Work-ups or Chief complaints

[AmoryBlaine]

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As an M3 one week away from being done with my first rotation I have a question for some of the EM vets...

Is there a part of (aome) EM docs that says "I don't really need to worry if I get this exactly right b/c I 100% must call Peds/Surg/Med/whatever."

I'm not trying to flame b/c I am becoming more sure I want to do EM, even with the uncertainties.

It just seems like from my limited experience there is such a broad range of skill in EM. Some docs would page my service with a complete work-up, DDx, and diagnostic plan already going to figure it out - basically just giving the heads up that we might have a pt admitted to our service. Others would give us "belly pain, fever, I haven't seen the pt."

Any thoughts would be cool.

 

[NinerNiner999]

Yes... and no. If the patient has obvious reasons for admission (86yo, h/o CABG, DM, here with chest pain) I'll make sure they're not having the big one and are stable right before I call medicine for the admit. But, I have never been able to pull off admitting a patient I haven't seen. Unless, the patient was to be direct admitted to the service I'm calling. Then, I have no problem saying they are here and waiting for you to get them out of my ED...

 

[waterski232002]

Our job isn't necessarily to make a final diagnosis in the ER. We often do this, but it is not crucial to what we do. Our job is to stabilize and treat patients who are acutely ill and in doing so, rule out life threatening emergencies. To do this, we have to have a high suspicion for serious illness and be able to treat WITHOUT the luxury of labs, baseline medical information, and often without even taking a history (what you see is what you get when the patient hits the door too tachypneic to talk, and no family is around). A diagnosis will surface, but ensuring that we do whatever is necessary to keep them alive (A,B,C's) is most important.

Of course, the vast majority of our patients are not this sick, but the basic principles still apply. If they are stable, we rule out life threatening diagnoses, and then shift into primary care mode... diagnose and refer back to the PMD for follow up.

As far as admitting a patient without a diagnosis... this depends on the case. The goal is optimal patient care. So, if the patient doesn't have a diagnosis, but you know that they will be admitted to a specific service regardless, then you mind as well bring them on board (particularly if the patient is sick).

It's just like the inpatient wards.... if you have a patient on the general medical service who develops peritonitis on rounds, you don't wait around and get an obstructive series and CT scan before calling surgery... you call surgery NOW, and let them decide how to work-up the patient. Same goes for the ER. Do what is best for the patient.

 

[DrQuinn]

Yes... and no. If the patient has obvious reasons for admission (86yo, h/o CABG, DM, here with chest pain) I'll make sure they're not having the big one and are stable right before I call medicine for the admit. But, I have never been able to pull off admitting a patient I haven't seen. Unless, the patient was to be direct admitted to the service I'm calling. Then, I have no problem saying they are here and waiting for you to get them out of my ED...

I dunno bro, I had a patient, 7 weeks pregnant, had an outpatient ultrasound that showed an ectopic. Called OB/GYN (had labs drawn at triage, ordered by me), told them 'bout her. They came down, wooshed her away. These cases are relaively straightforward, and I'm sure you've seen these before but have just forgotten. The ED is just a stepping stone to what they really need.

Q

 

[Apollyon]

I dunno bro, I had a patient, 7 weeks pregnant, had an outpatient ultrasound that showed an ectopic. Called OB/GYN (had labs drawn at triage, ordered by me), told them 'bout her. They came down, wooshed her away. These cases are relaively straightforward, and I'm sure you've seen these before but have just forgotten. The ED is just a stepping stone to what they really need.

Q

Dude - not the same. You had an emergent patient that had a diagnosis and an intervention already carved out. That is different from "belly pain I haven't seen".

I know what you're saying - it's just like the DVT people from outpatient ultrasound. Sometimes, people don't need us. Patients just need the right thing to be done for them.

 

[BKN]

It just seems like from my limited experience there is such a broad range of skill in EM.
Any thoughts would be cool.

Amory, I think you may have been listening to too many ranting IM (or surgery, or OB or . . .) residents. 😉 As you can see from the other posts, it may not be a matter of a broad range of skill. More like a broad range of patience (or not) with obstructionism.

As work loads have decreased hugely since the work hour rules, the attitudes of the receiving residents should change. In no other business is it acceptable for the troops to be obviously angry or unhappy to see another customer (patient). Nor is it acceptable to be rude to people who send business ($$) to you (that's us).

Anyway, Medicine is full of people who are not professional in their work. They backbite, argue and hang up on each other. Others are complete sweethearts. Since the EPs talk to everybody on the staff, we quickly figure out who is which and often get a little passive-aggressive with the jerks. And the staff quickly figures out who the strong EPs are and who are not. But, unlike the private slicks, all EPs must have excellent interpersonal skills, because the hospitals and groups will fire you elsewise.

For the record, the job of an EP is to quickly sort patients into stable or not, begin resuscitation for the former and arrange continuing care (if a medical emergency condition) for everyone. Early accurate diagnosis is often essential to accomplishing this, but sometimes is not. Think of MI or CAP as being examples of the former. I think intubation for respiratory failure without determining whether the underlying problem is Guillain-Barre, myasthenia, botulism etc as an example of the latter.

A secondary benefit to physicians in private practice is that we often let them sleep. When I was a MS1 (early 70s), I took JAMA. Since I couldn't understand anything in it, I took to reading the obituaries. Those docs were all dying in their 50s. Part of that was bad diet and smoking. But a big part of it was that everyone was on call all the time for their own patients (there were few group practices) and in rotation for the ED. Without EPs, most docs were up every night as well as having to run their own practice in the day. They had to come in to see their own patients, whether they needed admission or not. Things actually got worse after residency. Now, mostly the private guys never hear about the patient because we see em and street 80% of em. When we do call, frequently after a short conversation, the on call guy can roll over and go back to sleep, since we'll arrange to get the patient up to the floor and get the workup and therapy started.

So . . . do EM or not, as you desire. But if you do something else, as you drift off to sleep, instead of counting sheep, think "The EP is my friend . . . I 😍 th EP . . .The EP is my friend . . ."

 

[turtle md]

"The EP is my friend . . . I 😍 th EP . . .The EP is my friend . . ."

Just thought this needed to be repeated 🙂

 

[NinerNiner999]

I dunno bro, I had a patient, 7 weeks pregnant, had an outpatient ultrasound that showed an ectopic. Called OB/GYN (had labs drawn at triage, ordered by me), told them 'bout her. They came down, wooshed her away. These cases are relaively straightforward, and I'm sure you've seen these before but have just forgotten. The ED is just a stepping stone to what they really need.

Q

I agree completely, but I would probably lump this patient into a "direct admit" category. It doesn't happen often, but I truly do love it when patients walk in with their labs, studies, and diagnosis from earlier that day. I don't need to see them (except maybe to make sure they can say their name).

I like the stepping stone analogy, but the hard part is teasing out what the patients that Apollyon describes as nonspecific really want (i.e. meds, psych, etc) - and doing it quickly and accurately.

 

[EctopicFetus]

The PCP folks should be glad we see the "mosquito bite X 1.5 months"..

Uhh doc there is a little bump under there which doesnt hurt and doesnt itch..

 

[AmoryBlaine]

Thanks all for the replies, very informative as usual.

 

[docB]

As work loads have decreased hugely since the work hour rules, the attitudes of the receiving residents should change. In no other business is it acceptable for the troops to be obviously angry or unhappy to see another customer (patient). Nor is it acceptable to be rude to people who send business ($$) to you (that's us).

I agree with you but I'm not gonna hold my breath for it.

 

[BKN]

I agree with you but I'm not gonna hold my breath for it.

Me neither, but I've got to say the work hour restrictions have helped. I hardly knew a doc back in the 70s who wasn't seriously damaged by the experiences. Now I think most Docs are happy. The more than doubling of physicians per population since the early 70s has helped as well, but I think recently the pendulum is swinging towards the negative again.

 

[spyderdoc]

When I was a MS1 (early 70s), I took JAMA

I took it once or twice as well as a pre-med. Boy did it give me a nasty headache. The Annals gives me a MUCH smoother buzz w/ NO hangover...😀

 

[BKN]

I took it once or twice as well as a pre-med. Boy did it give me a nasty headache. The Annals gives me a MUCH smoother buzz w/ NO hangover...😀

True, but we didn't have it. JACEP (Annals v1.0) didn't show up till the late 70s. And frankly it was a buzz-killer. 😴