What’s in your MDM?

[Birdstrike]

You must order a lot of CTAs then.

I used to.

But currently, none.

Now, I order tons of MRIs.

DIfferent setting, same concept.

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[jw3600]

I used to.

But currently, none.

Now, I order tons of MRIs.

DIfferent setting, same concept.

Is it though? Assuming you mean the imaging you order for sub acute injuries and chronic pain.

 

[RoyBasch]

You must order a lot of CTAs then.

Yep.

I don't try to protect the holy virginity of CTA. If that pisses the radiologist off, they need need to get over it. Either staff up or stop crying. It's standard of care now. You can't just let these random dissections (aorta, cartoid, etc.) get away from you these days. There are too many effective interventions now for vascular conditions that otherwise causing devastating morbidity or death.

 

[maxxor]

Yep.

I don't try to protect the holy virginity of CTA. If that pisses the radiologist off, they need need to get over it. Either staff up or stop crying. It's standard of care now. You can't just let these random dissections (aorta, cartoid, etc.) get away from you these days. There are too many effective interventions now for vascular conditions that otherwise causing devastating morbidity or death.

Rad here.

I love CTAs. At least you’re giving contrast.

The worst is when ER doesn’t want to give contrast for throughput reasons and then we get suboptimal exams. That’s the only thing that really grinds my gears.

Please send me exams with a question for what you are looking for.

Please don’t just say pain.

 

[Birdstrike]

Is it though? Assuming you mean the imaging you order for sub acute injuries and chronic pain.

If you don't want to order tests, don't order tests. Don't let me convince you otherwise. But, I'm a tester. I order them liberally, and without remorse. If the patient doesn't want a test I ordered, fine. That's on them. But I'm not going to delude myself into thinking that if I miss something, they'll be okay with it when I pull out a copy of my chart and say, "See! I wrote down here that I didn't think you had it. Do you like me better now?"

You miss stuff, you get dragged into court and dinged with multimillion dollar lawsuits.

How many multi-million dollar awards, and get-out-of-court-free passes have you been given for writing, "I've considered _____and don't suspect it"?

And what's to be gained by not ordering tests and missing things, in the first place? Decreased length of stay, so some admin gets a tingle up and down his leg?

I don't know. I practice with the mindset that if I thought about it enough to write about it in the chart, I order the test to rule it out. And if I don’t think there’s a reasonable chance they have it, then I don’t waste time writing about it in the chart.

Do what works for you.

 

[GeneralVeers]

Rad here.

I love CTAs. At least you’re giving contrast.

The worst is when ER doesn’t want to give contrast for throughput reasons and then we get suboptimal exams. That’s the only thing that really grinds my gears.

Please send me exams with a question for what you are looking for.

Please don’t just say pain.

Sometimes necessary. In several of my facilities we do waiting-room only medicine. That means if the nurses are being passive-aggressive on a given day patients won't get labs, IVs, etc to give contrast. If I have low suspicion for a problem, I'll just get a non-contrast CT rather than have the patient sit 3-4 hours in the lobby. Honestly most radiologist should see the badness we are worried about, like dissections, aneurysms, perforated viscous, kidney stones w/ hydro, etc. Without contrast you may lose some of the subtlety but that's it.

 

[thegenius]

I thought reviving this thread was the best place for my question. I just started using EPIC again after....sheesh, probably 7 or 8 years. I noticed that the DDX is not anywhere as it is in Cerner. Cerner will typically list a few appropriate DDX based on the chief complaint that you can choose to click or not and therefore obtain what I've always understood as additional points for medical complexity. I notice that EPIC doesn't have a DDX anywhere to be found. However, they certainly have plenty of check boxes on the MDM page to allow you to indicate the level of complexity. Are you guys actually listing all your DDX in your MDM when using EPIC or are you skipping it and including it in say...your MDM as you dictate or somewhere else altogether? I've noticed some of my colleagues don't put a DDX at all.

I have an EPIC macro that prints the following:

DDx:
1. ***
2. ***
3. ***
4. ***
5. ***

and then I hit "F2" and skip to each "***" and type in something.
Thankfully it doesn't take more than 30 seconds. It is monotonous as every low risk chest pain all have the same DDx, for instance.

 

[thegenius]

Not sure if this is the right way, but the medicolegal specialist attending of mine in residency said it was best to not put a ddx because it gives away what you weren’t thinking of when you miss something. Instead said that to pull your orders in bc they show your ddx without specifically saying it.

Yea I think this is the freakout mode of doing charts. Put absolutely nothing in there except what is literally needed to code for your level of ESI.

I tend to think this is the wrong way to do it. I've never heard of a lawyer (plantiff or defense) indicate that less documentation is more protective than more documentation.

e.g. If you never indicate your thought process, how can you say you thought of SAH for a headache when you never did at CT or an LP?

 

[Groove]

I have an EPIC macro that prints the following:




and then I hit "F2" and skip to each "***" and type in something.
Thankfully it doesn't take more than 30 seconds. It is monotonous as every low risk chest pain all have the same DDx, for instance.

Nice, so it's a smart phrase or a dragon macro? I think I may copy this method exactly.

 

[thegenius]

I agree regarding testing versus clinical acumen... which means I order more d-dimers than I used to do and often cite medical decision making rules (PERC, HEART score, etc)... However I think there still is a role for documenting thought processes and clinical judgement.

This should be fine. Established clinical decision making tools are defensible in my opinion.

 

[thegenius]

Nice, so it's a smart phrase or a dragon macro? I think I may copy this method exactly.

I think it's a smart phrase. And it's already embedded in my H&P template.

When I start a new note I go to "My Notes" or "NoteWriter" or whatever it's called and I have a blank page. I type ".HPI" and it puts in an entire stubbed H&P. Then I type my HPI, and I have dot phrases for ROS, PE, and a few other things. Within this template I have the DDx section too.

And if you don't want to use it for a particular patient encounter you just delete the entire thing. I don't put in differentials for all the minor stuff that comes in (dental pain, ankle sprains, etc.)

 

[thegenius]

Rad here.

I love CTAs. At least you’re giving contrast.

The worst is when ER doesn’t want to give contrast for throughput reasons and then we get suboptimal exams. That’s the only thing that really grinds my gears.

Please send me exams with a question for what you are looking for.

Please don’t just say pain.

I don't understand how docs can order non-contrast CTs looking for vascular phenomenon. That doesn't make any sense.

 

[turkeyjerky]

I don't understand how docs can order non-contrast CTs looking for vascular phenomenon. That doesn't make any sense.

You definitely don’t need contrast for AAA (although if pt is meta-stable than maybe its preferable so as to consider perc repair) bit otherwise, yeah.

 

[southerndoc]

I think it's a smart phrase. And it's already embedded in my H&P template.

When I start a new note I go to "My Notes" or "NoteWriter" or whatever it's called and I have a blank page. I type ".HPI" and it puts in an entire stubbed H&P. Then I type my HPI, and I have dot phrases for ROS, PE, and a few other things. Within this template I have the DDx section too.

And if you don't want to use it for a particular patient encounter you just delete the entire thing. I don't put in differentials for all the minor stuff that comes in (dental pain, ankle sprains, etc.)

You can customize templates and add them to your list. If you use the tool/gear icon to the far right of the "my note, blank note" etc. tabs you can add your own tabs that point to specific smartphrases.

I created several so that I click one button and it brings up the appropriate template to document with. Dictation, Level I Trauma, Level II Trauma, Trauma (for seeing a trauma patient not an alert), Code FAST from EMS, Code FAST from Triage, Stroke Protocol, STEMI, Chest Pain, Asthma, Mental Health, etc.

I would post a screenshot but the Epic people frown upon that (to put it very very lightly).

 

[GeneralVeers]

I don't understand how docs can order non-contrast CTs looking for vascular phenomenon. That doesn't make any sense.

It's preferred for ruptured AAA. For high suspicion patients I get a non-contrast and can have them in the OR very quickly. Much safer than waiting for labs, getting a CT consent, then another hour to get the CT done.

 

[NITRAS]

I don't understand how docs can order non-contrast CTs looking for vascular phenomenon. That doesn't make any sense.

I will say that I was shocked when a radiologist called me cause I ordered CT abd/pelv for some nonspecific abdominal pain with kinda crummy kidneys. Radiologist says, “I’m pretty sure there is a DVT in the left femoral vein.” It was without contrast. I wasn’t looking for a DVT. US shows DVT in left femoral vein. .. and right and most of her veins.

I was impressed.

 

[thegenius]

It's preferred for ruptured AAA. For high suspicion patients I get a non-contrast and can have them in the OR very quickly. Much safer than waiting for labs, getting a CT consent, then another hour to get the CT done.

The issue here is that ruptured AAA don't sit in the waiting room for hours on end waiting for a bed, and if they do the frequency is 1:1000 per diagnosed ruptured AAA, which is already extraordinarily low given that ruptured AAA is extraordinarily low.

CIN is a myth in some radiologists opinion, and certainly not slam-dunk proof-of-existence medicine. if I have some hypotensive severe abdominal pain pt they get lined with IV's, pressure-bagged fluids, labs sent off, and they go immediately to the CT with IV contrast (provided I think they will not have a cardiac arrest on the scanner) if I think they need an emergent CT. There is no hesitation using contrast. It's the same though process for why trauma surgeons CT every severe trauma with IV contrast. They don't wait for IV contrast.

And BTW I'm not sure it's "preferred". It might be "adequate" but it's not "preferred". I would like to hear rads chime in on this. Q: what is the "preferred" study to diagnose a ruptured abdominal aortic aneurysm?

 

[maxxor]

I will say that I was shocked when a radiologist called me cause I ordered CT abd/pelv for some nonspecific abdominal pain with kinda crummy kidneys. Radiologist says, “I’m pretty sure there is a DVT in the left femoral vein.” It was without contrast. I wasn’t looking for a DVT. US shows DVT in left femoral vein. .. and right and most of her veins.

I was impressed.

You can get lucky with acute thrombosis as the vein will be distended with asymmetric perivascular stranding and extremity edema. But it's subtle and you have to be looking for it.

Dissection you better hope they have either an IMH or severe pre-existing aortic intimal calcs to notice the dissection without contrast.

Much safer than waiting for labs, getting a CT consent, then another hour to get the CT done.

Wow you have a hyper conservative radiology department. I personally don’t think CIN is a true entity using modern contrast agents. I ok it all the time. The ER and Radiology literature support this.

Preferred exam for aortic pathology in ER setting? CTA I-, I+, and Venous delay for everything else (ie all the other sources of badness). I- for intramural hematoma; perhaps with fancy dual energy CT you can omit the I- but for now it’s useful to have.

 

[thegenius]

You can get lucky with acute thrombosis as the vein will be distended with asymmetric perivascular stranding and extremity edema. But it's subtle and you have to be looking for it.

Dissection you better hope they have either an IMH or severe pre-existing aortic intimal calcs to notice the dissection without contrast.


Wow you have a hyper conservative radiology department. I personally don’t think CIN is a true entity using modern contrast agents. I ok it all the time. The ER and Radiology literature support this.

Preferred exam for aortic pathology in ER setting? CTA I-, I+, and Venous delay for everything else (ie all the other sources of badness). I- for intramural hematoma; perhaps with fancy dual energy CT you can omit the I- but for now it’s useful to have.

What is IMH

 

[maxxor]

What is IMH

Intramural hematoma.

Pulled this from google images. It's where there is a rupture of the vaso vasorum with hematoma propagating along the media. It's best thought of as a contained dissection as there's no definite intimal flap.

Noncon images show crescenting mural hyperattenuation. You can miss it if you have arterial phase only images as the relative contrast densities can hide it.

 

[GeneralVeers]

Tonight: 69 yo male with no medical history had sudden onset abdominal pain, and collapsed at home. He arrives A&Ox4 but writhing in pain. I tried to order the CTA with contrast, but after 30 minutes of fiddling around, nurses blow the IV x 2. I gave up and ordered the non-con abdomen. 7.0 cm infrarenal AAA ruptured with extravasation. Transferred out in 73 minutes to nearby hospital with vascular.

 

[MechEDoc]

Tonight: 69 yo male with no medical history had sudden onset abdominal pain, and collapsed at home. He arrives A&Ox4 but writhing in pain. I tried to order the CTA with contrast, but after 30 minutes of fiddling around, nurses blow the IV x 2. I gave up and ordered the non-con abdomen. 7.0 cm infrarenal AAA ruptured with extravasation. Transferred out in 73 minutes to nearby hospital with vascular.

Why not ultrasound at the bedside?

 

[deleted6669]

I agree regarding testing versus clinical acumen... which means I order more d-dimers than I used to do and often cite medical decision making rules (PERC, HEART score, etc)... However I think there still is a role for documenting thought processes and clinical judgement.

I do this as well with pecarn, geneva scores, heart scores, curb-65, etc directly into my note. My DDx smart phrase is "differential diagnosis includes, but is not limited to, the following..." I do put in things like considered PE, but very unlikely given neg perc/geneva , no family hx, and stable vs with nl room air sao2, etc

 

[deleted6669]

Why not ultrasound at the bedside?

or EJ or IO or central line?

 

[GeneralVeers]

or EJ or IO or central line?

We did IO. My bedside US isn't adequate for the surgeon to take to the OR. Geez u guys are tough....

Guy lived BTW!

 

[dadaddadaBATMAN]

or EJ or IO or central line?

Ej many institutions refuse to use due to risk of extrav (which is asinine)
Io rate of contrast administration isn’t fast enough to my understanding

Central line with fem probably reasonable.

I’d us and call, and if they refuse based on image from my phone I’d probably stick in a peripheral in the ij or fem.

 

[dadaddadaBATMAN]

We did IO. My bedside US isn't adequate for the surgeon to take to the OR. Geez u guys are tough....

Guy lived BTW!

Good job!

 

[MechEDoc]

Guy lived BTW!

That is what matters!