What are obvious, can't-miss complaints/sxs/presentations that a M3 should leave the room and find the attending?

[Doctor_Strange]

I had a pt who was in acute pain while laying down and had to stand while I took a history. I cut the history a little short and got my attending. He later said good job at identifying a pt who he needed to see before others. Today I had a lady who appeared in acute pain, HA, photophobia, recent palpitations, and "right-sided CP" that radiating down her arm. I cut the interview short and went to find the doc. She was wretching as well while we were outside as I provided a brief history. Long story short, turned out to be Cannabinoid Hyperemesis Syndrome. To me it seemed it needed to be addressed ASAP, but the doc was like I could just tell it was likely cannabinoid-related just by hearing the wrenching and I could tell it didn’t need to be looked at ASAP and he told me I could have likely finished my history and even done a physical! So, I wanted ask what are actual go-to signs or clinical presentations that I should be on the look out for where as a M3 I should go find the attending.

Thanks in advance!

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[jurassicpark]

First of all, you're an M3, you don't know yet what is serious and not serious. If you feel yourself thinking you may need an attending, get one.

 

[EMikate]

I pretty much only go get someone if there are unstable VS or if there is a super concerning story for CVA or ACS.

 

[cyanide12345678]

Comes with experience i feel. Every chief complaint can be something terrible more or less.

If they look like crap, are pale, diaphoretic, abnormal vitals, then they probably need a very fast history and focused exam.

 

[namethatsmell]

Diaphorisis+nearly any complaint=get attending

Also, one of the things I see frequently under-appreciated is tachypnea. Don’t trust the triage vitals. Count the respirations on your own, look for accessory muscle use, and tell the attending if abnormal. Good for patients and will make you look like a rockstar.


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[RustedFox]

Penis on forehead.

 

[Shabeer]

Penis on forehead.

Ah, the 'ol shroom stamp.

Gen:Appears well, moderate distress
HEENT: Neck supple, thyroid normal, no lymphadenopathy. PERRL, sclera non icteric.
Card: S1,S2 auscultated. No MRG, pulses intact.
Pulm: CTALB
Abdomen: Soft and non tender. Bowel sounds present throughout.
MSK: Full ROM, no appreciable atrophy.
Neuro: CN II-XII normal. No focal deficits. Speech clear.
Skin: Well demarcated erythematous border 2cm cephlad of nasal bridge in shape of various fungi. Ecchymosis noted throughout. Lesion is actively exsanguinating despite compression.

A/P

Jenny McJennerson is a 29 y/o knowitall who is persistently on the first peak of the Dunning Kruger curve who presents 5 minutes post penile trauma from Rusted Fox.

CT head
Plastic sx consultation
Analgesia with pentobarbital

 

[Porfirio]

Do you get a forehead skin culture for GC?

 

[Shabeer]

Do you get a forehead skin culture for GC?

Dunno, depends on how rusted the fox is. You'd have to ask him.

TDaP for sure though

 

[Tenk]

Abnormal vitals.
Altered mental status.
Respiratory distress.
Chest pain + distress in middle aged to older.
Abdominal pain + distress in middle aged to older.
Symptoms of CVA.
Older individuals in any type of distress.

That’s a pretty decent list I think.

 

[clibby]

I will never get mad at a medical student for coming to get help. If your gut says something is off, always ask for help. Classic signs of badness are pain out of proportion to exam, classic chest pain, abnormal HR or RR, diaphoresis, hypotension, stroke like symptoms, and AMS. The subtle things come with experience which is why we have decision rules to guide people in developing a minimum gestalt. My favorite one is the WALLS score: The LLS Score

The longer I am in residency, the more I learn the subtle signs of badness vs bs. I also feel like I will continue to worry for several years after residency as there is so much badness to learn from that residency both seems like enough to learn to not kill anyone, but not enough to see it all. The attending who isn’t worried got that way from a lot of experience with badness; that isn’t you and you shouldn’t try to achieve that via any shortcuts. The medical student who thinks they know everything is far more dangerous than one who is overly cautious.

 

[deleted109597]

Spidey sense comes from practice. See as many as you can. You'll start to identify the cues that help you distinguish sick vs not sick.

 

[SamtheWise]

It's hard to know, don't feel bad for getting an attending, any attending or senior resident who shames you for getting them on someone you think may be sick is just being a loser.

Also cannabinoid hyperemesis syndrome are some of the sickest looking not sick patient's you'll see. Pale, diaphoretic, hyperalgesic so screaming when you palp their abdomen, non-stop vomiting, etc, but completely resolves with haldol.

 

[Birdstrike]

I had a pt who was in acute pain while laying down and had to stand while I took a history. I cut the history a little short and got my attending. He later said good job at identifying a pt who he needed to see before others. Today I had a lady who appeared in acute pain, HA, photophobia, recent palpitations, and "right-sided CP" that radiating down her arm. I cut the interview short and went to find the doc. She was wretching as well while we were outside as I provided a brief history. Long story short, turned out to be Cannabinoid Hyperemesis Syndrome. To me it seemed it needed to be addressed ASAP, but the doc was like I could just tell it was likely cannabinoid-related just by hearing the wrenching and I could tell it didn’t need to be looked at ASAP and he told me I could have likely finished my history and even done a physical! So, I wanted ask what are actual go-to signs or clinical presentations that I should be on the look out for where as a M3 I should go find the attending.

Thanks in advance!

The vast majority of the obvious ones have already been brought to the attention of an attending by the triage nurse and have bypassed you. There will be occasional exceptions but the system is set up to work this way. The system is not set up to leave hidden land mind cases waiting for the MS3 to test your mettle.

 

[dadaddadaBATMAN]

The vast majority of the obvious ones have already been brought to the attention of an attending by the triage nurse and have bypassed you. There will be occasional exceptions but the system is set up to work this way. The system is not set up to leave hidden land mind cases waiting for the MS3 to test your mettle.

I’ll respectfully disagree, though in general this is true. Many of our nurses are wonderful, others literally don’t recognize a stemi when it’s printed on the top of an ekg.

The correct answer was the first one. If you think you need an attending, get one. Anyone who gets pissy about this is an as*hat unless you’re doing it on every other patient.

 

[WilcoWorld]

The vast majority of the obvious ones have already been brought to the attention of an attending by the triage nurse and have bypassed you. There will be occasional exceptions but the system is set up to work this way. The system is not set up to leave hidden land mind cases waiting for the MS3 to test your mettle.

I’ll respectfully disagree, though in general this is true. Many of our nurses are wonderful, others literally don’t recognize a stemi when it’s printed on the top of an ekg.

The correct answer was the first one. If you think you need an attending, get one. Anyone who gets pissy about this is an as*hat unless you’re doing it on every other patient.

I agree with you both - Birdstrike is correct that the system is set up to bring badness to the attending's attention STAT, while Batman is correct that the system can fail and an attending who gives you a hard time about expressing concern is doing it wrong. Now, that's very different from sitting down with the MS3, identifying the salient features & explaining why this seemingly concerning presentation is very clearly benign.

I'm wondering if the two encounters described by @Doctor_Strange were with different attendings?

Personally, if an MS3 blew off someone with headache, chest pain and neuro symptoms as cannabinoid hyperemesis (even if they turned out to be correct) I'd have a long talk with them about thinking "worst first" and being humble.

 

[thegenius]

And for what it's worth...

even experienced docs may not know if a patient is sick or not. Sometimes it helps to know your patient population. There is a woman where I work who comes into our ER every 4 days, give or take. In 2018 she had 92 visits. Of course she is on Medicaid, is a hypochondriac, and refuses to see her doctor. She has declared every single complaint ever. You name it. When I first saw her, this was within the first few months of coming working there, I worked her up for her chest pain. My colleagues laughed a little.

Now that I've been there for years, I ignore her everytime she comes in. However our moonlighters (PGY-4s from regional ER programs) will occasionally pick her up. They don't know her. They don't know her shenanigans. So they work her up.

 

[Doctor_Strange]

I agree with you both - Birdstrike is correct that the system is set up to bring badness to the attending's attention STAT, while Batman is correct that the system can fail and an attending who gives you a hard time about expressing concern is doing it wrong. Now, that's very different from sitting down with the MS3, identifying the salient features & explaining why this seemingly concerning presentation is very clearly benign.

I'm wondering if the two encounters described by @Doctor_Strange were with different attendings?

Personally, if an MS3 blew off someone with headache, chest pain and neuro symptoms as cannabinoid hyperemesis (even if they turned out to be correct) I'd have a long talk with them about thinking "worst first" and being humble.

I edited my original comment. I think it may have come off as the attending was annoyed or something which was not the case. He had a laugh about it ie I was really worried but he's seen it so many times before. He said he was glad I got him regardless. Same attending btw. This was just for me to reach out and see what I should focus on moving forward and hopefully better develop that skillset!

 

[thegenius]

It's hard to know, don't feel bad for getting an attending, any attending or senior resident who shames you for getting them on someone you think may be sick is just being a loser.

Also cannabinoid hyperemesis syndrome are some of the sickest looking not sick patient's you'll see. Pale, diaphoretic, hyperalgesic so screaming when you palp their abdomen, non-stop vomiting, etc, but completely resolves with haldol.

Yea man....there is vomiting that makes me concerned...and vomiting that I ignore. The more gregarious, loud, and obnoxious the vomiting is, the less likely it's serious. If you are really sick, you don't have the energy to make loud sounds.

Those obnoxious vomiters, by the way, are also the ones that are more likely to just stop vomiting regardless of what you do. Just leave them alone, come back in 1-2 hours and they will be asleep on the gurney.

 

[RustedFox]

Those obnoxious vomiters, by the way, are also the ones that are more likely to just stop vomiting regardless of what you do. Just leave them along, come back in 1-2 hours and they will be asleep on the gurney.

Ahhh.
"Therapeutic Neglect"
One of my favorite things.

 

[CajunMedic]

Ahhh.
"Therapeutic Neglect"
One of my favorite things.

AKA “fluorescent light therapy”


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[The Knife & Gun Club]

My MS4 subI check list for “get an attending without finishing the history”

Chest pain (if they haven’t had a CP bundle ordered in triage)
Depressed mental status in a kid or old person (like falling asleep mid exam)
Focal Neuro deficit
Shortness of breath (“I feel in I can’t breath”, gasping, or tripoding)
Any abnormal vital sign that’s symptomatic
Severe pain (crying, yelling, unable to complete exam)

Probably others that I’m forgetting now that I’ve been out of the ED for 4 months

Basically it’s things that could lead to imminent badness or things tied to a time sensitive metric bundle.

 

[deleted836128]

Diaphorisis+nearly any complaint=get attending

Also, one of the things I see frequently under-appreciated is tachypnea. Don’t trust the triage vitals. Count the respirations on your own, look for accessory muscle use, and tell the attending if abnormal. Good for patients and will make you look like a rockstar.


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Except for “I am withdrawing from my Percocet - can I get a refill?” In all seriousness I agree that diaphoresis usually equals badness.

 

[deleted836128]

As a PA - trying to think of some of the things I get my attending to see:

- someone who just looks toxic
- someone who seems altered and I don’t have a solid, comforting explanation for it (I.e heroin user “nodding off” during the history - pretty easy to tell)
- someone with potential or existing airway compromise
- any patient who’s truly in distress (minus certain slam dunk ones like cannabinoid induced hyperemesis patients or ureterolithiasis patients - they often are that way)
- someone with pain out of proportion
- MVA or other traumatic event with signs of bad trauma (ie seatbelt sign) or a really bad mechanism of injury
- very concerning belly exam especially if vitals are also abnormal
- anyone with significantly abnormal vitals, especially in an old person or baby
- someone with stroke symptoms

Stuff I like them to see (but doesn’t need to happen right away):
- any case that is likely to result in going to court (seriously) - for example, a domestic assault case
- serious hand trauma (sometimes, depends on what it is)
- the really fresh ones (<90 days old)

Okay, I am done. Can’t think of any more and I am sleepy! But I am sure there are others I will think of.

 

[RuralEDDoc]

Ahhh.
"Therapeutic Neglect"
One of my favorite things.

“Tincture of Boredom”, natural cure all.

 

[thegenius]

“Tincture of Boredom”, natural cure all.

Sometimes you ignore them long enough and they just elope. That's also a win-win situation