Vag Bleeding in Preg

[thegenius]

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Do you guys (and gals) routinely get ultrasounds for all vag bleeding in first (or for that matter second) trimester pregnancy?

And I mean those who are spotting / dripping (not hemorrhaging)
regardless of EGA
and regardless of whether you know there is an IUP or not.

Obviously one has be done to exclude ectopic, but sometimes we already know they have an IUP.

I do for the most part but I often question how it changes my management. Which is basically never. "Your pregnancy is [OK/Not OK] you have to see an OB for further management."

I guess the question really is (like a PICO question), among first trimester women who present to the ED with a known IUP and vaginal spotting / dripping, has an ED doc ever been successfully sued for missing any one of the various kinds of miscarriage classifications (threatened, incomplete, complete, missed, etc...)?

Is fetal demise, or incomplete AB, or threatened AB an emergency diagnosis?
These pregnancy vag bleeding patients very frequent, like chronic orthopedic pain.


It's so interesting...I work at two hospital systems and at one I never see these, ever! In that system all patients have good OB access. At the other hospital system which is more low-socioeconomic and lots of medicaid, I see almost one every single shift. Often more than one.

 

[Rendar5]

Do you guys (and gals) routinely get ultrasounds for all vag bleeding in first (or for that matter second) trimester pregnancy?

And I mean those who are spotting / dripping (not hemorrhaging)
regardless of EGA
and regardless of whether you know there is an IUP or not.

Obviously one has be done to exclude ectopic, but sometimes we already know they have an IUP.

I do for the most part but I often question how it changes my management. Which is basically never. "Your pregnancy is [OK/Not OK] you have to see an OB for further management."

I guess the question really is (like a PICO question), among first trimester women who present to the ED with a known IUP and vaginal spotting / dripping, has an ED doc ever been successfully sued for missing any one of the various kinds of miscarriage classifications (threatened, incomplete, complete, missed, etc...)?

Is fetal demise, or incomplete AB, or threatened AB an emergency diagnosis?
These pregnancy vag bleeding patients very frequent, like chronic orthopedic pain.


It's so interesting...I work at two hospital systems and at one I never see these, ever! In that system all patients have good OB access. At the other hospital system which is more low-socioeconomic and lots of medicaid, I see almost one every single shift. Often more than one.

Well, you kinda need to know if they need to get a D&C or not to time f/u and arrange care w/ ob/gyn. So gotta see if it's an incomplete m/c or fetal demise. Threatened Ab is just simply a diagnosis of exclusion: it's an IUP w/ bleeding or complication, so I don't really care about it, but will make it all the time.

 

[southerndoc]

https://qpp.cms.gov/docs/QPP_qualit...Registry-Measures/2017_Measure_254_Claims.pdf

This is a CMS MIPS measure. Your performance in all MIPS measures (collectively) for 2018 will determine your reimbursement in 2020. If you underperform, you will be penalized for your 2020 reimbursements. If you outperform others, you will receive higher reimbursements.

If you do not perform an ultrasound, you must document clear reasons why: ultrasound not performed due to HCG below discriminatory zone, ultrasound not performed this visit because IUP documented by ultrasound on 10/15/2018, etc.

This does NOT mean that radiology must perform the ultrasound. ED physicians may perform the exam so long as they document that they performed an ultrasound and documented the location of the pregnancy (IUP, ectopic, etc.).

 

[thegenius]

https://qpp.cms.gov/docs/QPP_qualit...Registry-Measures/2017_Measure_254_Claims.pdf

This is a CMS MIPS measure. Your performance in all MIPS measures (collectively) for 2018 will determine your reimbursement in 2020. If you underperform, you will be penalized for your 2020 reimbursements. If you outperform others, you will receive higher reimbursements.

If you do not perform an ultrasound, you must document clear reasons why: ultrasound not performed due to HCG below discriminatory zone, ultrasound not performed this visit because IUP documented by ultrasound on 10/15/2018, etc.

This does NOT mean that radiology must perform the ultrasound. ED physicians may perform the exam so long as they document that they performed an ultrasound and documented the location of the pregnancy (IUP, ectopic, etc.).

Yea I'm aware of this. My question above has lots of potential different answers depending on the situation, but it's really intended for those patients in whom we already know they have an IUP, and they have a little bit of bleeding w or w/o mild pain.

Where I work, we have to "sign up" for MIPS measures, and I didn't sign up for this one. However it would be easy to accomplish IMO.

 

[thegenius]

Well, you kinda need to know if they need to get a D&C or not to time f/u and arrange care w/ ob/gyn. So gotta see if it's an incomplete m/c or fetal demise. Threatened Ab is just simply a diagnosis of exclusion: it's an IUP w/ bleeding or complication, so I don't really care about it, but will make it all the time.

We are not trained to know if someone needs a D&C. Most of the time pregnant women miscarry to completion, so I think they can be discharged. They may have bleeding afterwards but hardly ever warrant an emergent D&C. Even fetal demise or missed AB, the body will most likely expel it at some point.

 

[carbonizedeyesockets]

Yes, every pregnant patient with vaginal bleeding gets an US.

I perform a bedside US first. If IUP, then I'm pretty much done and they can follow-up with OB. If no IUP, then I get a formal along with CBC, quant HCG, LFTs (incase methotrexate is indicated), type and screen.

 

[gamerEMdoc]

ultrasound not performed due to HCG below discriminatory zone

There is no discrimitory zone below which you shouldn't get an US to rule out ectopic. Many ectopics have lower quants than typical. I've seen ectopic pregnancies with quants of only 200. There are case reports of ectopics with negative pregnancy tests. ACOG recommends specifically against using the HCG to determine who should get an US to rule out ectopic for this reason.

Here's how I approach 1st trimester vaginal bleeding:

1. Bedside US. If I see a fetus with a heart beat on US, and no major pelvic free fluid (heterotopic) dc with OB followup. No formal US.

2. If bedside US shows no obvious IUP, formal US and quant ordered. If IUP, dc with OB followup. If ectopic, OB consult. If neither (too early to tell), followup with OB in 2 days with 48 hr quant and good return precautions.

3. If bedside US shows fetal demise (IUP, no heart beat), I get a formal US to confirm, then discuss with OB who usually has them followup in office in a day or two for a d+c if they don't pass the miscarriage naturally.

Only pitfall is what you are calling an IUP. Ectopics can have a gestational sac (pseudogestational sac). The first reliable finding on US that defines an IUP is a yolk sac. So be careful if a formal US shows an early gestational sac, that isn't technically a confirmed IUP yet.

 

[Rendar5]

We are not trained to know if someone needs a D&C. Most of the time pregnant women miscarry to completion, so I think they can be discharged. They may have bleeding afterwards but hardly ever warrant an emergent D&C. Even fetal demise or missed AB, the body will most likely expel it at some point.

::eye roll:: They still need follow up with someone in case they end up needing a D&C, since I did not express myself as accurately as you would have liked.

 

[Rendar5]

My practice pattern is the same as gamer docs with the additional caveat that I’ll also chat with my on call Ob/Gyn if there is evidence of an incomplete miscarriage with RPOC on u/s for follow up. I won’t chat with them in the cases of threatened Ab, complete Ab, or inevitable Ab.

 

[pkwraith]

First trimester known IUP and threatened abortion = no ultrasound, expectant management, ob followup, rhogam if indicated. Unless there is something very unusual.

 

[GeneralVeers]

I just get a formal US on all of them. It goes back to efficiency. It saves me a ton of time by getting a reassuring US for them, versus spending time arguing as to why they don't need one. I just really don't like arguing with uneducated people over irrelevant things.

 

[southerndoc]

There is no discrimitory zone below which you shouldn't get an US to rule out ectopic. Many ectopics have lower quants than typical. I've seen ectopic pregnancies with quants of only 200. There are case reports of ectopics with negative pregnancy tests. ACOG recommends specifically against using the HCG to determine who should get an US to rule out ectopic for this reason.

Not how I practice (I order ultrasounds on them even if they had one the day before). You are correct that HCG shouldn't be used as a cutoff to rule out ectopic, but it is still defensible that some people still practice. I see it a lot in outlying hospitals. They come to my shop after not getting an ultrasound at a facility 60 miles away because their HCG was low. I've seen a decent amount of ectopics with HCG's <1500.

 

[Vandalia]

Agree with the above. I had a very low threshold for obtaining an ultrasound in these cases. Negligible risk to the patient, Low marginal cost to the hospital (not that I particularly care.) It will also be a small component of their overall ED bill (care slightly more about that.) Yeah it can slow things down a bit, but the risk outweighs that. In other posts I have said I was not particularly worried about a malpractice suit... but if I am getting sued I don't want it being an OB/GYN case.

Some analyst will say that not doing an ultrasound in these cases (low HCG) might reduce our healthcare spending, but I will worry about that when I am getting paid for that outcome.

 

[anonperson]

Do you guys (and gals) routinely get ultrasounds for all vag bleeding in first (or for that matter second) trimester pregnancy?

And I mean those who are spotting / dripping (not hemorrhaging)
regardless of EGA
and regardless of whether you know there is an IUP or not.

Obviously one has be done to exclude ectopic, but sometimes we already know they have an IUP.

I do for the most part but I often question how it changes my management. Which is basically never. "Your pregnancy is [OK/Not OK] you have to see an OB for further management."

I guess the question really is (like a PICO question), among first trimester women who present to the ED with a known IUP and vaginal spotting / dripping, has an ED doc ever been successfully sued for missing any one of the various kinds of miscarriage classifications (threatened, incomplete, complete, missed, etc...)?

Is fetal demise, or incomplete AB, or threatened AB an emergency diagnosis?
These pregnancy vag bleeding patients very frequent, like chronic orthopedic pain.


It's so interesting...I work at two hospital systems and at one I never see these, ever! In that system all patients have good OB access. At the other hospital system which is more low-socioeconomic and lots of medicaid, I see almost one every single shift. Often more than one.

Regardless if they have an IUP based on prior knowledge, an US will at least help confirm viability in this setting which is important for follow up purposes.

As far as concern for ectopic, even with low Beta hcg, the US can provide valuable information (free fluid in the cul de sac, complex adnexal mass etc) .

Also, second trimester encompasses 14 weeks to 27+6. How would you know you aren't missing a placenta previa or low lying placenta? Those won't always present with hemorrhage either.

US is low cost with minimal risk

 

[GonnaBeADoc2222]

Formal ultrasound for all.

They came in because they are worried about their baby. Check out the baby.

Who cares?

 

[gro2001]

Not doing an ultrasound on a pregnant vag bleeder, even when I know they have an IUP, is like not listening to the heart/lungs on a patient in my book. I'm sure the practice of not doing it can probably be backed up with evidence, but the visit just would be incomplete without it. The patient expects it, and it's not an unreasonable expectation. It will make them more comfortable in a very stressful situation. It's not harmful. Just do it.

 

[TheComebacKid]

If the patient has vaginal bleeding + IUP, they are threatened Ab and go home with outpatient f/u with OB. I don't see the utility to obtaining a beta in these patients, but I guess many OBs like it because it assists with outpatient follow-up. From the ED standpoint though, it has no utility IMO.

If the patient has vaginal bleeding + NO IUP + free fluid/adnexal mass, they are an ectopic pregnancy until proven otherwise. You can get a beta if you want (mostly because OB probably will ask you for it), but it's not going to help me rule in/rule out ectopic, since as stated above, patients can have ectopic with low betas. They get a formal US and/or OB consult depending on the findings.

If the patient has vaginal bleeding + NO IUP + NO free fluid/adnexal mass, they get a beta to see where they are at. With respect to the discriminatory zone, the beta does not tell you anything with respect to when to perform an ultrasound. If it's above 1500 and you don't have an IUP on bedside US, then it's ectopic unless proven otherwise. You can get a formal US, talk to OB, do whatever you want to ensure ectopic is ruled out at that point. If it's less than 1500, the patient doesn't have any free fluid, peritonitis, unstable vitals etc, they get 48 hour follow-up with OB and a repeat beta at that point in the event they have a small ectopic.

My understanding of the utility of the beta, especially when its less than 1500, deals with the percentage increase at 48 hours which can clue you in on the likelihood of an ectopic or not. These patients can get serial betas and US to follow the prospect of ectopic with OB as an outpatient.

I really don't entertain the prospect of a heterotopic pregnancy unless the patient is on fertility treatments. Who knows, maybe I'll get sued for this at some point in my career, but it's one of those things that's so rare that I think it's not worth routinely chasing unless you have a really high suspicion.

If pregnant patients come in hemodynamically unstable, hemorrhaging, peritonitis, free fluid in the pelvis, all bets are off, they get reliable access, aggressively resuscitated, type and crossed, and I'll err on the side of just consulting OB without formal US/beta yet. In the event that it's appendicitis or something else that is non-OB related, I still figure OB will be involved in their care and it doesn't hurt to get them involved early.

 

[Apollyon]

Heterotopic 1/30000 in female not on fertility tx. That's why, if you order US for ectopic, first thing they do is look at the uterus. IUP? They stop there.

On fertility tx? Heterotopic drops to 1/100. Then, US goes searching.

 

[BoardingDoc]

Not doing an ultrasound on a pregnant vag bleeder, even when I know they have an IUP, is like not listening to the heart/lungs on a patient in my book.

I agree about the US. I find the analogy confusing though. I certainly don't listen to the heart/lungs of every patient that rolls in, including my vag bleeding patients.

 

[Fox800]

Not how I practice (I order ultrasounds on them even if they had one the day before). You are correct that HCG shouldn't be used as a cutoff to rule out ectopic, but it is still defensible that some people still practice. I see it a lot in outlying hospitals. They come to my shop after not getting an ultrasound at a facility 60 miles away because their HCG was low. I've seen a decent amount of ectopics with HCG's <1500.

Just had an ectopic with a bHCG of 46. And we've seen them with betas in the single digits.

 

[Apollyon]

Just had an ectopic with a bHCG of 46. And we've seen them with betas in the single digits.

That had to be trending down, though. If it was going up, and only 46, then there would be no way to see it on US, even transvag.

 

[RustedFox]

I just get a formal US on all of them. It goes back to efficiency. It saves me a ton of time by getting a reassuring US for them, versus spending time arguing as to why they don't need one. I just really don't like arguing with uneducated people over irrelevant things.

So much this.
I've recently changed my practice so much because of this.
Had a guy last night who wanted a drug and alcohol test "to prove that the sobriety house's test was wrong". I tried only once to explain to him why "that won't work" and then ordered the UA/serum EtOH. Surprise! both positive.

 

[turkeyjerky]

Formal ultrasound for all.

They came in because they are worried about their baby. Check out the baby.

Who cares?

I'm sure the nstemi who has to sit in the WR for an extra 3 hrs cares. Or the US tech who has to cone in at 3am and then work the next day.

I sometimes order an ultrasound, sometimes don't. I work in an inner city ED and we see a ton of these patients, frequently coming back several times without attempting to see obgyn. Yesterday I discharged one without an ultrasound. She came in with 2 hrs of light bleeding, quant was trending up from two days ago when she had an IUP on her ultrasound. She has an ob appt scheduled for Monday. At some point you have to think about resource allocation.

 

[Fox800]

That had to be trending down, though. If it was going up, and only 46, then there would be no way to see it on US, even transvag.

Fair. I'm just promoting the dogmalysis of "it *can't* be an ectopic if the beta is only XXXX".

 

[RustedFox]

I'm sure the nstemi who has to sit in the WR for an extra 3 hrs cares. Or the US tech who has to cone in at 3am and then work the next day.

I sometimes order an ultrasound, sometimes don't. I work in an inner city ED and we see a ton of these patients, frequently coming back several times without attempting to see obgyn. Yesterday I discharged one without an ultrasound. She came in with 2 hrs of light bleeding, quant was trending up from two days ago when she had an IUP on her ultrasound. She has an ob appt scheduled for Monday. At some point you have to think about resource allocation.

I'm in agreement with you about resource allocation, but here's the ballgame. Pay attention.
Resource allocation isn't a threat to your job.
Patient satisfaction nonsense most certainly is.
The NSTEMI gets admitted, with likely no change in outcome. They don't get a "survey".
The US tech gets pissy, but nobody asks her about her "satisfaction".
The G22P16 female who wants her ultrasounds (sic), now! -Yeah, she knows how to make noise. She is the biggest threat to your job security.
Its a shame that's the way it is, but... that's the way it is.

 

[Angry Birds]

This is a difficult issue for those of us without ultrasound overnight. That’s why I hate these.

 

[GonnaBeADoc2222]

I'm sure the nstemi who has to sit in the WR for an extra 3 hrs cares. Or the US tech who has to cone in at 3am and then work the next day.

I sometimes order an ultrasound, sometimes don't. I work in an inner city ED and we see a ton of these patients, frequently coming back several times without attempting to see obgyn. Yesterday I discharged one without an ultrasound. She came in with 2 hrs of light bleeding, quant was trending up from two days ago when she had an IUP on her ultrasound. She has an ob appt scheduled for Monday. At some point you have to think about resource allocation.

If someone had a normal ultrasound in the same clinical setting (i.e. bleeding 2 days ago, got normal u/s, now here again cause same bleeding) then I 100% agree. If first episode of bleeding +/- pain even if known IUP, just get the ultrasound. I don't care about "resource allocation." The system certainly doesn't care about "allocation" of my "resources" when I'm solo coverage seeing 4 pph in a surge and getting interrupted 5x/min with nonsense. Couldn't care less about US tech having to come in. They are paid to be on call, just like I am paid to see patients in the ED. Why should one's practice change depending on the time of day?

This is a difficult issue for those of us without ultrasound overnight. That’s why I hate these.

If no prior confirmed IUP, and no bedside u/s machine, or if I'm not definitive on my bedside u/s, this gets transferred in a heartbeat to a real hospital. Not our responsibility to absorb risk for hospitals that don't want to staff their facilities appropriately.

 

[GeneralVeers]

This is a difficult issue for those of us without ultrasound overnight. That’s why I hate these.

You work in a place with no US overnight? I've been in smallish rural hospitals and have never had this issue. How do you address it when someone needs a stat US to rule out an emergency. Do you transfer all the pregnant vag bleeders, female lower abdominal pain, and testicular pain out?

 

[Angry Birds]

You work in a place with no US overnight? I've been in smallish rural hospitals and have never had this issue. How do you address it when someone needs a stat US to rule out an emergency. Do you transfer all the pregnant vag bleeders, female lower abdominal pain, and testicular pain out?

We used to have overnight u/s and they recently axed it due to how infrequently it was used, without listening to any of our protestations that it is a necessity. This would be a "deal breaker" except that I love my job precisely because it is rural and "middle of nowhere."

And yeah, you need to transfer out what you need to. But, sometimes it can lead to a lot of begging and pleading, and also dealing with very cranky GYN doctors.

As an aside, do you all feel very confident when you have to report how many cm's the Os is open? For the life of me, I was never able to learn this skill properly, even though I did plenty of OB-GYN in residency.

 

[GeneralVeers]

We used to have overnight u/s and they recently axed it due to how infrequently it was used, without listening to any of our protestations that it is a necessity. This would be a "deal breaker" except that I love my job precisely because it is rural and "middle of nowhere."

And yeah, you need to transfer out what you need to. But, sometimes it can lead to a lot of begging and pleading, and also dealing with very cranky GYN doctors.

As an aside, do you all feel very confident when you have to report how many cm's the Os is open? For the life of me, I was never able to learn this skill properly, even though I did plenty of OB-GYN in residency.

It almost never comes up. In any female with > 20 weeks pregnancy, they are going to go to L&D. Less than 20 weeks I'm just getting an US and not even doing a pelvic unless hemorrhaging out of control.

The only time this came up is when a busy suburban hospital I was working at lost their OB services. They centralized it to the newer hospital down the road. We of course still had women in labor present to the ED. We were told we could transfer any of them if the Cervical OS was less than 5 cm dilated. Otherwise they would be "unstable" for transfer and we had to keep them in the ER and do an ER delivery. Needless to say every single pregnant patient in labor I evaluated was <5 cm dilated, so I could transfer them out.

 

[Apollyon]

You work in a place with no US overnight? I've been in smallish rural hospitals and have never had this issue. How do you address it when someone needs a stat US to rule out an emergency. Do you transfer all the pregnant vag bleeders, female lower abdominal pain, and testicular pain out?

Small, rural places (like where I work) rarely have cases that need US when I need it. My US tech is here M-F, 0730-4. Outside those hours, nada. Poss testicular tortion, I can transfer 1hr away for US. Rare. Preg vag bleed? Rare. I call OB 40 minutes, 1hr, or 1 hr away, and follow their advice.

But, our volume is 7k/year. There isn't a lot of anything.

When you're uncovered, you are. You learn to make do.

 

[thegenius]

I just get a formal US on all of them. It goes back to efficiency. It saves me a ton of time by getting a reassuring US for them, versus spending time arguing as to why they don't need one. I just really don't like arguing with uneducated people over irrelevant things.

I need to practice more like you do. I'm still in the "want to educate" mode and i probably get through about 1 in 50 patients. A potential waste of time. Occasionally I feel good about myself but the NNFM (number needed to frustrate me) is like 10.

 

[thegenius]

Formal ultrasound for all.

They came in because they are worried about their baby. Check out the baby.

Who cares?

This stuff gets me so frustrated...the IUP with intermittent spotting/bleeding over 6 weeks and we ask, even plead, with these patients to go to outpatient OB and they don't do it, and they get 5 ultrasounds that all say the same thing except a change in dates. It's frustrating because the path of least resistance is chosen by patients by coming to an ER where they don't have to pay anything. It's the path of least resistance by us because it takes 5 seconds to order the US and be done with it.

And I get pissed off when my insurance premiums continue to rise by 10% a year. I now pay $1,600/month for my family and it's because (in part), crap like this in our health care system.

Maybe I shouldn't care.

 

[thegenius]

Just had an ectopic with a bHCG of 46. And we've seen them with betas in the single digits.

What did the US show? Something on the adnexa? Can't see much of anything with beta of 46.

 

[thegenius]

I'm in agreement with you about resource allocation, but here's the ballgame. Pay attention.
Resource allocation isn't a threat to your job...

LMAO

 

[GonnaBeADoc2222]

This stuff gets me so frustrated...the IUP with intermittent spotting/bleeding over 6 weeks and we ask, even plead, with these patients to go to outpatient OB and they don't do it, and they get 5 ultrasounds that all say the same thing except a change in dates. It's frustrating because the path of least resistance is chosen by patients by coming to an ER where they don't have to pay anything. It's the path of least resistance by us because some of these ultrasounds are not indicated.

And I get pissed off when my insurance premiums continue to rise by 10% a year. I now pay $1,600/month for my family and it's because (in part), crap like this in our health care system.

Maybe I shouldn't care.

Believe me. I hear you bro.

 

[GeneralVeers]

And I get pissed off when my insurance premiums continue to rise by 10% a year. I now pay $1,600/month for my family and it's because (in part), crap like this in our health care system.

Maybe I shouldn't care.

The issue is patient complaints. I would happily turf all of the obvious IUP patients with bleeding out the door without repeating multiple ultrasounds. Unfortunately complaints are what will get me fired. Even if I'm not fired, responding to every patient complaint and justifying my actions to non-clinical *****s who run admin takes away hours of my life I'm not getting back.

 

[thegenius]

You work in a place with no US overnight? I've been in smallish rural hospitals and have never had this issue. How do you address it when someone needs a stat US to rule out an emergency. Do you transfer all the pregnant vag bleeders, female lower abdominal pain, and testicular pain out?

I too work part time at a hospital with no overnight US.
I've been there for 2.5 years...
-- Preg Vag Bleeder = I rarely get this, sometimes I'll do trans abd US, sometimes I do trans vag US, will get labs, basically it's not really an emergency unless they are unstable. They can get the US the following morning. We do have OB on call though for the unstable ones.
-- Testicular Pain = Actually never had one, but if one came in I would consult Urology and they would come in.
-- DVT = I sometimes do my own US, sometimes I give lovenox and d/c (with OP US the next day), sometimes I just keep in the ED until the AM.
-- RUQ pain = I'll do my own US, and have admitted cholecystitis based on my US imaging before.

 

[thegenius]

As an aside, do you all feel very confident when you have to report how many cm's the Os is open? For the life of me, I was never able to learn this skill properly, even though I did plenty of OB-GYN in residency.

Nope...I usually say one finger wide, or two finger wide. Or 2 finger wide and I can feel the head. And I don't know jack about station.

 

[RustedFox]

This stuff gets me so frustrated...the IUP with intermittent spotting/bleeding over 6 weeks and we ask, even plead, with these patients to go to outpatient OB and they don't do it, and they get 5 ultrasounds that all say the same thing except a change in dates. It's frustrating because the path of least resistance is chosen by patients by coming to an ER where they don't have to pay anything. It's the path of least resistance by us because it takes 5 seconds to order the US and be done with it.

And I get pissed off when my insurance premiums continue to rise by 10% a year. I now pay $1,600/month for my family and it's because (in part), crap like this in our health care system.

Maybe I shouldn't care.

LMAO.
2K for my wife and I each month. No kids.
Thank you, please drive thru.

 

[thegenius]

The issue is patient complaints. I would happily turf all of the obvious IUP patients with bleeding out the door without repeating multiple ultrasounds. Unfortunately complaints are what will get me fired. Even if I'm not fired, responding to every patient complaint and justifying my actions to non-clinical *****s who run admin takes away hours of my life I'm not getting back.

I hear ya man. F'ing terrible. It's often actually hard to do the right thing.

 

[thegenius]

LMAO.
2K for my wife and I each month. No kids.
Thank you, please drive thru.

You must have the "Gold Card" insurance. Or your 60 years old. LOL.
I went through the drive through, gonna go through it again.

 

[RustedFox]

You must have the "Gold Card" insurance. Or your 60 years old. LOL.
I went through the drive through, gonna go through it again.

Platinum care plan.
I am 36 with inflammatory bowel disease.
Wife is 35 and is a cancer survivor.
"Uninsurable."
You don't skimp on these things when there's good reason not to.

 

[RustedFox]

I hear ya man. F'ing terrible. It's often actually hard to do the right thing.

I hear you, man.
I recently was up for re-credentialing, and had to explain why so many patients had complained about me to the med.exec committee.
I sat in that room and said some things that made all the other docs uncomfortable about "what the right thing to do" is in some bizarre situations.
I even pulled up a chart where I DC'ed home the obviously abusive fibromyalgia patient, where I ran the database search and said "no".
The next day, the patient came back, saw the next doc.
"Dilaudid 2mg oral tablets, here you go", said the next doc.
I invited the committee to come spend a shift with me by saying "You don't go to Home Depot, order spaghetti, and then get mad because the priest won't listen to your confession and didn't bring you extra breadsticks. That's all day, every day for us here in the ER."
I also said: "Take a look at our Facebook page. There's scores of people thanking me for being down-to-earth and understandable. One guy even said "Dr. Fox isn't just another egghead in a white coat. You can tell that he cares about what he does. Thank you for your ministry."
I am re-credentialed. I hope that the office-based OBGYN, the dumb Orthopedic surgeon, and the mouthbreather Nephrologist learned something from me.

 

[miacomet]

You work in a place with no US overnight? I've been in smallish rural hospitals and have never had this issue. How do you address it when someone needs a stat US to rule out an emergency. Do you transfer all the pregnant vag bleeders, female lower abdominal pain, and testicular pain out?

There is a level 1 trauma center in NYC without US overnight. Seriously insane.

 

[RustedFox]

While I'm thinking about it... this is the perfect thread for this. How serendipitous.

/b/

Be me.
Two weeks ago.
2 am.
Momma brings 13 year old female to ER for abdominal pain.
13 year old screams at momma that she doesn't have any abdominal pain, and wants to go home. Now.
Exam totally normal.
13 year old keeps screaming at mom. I would have been mad, too if my kid kept mouthing off at me like she did.
Mom cuts to the chase.
"I want you to do a test to see if she's going to get her first period anytime soon."
"MOOOOM!"
"Listen, I don't think I can help a girl who is in no pain, says she doesn't want to be here, and by the way; no such test exists."
Mom gets all 'Bye Felicia!' on me, promises to complain.
K.
Listen lady, you brought your 13 year old daughter to the ER at 2 AM to have an "Are you There God? It's Me, Margaret" talk with a strange man in his late 30s.
Strong work.
You are what is wrong with America.
Don't let that stop you from getting your next tattoo and upgrading your iPhone, though.
Don't worry; I got the tab for the important things.

 

[GeneralVeers]

My PA (who is very capable) saw this pregnant lady yesterday at about midnight who was 8 weeks pregnant and in a car accident 4 days previously. She had no vaginal bleeding or fluid leakage but was demanding an ultrasound. My PA tried to explain things like science, facts, and logic to her with no avail. The lady demanded to see me instead.

I went in to talk to her and this gypsy lady begins screaming at me and wouldn't let me even get a word in: "God put a baby in me, and I'm just trynna take care of my baby, and you don't need to be told what you should do, you should just do it!"

I basically just agreed to do it at that point. Otherwise it would take too much of my time to argue. I told my PA to order it, but slow-walk the exam and discharge so that it would take at least 2 hours.

 

[RustedFox]

My PA (who is very capable) saw this pregnant lady yesterday at about midnight who was 8 weeks pregnant and in a car accident 4 days previously. She had no vaginal bleeding or fluid leakage but was demanding an ultrasound. My PA tried to explain things like science, facts, and logic to her with no avail. The lady demanded to see me instead.

I went in to talk to her and this gypsy lady begins screaming at me and wouldn't let me even get a word in: "God put a baby in me, and I'm just trynna take care of my baby, and you don't need to be told what you should do, you should just do it!"

I basically just agreed to do it at that point. Otherwise it would take too much of my time to argue. I told my PA to order it, but slow-walk the exam and discharge so that it would take at least 2 hours.

1 year into my first job, I said to myself "we need a separate 'bull****' department for people who want meaningless nonsense".
3 jobs later (I still have the first job, by the way), that's everywhere.

 

[thegenius]

My PA (who is very capable) saw this pregnant lady yesterday at about midnight who was 8 weeks pregnant and in a car accident 4 days previously. She had no vaginal bleeding or fluid leakage but was demanding an ultrasound. My PA tried to explain things like science, facts, and logic to her with no avail. The lady demanded to see me instead.

I went in to talk to her and this gypsy lady begins screaming at me and wouldn't let me even get a word in: "God put a baby in me, and I'm just trynna take care of my baby, and you don't need to be told what you should do, you should just do it!"

I basically just agreed to do it at that point. Otherwise it would take too much of my time to argue. I told my PA to order it, but slow-walk the exam and discharge so that it would take at least 2 hours.

OMG I would have just walked out and said "I'm discharging you."
Or called security to the room and tell security that I'm being threatened by a patient.

The best though, would be to say "That will cost $100".

 

[GeneralVeers]

OMG I would have just walked out and said "I'm discharging you."
Or called security to the room and tell security that I'm being threatened by a patient.

The best though, would be to say "That will cost $100".

All of those things would result in me being fired.