Vag Bleeding in Preg

[thegenius]

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Just thinking about this...all vag bleeding should get an Rh too as that is a MIPS meausre

2017 MIPS Measure #255: Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure

That is an annoying big copy-paste.

 

[miacomet]

Just thinking about this...all vag bleeding should get an Rh too as that is a MIPS meausre

2017 MIPS Measure #255: Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure

That is an annoying big copy-paste.

Well, that makes medical sense, no?

 

[thegenius]

Well, that makes medical sense, no?

I worked with someone who recently graduated and knows more about current EBM and he said that Rh early on in pregnancy basically doesn't change outcomes. I said "wooh hoo!!!" and told myself that until guidelines change, you get rhogam.

Which, at our institution, is a pain in the butt to administer. Literally and figuratively.

 

[miacomet]

I worked with someone who recently graduated and knows more about current EBM and he said that Rh early on in pregnancy basically doesn't change outcomes. I said "wooh hoo!!!" and told myself that until guidelines change, you get rhogam.

Which, at our institution, is a pain in the butt to administer. Literally and figuratively.

Sure, you need to have a critical amount of fetal blood. It's true.

 

[coachB]

I worked with someone who recently graduated and knows more about current EBM and he said that Rh early on in pregnancy basically doesn't change outcomes. I said "wooh hoo!!!" and told myself that until guidelines change, you get rhogam.

Which, at our institution, is a pain in the butt to administer. Literally and figuratively.

UK guidelines specifically say don't give it in the first trimester. The ancient US guideline from the 1990s that everyone refers to really only says you should "consider" it. And if you are worried about adhering to the measure referenced, there is really no "risk of fetal blood exposure" prior to 8 weeks gestational age.

 

[Rendar5]

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.

I had a somewhat similar patient but with reasonable parents and some questionable pain a month ago. Diagnosed with imperforate hymen. Of course i gave the kid an option of me checking them or their pediatrician at a f/u app’t and they opted for their own doctor who they were comfortable with.

Remove the attitude (parents, not yours) and occasionally you have a real diagnosis to find. Of course you still have plenty of BS to wade through to get to those real cases and I would have done the same thing as you did.

 

[GeneralVeers]

Sure, you need to have a critical amount of fetal blood. It's true.

UK guidelines specifically say don't give it in the first trimester. The ancient US guideline from the 1990s that everyone refers to really only says you should "consider" it. And if you are worried about adhering to the measure referenced, there is really no "risk of fetal blood exposure" prior to 8 weeks gestational age.

In the US "consider" means "give in every situation or else". If it's something that a lawyer could latch onto in a potential lawsuit, then you have to cover for it.

 

[RoyBasch]

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.

This has demonstrated to me that the /b/ notation is the perfect way to document most ER encounters. Perhaps this will be the structure of my future MDMs.


"be me
patient with abdominal pain x3 years, unchanged, constant
multiple ER visits with every possible test done and negative
HitTheBricks.jpg"

 

[thegenius]

In the US "consider" means "give in every situation or else". If it's something that a lawyer could latch onto in a potential lawsuit, then you have to cover for it.

i do find "consider" language in clinical guidelines to be rather unhelpful. I agree.
consider flomax for renal colic
consider rhogam for Rh- pregnant vag bleeders early first trimester
consider abx for uncomplicated diverticulitis

problem is most urologists, gynecologists, and GI doctors all say do the above if you consult them.

Out of the three above I have sent home a few uncomplicated diverticulitis without antibiotics and have not had a problem. these patients are educated and get it when I explain to them several recent studies showing no benefit

 

[gamerEMdoc]

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.

Honestly, I've found that the beside US is more reassuring than you think. When you see an IUP and can show them the fetus, show them the heart beat, and print them the picture... patients generally are instantly reassured.

 

[gamerEMdoc]

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.

I'm not sure it's defensible. Both ACOG and ACEP recommend against using a specific quant level to determine if an US is necessary to rule out ectopic. I think if someone died of a ruptured ectopic that wasn't diagnosed because someone didn't order an US because the quant was 1200, that would be an easy win for the plantiff's attorney IMO. It would be hard to find an expert witness to say the standard of care is to not order an US when the the societies for both specialties say that is not the standard of care.

 

[gamerEMdoc]

UK guidelines specifically say don't give it in the first trimester. The ancient US guideline from the 1990s that everyone refers to really only says you should "consider" it. And if you are worried about adhering to the measure referenced, there is really no "risk of fetal blood exposure" prior to 8 weeks gestational age.

This has been a pet peave of mine for years ever since hearing the infamous David Newman's breakdown on the Rh literature. Its amazing to me that all other OB societies recommend against first trimester Rhogam, and ACOG continues to recommend "considering" it.

 

[Apollyon]

Honestly, I've found that the beside US is more reassuring than you think. When you see an IUP and can show them the fetus, show them the heart beat, and print them the picture... patients generally are instantly reassured.

I never ever give the pt a printout of the bedside US. What happens when the kid is born with undiagnosed HLHS? What about ANYTHING else wonky? You're on the hook for "that doctor told me everything was good!" Even if you didn't say that, they WILL say that you did, and the express evidence is that you gave them a picture.

And this is not my individual advice.

 

[GeneralVeers]

I never ever give the pt a printout of the bedside US. What happens when the kid is born with undiagnosed HLHS? What about ANYTHING else wonky? You're on the hook for "that doctor told me everything was good!" Even if you didn't say that, they WILL say that you did, and the express evidence is that you gave them a picture.

And this is not my individual advice.

Another reason why I like a formal US read by a radiologist. It gives me a lot of supporting evidence if there's a bad outcome and I get sued. They can't blame for "user error" or "missing a finding" on the US if the radiologist reads it.

 

[gamerEMdoc]

I never ever give the pt a printout of the bedside US. What happens when the kid is born with undiagnosed HLHS? What about ANYTHING else wonky? You're on the hook for "that doctor told me everything was good!" Even if you didn't say that, they WILL say that you did, and the express evidence is that you gave them a picture.

And this is not my individual advice.

HLHS? Man, I'm doing US on a 6 week fetus and showing a picture of something that has a flicker on the screen and I'm lucky if I can make out the head. I don't do fetal cardiac ultrasonography in the 3rd trimester.

Interesting point though. I wonder if there is any cases of someone getting sued for giving a first trimester bleeding mom a still photo of their US that was used against them. I'm not saying it couldn't be used against you, I'm just saying I would be surprised if it has actually happened in the case of a first trimester US in the ED.

 

[deleted109597]

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.

Best part of vertical patients. Order the test. Put them in the lobby for results.

 

[deleted109597]

I never ever give the pt a printout of the bedside US. What happens when the kid is born with undiagnosed HLHS? What about ANYTHING else wonky? You're on the hook for "that doctor told me everything was good!" Even if you didn't say that, they WILL say that you did, and the express evidence is that you gave them a picture.

And this is not my individual advice.

I just tell them I don't have a machine that prints, and the ER tech uses this machine. If they want a printout, they need an outpatient exam.

 

[Apollyon]

HLHS? Man, I'm doing US on a 6 week fetus and showing a picture of something that has a flicker on the screen and I'm lucky if I can make out the head. I don't do fetal cardiac ultrasonography in the 3rd trimester.

Interesting point though. I wonder if there is any cases of someone getting sued for giving a first trimester bleeding mom a still photo of their US that was used against them. I'm not saying it couldn't be used against you, I'm just saying I would be surprised if it has actually happened in the case of a first trimester US in the ED.

My great niece. No anatomy scan picked it up. She lived for 3 weeks. No smiley face at the end of this story.

And why would you give a first trimester US to a patient? That looks like nothing. Or, to involve our Muslim friends, "a chewed thing" - like a piece of gum or meat.

 

[GeneralVeers]

My great niece. No anatomy scan picked it up. She lived for 3 weeks. No smiley face at the end of this story.

And why would you give a first trimester US to a patient? That looks like nothing. Or, to involve our Muslim friends, "a chewed thing" - like a piece of gum or meat.

How did that result in a lawsuit? A congenital heart defect not picked upon US?

 

[Apollyon]

How did that result in a lawsuit? A congenital heart defect not picked upon US?

No, no lawsuit. She just died.

 

[gamerEMdoc]

No, no lawsuit. She just died.

Oh god that's terrible.

The reason I give them a picture of something they is nothing but a yolk sac and a fetal pole... its the first picture they see of the fetus and there really isn't anything else we do that makes a difference in these patients once we exclude ectopic. It's just mainly managing the patient's fear and anxiety about the whole thing and setting expectations (so they don't keep coming back for more spotting every other day). It takes a terribly stressful situation for the mother (100% of which think they are miscarrying) and gives them something to hold on to (proof the haven't miscarried yet).

I've realized a long time ago, for all 1st trimester bleeding patients that aren't ectopics, we make zero difference in their care. When we do the US, check labs, etc. None of it affects the outcome. We can't stop a miscarriage if its going to happen. So because we can't actually do anything for the patient, I figured at the very least I can give them good solid information and relieve their suffering. Because make no mistake, these people are all suffering; they are anxious and paranoid what they hope to be their child is dying, they feel helpless, and have no idea what to do. Taking the time out of the shift to spend 2 minutes is worth it, it makes a big difference in the patient's perception of their care they received even though we really didn't do anything for them but listened to their fear and gave them expectations of what could happen and how likely it is to occur.

I give the same talk over and over in these patients once I identify an IUP with a heart beat. This is usually what I say:

"Miscarriage is unfortunately very common and not preventable. Anywhere from 1/4 to 1/2 of all pregnancies end in miscarriage. Seeing the fetus on the ultrasound with a heart beat is a really good sign, once you see that in a mom with bleeding in the first trimester, the chance they are going to miscarry goes down, but still is like a 10-15% chance at that point (I've seen a study that actually quotes 8% once you have a heart beat in an IUP, but I overestimate a little). If it happens, it was unavoidable and nothing you did wrong. The good thing is, in your case we know the pregnancy appears to be in the right place at this time and is alive at this point all of which is a positive sign to be hopeful about. We call this a threatened miscarriage, but don't be alarmed by the name. It just means this could be an early sign of a miscarriage, but at this point we know the odds are at least in your favor. You may continue to have spotting but need to come back for heavy bleeding more than two pads/hr and in the meantime need to call your OB/GYN tomorrow to schedule followup so they can reassess the pregnancy to make sure everything is hopefully progressing ok. I know I gave you a lot of information, what questions do you have for me?"

 

[Apollyon]

I concur with everything. I tell the first trimester folks that somewhere between 33% and 40% of pregnancies are lost in the 1st TM due to gross genetic abnormalities. There's a bad plan, and nature takes care of itself. However, if you can get pregnant once, you can do it again. Then, I say, 90% of first trimester bleeding go on to deliver a full term, healthy baby.

So, hope springs eternal.

 

[southerndoc]

I'm not sure it's defensible. Both ACOG and ACEP recommend against using a specific quant level to determine if an US is necessary to rule out ectopic. I think if someone died of a ruptured ectopic that wasn't diagnosed because someone didn't order an US because the quant was 1200, that would be an easy win for the plantiff's attorney IMO. It would be hard to find an expert witness to say the standard of care is to not order an US when the the societies for both specialties say that is not the standard of care.

The beauty of living in a gross negligence state...

 

[Apollyon]

Oh dear - drunken posting strikes again. I say, if a pregnancy makes it past the first term, then, it's 90% to a healthy delivery.

 

[gro2001]

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.

What I meant by comparing routine heart/lung exams to the use of US in these cases is that if I had to provide evidence for either practice I would not be able to. Which is why I understand clinicians who do neither. I myself have skipped both on occasion. However, skipping either would make a lot of people (both lay people and other MDs, including myself) feel the visit was incomplete. Not for any scientific reason, but then again medicine is not all science.

 

[gro2001]

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 understand you are making an argument about resource utilization, but this is stretching it beyond reasonable. If you work in a system where ordering an ultrasound on somebody prevents you from being able to get an NSTEMI out of the waiting room for 3 hours, there is something horribly wrong with the system you work in. And unless you are the administrator that makes decisions about US tech staffing, any inconvenience to them is neither your fault nor your responsibility. And neither is it the patient's.

If we were talking about unnecessary CTs that end up clogging up the scanner or MRIs, then yes, I would agree with you. But we were not, and I would not advocate for those.

 

[thegenius]

The reason I give them a picture of something they is nothing but a yolk sac and a fetal pole... its the first picture they see of the fetus and there really isn't anything else we do that makes a difference in these patients once we exclude ectopic. It's just mainly managing the patient's fear and anxiety about the whole thing and setting expectations (so they don't keep coming back for more spotting every other day). It takes a terribly stressful situation for the mother (100% of which think they are miscarrying) and gives them something to hold on to (proof the haven't miscarried yet).

I've realized a long time ago, for all 1st trimester bleeding patients that aren't ectopics, we make zero difference in their care. When we do the US, check labs, etc. None of it affects the outcome. We can't stop a miscarriage if its going to happen. So because we can't actually do anything for the patient, I figured at the very least I can give them good solid information and relieve their suffering. Because make no mistake, these people are all suffering; they are anxious and paranoid what they hope to be their child is dying, they feel helpless, and have no idea what to do. Taking the time out of the shift to spend 2 minutes is worth it, it makes a big difference in the patient's perception of their care they received even though we really didn't do anything for them but listened to their fear and gave them expectations of what could happen and how likely it is to occur.

I give the same talk over and over in these patients once I identify an IUP with a heart beat. This is usually what I say:

"Miscarriage is unfortunately very common and not preventable. Anywhere from 1/4 to 1/2 of all pregnancies end in miscarriage. Seeing the fetus on the ultrasound with a heart beat is a really good sign, once you see that in a mom with bleeding in the first trimester, the chance they are going to miscarry goes down, but still is like a 10-15% chance at that point (I've seen a study that actually quotes 8% once you have a heart beat in an IUP, but I overestimate a little). If it happens, it was unavoidable and nothing you did wrong. The good thing is, in your case we know the pregnancy appears to be in the right place at this time and is alive at this point all of which is a positive sign to be hopeful about. We call this a threatened miscarriage, but don't be alarmed by the name. It just means this could be an early sign of a miscarriage, but at this point we know the odds are at least in your favor. You may continue to have spotting but need to come back for heavy bleeding more than two pads/hr and in the meantime need to call your OB/GYN tomorrow to schedule followup so they can reassess the pregnancy to make sure everything is hopefully progressing ok. I know I gave you a lot of information, what questions do you have for me?"

I wish I had your patient population. While I think most women are suffering, at my work there is a sizable contingent of women that come in to verify their 6 + home pregnancy tests, make up symptoms, and do whatever to see their baby on an ultrasound, then come in when a fly lands on their stomach just to ensure there fetus is OK. "I just want to make sure everything is OK."

I guess it really depends on the mood I'm in, sometimes I have nothing to do and I'll show them on ultrasound (also because we get paid to do our own bedside ultrasounds), but if I'm not in a good mood I have told more than one PVB with a known IUP that they need to see their OB because there isn't anything I can do about anything and I even told one patient there are really sick patients I need to take care of right now.

I really need an attitude shift....these patients are easy money and are very rarely ever complicated, and they can just sit in a chair and wait 4 hours. Ultimately it just bugs me that free medical care, which is what I provide at my main hospital, gets abused so thoroughly every single day, and my premiums go up 10% every year and costs me $250 to go to the ED. Then again, I would rather be in my position than theirs...but something has to change.

 

[thegenius]

Actually what's going to change is there will be more freeloaders on our health care system as it becomes more and more expensive.

 

[gamerEMdoc]

I think the more likely change will be we will all be freeloaders in a single payer system. Well, except for the enormous tax bill that like 40% of the population will get to fund it...

 

[RoyBasch]

I never ever give the pt a printout of the bedside US. What happens when the kid is born with undiagnosed HLHS? What about ANYTHING else wonky? You're on the hook for "that doctor told me everything was good!" Even if you didn't say that, they WILL say that you did, and the express evidence is that you gave them a picture.

And this is not my individual advice.

I'm not a big US guy in general, and I don't regularly do my own OB US (huge believer that the gold standard for dx'ing IUP and ruling out ectopic is a formal US done by RDMS and interpreted by board certified radiologist), and I don't think I've ever printed a US baby picture for a patient.

That being said, I can't possibly see any real medicolegal liability come from this. Where is the deviation from standard of care? If the patient is destined to have an infant with HLHS what can be done to change or prevent that prenatally at the time of dx with abnormal US? Also how could this possibly be diagnosed on an early first trimester US?

On some level a pregnant patient has a responsibility to follow up with an obstetrician at some point (after the immediate emergencies such as ectopic have been ruled out) and if they have unreassuring ultrasounds, get the proper council regarding a fetus with severe abnormalities. This is the very definition of important but NOT emergent care that goes way beyond the scope of our practice as emergency physicians.

 

[GeneralVeers]

I used to get angry about these patients. Now I don't waste one iota of brainpower on them. If we are busy, much of the time I'll just order the US, RH, and HCG, then see them when everything is back to deliver the "good news" and discharge them home.

 

[deleted109597]

I used to get angry about these patients. Now I don't waste one iota of brainpower on them. If we are busy, much of the time I'll just order the US, RH, and HCG, then see them when everything is back to deliver the "good news" and discharge them home.

They can also wait in a chair, or in the lobby. They don't need a stretcher unless they're sick (which they can be).

 

[gamerEMdoc]

(huge believer that the gold standard for dx'ing IUP and ruling out ectopic is a formal US done by RDMS and interpreted by board certified radiologist)

I respectively disagree with this sentiment. This is a basic US of EM training, and all the data on bedside US to rule in IUP shows we are very effective at this. If you see a fetus in the uterus as an ED physician, unless its a heterotopic pregnancy (which rads is going to miss anyways and you are just really unlucky if you get a heterotopic case), you've ruled out ectopic. The need for a formal US by radiology is unnecessary. In my health system, radiology doesn't even do the routine US's for OB, OB does there own too. In my opinion, I'm not sure why we have US as a core part of our specialty training, spend a fortune on machines in departments, if our residency grads graduate from residency and don't use it for basic core US cases.

Don't get me wrong, you have to know your limitations. I get formal US's for these cases from time to time. The cases I would get a formal US on:

1. See an IUP but no heart beat. Formal US to confirm demise.
2. No IUP seen (empty uterus or just see a gest sac)
3. IUP seen but there is significant free fluid (gotta at least acknowledge that heterotopic pregnancies exist, no matter how rare they are)
4. Any woman who is on hormone therapy or had IUI to facilitate pregnancy. Heterotopic is much higher risk in these cases.

But that's not most of these cases. Most have an easily identifiable fetus with a heart beat in the uterus and ordering a formal US just keeps the patient in the department longer.

 

[RoyBasch]

I respectively disagree with this sentiment. This is a basic US of EM training, and all the data on bedside US to rule in IUP shows we are very effective at this. If you see a fetus in the uterus as an ED physician, unless its a heterotopic pregnancy (which rads is going to miss anyways and you are just really unlucky if you get a heterotopic case), you've ruled out ectopic. The need for a formal US by radiology is unnecessary. In my health system, radiology doesn't even do the routine US's for OB, OB does there own too. In my opinion, I'm not sure why we have US as a core part of our specialty training, spend a fortune on machines in departments, if our residency grads graduate from residency and don't use it for basic core US cases.

Don't get me wrong, you have to know your limitations. I get formal US's for these cases from time to time. The cases I would get a formal US on:

1. See an IUP but no heart beat. Formal US to confirm demise.
2. No IUP seen (empty uterus or just see a gest sac)
3. IUP seen but there is significant free fluid (gotta at least acknowledge that heterotopic pregnancies exist, no matter how rare they are)
4. Any woman who is on hormone therapy or had IUI to facilitate pregnancy. Heterotopic is much higher risk in these cases.

But that's not most of these cases. Most have an easily identifiable fetus with a heart beat in the uterus and ordering a formal US just keeps the patient in the department longer.

I hear you. But in the event of a miss, it will be very difficult to defend anything short of the gold standard I cited. For the most part I take the GeneralVeers approach on these patients.

 

[miacomet]

I hear you. But in the event of a miss, it will be very difficult to defend anything short of the gold standard I cited. For the most part I take the GeneralVeers approach on these patients.

Agreed. Ultrasound is like super inefficient out in the community (ignoring the fact that my otherwise functional shop can't figure out how to clean an endocavity probe, but I digress). By the time the labs have come back, the ultrasound is done and read. Why would I waste my time?

I actually question, Gamer, why we do spend so much time and money on ultrasound training? It may be useful in academia, but I just don't see how it makes the department move faster out in the community. Why would I spend my time when I can just see another patient? We FAST our (numerous) blunt traumas, but since I have to transfer a patient with liver lacs etc, I get the CT because who wants a chopper ride without a more definitive reason than "I saw free fluid" which could turn out to be ascites or something else? Even a pneumo gets a chest xray/CT to assess volume. I'm not saying US isn't useful for diagnosis- it is- but that the diagnoses don't really help flow or patient care in most of the community departments I've worked in.

 

[gamerEMdoc]

Agreed. Ultrasound is like super inefficient out in the community (ignoring the fact that my otherwise functional shop can't figure out how to clean an endocavity probe, but I digress). By the time the labs have come back, the ultrasound is done and read. Why would I waste my time?

I actually question, Gamer, why we do spend so much time and money on ultrasound training? It may be useful in academia, but I just don't see how it makes the department move faster out in the community. Why would I spend my time when I can just see another patient? We FAST our (numerous) blunt traumas, but since I have to transfer a patient with liver lacs etc, I get the CT because who wants a chopper ride without a more definitive reason than "I saw free fluid" which could turn out to be ascites or something else? Even a pneumo gets a chest xray/CT to assess volume. I'm not saying US isn't useful for diagnosis- it is- but that the diagnoses don't really help flow or patient care in most of the community departments I've worked in.

I've wondered this myself. I mean, if people don't use the skill when they get out, why spend the money on the machines and making it so integral to training? I guess the answer is, because the specialty has decided it was a valuable key skill to have and added value to patient care. Its not just our specialty, others use it as well. Personally, I've always found that the US makes me more efficient, but I use it a lot, I always have, even when I wasn't in academics. It lets me hone in on the right diagnosis faster, even if I still end up ordering formal studies for whatever reason. This is especially true at night. In residency, where I worked in the military, and where I work now, you have to call in an US tech from home to do the study. This took time and the patients just took up a bed and sat on my list. If I could quickly triage the patient during my exam with the US, not only would I cut down on unnecessary studies, but I would order the correct confirmatory study more often when I did order one. So personally, I find US extremely useful. But I also recognize others don't.

 

[gamerEMdoc]

But in the event of a miss, it will be very difficult to defend anything short of the gold standard I cited. For the most part I take the GeneralVeers approach on these patients.

Not sure why it would be very difficult to defend. Med Mal is trying to prove a breach in the standard of care. An ED bedside US is considered a viable standard of care for first trimester bleeding. ACEP backs us up on this. I've done far more first trimester USs than I've done chest tubes in my career, both of which are core privileges and both of which I'm perfectly comfortable doing. Why would I have to call an US tech in to do the US, but not have to call a CT surgeon to put in a chest tube for me? In ED, there is always someone more specialized than we are in many of the things we do. That doesn't mean we can't be competent in the basics. And saying, "yep, there is a fetus in that uterus" is about the easiest US you can do.

Sure you'd probably find an ED doc that would testify that its not the standard of care, but the defense would just as easily find one that would say it is, and would read them ACEPs position on the matter. If you've had the requisite training to be considered competent in these studies, there's tons of literature showing comparable accuracy to formal studies, and a professional organization saying this is an appropriate standard, I'd say that wouldn't be to difficult to defend.

That being said, you can get sued for anything. I practice medicine if its good medicine. I legit don't lose a second of sleep worrying about medical malpractice and what I could get sued for. Most providers that do over order tests and aren't any more likely to avoid lawsuits than those that don't worry about it. Its just bad luck when you get sued, most of the time you were in the wrong place at the wrong time. That's why we pay malpractice premiums.

 

[gro2001]

Agreed. Ultrasound is like super inefficient out in the community (ignoring the fact that my otherwise functional shop can't figure out how to clean an endocavity probe, but I digress). By the time the labs have come back, the ultrasound is done and read. Why would I waste my time?

I actually question, Gamer, why we do spend so much time and money on ultrasound training? It may be useful in academia, but I just don't see how it makes the department move faster out in the community. Why would I spend my time when I can just see another patient? We FAST our (numerous) blunt traumas, but since I have to transfer a patient with liver lacs etc, I get the CT because who wants a chopper ride without a more definitive reason than "I saw free fluid" which could turn out to be ascites or something else? Even a pneumo gets a chest xray/CT to assess volume. I'm not saying US isn't useful for diagnosis- it is- but that the diagnoses don't really help flow or patient care in most of the community departments I've worked in.

I think US is most useful in resuscitation. I see a lot of sick people, and these are the indications I find most useful in practice:

-cardiac to r/o tamponade
-IVC to help guide volume resuscitation
-procedural

I don't see how we could easily replace US for any of those indications.

 

[GeneralVeers]

I only use it for vascular procedures, and during arrests to assess cardiac activity. I don't use it for anything diagnostic anymore. My time is better spent seeing other patients.

 

[gamerEMdoc]

Figured I'd post this as a good reminder again never to use a low quant to decide not to get do an US. Had a ruptured ectopic with a HCG of 500 this week.

 

[miacomet]

Figured I'd post this as a good reminder again never to use a low quant to decide not to get do an US. Had a ruptured ectopic with a HCG of 500 this week.

Someone please tell the OBs. I don't get why they don't understand this.

 

[carbonizedeyesockets]

I bring the US in the room with me when I eval a pregnant vaginal bleeder. If IUP with heartbeat, we are done and they are out the door and chart complete in under 30 minutes the majority of the time. It’s inefficient to not do it and then tie up a space for 2 hours while they get the formal.

The scenario where I wouldn’t do it: no formal archiving of images and no formal QA/QI.

It takes me about 5 seconds to see an IUP, and if there isn’t one, then I order a formal and get labs.

This is seriously the easiest and fastest of bedside ultrasounds. I’ll even do them for PAs when I’m not busy because we can turn a care space over so much more quickly than if they order a formal.

 

[gamerEMdoc]

Someone please tell the OBs. I don't get why they don't understand this.

You could always qoute to them from the most recent article on this from the NEJM (attached):

"Women with ectopic pregnancies have highly variable hCG levels, often less than 1000 mIU per milliliter, and the hCG level does not predict the likelihood of ectopic pregnancy rupture. That is, a single hCG value, even if low, does not rule out a potentially life-threatening ruptured ectopic pregnancy. Hence, ultrasonography is indicated in any woman with a positive pregnancy test who is clinically suspected of having an ectopic pregnancy"

The fact is, 50% of tubal pregnancies have HCGs under 2000 by the time they are identified. If you are waiting to have a quant of 2000 before ordering an US, you'll miss ectopics. I've had one of 500 this week and one in the 200's a few months ago.

I think the misunderstanding of the discriminatory zone is that it was never meant to discriminate who should get an US. It's meant to discriminate what the US means in someone with no IUP seen. It discriminates which empty uterus is an ectopic or failed pregnancy and which is just too early to tell. A quant over 2000 with an empty uterus on TVUS used to be considered a sign of tubal or failed pregnancy. Turns out that number has been challenged a lot and probably isn't very specific enough to give all these methotrexate. ACEP recommends a higher cutoff of 3000 before it being considered likely that its an ectopic or nonviable pregnancy, but even then still suggest a followup HCG/US if the patient is stable.

 

[miacomet]

You could always qoute to them from the most recent article on this from the NEJM (attached):

"Women with ectopic pregnancies have highly variable hCG levels, often less than 1000 mIU per milliliter, and the hCG level does not predict the likelihood of ectopic pregnancy rupture. That is, a single hCG value, even if low, does not rule out a potentially life-threatening ruptured ectopic pregnancy. Hence, ultrasonography is indicated in any woman with a positive pregnancy test who is clinically suspected of having an ectopic pregnancy"

The fact is, 50% of tubal pregnancies have HCGs under 2000 by the time they are identified. If you are waiting to have a quant of 2000 before ordering an US, you'll miss ectopics. I've had one of 500 this week and one in the 200's a few months ago.

I think the misunderstanding of the discriminatory zone is that it was never meant to discriminate who should get an US. It's meant to discriminate what the US means in someone with no IUP seen. It discriminates which empty uterus is an ectopic or failed pregnancy and which is just too early to tell. A quant over 2000 with an empty uterus on TVUS used to be considered a sign of tubal or failed pregnancy. Turns out that number has been challenged a lot and probably isn't very specific enough to give all these methotrexate. ACEP recommends a higher cutoff of 3000 before it being considered likely that its an ectopic or nonviable pregnancy, but even then still suggest a followup HCG/US if the patient is stable.

Thank you. I doubt if it will sink in, though. We see these fairly regularly- I always wonder, don't they? Does one OB take care of all the ectopics with low quants while the others remain in the dark?