme.

Plus, you are really robbing your hospital of revenue that is deserved. Again, if they're low-risk, then you shouldn't be checking a second enzyme in the first place.

EDIT: Two caveats to consider are accreditation as a chest pain center (which highly encourages inpatient stress testing; we were dinged for the number of patients we discharge to follow-up with cardiology for stress testing) and the door-to-floor times that will be reportable very soon. Tie up your beds in the ED checking repeat enzymes and you'll cause more patients to wait in the waiting room, which will ultimately cause havoc on your D2F times.

 

[dotcb]

I admit most intermittent chest pain for concern of unstable angina, but if you've had constant chest pain and 1 or 2 negative troponins (depending on onset), usually it's home with a follow-up provocative test. I also recommend and explain a lot of things to patients and let them refuse, depending on my level of concern/risk for the patient and document it as so. I don't feel it's CYA medicine and I try to admit only people who really seem to need it.

 

[la gringa]

Agreed, but you work in an idyllic system where an outpatient stress is a reality. In my city, a patient would be lucky if they got a stress test within the next week. The only ones I ever send home are ones who have a cardiologist who has agreed to see in the office the next day.

+1... lots of medicaid/uninsured, poor access and pts not good advocates for themselves.

some say you shouldn't have to babysit people, but i always think of 1. the Temple case and 2. how would this look if something bad happens? no way your documented "MDM" holds up, unfortunately, if there's a bad outcome and pt came in for cp/sob and any perceivable RF (real or imagined! see old thread on flp's)

frustrating, but again, it's the world in which we live.

 

[Pinner Doc]

Too many emergency docs don't know what the cardiologists consider "high-risk". Here's a link to their guidelines:

http://circ.ahajournals.org/content/102/10/1193/T1.expansion.html

Prior MI or stroke, age over 70, abnormal EKG, positive troponins, physical exam abnormalities, syncope, typical pain (most of the pain we see isn't) etc.

Notice there's no discussion of hyperlipidemia, DM, HTN etc.

You don't have to admit someone with some type of vague chest pain who happens to have hyperlipidemia "just in case." What you do have to do is be a doctor, determine his risk level, be cautious and conservative, have a real discussion of his risks, and treat him like you'd treat your family member.

Your point is duly noted, but don't I remember a lecture by Amal Mattu about how cardiologists see all of the sick patients, but we are the ones who actually have to do the weeding through to separate the sick from the not-sick? Do we trust cardiology literature on how best to do this? I think Mattu's emphasis was on a concerning history as the number one risk factor. Just food for thought.

 

[keeping-it-real]

You admit them ALL? What's the point of you being there?

I'd say I discharge the majority of my chest pain patients. The STEMIs go to the cath lab. The high risk ones go to tele. The low risk ones go home and get a stress test tomorrow, usually after two sets of enzymes and EKGs and a few hours of being pain free.

Working with your cardiologists to ensure you can reliably get next-day stress tests improves your life, your cardiologists' lives, and your patients' lives.

What exactly do you think the risk is of a patient who has been pain-free for hours and had two negative troponins and EKGs over several hours in the ED having a fatal arrythmia in the 12-18 hours from the time you discharge them until they walk in for the stress test? It seems to me you're more likely to miss an MI in a patient without chest pain.

Don't get me wrong. I offer all these guys admission. But when I explain the real risk they're running by going home (especially versus the risks and costs of hospitalization), they all choose to run it. I document the conversation and off they go. The cardiology office calls them at 8 am and schedules the test.

Too many emergency docs don't know what the cardiologists consider "high-risk". Here's a link to their guidelines:

http://circ.ahajournals.org/content/102/10/1193/T1.expansion.html

Prior MI or stroke, age over 70, abnormal EKG, positive troponins, physical exam abnormalities, syncope, typical pain (most of the pain we see isn't) etc.

Notice there's no discussion of hyperlipidemia, DM, HTN etc.

You don't have to admit someone with some type of vague chest pain who happens to have hyperlipidemia "just in case." What you do have to do is be a doctor, determine his risk level, be cautious and conservative, have a real discussion of his risks, and treat him like you'd treat your family member.

There's no incentive to "be a doctor"...and let's not forget that not every MI is "typical." If you'd like to be cavalier about it, that's great, but at what cost? Lost revenue to the hospital? Increased liability? Potentially worse outcomes for the patient?

If my family member or even myself had chest pain that was concerning enough to warrant "emergency" evaluation, you bet I'd want them admitted, ruled-out, and then stressed. There's virtually no risk to observing a patient and then doing an inpatient stress... it's not like we're talking about cathing every low-risk chest pain.

And in regards to the quoted literature, everything there is mostly "C" evidence with one "B". That's not very convincing IMO. And I've seen too many "atypical, low-risk chest pain" patients rule-in to think that history/physical/initial negative work-up is definitive enough to be reassured. Also, it's ridiculous to think about keeping someone in the ER for 4-6 hours when they can be admitted in less than 1 hour.

The only "loser" when a low-risk chest pain patient is admitted is the insurance company... private or otherwise. And I'm not going to lose any sleep over this fact.

 

[keeping-it-real]

+1... lots of medicaid/uninsured, poor access and pts not good advocates for themselves.

some say you shouldn't have to babysit people, but i always think of 1. the Temple case and 2. how would this look if something bad happens? no way your documented "MDM" holds up, unfortunately, if there's a bad outcome and pt came in for cp/sob and any perceivable RF (real or imagined! see old thread on flp's)

frustrating, but again, it's the world in which we live.

Exactly.

Everyone can pretend otherwise, but the reality is pretty clear: you can't miss even one. Until there are protections in place, it's not worth it to take unnecessary risk. Most physicians are pretty good, but few are 100%.

If we had a reasonable medical system with reasonable patients, then that would be ideal. But since we do not and since there is no expectation of personal responsibility anymore, we do have to babysit and we do have to assume that every patient is incompetent of following our instructions. You can chose to do otherwise, but you're unnecessarily putting yourself at risk.

 

[The White Coat Investor]

ED beds fortunately not an issue for me. Nurses yes, but it doesn't take much nurse time to wait on a patient getting a second set and doing another EKG.

I'm impressed that you can get anyone admitted in less than an hour. The admitting docs don't care about the other labs, the chest x-ray etc? Surprised I guess, but that's great.

I agree that I don't discharge pts who I think are unreliable for follow-up. Fortunately we have a pretty good population. If the patient has a cardiologist, they're probably high risk and I'm admitting them. These are the patients with the lousy story- my chest has been hurting for 18 hours and my enzymes and EKG are still normal that I'm talking about. I also agree that patients with intermittent pain are scarier- much more likely to admit.

And there certainly is risk putting any patient in a hospital. They're dangerous places with lots of dangerous stuff.

 

[southerndoc]

I'm impressed that you can get anyone admitted in less than an hour. The admitting docs don't care about the other labs, the chest x-ray etc? Surprised I guess, but that's great.

I-STAT chem-8, troponin, CBC, and CXR in less than 30 minutes. Coags take about 40 minutes, but we only order them if we're heparinizing. Takes 5 minutes to discuss the patient. Transported out of the ED in less than 20 minutes usually. So long as the hospital isn't full, the turnaround time for a chest pain is pretty quick. Even high-risk patients where cardiologists come down to see the patient (in-house 24/7) can be out of the ED in less than 90 minutes.

We have a great system where we use transition orders and the hospitalizes see patients on the floors. We operate our own observation unit with internists staffing it.

We really have maximized flow pretty well.

And there certainly is risk putting any patient in a hospital. They're dangerous places with lots of dangerous stuff.

I think admitting a patient is less dangerous than sending them home. Lawyers have a dangerous appetite.

 

[8654Marine]

That is amazing throughput times. Congrats.

 

[Interpolfanclub]

I agree with the other docs who lean to admit. I've been out of residency several years and this was one of the most confusing things for me when I went into the community. The longer I do this the more I just admit chest pain patients. I rarely send one home. I've seen young people with awful stories rule in for an MI after admission.

And how many times have we read articles that state description, characteristics of the pain don't help us decide? Crummy story with no risk factors? Still could be badness. You're never safe. You and your patient have everything to lose and nothing to gain by sending these people home. For what, to save "the system" some money? As someone else said it only takes one. Miss one of these and it could potentially be years of litigation. I'd rather not roll the dice on chest pain. In the end it comes down to what you're personally comfortable with. I've worked with docs who send home 55 year old smokers after an EKG and a trop. I'd prefer to be able to sleep at night.

 

[The White Coat Investor]

Pretty amazing throughput. Very impressive.

I think part of the reason I'm able to send so many home is that we have a relatively young, healthy, reliable population.

Those of you who think you've never sent home an MI are fooling yourselves. You just didn't know it and neither did the patient (probably because the patient didn't have chest pain). Most MIs do just fine without medical care. I managed a STEMI in Guatemala with an aspirin and some heparin I got out of some heparin flushes. I put the defibrillator on him and laid on a gurney next to his all night waiting to use it. The next day he had Q waves, felt fine, and wanted to go home. No failure. No arrythmias. Not that I recommend that, just that I'm saying many people who have an unrecognized MI don't necessarily have a bad outcome.

 

[Arcan57]

Pretty amazing throughput. Very impressive.

I think part of the reason I'm able to send so many home is that we have a relatively young, healthy, reliable population.

Those of you who think you've never sent home an MI are fooling yourselves. You just didn't know it and neither did the patient (probably because the patient didn't have chest pain). Most MIs do just fine without medical care. I managed a STEMI in Guatemala with an aspirin and some heparin I got out of some heparin flushes. I put the defibrillator on him and laid on a gurney next to his all night waiting to use it. The next day he had Q waves, felt fine, and wanted to go home. No failure. No arrythmias. Not that I recommend that, just that I'm saying many people who have an unrecognized MI don't necessarily have a bad outcome.

Most MIs don't kill the patient in the same way that most turns in Russian roulette don't kill the player.

 

[RustedFox]

I admit most intermittent chest pain for concern of unstable angina, but if you've had constant chest pain and 1 or 2 negative troponins (depending on onset), usually it's home with a follow-up provocative test. I also recommend and explain a lot of things to patients and let them refuse, depending on my level of concern/risk for the patient and document it as so. I don't feel it's CYA medicine and I try to admit only people who really seem to need it.

Sadly, I do a lot of the same. I explain what's going to go on after this, and I document: "Patient refused X...Y... and Z."

 

[AmoryBlaine]

Exactly.

Everyone can pretend otherwise, but the reality is pretty clear: you can't miss even one. Until there are protections in place, it's not worth it to take unnecessary risk. Most physicians are pretty good, but few are 100%.

If we had a reasonable medical system with reasonable patients, then that would be ideal. But since we do not and since there is no expectation of personal responsibility anymore, we do have to babysit and we do have to assume that every patient is incompetent of following our instructions. You can chose to do otherwise, but you're unnecessarily putting yourself at risk.

Discharging a patient with 2 sets of neg enzymes who has an appt to see a cardiologist the next day and is pain free is well within the standard of care.

Someone might try to sue you for a bad outcome but I doubt they would get very far.

 

[diphenyl]

I get tired of giving the same speech explaining what an emergency department is for to the woman who expect me to explain why she has been having abdominal pain for 4 years.

Other things that top my list:

1. When I ask them if these symptoms have been going on for over a week, did they call there doctor? Of course they didn't.

2. Seeing fibromyalgia or any other chronic pain in the PMH.

3. Seeing more than 2 ED visits within the past 30 days on the visit history unless they are an old legitimately sickly person.

4. Explaining that the taxpayers aren't interested in paying for your child's tylenol since you obviously have enough money for an iphone, the tattoos on your body and the pack of cig's I see sticking out of your purse. (this was last week)