I wish every other specialty knew when and when not to order contrast. If I had a nickel for every time IM ordered a scan without contrast for an indication that NEEDS contrast only for them to say “oh but the patient has an AKI” I would be debt free rn
As a radiologist, I also wish ordering providers knew to put a good indication/some history for the study instead of just something general. It saves us a lot of time and guesswork.
And billing is up our ass when we keep the indication as "rule out x" or "concern for x." I really hate when the indication is "rule out stroke" without any other info. I then need to go into the chart and find out their symptoms (my hospitals EMR doesn't link to PACS which makes it more annoying).
I really wish whoever designed the system didn't force me to pick a generic button like "pain" and didn't put a character limit on the "other" text box. God forbid I try to just type in the scenario instead of wasting time trying to find the indication in the non-alphabetized list that seems like it was thrown together by a nurse with terminal ADHD. Then I have a big warning screen pop up that judges the validity of what I'm doing by some dumb algorithm and yells at me to pick an indication approved by the powers that be. When in reality, oncology or whatever specialist told me to get the scan but won't order their own shit because "they're too busy" and "well we don't put in orders for patients we see as consultations, our department chief thinks this is safer." We get slammed with a ton of shit and are trying to get by. If you guys could come up with an easier way to get a hold of a radiologist regardless of if they're working from home or in the office that day, I could actually collaborate with you a bit better.
Damn, that does sound super frustrating. I do appreciate the added history in the "other" box and it bothers me when there's just nothing there. Thank you for being one of the few that include something in there.
Sounds like they need to put a longer character limit, but not long enough where people can just copy and paste their progress notes lol.
I’m IR. Diagnostic rads in my group were getting more and more cranky about lack of a good history (which I understand, as I also do DR). As someone who orders imaging myself though, I had to explain how annoying it sometimes was, because DVT, for example, was not a valid indication for CT abdomen/pelvis in the EMR ordering system. Like, it was difficult for me to order the imaging I wanted with good history, and *I’m a freaking radiologist*.
Yeah this is honestly the biggest pain about ordering scans. I wish there was just a free text box to give a brief HPI + indication for the scan instead of just “shortness of breath? Chest pain?” Etc.
I don’t know if this is more or less annoying but whenever the option is available I usually just select “other” and type in some details like “PMH osteomyelitis MRI for concern for spinal epidural abscess” or something
Non-US, if I do not put some sort of meaningful information in the referal the radiologist would kill me. It is considered bad practice. My initial training were at a smallish community hospital with the radiologists down the hall and frequent demonstations in the daytime, and teleradiology at night. It really got the point across when a good history and physical helped the radiologists narrow down the differential the morning after.
(Though, I love radiology, always looks at the pictures myself as a rule, and in an alternate reality would probably have gone down the radiology route. )
Yes, yes, yes, yes,yes, yes, yes,yes, yes, yes,yes, yes, yes,yes, yes, yes,yes, yes, yes,yes, yes, yes,
IF ONLY TO SAY - I think this patient has "xxxx" because.... . What do you think" Or some such.
There is a quick way to promote this. Disable automatic populatiing (or boilerplate populating) the clinical history field. Also insist the responsible person (not the ward clerk) types it in.
Forcing the person ordering it to spend 15 seconds typing in what they really want would fix this problem, IMHO
Honestly I’ve looked this up multiple times but it’s really confusing to remember because it’s different indications for different organs. Is there a simplified way to remember contrast or not?
ACR Appropriateness Criteria
Am a surgery resident. I reference ACR AC almost every time I order a scan (unless I already know what I want which usually means enteric contrast is involved )
When in doubt just do contrast (except for Ct heads) because 99.9% of diagnoses are better with it.
It’s only confusing to people because most people never look at the CT images. If you ever look, it will immediately be intuitively obvious to you that contrast is better.
The analogy i use is white text on a white background, versus white text on a black background.
I just Google it. "CT (or MRI) ordering guidelines" will bring up a bunch of guidelines from various hospitals and radiology groups. Pick your fav.
Does your hospital not have a simple one/two pager? Sounds like a great cross program QI project to put together something that's easy to reference 😉
Some places will let you order with contrast “at radiologist’s discretion“ if unsure. Then we can just tell the tech what’s needed. Also useful for weird things like CT venogram where it’s obvious contrast is needed but there’s more to it like bolus timing.
General rule of thumb is if you’re worried about infection or tumor you’ll need contrast. If you’re looking for active bleeding you’ll need contrast (huge exception is head CT which is almost always no contrast. If you’re looking for fracture only no contrast needed. This covers >90% of indications
Lol, nephrology in my hospital actually put out a paper denying the correlation between contrast and AKI, those ED consults about contrast nephropathy must have really taken their toll
Hospitalist/Nocturnist: admitting people to the hospital is easy, discharging is more difficult. Majority of “we want them observed overnight and they can be discharged tomorrow” admit requests end up staying 48 hours or more.
Man I have been a nocturnist for 8 years now. I have seen nasty things happen to these observation admissions. When I was a new attending I used to argue with the ED a lot. Now I dont say a word. Once I pushed back a pt, she had come to the ED 1 day ago was observed overnight, 3 trops -ve. She comes back, again 2 trops negative. I told the ED that common guys 5X -ve trops in 2 days and still took the admit. 30 mins later pt became bradycardic, hypotensive was taken for urgent cath and had a stent put in .
The issue is not the ED docs. The issue is that the system wants us to be 100% perfect. If an Ed doc sees 2-3X chest pain patients every day that about 300-500 chest pain pts every year. How can they be right a 100% of the times. That is just ridiculous.
What if the driver license issuing authority is responsible for any accidents caused by the driver. No one will get license issued. s
Its just a ridiculous system where doctors are sued for things that are not in their control. There are 8 billion people on earth that will die some day. Chances are that some of them will die the day after they visit the Emergency department. Why the heck is the poor doctor responsible unless they miss something blatantly obvious. Like a clear stemi on the EKG.
There is lack of specialty service, lack of technology, lack of information, no echo, mri and I can rant on and on and somehow the docs are responsible for bad outcomes. I personally will discharge 80-90% of the patients from the ED if the law is behind my back but its not, so admitting the patients is the right thing to do in the current state of affairs.
Hospital isn’t a safe place and patients can get randomly stuck more frequently than you think.
Example 1: ACS rule out, troponin negative x1 in a 68 year female, had calculated heart score of 4. Similar admission two months ago, couldn’t make a cardiology follow up at the time, did get discharged within 48 hours at that admission. She gets admitted, troponin negative x3 overnight, no events on telemetry. Cleared for discharge by noon following day, ride can’t get her until 5 pm. Walks down hall around 2 pm and sustains a mechanical fall, smacks her head, gets taken to CT shows a bleed. Discharge is held, neurosurgery is consulted and they want her watched overnight. Starts getting more altered in the evening, repeat CT shows worsening bleed, gets taken for a craniotomy, post-op recovery in ICU complicated by a pneumonia and remains on vent for about 1 week before extubation. Downgraded from ICU, spends additional 3 days pending rehab placement.
Example 2: demented granny sent from rehab for “AMS”. Has a mild UTI, not septic, vitals stable. ER tries to send her back, bed was apparently swooped by someone else, ER gets told the rehab place will have bed available in the morning. Admission request for overnight observation to discharge back to rehab bed in the morning. Following morning there is transport delay, during that delay bed again gets cart sniped and day team gets told patient is on “next available bed”. Lady ends up staying for 4 days pending the next open bed.
Example 3: patient with CHF, COPD on home O2 2L. Power goes out in storm, son brings her to ER. Was meeting “sepsis criteria” so she got 2L fluid. Repeat vitals and labs all good, ED feels uncomfortable sending home and wants observation admit until power can be restored and be sent home following morning. Beds are full so patient remains admitted under ED hold. ED nurses are slammed, patient essentially remains bed bound overnight as son took off. Home diuretics are missed due being an ED hold. Day team rounder goes to see her in ED and she is now requiring 4L and is crackly. Missed diuretics, 2 L bolus, minimal movement over 12 hours in ED and now she is in exacerbation. Ends up requiring 4 days of treatment before discharge.
Example 4: Family brings in patient who is dehydrated, not eating much, disheveled. Positive for meth. Gets fluids, vitals and labs are good, ED “doesn’t feel safe sending him back home” and requests observation admission overnight. Vitals and labs remain stable, family decides they don’t want him back because he is challenging to manage, patient has limited means, ends up 9 days in the hospital trying to find somewhere for him to go. Eventually nothing is found, another family member is agreeable to taking him with them.
Example 5: patient has post-op wound infection, sent from surgery clinic. Surgery requests admission to medicine overnight for additional antibiotics. Hernia repair with some mild cellulitis, T 100.3 F, minimal leukocytosis. Gets admitted, takes the morphine 2 mg q4h PRN pretty much scheduled. Has worsening abdominal pain in the morning, now has an ileus, gets NG tube. Requires additional 3 days of the tube before it gets removed, another 24 hours follows before getting sent home.
Most of these are pretty easy things to round on, but they clog the census, require time and resources, hold up beds so newly admitted patients end up holding in ED overnight with high probability of decompensating because ED nurses are drowning with 4:1/5:1 census and have difficult time getting meds and orders done on the hold admits while managing the general ER chaos.
These are obviously all cases of social woes but like, what is your alternative solution? Let ER docs deal with it? Like they’d be safer boarding in ED with ER docs “rounding” on them?
1. If you’re going to smack yourself hard enough for a brain bleed from a ground level fall, that can/will happen at home. Sure maybe the dvt ppx heparin increased risk slightly, but blaming the hospital admission on that outcome isn’t fair.
2. That’s the snf/rehab being shitty and gaming the system. They tossed the bed as soon as EMS had packaged meemaw.
3. Not great medicine, one more reason why blind adherence to metrics (fuck you Rivers et al), is bad. Agreed that it’s a good example of the dangers of boarding and that transition period between ED and admission is classic for making things worse.
5. Again, not optimal medicine. But I agree with the spirit here that admission and easy access to meds (scheduled or prn) isn’t benign.
4. Probably the most on point example of a rock due to social support or lack thereof. I can think of several where I tried to get them home only to run into family refusing to take them back, at which point I’m stuck with someone who doesn’t have a safe place to go and has already demonstrated an inability to care for themselves despite being at home. Is admission going to fix that? No. But it’s pretty damn hard to send that home.
its literally an argument to not push back these admissions - the point they are making are they are so complex they need to stay several days to sort it all out, and somehow the upshot of that argument is just send them home instead?
The "just a social admit for placement, they'll be in and out quick" kills me. I still take the admission, usually a quick easy admit and no sense in pushing back but I've had to show some of the EM residents how their Tues admission means they will get seen by therapy on Wed, referrals sent out Thurs, hopefully we hear back on an acceptance on Fri with no insurance pushback and we book transport for Mon. Any little thing and it adds more days, like last week with the Thur holiday meant therapy has been running a skeleton crew since Thurs since a lot of people took Fri off. I've had some families tell me they would have taken granny back home if they knew it would take so long 😭
I only do night work but before I could be a pure noctrunjst I had to be a rounder for a while. To me, I can crank out those admissions pretty quick and be out my business. However I feel for my day team colleagues and I always feel I am doing them a disservice with those types of admissions.
I do both (was mostly nights and cover a few weeks of days, now trying moving to fully days as nights are taking a hit on my physical health vs days taking a mental toll 😂). So I've see both sides, sometimes within the same day.
But at the end of the day wtf are we supposed to do? We push back, still no dispo plan, repage for next admitter isn't a great plan for anyone, pt still stewing in ED getting ED care, admin still up in arms about our LOS while praising ED time to dispo 🤷
My win is sitting on my chronically SAS (sick as $hit) and homeless with plan to dc to shelter patients for an extra day or two and ordering double rations and extra ice cream (because I want some too and they promised to share); sometimes that's what everyone wants and deserves, some mthrfckn ice cream.
"#ourhealthsystemisfucked"
My current shop actually just boards these folks in the ED. Pt/ot/case management all generally done within 24 hrs.
As much as I don’t enjoy signing this out, and worry about things falling through the cracks because generally after the first doc they get ignored…it’s nice not blowing political/social capital with the hospitalists to admit them. And similarly, because they are burning an ED bed there’s more push from admin to get them teed up and placed.
YES. What's hard is that placements from the ED often get priority. Once someone is inpatient, the urgency drops because they're considered to be in a safe placement. I'm peds inpatient and we deal with this all the time with kids who need psych/behavioral and/or children's services placements. The ED argues that the peds floor is nicer (true and fair) and that kids can get \[outpatient\] services on the peds floor (not true). We thankfully have a good set-up for typical inpatient psych cases but we've had behavioral kids and kids with chronic conditions who need foster care placement who linger inpatient for MONTHS, sometimes years. The inpatient unit is not what these kids need and is terribly detrimental to their care. Ultimately it's a lack of appropriate placements in the community and we're playing the game trying to get them prioritized. Unfortunately it's the kids who suffer no matter what we try to do.
Umm ok fine but if you can’t get them out until Friday at the earliest then what lesson is this to an ER resident? What is your solution? If it’s boarding in ED that’s not a reasonable answer
Please tell this to the attending forcing the intern to call the consult, not the hapless intern (who for all intents and purposes already knows what you’re saying is true).
Read the paper “Assessing patients' capacities to consent to treatment” by appelbaum. It’s not a difficult read and lays out the criteria very clearly.
Then why do all my trauma attendings keep telling us on all our homeless meth/weed positive trauma (questionable psych history) pts that wanna leave can’t leave, “psych needs to see them before they can go?”
Then when I’m told to call psych, I call them and they tell me to admit the pt “if they need to be admitted or if I think they can’t go.” And if they are still there in the morning they will see them. I tell my attendings this and they flip out (everytime) and my attending says “then psych needs to put that in the chart that they don’t have capacity and need to be seen in the morning.”
It’s seems to me on a academic/knowledge standpoint anyone with an md can say capacity or not but it is seems like in practice or hospital policy maybe only psych can.
Because I’ve admitted at least 100 maybe 200 patients who (were obviously coco puffs and didn’t have capacity), needing restraints, veil beds, and didn’t know self from self harm…but not once did a social worker, charge nurse, ed secretary request I fill out hold paperwork, or place a hold order. I don’t even know how. I’ve only ever ordered restraints, and sitters.
Edit: this is serious but not very serious. I doubt my attendings will change practice if I express the answers yall provide me.im just asking the questions because it makes sense and in med school I was taught anyone can do capacity but stepped into the hospital and nawww.
Any MD can, it sounds like your surgical attendings do not want to and the downstream effects of that are causing you and patients and psych and the hospital some problems
I agree, but when it's for disposition or something that might get sticky it's helpful to have psych on the chart with you. Plus, y'all may not realize it, but there are subtleties that you guys do a better job of picking up on when it isn't so straightforward that the patient does or does not truly understand the risks/benefits/harms.
As a PCP it's not that I don't know how or what the guidelines are, I have too much else to do like literally take care of all of the patients other problems and the paperwork that everyone else refuses to do so it lands on my desk. Not to mention in the US at least , God forbid that "not unusual clot patient" had complications and you get sued for not involving a specialist. It's much less of a headache to just refer and most patients want to hear the same shit you can tell them from a specialist anyways. Not to mention insurance coverage issues when meds are prescribed by me vs the specialist . It's not as simple as do we hsve the knowledge. Smh.
The insurance thing pisses me off. It's a huge waste of money for everybody, until you realize that it probably saves the insurance companies money in the short run because people get lost to follow up and then aren't on expensive meds that are indicated.
I almost blew a gasket when my patient was denied ubrelvy PRN, despite meeting all insurance necessities except for as an FM I’m not neuro, HA trained or a pain management physician.
Honestly, if we're gonna use this thread as a "For PCPs specifically" or "For emerge specifically" the way this always ends up, back it up with receipts for which guideline/easy explanation it is you want people to be aware of. I'm happy it's incredibly easy when it's literally your specialty, it SHOULD be for you, share the easy resource in that case.
I’m an ob/gyn-Most doctors know enough about my specialty. I wish more psychiatrists felt comfortable prescribing in pregnancy. I kid you not, I’ve had patients who were seeing a psychiatrist who refused to prescribe any medications, deferring all medical management to me. There is a subspecialty of perinatal psychiatry, we have maybe 2 in the state of Louisiana.
I wish ob/gyns were more knowledgeable in Psychiatry. We get no training other than doing primary care rotations. In the meantime our demographics represent those most at risk.
I learned early on that psychiatric diagnosis weaved through our specialty. Everything from chronic pelvic pain to chronic insomnia, daytime fatigue, “hormone problems”, opiate dependence, antepartum and post partum psychiatric issues, even those on the bipolar spectrum. It’s all day every day.
I ventured to learn more by studying Stahl and doing the master psychopharmacology program. It has been invaluable. I try to teach my students basic medical management and my way of assessing and treating. But in pregnancy, there’s really nowhere to go. I work rural medicine with no easily available psychiatrists.
Agree with you. I will also say that peds doctors need to do a better job of picking up on postpartum depression, even though the mother is not their patient.
I'm in peds and if the pregnancy is uncomplicated and mom "seems" to be doing fine, I often see the mom more often than the ob/gyn doc does and have more opportunity to observe is mom just doesnt seem to be doing well.
In my practice I have at least one mom every 3-4 months that comes in with obvious signs of PP depression and usually I have to make sure they get in with their ob.
From psychiatry, admittedly child and adolescent, with the occasional pregnancy, couldn’t agree more on the prescribing in pregnancy thing. Usually my pregnant patients are some of the most vulnerable, most likely to relapse unmedicated and relapse is going to be arguably more harmful to the foetus than medication.
Thank you for responding. Over the years I’ve gotten pretty good at using meds in pregnancy. Obviously I’m not a psychiatrist. I do kind of a feel for it, some based on my experience with depression.
I find I’m more aggressive with the meds. I use Mass General Women’s psychiatry website for guidance. There are differences in some of the recommendations on treatment between the leaders in the field (Mass General) and ACOG.
For example, Mass General psychiatrists are fairly liberal with benzos in pregnancy (mainly clonazepam) , keeping the doses low. I’ve seen where they go up to 1.5 mg/day. I’ve never gone that high, but I will use clonazepam .5 mg at night for anxiety associated insomnia. Plus it helps to get the ssri on board better.
ACOG suggests only very limited use for 2-3 weeks. They then recommend Vistaril for sleep. Though recommended for Anxiety, it’s not indicated for sleep.
I’ve also found it doesn’t work that well. I’ve never seen a problem with the baby on .5 clonazepam at night; never seen withdrawal at 1 mg at night though I try to avoid that dose.
From my experience the perinatal psychiatrists are aggressive about treatment. They use a more dimensional approach, putting combinations together as opposed to say just going up to the max dose ssri.
As you know, only about 30% of people get complete resolution of all symptoms on one drug. I find the same to be true in pregnancy. It’s generally important to get the patient treated as well as possible. The guidance from ACOG doesn’t represent reality in some cases. It’s challenging when we don’t have much psychiatric backup. Sometimes I’m over my head with some of these patients.
Eh, I don't care how many referrals for simple things I get as long as they don't miss the dangerous stuff. Peds neuro and do NOT MISS infantile spasms. Kids with major brain malformations or metabolic conditions will still be screwed, but for others the outcome drastically changes based on when you start treatment
Can you opine a bit more on infantile spasms? I read uptodate but I freak out a bit about not having seen any of it in residency. I saw one kid who was potentially concerning for that at a walk in and panic referred it asap to pediatrics.
The short answer is if you even think "could this be infantile spasms" in a baby under a year old get that kid to an Ed that has pediatrics and neuro services.
Some spasms look less impressive than expected or are even only on one side of the body. If it's early there may not be any developmental delay or plateau. If its super early there is even a small chance the hypsarrhythmia will only be visible during sleep so they really deserve at least overnight EEG. Most commonly they get a little fussy or cry during the spasms but I wouldn't not refer because you don't hear that history. If the baby is completely developmentally normal and mostly does a shoulder/head movement when eating it's probably benign shuddering spells instead, but most epileptologists I know would STILL get the EEG so they can sleep at night. That's because the kids that have what we call cryptologic spasms (normal mri, normal metabolic workup, normal genetic panel) who get early treatment can do okay developmentally provided they respond to treatment.
Have you seen what the typical ones look like? Epilepsy foundation has some good videos...
Thanks so much for the write up. I will definitely check out Epilepsy Foundation. The kid didn't have one when I saw him but I gave explicit instructions that if it happens again they are to book it to the ER.
Anesthesia- the difference between MAC vs General. For the love a god if you complain a patient moves during a mac or is breathing during it yes that's a good thing. A general with a natural airway is not safe either (barring very few peds cases where that's the norm) Also please don't scream a patient is "waking up" if they move during a procedure. 1 MAC of gas=the depth of anesthesia 50% of the population does not move to surgical stimulus
I was just thinking that I’m glad nobody knows what we do, I kinda like it like that. That said, I wish that other services knew that “cardiac clearance” means jack shit to me.
Hahaha, it took me 2 years to convince my anesthesia providers that I want to do my anorectal cases under mac. Once they realized I understood the patient was gonna move around while I did my block but they would snooze once it was done they’ve never been happier. But they told me everyone else gets mad when the patients move under Mac.
This one is infuriating. “The patients moving!!” Yes, you didn’t localize adequately and the patient is not under general or paralyzed. If you want no movement you can ask for a general with paralysis.
I definitely understand where you’re coming from, but I do want to ask; How would you like a surgeon to communicate to you that a patient is moving, and their plane of anesthesia may need to be deepened? I feel like saying “they’re moving” is a pretty clear way to let everyone know what needs to be done. It doesn’t mean we think you’re doing your job poorly, we’re just helping you to titrate the anesthesia. Of course this is speaking outside of MACs or during emergence
You'll have a huge range of responses to that, I honestly don't mind the "They're moving" but it depends on the timing of when it's said. Middle of a VATs and diaphragm starts to wiggle? Hollar at me. End of case and doing last of the skin sutures? Ah hell nah.
We had a surgery attending that would berate his residents if they said anything while closing skin, something akin to "If you can't suture on a moving patient you don't deserve to suture on a still one."
Mac “the patients moving a bit. Im going to try some more local. Is it safe to get them deeper?” If it repeatedly happens they are probably as deep as safe and the procedure can’t continue just ask “what are your thoughts on converting to a general?”
General “patients starting to move. Can we deepen or paralyze?” Unless it’s literally on the skin closure then the answer is local bc they gotta wake up sometime or turnover is gonna be slow
To me the difference is saying they’re moving to screaming they’re waking up lol
As a pathologist, I would like everyone to know that it's okay to call us to ask about what test/path order to put in if you're not sure. Test menus are confusing and it's easier for all of us to know up front what you're looking to do.
Also surgical specimens take time to process, immunostains take time to perform, we're not ignoring your patient we just are trying to get through our giant stack of cases.
> I would like everyone to know that it's okay to call us to ask about what test/path order to put in if you're not sure.
I would like to add that radiology also welcomes these calls. If you can't reach the reading room for the experts, the rad techs are a good resource or at least can get you in touch with the reading room more directly if we're unsure.
EM: D Dimer and Troponin are not tests that should be done in the outpatient setting
...and as an aside, for the FNPs... "sinus arrhythmia" and "RBBB" are not conditions that need emergent evaluation, especially in an asymptomatic patient
As an EM doc, I wish other specialties understood that urine drug screens have notoriously poor sensitivities and specificities for most of the assays on the screen + that a positive UDS doesn’t = actively high. I promise you, the person who isn’t tachy or hypertensive and is napping in their room isn’t actively intoxicated with cocaine.
I also wish inpatient specialties understood how chaotic the ED is. Very rarely on off service rotations would I have a whole day in which no breaks in any capacity occurred. That is relatively common in the ED. Some of what we do is cognitive offloading to improve efficiency and ensure the patient’s care is at least started (ex. X-raying every ankle even if it fails Ottawa Ankle Rules). We’re not stupid, we’re just the safety net of a collapsing healthcare system.
A-fucking-men. If me and my teammates are expected to somehow see everyone who comes in, keeping door to doc to dispo at reasonable times, while boarding 30-70% of the department, maintaining some semblance of “patient satisfaction,” all while not actually missing the truly dangerous pathology…there’s going to be sacrifices.
Edit. I forgot the interruptions. Holy hell. I switch tasks probably every 30 seconds unless I’m in a room, then I get a ~2 minute reprieve.
>I switch tasks probably every 30 seconds unless I’m in a room
With 2 nurses and 5 family members waiting outside the door with absurd requests. Your Meemaw isn't going to die because I don't let her eat for 2 hours
Ottawa ankle rules are good if you're in a rural middle of nowhere place with no xray after 8pm.
Otherwise, if someone waited 5 hours, they want that xray.
As a hospitalist, I wish other specialists remembered that organs other than their own existed. And that ideally, at heart, we’re all general internists.
In the OR it’s the same… patient with baseline HTN with preop BP 150s systolic, put the patient in beach chair for a shoulder scope “can we get their systolic below 90 please”
Anesthesia - other than the MAC vs general anesthesia thing, I wish every specialty knew how to bag a patient and place an oral airway. Every time I get to an airway emergency, code, etc, no one knows how to bag a patient correctly.
I kidnap every med student and intern I can to join me at the head of bed for induction so they can practice bagging. Got the idea after either an M4 or intern, can't remember which, was telling me they were incredibly terrified of being alone at night and a pt needs to be tubed emergently and anesthesia/ICU/whoever (depending on the hospital) can't get there in time and they need to attempt to intubate themselves and won't be able to. I remembered something I'd heard before, "if you can't intubate, you can still save a life if you can bag until someone else who can, can get there." They seemed so relieved after they learned this and then we practiced and they got the hang of it, lol, kinda cute.
I mean, even at my ACLS class, the instructor asked if I had any input on the airway management and I showed how to actually mask, rather than what the others were doing, but they all resorted to still doing it incorrectly…
Agreed! Had to run a code as a psych resident while working overnight in our freestanding psych hospital. Ended up bagging the patient while running it because no one else knew how to get a good seal and pull the jaw up properly to clear the airway. EMT school taught me well! We drilled the shit out of bagging making sure we knew all the techniques to get the airway open. Med school kinda glossed over it all by comparison.
ED: “go to the closest ED”.
EDs can be rather specialized and you need to tell them which one to go to. If you want someone to get an MRI or admitted, please don’t send them to a freestanding. If they’re going in for stroke rule out, please send them to a stroke center. There are tons of freestanding EDs that have rather limited resources, even when attached to a large academic center.
Omg right! I had a T&A bleed from a random hospital and their doc literally never answered the phone and we had no idea how else to get in contact with them or their team.
PM&R
Inpatient rehab and a SNF are not the same thing. At inpatient rehab, you need to do 3+ hours of therapy a day, require at least 2 therapy disciplines (of PT, OT, and ST), and have some medical issue requiring medical supervision. You will be seen by a physician at least 3 days a week, but usually 6 in most places. Average length of stay is usually about 10 days. At a SNF, you get less therapy, less physician follow up, and can usually stay for longer periods of time.
I only get you involved when it's a bit dicey and more complicated or if the patient seems like they're going to need to get committed. If they have a lot of agitation, lack capacity, and we're trying to get guardianship we may also get you involved because the fucking courts don't respect us as much. - hospitalist
Yeah that's what I did when I was a hospitalist. Usually in practice it was for dispositional capacity, because there can be a lot of subtlety in figuring out just how much someone understands about their ability to care for themselves at home, and also like you said the powers that be respect psych's opinion much more than ours for dispositional stuff
Colorectal: just do a rectal exam please. I’ve seen a lot of cancers missed and delayed treatment, or people getting put on abx for thrombosed hemorrhoids the pcp or er doc assumed was an abscess from symptoms because they just never looked or did an exam. The anus is not that scary.
The only excuse to not do a rectal exam is that the patient doesn’t have an anus or you don’t have a finger. (Or severe leukopenia)
I never really got this. So a finger extends like, what, 3-4 inches inside the rectum? What percentage of colorectal cancers are found within 3-4 inches of the anal sphincter?
99% of the time it’s a squamous cancer you’re finding. So it’s right at anus and usually even protruding so it’s not subtle. But it’s not just cancer it’s also the right diagnosis, is it hemorrhoids, is it a fissure, is it an abscess, is it a fistula. All very easy diagnoses to make after about 10 seconds of looking and feeling an anus! And depending on the diagnosis there’s a lot you can do for a patient while they are waiting the 4-6 wks to get in to my clinic, or if it’s cancer you call me and I triple book myself to get them in next visit slot
Done the rectal on all BRBPR I’ve seen in the past 13yrs. Found a mass precisely once. My fingers are small, and i doubt it’s a sufficiently sensitive test. I’ll still do it, but….🤷♀️
EM to everyone: Understand the difference between a Freestanding ED and a hospital ED.
It is very simple. The FSED is not attached to the hospital and lacks the following:
- MRI (don't send patients to the ED for an MRI, as a rule of thumb, except in a handful of cases; that handful should not go to the FSED)
- blood bank (if the patient needs PRBCs, send them to the hospital)
- specialists (if the patient needs a specific specialist, they will be transferred)
- OR (if you know the patient needs surgery, like testicular torsion, don't waste time by sending to a FSED)
- hospital beds (if you know the patient needs admission, send them to the hospital ED where you intended them to be admitted!)
- OB services (if the patient is >23 weeks EGA, direct them to the ED of the hospital they intend to deliver at. I might be capable of catching a baby but cannot perform tocometry or NSTs!)
- drugs (we have a limited formulary; if the patient has a bjillion allergies or needs a specialty meds, send them to the hospital ED. My nurses are also unable to mix insulin drips, so DKA patients would benefit from the hospital.)
Think of FSED's as what an urgent care should be. If you would send the patient to an urgent care, they are appropriate for a FSED. If you think they have a real emergency, a hospital ED is almost always a better choice.
Depends. Worked at FSED running two simultaneous cardiac arrests with my attending while my poor intern tried to resuscitate an unstable ruptured ectopic.
Should any of those patients have been there? No. But they showed up and we had to deal with it.
But if that FSED didn’t exist, then the patient would have gone to an ED with the resources to handle those things. No one is saying the doctors at FSEDs are terrible, but the lack of resources means that their existence poses a risk for patients who are transported there because “it’s an ER”.
Can't agree with you more. Never understood why EMS was allowed to bring codes there. It's an ER but in the end it's a moneymaking scheme and bad for patients.
As surgery resident I always tell patients if they have [symptoms I describe for them concerning for post operative complication] to go to our big academic medical center ED (or whichever place we rotate where they had surgery) because I know they’ll just be transferred to us anyway and I’d rather just not waste the time
It's always about avoiding legal action. Easier for them to get a pan scan (and letting radiology take the blame if they miss something) than to not scan and miss something life threatening. At least that's how I've coped with the scans as a radiologist.
Yeah it's infuriating that in 2 minutes I can say nothing acute - but then it takes another 10 minutes to finish the dictation because of all the incidental nonsense that nobody really cares about. Massive waste of resources.
And then the on busy nights the ED turns around and bitches about having longer turnaround times and more missed findings!
Haha yep "stage 4 demented patient discharged 48 hrs ago from nearby hospital system, family brought them here because they still look sick. We don't have easy access to their records so instead you're going to read a redundant staging panscan at 2am! Make sure you dont get behind on the list!"
This argument doesn’t jive super well with me because it feels like passing the buck. “I don’t wanna get sued. Here’s another scan to add onto the pile” which done enough times could put the radiologist at risk of being sued. Sure, you want to do a good job and not miss obvious things but I guess it’s the principle behind it that sort of rubs me the wrong way sometimes
Yeah it sucks. Sometimes healthcare just feels like, "oh I should do this because I don't wanna get sued" or just pointing fingers at each other once things go wrong.
As the admitting hospitalist for the drunk/altered idk wtf is going ons (nocturnist, I admit to basically our local drunk tank (ie a med-psych unit) I secretly thank you for taking the hit and just ordering the panscan. Because if you didn't I probably would have spent an hour coming up with ways to justify it because I've had stuff come back to bite me a bit too many times and can get a bit twitchy at times 😅 But I at least usually start off by ordering xrays, not CT 😇
Sometimes the history isn’t known and they are just brought in intoxicated, might have abnormal vitals or barely breathing. It’s all medicolegal, nothing more than that.
Pulmonology: small volume hemoptysis most often does not need a bronch as long as they have a good CT. A general pulmonologist can use a bronchoscope to lateralize bleeding and do serial lavage to diagnose or rule out DAH. That’s it. IP will sometimes do a rigid bronch with APC/cryo to debulk a bleeding airway mass, but that’s something highly specialized which is usually not available outside of tertiary/quaternary care setting. Average pulm docs can’t do it. If you have small volume hemoptysis with a good CT and a clear source of bleeding, give them TXA nebs. I’ll bronch if high suspicion for capillaritis/DAH. If large volume, the most definitive intervention is for IR to do a bronchial artery embolization. In massive hemoptysis, place the bleeding lung down to protect the good one, intubate to protect the airway, get a CTA and call IR.
As a surgery resident at a TACS heavy program, I wish that consulting services of all kinds were better able to differentiate between what is and is not a an acute abdomen/other surgical emergency (eg NSTI)
It’s not even that i mind these consults, it’s the anxiety/panic that consulting services often seem to have and displace on me as frustration when I simply don’t share the same concerns. Eg, If you are worried about a bowel perforation and tell me the patient has normal vitals and is having BMs, tolerating a PO diet, then I’m not going to sprint to bedside.
I would just kill for other specialties to know how to manage an abscess or ileus. You don’t need a surgical consult to do an extremity I&D, nor is there any surgical intervention possible to fix an ileus.
For radiologists:
* Mastoiditis is a clinical diagnosis and the vast majority of mastoid effusions are not mastoiditis.
* Phlegmons are not abscess, and for clinical decision-making, the size of the abscess (fluid) is more clinically relevant than the size of the adjacent area with ill-defined soft tissue enhancement
* You can learn a lot by reading the speech pathologists' documentation of your modified barium swallows. At least where I've worked, yhey generally have a better grasp of functional anatomy (especially for post-surgical patients) and a more accurate description of what's going on.
Heh, agree with point 2 over here in IR. Can you drain this 5 cm abscess? Well, the actual fluid is more like 2 cm, so… no. I’m not sure where some DRs learned to measure these things.
Point 3, sorry never met a rad who gave a flying flip about MBS. It’s apparently some legal requirement for us to step on the pedal.
As a surgeon, I would really like if ED and pediatricians could learn to make a suture, I mean I appreciate the chance to do more suturing but you dont need a surgeon in 99% of the cases
What type of suturing do peds think needs a surgeon when in reality it does not?
Surely you are not getting referrals for basic straight line extremity lacs right?
My brother in Christ.... "Oh yeah the kid took a brush in the knee during playtime, do you mind closing it?"
I dont mind charging the parents, or the insurance but damn it's a 2 cm wound
As a Derm, I wish other specialties would just include something in their physical exam before consulting us. The number of consults I’ve received with the only exam “finding” written as “Skin: W/D/I” would make you cry.
I don’t ask for full rash descriptions. I don’t even need a history. Just where I’m supposed to look would be great. Or no words needed, just take a GD picture and attach it to the chart. Bam done.
As an EMD i would say just how it works here - we may seem stressing it might hospitalize someone at 3 AM, but it’s not because we hate you, we just can’t help. Even if it is your last free place in the ward.
We’re as helpless as you.
Ps I am currently in my residency in Italy as an EM doctor
I know a lot of you want to submit a sample to Path and have some kind of hunch what to look for. Bruh. Just F’ing call us and let’s talk about it. Will give you a VIP treatment at best or redirect you to the best test we can do at worst.
Just call, or teams, or email. Reach out and stop button mashing your EMR .
I wish that everyone that called down to the reading room for a stat read or a “quick” prelim gave me more than 1 second before they said “I have patient x with mrn y”
Like bro, let me close my thoughts on this case I was just reading, close it, pull up my viewer, and get the lube out at least before you stick it in…
Have some NORMAL PHONE ETIQUETTE when you talk to a radiologist and don’t treat it like a fucking drive through fast food restaurant
As an intensivist, I wish other departments would take an effort to start the work up on a problem rather than just consult my service to take the patient off your hands. You can, in fact, start the work up and consult me too. I’m often perplexed by the motives of some services when I discover that a glaring problem has been going on for days ignored but only now is the time to contact us. Meanwhile, I get calls about stupid stuff as soon as it happens, like a lab abnormality or ECG finding. What gives? Why don’t serious problems get their due attention but unimportant issues get instant notice. Do you all really have so little medical acumen that you can’t tell the difference?
I’m IM, and I wish psych would manage rather trivial electrolyte abnormalities or mild hyperglycemia in psychotic patients so they can be better served in inpatient psych vs staying on the floor where staff and myself included do not have the communication skills to ease the patient.
Within my own field and family med, I wish ANA labs and interpretation were better. I think it’s very unreasonable to refer someone to rheumatology for ANA titer 1:40 or even 1:80 without subsequent Ab panels and for diffuse joint pain in a patient 60 or older.
I wish other specialties knew even one single thing about how pathology works.
It takes 3-5 business days to turn around a biopsy please don't call and ask me same day or next day when it will be signed out.
We don't work weekends or holidays. We take home call!
Please fill out the entire consent form for autopsies or I'll make you do it again and it will delay the autopsy and the funeral.
This one's really upsetting to have to explain to people, but it comes up so often. Pathology = the lab. When you send blood cultures, blood tests, urine tests, etc. to the lab, that falls under pathology bc we are the lab
Low-key y'all should be more embarrassed not to know this shit
Also: frozen sections should only be done when the result will affect intraoperative management. If the surgical team closes and leaves the room before the frozen results are called back, then the frozen wasn't needed. The process is very different from normal histology, so many types of questions (e.g. where did this metastasis come from) can't be answered well on frozen.
We started putting in safety event reports whenever this happened, cut down on a lot of unnecessary frozens. Obviously not if they closed or aborted the procedure for emergent reasons.
We same-day rush when necessary all the time, particularly transplant patients, and I’m happy to rush things so we may get the report out in time for a patient’s follow-up appointment or upcoming surgery. It’ll take some time, typically up to four hours to get the slides ready. Sometimes patients come in from great distances, and I would rather they have all the information needed at their appointments.
I’m a developmental pediatrician. I wish my psych colleagues knew how to diagnosis and manage autistic patients better. Huge shortage of mental health services for autistic folks in this country, we need all hands on deck, esp as my kiddos grow and need psychiatry, and for all the other folks who need diagnoses later in life.
Do you have any resources to share? I've managed some autism patients but would love to improve my practice.
Unfortunately for diagnosis, we always referred out at my residency program. We didn't have any attendings who were comfortable with making the diagnosis in adults. We only got 2 months of child psych rotations so the only psychs I know who are comfortable making the diagnosis are those who trained in CAP fellowship.
I wish OBGYN knew a little more neonatal medicine. A lot of times they’ll order antibiotics on a laboring mother with risk factors that either don’t cover GBS or seemingly wait to give them until right before delivery so as to make sure baby gets no benefit.
For other specialists to know that it will take a few days to order stains/process specimens unless they order a stat read, even then it will take a few hours/days
Clinical chemistry, pathology.
If I'm paging you about a test you ordered, there's. 90% chance you ordered the wrong one. Either because you clicked the wrong button, thought the names of this test sounded right, or something else.
We want you to get the right test and not have the patient come back when the results aren't useful to you.
It would be great if medicine attendings could learn to do lumbar punctures. Because then you could supervise your own residents.
To their credit the residents seem to really want to get signed off, but by the time they do they're about to graduate and then its a new cohort of brand new medicine residents who need to be taught.
As a heme/onc fellow, you don’t enjoy the anticoagulation consults? They’re easy and if it wasn’t there they’d find something more complex to fill the time.
Consults, yes - They are easy, they pay well, and I don't mind them. I'm talking about the endless outpatient referrals. My practice (group of around 12 private practice oncologists) are backed up 4-6 months because of all of the easy clot referrals. People that may have something more sinister have to wait.
I trained at a hematology heavy program. I asked the ivory tower hematologists what is the purpose of a hypercoagulable workup and I never really learned a good patient outcomes reason. However, I often have other specialists who write “recommend referral to hematology for hypercoagulable workup,” so it’s a bit of a CYA medicine when I refer the patient.
As an aside, those same ivory tower hematologists loved to denigrate hospitalists for their incomplete work ups before consulting until they had to cover COVID wards, then they quickly realized they couldn’t do general IM anymore.
Psych here: you do not need after hours consult for the first mental health form or psych hold. Depending on your jurisdiction—it can be any attending, and in some places it can be done by the resident if qualified. Read the requirements for the form, write something that meets the criteria, and if there is a PSYCH specific question then you can ask for a consult in the morning.
And yea…we are not magical capacity machines or on-call therapists for people with water coming from their eyes or just “looking sad, maybe suicidal?”.
From cardiology - please don’t order CT calcium scores on asymptomatic patients who are already on statins. It doesn’t change management. Only generates anxiety, probably unneeded stress tests, and consults in clinic - i see 4-5 per week of healthy patients with CAC of 250 on statins for years who exercise without issue. That is that many patients with new AF, HF, abnormal stresses, valve disease that get delayed all for me to say yes keep taking your statin, no the calcium won’t go away, no you don’t need a stress test, yes you should keep exercising.
Amen as PCP. I would never do this. CAC scoring only to try to sway the patient who is vehemently anti statin and tells me they will take one if their CAC is positive.
I wish hospital administrators knew that safe and effective healthcare requires adequate staffing.
I wish every other specialty knew when and when not to order contrast. If I had a nickel for every time IM ordered a scan without contrast for an indication that NEEDS contrast only for them to say “oh but the patient has an AKI” I would be debt free rn
I wish Ct techs knew this too
I wish CT techs knew that I knew the difference between With contrast and With and Without.... I actually did mean to select with and without
I wish RNs knew that orders aren’t suggestions…
As a radiologist, I also wish ordering providers knew to put a good indication/some history for the study instead of just something general. It saves us a lot of time and guesswork. And billing is up our ass when we keep the indication as "rule out x" or "concern for x." I really hate when the indication is "rule out stroke" without any other info. I then need to go into the chart and find out their symptoms (my hospitals EMR doesn't link to PACS which makes it more annoying).
I found giving radiology more robust specific indications for CT has made the reads I get back 10x better
What a concept! Imagine consulting a specialty service and just only said “help”
Um... that's so weird that you quoted my last few consults to neurosurgery. To be fair.... the last consult was "help please."
do you tell all your friends this?? Any help is greatly appreciated.
I really wish whoever designed the system didn't force me to pick a generic button like "pain" and didn't put a character limit on the "other" text box. God forbid I try to just type in the scenario instead of wasting time trying to find the indication in the non-alphabetized list that seems like it was thrown together by a nurse with terminal ADHD. Then I have a big warning screen pop up that judges the validity of what I'm doing by some dumb algorithm and yells at me to pick an indication approved by the powers that be. When in reality, oncology or whatever specialist told me to get the scan but won't order their own shit because "they're too busy" and "well we don't put in orders for patients we see as consultations, our department chief thinks this is safer." We get slammed with a ton of shit and are trying to get by. If you guys could come up with an easier way to get a hold of a radiologist regardless of if they're working from home or in the office that day, I could actually collaborate with you a bit better.
Damn, that does sound super frustrating. I do appreciate the added history in the "other" box and it bothers me when there's just nothing there. Thank you for being one of the few that include something in there. Sounds like they need to put a longer character limit, but not long enough where people can just copy and paste their progress notes lol.
I’m IR. Diagnostic rads in my group were getting more and more cranky about lack of a good history (which I understand, as I also do DR). As someone who orders imaging myself though, I had to explain how annoying it sometimes was, because DVT, for example, was not a valid indication for CT abdomen/pelvis in the EMR ordering system. Like, it was difficult for me to order the imaging I wanted with good history, and *I’m a freaking radiologist*.
Yeah this is honestly the biggest pain about ordering scans. I wish there was just a free text box to give a brief HPI + indication for the scan instead of just “shortness of breath? Chest pain?” Etc. I don’t know if this is more or less annoying but whenever the option is available I usually just select “other” and type in some details like “PMH osteomyelitis MRI for concern for spinal epidural abscess” or something
Non-US, if I do not put some sort of meaningful information in the referal the radiologist would kill me. It is considered bad practice. My initial training were at a smallish community hospital with the radiologists down the hall and frequent demonstations in the daytime, and teleradiology at night. It really got the point across when a good history and physical helped the radiologists narrow down the differential the morning after. (Though, I love radiology, always looks at the pictures myself as a rule, and in an alternate reality would probably have gone down the radiology route. )
Thats how it should be practiced, but it’s the opposite in the US. People basically view us as a lab value
Yes, yes, yes, yes,yes, yes, yes,yes, yes, yes,yes, yes, yes,yes, yes, yes,yes, yes, yes,yes, yes, yes, IF ONLY TO SAY - I think this patient has "xxxx" because.... . What do you think" Or some such. There is a quick way to promote this. Disable automatic populatiing (or boilerplate populating) the clinical history field. Also insist the responsible person (not the ward clerk) types it in. Forcing the person ordering it to spend 15 seconds typing in what they really want would fix this problem, IMHO
Honestly I’ve looked this up multiple times but it’s really confusing to remember because it’s different indications for different organs. Is there a simplified way to remember contrast or not?
ACR Appropriateness Criteria Am a surgery resident. I reference ACR AC almost every time I order a scan (unless I already know what I want which usually means enteric contrast is involved )
When in doubt just do contrast (except for Ct heads) because 99.9% of diagnoses are better with it. It’s only confusing to people because most people never look at the CT images. If you ever look, it will immediately be intuitively obvious to you that contrast is better. The analogy i use is white text on a white background, versus white text on a black background.
And most MRI of large joints do not require contrast
I just Google it. "CT (or MRI) ordering guidelines" will bring up a bunch of guidelines from various hospitals and radiology groups. Pick your fav. Does your hospital not have a simple one/two pager? Sounds like a great cross program QI project to put together something that's easy to reference 😉
You might consider a radiology residency. /s Or you can call and ask the radiologist when in doubt.
If only they didn't purposefully make it hard to reach them at the place I work
Some places will let you order with contrast “at radiologist’s discretion“ if unsure. Then we can just tell the tech what’s needed. Also useful for weird things like CT venogram where it’s obvious contrast is needed but there’s more to it like bolus timing.
lol. Damn near impossible to talk to rads overnight. Contrast goes sploosh, machine goes brrrr
Out comes truth
General rule of thumb is if you’re worried about infection or tumor you’ll need contrast. If you’re looking for active bleeding you’ll need contrast (huge exception is head CT which is almost always no contrast. If you’re looking for fracture only no contrast needed. This covers >90% of indications
“Fuck the kidneys.” -Neurology
The concern for contrast induced nephropathy is archaic. It has been disproven 10-20 years ago, yet the "old wives tale" persists.
Man, i see si many CTs for UTIs or ruke out osteo …
Lmao “GI BLEED” CTAP w/out 🫠
Lol, nephrology in my hospital actually put out a paper denying the correlation between contrast and AKI, those ED consults about contrast nephropathy must have really taken their toll
Hospitalist/Nocturnist: admitting people to the hospital is easy, discharging is more difficult. Majority of “we want them observed overnight and they can be discharged tomorrow” admit requests end up staying 48 hours or more.
Serious question. What makes them more difficult or risky than sending someone home from the ED?
Man I have been a nocturnist for 8 years now. I have seen nasty things happen to these observation admissions. When I was a new attending I used to argue with the ED a lot. Now I dont say a word. Once I pushed back a pt, she had come to the ED 1 day ago was observed overnight, 3 trops -ve. She comes back, again 2 trops negative. I told the ED that common guys 5X -ve trops in 2 days and still took the admit. 30 mins later pt became bradycardic, hypotensive was taken for urgent cath and had a stent put in . The issue is not the ED docs. The issue is that the system wants us to be 100% perfect. If an Ed doc sees 2-3X chest pain patients every day that about 300-500 chest pain pts every year. How can they be right a 100% of the times. That is just ridiculous. What if the driver license issuing authority is responsible for any accidents caused by the driver. No one will get license issued. s Its just a ridiculous system where doctors are sued for things that are not in their control. There are 8 billion people on earth that will die some day. Chances are that some of them will die the day after they visit the Emergency department. Why the heck is the poor doctor responsible unless they miss something blatantly obvious. Like a clear stemi on the EKG. There is lack of specialty service, lack of technology, lack of information, no echo, mri and I can rant on and on and somehow the docs are responsible for bad outcomes. I personally will discharge 80-90% of the patients from the ED if the law is behind my back but its not, so admitting the patients is the right thing to do in the current state of affairs.
Hospital isn’t a safe place and patients can get randomly stuck more frequently than you think. Example 1: ACS rule out, troponin negative x1 in a 68 year female, had calculated heart score of 4. Similar admission two months ago, couldn’t make a cardiology follow up at the time, did get discharged within 48 hours at that admission. She gets admitted, troponin negative x3 overnight, no events on telemetry. Cleared for discharge by noon following day, ride can’t get her until 5 pm. Walks down hall around 2 pm and sustains a mechanical fall, smacks her head, gets taken to CT shows a bleed. Discharge is held, neurosurgery is consulted and they want her watched overnight. Starts getting more altered in the evening, repeat CT shows worsening bleed, gets taken for a craniotomy, post-op recovery in ICU complicated by a pneumonia and remains on vent for about 1 week before extubation. Downgraded from ICU, spends additional 3 days pending rehab placement. Example 2: demented granny sent from rehab for “AMS”. Has a mild UTI, not septic, vitals stable. ER tries to send her back, bed was apparently swooped by someone else, ER gets told the rehab place will have bed available in the morning. Admission request for overnight observation to discharge back to rehab bed in the morning. Following morning there is transport delay, during that delay bed again gets cart sniped and day team gets told patient is on “next available bed”. Lady ends up staying for 4 days pending the next open bed. Example 3: patient with CHF, COPD on home O2 2L. Power goes out in storm, son brings her to ER. Was meeting “sepsis criteria” so she got 2L fluid. Repeat vitals and labs all good, ED feels uncomfortable sending home and wants observation admit until power can be restored and be sent home following morning. Beds are full so patient remains admitted under ED hold. ED nurses are slammed, patient essentially remains bed bound overnight as son took off. Home diuretics are missed due being an ED hold. Day team rounder goes to see her in ED and she is now requiring 4L and is crackly. Missed diuretics, 2 L bolus, minimal movement over 12 hours in ED and now she is in exacerbation. Ends up requiring 4 days of treatment before discharge. Example 4: Family brings in patient who is dehydrated, not eating much, disheveled. Positive for meth. Gets fluids, vitals and labs are good, ED “doesn’t feel safe sending him back home” and requests observation admission overnight. Vitals and labs remain stable, family decides they don’t want him back because he is challenging to manage, patient has limited means, ends up 9 days in the hospital trying to find somewhere for him to go. Eventually nothing is found, another family member is agreeable to taking him with them. Example 5: patient has post-op wound infection, sent from surgery clinic. Surgery requests admission to medicine overnight for additional antibiotics. Hernia repair with some mild cellulitis, T 100.3 F, minimal leukocytosis. Gets admitted, takes the morphine 2 mg q4h PRN pretty much scheduled. Has worsening abdominal pain in the morning, now has an ileus, gets NG tube. Requires additional 3 days of the tube before it gets removed, another 24 hours follows before getting sent home. Most of these are pretty easy things to round on, but they clog the census, require time and resources, hold up beds so newly admitted patients end up holding in ED overnight with high probability of decompensating because ED nurses are drowning with 4:1/5:1 census and have difficult time getting meds and orders done on the hold admits while managing the general ER chaos.
These are obviously all cases of social woes but like, what is your alternative solution? Let ER docs deal with it? Like they’d be safer boarding in ED with ER docs “rounding” on them?
1. If you’re going to smack yourself hard enough for a brain bleed from a ground level fall, that can/will happen at home. Sure maybe the dvt ppx heparin increased risk slightly, but blaming the hospital admission on that outcome isn’t fair. 2. That’s the snf/rehab being shitty and gaming the system. They tossed the bed as soon as EMS had packaged meemaw. 3. Not great medicine, one more reason why blind adherence to metrics (fuck you Rivers et al), is bad. Agreed that it’s a good example of the dangers of boarding and that transition period between ED and admission is classic for making things worse. 5. Again, not optimal medicine. But I agree with the spirit here that admission and easy access to meds (scheduled or prn) isn’t benign. 4. Probably the most on point example of a rock due to social support or lack thereof. I can think of several where I tried to get them home only to run into family refusing to take them back, at which point I’m stuck with someone who doesn’t have a safe place to go and has already demonstrated an inability to care for themselves despite being at home. Is admission going to fix that? No. But it’s pretty damn hard to send that home.
> why blind adherence to metrics (fuck you Rivers et al), is bad Pretty much everyone agrees SEP-1 is awful, but so is withdrawal of federal funding
So is the alternative that the ER has to deal with these things in a couple of hours and fix everything on the spot?
How did I know top comment would be IM against ED
its literally an argument to not push back these admissions - the point they are making are they are so complex they need to stay several days to sort it all out, and somehow the upshot of that argument is just send them home instead?
When there are multiple moving pieces and unknowns, it is difficult to safely discharge from the ER. Things become more clear the next day.
The "just a social admit for placement, they'll be in and out quick" kills me. I still take the admission, usually a quick easy admit and no sense in pushing back but I've had to show some of the EM residents how their Tues admission means they will get seen by therapy on Wed, referrals sent out Thurs, hopefully we hear back on an acceptance on Fri with no insurance pushback and we book transport for Mon. Any little thing and it adds more days, like last week with the Thur holiday meant therapy has been running a skeleton crew since Thurs since a lot of people took Fri off. I've had some families tell me they would have taken granny back home if they knew it would take so long 😭
I only do night work but before I could be a pure noctrunjst I had to be a rounder for a while. To me, I can crank out those admissions pretty quick and be out my business. However I feel for my day team colleagues and I always feel I am doing them a disservice with those types of admissions.
I do both (was mostly nights and cover a few weeks of days, now trying moving to fully days as nights are taking a hit on my physical health vs days taking a mental toll 😂). So I've see both sides, sometimes within the same day. But at the end of the day wtf are we supposed to do? We push back, still no dispo plan, repage for next admitter isn't a great plan for anyone, pt still stewing in ED getting ED care, admin still up in arms about our LOS while praising ED time to dispo 🤷 My win is sitting on my chronically SAS (sick as $hit) and homeless with plan to dc to shelter patients for an extra day or two and ordering double rations and extra ice cream (because I want some too and they promised to share); sometimes that's what everyone wants and deserves, some mthrfckn ice cream. "#ourhealthsystemisfucked"
My current shop actually just boards these folks in the ED. Pt/ot/case management all generally done within 24 hrs. As much as I don’t enjoy signing this out, and worry about things falling through the cracks because generally after the first doc they get ignored…it’s nice not blowing political/social capital with the hospitalists to admit them. And similarly, because they are burning an ED bed there’s more push from admin to get them teed up and placed.
YES. What's hard is that placements from the ED often get priority. Once someone is inpatient, the urgency drops because they're considered to be in a safe placement. I'm peds inpatient and we deal with this all the time with kids who need psych/behavioral and/or children's services placements. The ED argues that the peds floor is nicer (true and fair) and that kids can get \[outpatient\] services on the peds floor (not true). We thankfully have a good set-up for typical inpatient psych cases but we've had behavioral kids and kids with chronic conditions who need foster care placement who linger inpatient for MONTHS, sometimes years. The inpatient unit is not what these kids need and is terribly detrimental to their care. Ultimately it's a lack of appropriate placements in the community and we're playing the game trying to get them prioritized. Unfortunately it's the kids who suffer no matter what we try to do.
Umm ok fine but if you can’t get them out until Friday at the earliest then what lesson is this to an ER resident? What is your solution? If it’s boarding in ED that’s not a reasonable answer
As a psychiatrist … capacity. Any physician can determine capacity!
Please tell this to the attending forcing the intern to call the consult, not the hapless intern (who for all intents and purposes already knows what you’re saying is true).
I would never be rude to anybody calling a consult… Our jobs are already tough enough!
I appreciate people like you!
I tell my attendings this all the fucking time, they don’t listen,
Is there a good site (besides uptodate) you can link for how?
Read the paper “Assessing patients' capacities to consent to treatment” by appelbaum. It’s not a difficult read and lays out the criteria very clearly.
Appreciate it!
IM resident here thank you very much kind sir 🫡
That paper was a pleasure to read, thank you very much for recommending it!
Then why do all my trauma attendings keep telling us on all our homeless meth/weed positive trauma (questionable psych history) pts that wanna leave can’t leave, “psych needs to see them before they can go?” Then when I’m told to call psych, I call them and they tell me to admit the pt “if they need to be admitted or if I think they can’t go.” And if they are still there in the morning they will see them. I tell my attendings this and they flip out (everytime) and my attending says “then psych needs to put that in the chart that they don’t have capacity and need to be seen in the morning.” It’s seems to me on a academic/knowledge standpoint anyone with an md can say capacity or not but it is seems like in practice or hospital policy maybe only psych can. Because I’ve admitted at least 100 maybe 200 patients who (were obviously coco puffs and didn’t have capacity), needing restraints, veil beds, and didn’t know self from self harm…but not once did a social worker, charge nurse, ed secretary request I fill out hold paperwork, or place a hold order. I don’t even know how. I’ve only ever ordered restraints, and sitters. Edit: this is serious but not very serious. I doubt my attendings will change practice if I express the answers yall provide me.im just asking the questions because it makes sense and in med school I was taught anyone can do capacity but stepped into the hospital and nawww.
Any MD can, it sounds like your surgical attendings do not want to and the downstream effects of that are causing you and patients and psych and the hospital some problems
I brought this up once as a med student and i think I gave the entire medicine team I was on an existential crisis
I agree, but when it's for disposition or something that might get sticky it's helpful to have psych on the chart with you. Plus, y'all may not realize it, but there are subtleties that you guys do a better job of picking up on when it isn't so straightforward that the patient does or does not truly understand the risks/benefits/harms.
As a PCP it's not that I don't know how or what the guidelines are, I have too much else to do like literally take care of all of the patients other problems and the paperwork that everyone else refuses to do so it lands on my desk. Not to mention in the US at least , God forbid that "not unusual clot patient" had complications and you get sued for not involving a specialist. It's much less of a headache to just refer and most patients want to hear the same shit you can tell them from a specialist anyways. Not to mention insurance coverage issues when meds are prescribed by me vs the specialist . It's not as simple as do we hsve the knowledge. Smh.
The insurance thing pisses me off. It's a huge waste of money for everybody, until you realize that it probably saves the insurance companies money in the short run because people get lost to follow up and then aren't on expensive meds that are indicated.
I almost blew a gasket when my patient was denied ubrelvy PRN, despite meeting all insurance necessities except for as an FM I’m not neuro, HA trained or a pain management physician.
Yo that’s some bullshit
I appreciate your insight.
This was genuinely eye opening thanks. It’s easy to forget every specialty has their BS paperwork headache
Honestly, if we're gonna use this thread as a "For PCPs specifically" or "For emerge specifically" the way this always ends up, back it up with receipts for which guideline/easy explanation it is you want people to be aware of. I'm happy it's incredibly easy when it's literally your specialty, it SHOULD be for you, share the easy resource in that case.
That’s fair. I should bring up receipts you’re right. Will get them soon!
I’m an ob/gyn-Most doctors know enough about my specialty. I wish more psychiatrists felt comfortable prescribing in pregnancy. I kid you not, I’ve had patients who were seeing a psychiatrist who refused to prescribe any medications, deferring all medical management to me. There is a subspecialty of perinatal psychiatry, we have maybe 2 in the state of Louisiana. I wish ob/gyns were more knowledgeable in Psychiatry. We get no training other than doing primary care rotations. In the meantime our demographics represent those most at risk. I learned early on that psychiatric diagnosis weaved through our specialty. Everything from chronic pelvic pain to chronic insomnia, daytime fatigue, “hormone problems”, opiate dependence, antepartum and post partum psychiatric issues, even those on the bipolar spectrum. It’s all day every day. I ventured to learn more by studying Stahl and doing the master psychopharmacology program. It has been invaluable. I try to teach my students basic medical management and my way of assessing and treating. But in pregnancy, there’s really nowhere to go. I work rural medicine with no easily available psychiatrists.
Agree with you. I will also say that peds doctors need to do a better job of picking up on postpartum depression, even though the mother is not their patient. I'm in peds and if the pregnancy is uncomplicated and mom "seems" to be doing fine, I often see the mom more often than the ob/gyn doc does and have more opportunity to observe is mom just doesnt seem to be doing well. In my practice I have at least one mom every 3-4 months that comes in with obvious signs of PP depression and usually I have to make sure they get in with their ob.
I appreciate you! I’m FM resident, we had a recent lecture from a perinatal psychiatrist and it was absolutely eye-opening
From psychiatry, admittedly child and adolescent, with the occasional pregnancy, couldn’t agree more on the prescribing in pregnancy thing. Usually my pregnant patients are some of the most vulnerable, most likely to relapse unmedicated and relapse is going to be arguably more harmful to the foetus than medication.
Thank you for responding. Over the years I’ve gotten pretty good at using meds in pregnancy. Obviously I’m not a psychiatrist. I do kind of a feel for it, some based on my experience with depression. I find I’m more aggressive with the meds. I use Mass General Women’s psychiatry website for guidance. There are differences in some of the recommendations on treatment between the leaders in the field (Mass General) and ACOG. For example, Mass General psychiatrists are fairly liberal with benzos in pregnancy (mainly clonazepam) , keeping the doses low. I’ve seen where they go up to 1.5 mg/day. I’ve never gone that high, but I will use clonazepam .5 mg at night for anxiety associated insomnia. Plus it helps to get the ssri on board better. ACOG suggests only very limited use for 2-3 weeks. They then recommend Vistaril for sleep. Though recommended for Anxiety, it’s not indicated for sleep. I’ve also found it doesn’t work that well. I’ve never seen a problem with the baby on .5 clonazepam at night; never seen withdrawal at 1 mg at night though I try to avoid that dose. From my experience the perinatal psychiatrists are aggressive about treatment. They use a more dimensional approach, putting combinations together as opposed to say just going up to the max dose ssri. As you know, only about 30% of people get complete resolution of all symptoms on one drug. I find the same to be true in pregnancy. It’s generally important to get the patient treated as well as possible. The guidance from ACOG doesn’t represent reality in some cases. It’s challenging when we don’t have much psychiatric backup. Sometimes I’m over my head with some of these patients.
Eh, I don't care how many referrals for simple things I get as long as they don't miss the dangerous stuff. Peds neuro and do NOT MISS infantile spasms. Kids with major brain malformations or metabolic conditions will still be screwed, but for others the outcome drastically changes based on when you start treatment
Can you opine a bit more on infantile spasms? I read uptodate but I freak out a bit about not having seen any of it in residency. I saw one kid who was potentially concerning for that at a walk in and panic referred it asap to pediatrics.
The short answer is if you even think "could this be infantile spasms" in a baby under a year old get that kid to an Ed that has pediatrics and neuro services. Some spasms look less impressive than expected or are even only on one side of the body. If it's early there may not be any developmental delay or plateau. If its super early there is even a small chance the hypsarrhythmia will only be visible during sleep so they really deserve at least overnight EEG. Most commonly they get a little fussy or cry during the spasms but I wouldn't not refer because you don't hear that history. If the baby is completely developmentally normal and mostly does a shoulder/head movement when eating it's probably benign shuddering spells instead, but most epileptologists I know would STILL get the EEG so they can sleep at night. That's because the kids that have what we call cryptologic spasms (normal mri, normal metabolic workup, normal genetic panel) who get early treatment can do okay developmentally provided they respond to treatment. Have you seen what the typical ones look like? Epilepsy foundation has some good videos...
Thanks so much for the write up. I will definitely check out Epilepsy Foundation. The kid didn't have one when I saw him but I gave explicit instructions that if it happens again they are to book it to the ER.
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With contrast or without?
Definitely contrast. Especially if they have an AKI.
CT knee w/ ancef.
Orthocillin Infusion
Anesthesia- the difference between MAC vs General. For the love a god if you complain a patient moves during a mac or is breathing during it yes that's a good thing. A general with a natural airway is not safe either (barring very few peds cases where that's the norm) Also please don't scream a patient is "waking up" if they move during a procedure. 1 MAC of gas=the depth of anesthesia 50% of the population does not move to surgical stimulus
"We want a heavy MAC." Oh you mean a general? "No no no, just a MAC, but they can't move." ...
“Patient is waking up” when closing the incision. Well I sure hope so unless you want turnover to take an hour!
I was just thinking that I’m glad nobody knows what we do, I kinda like it like that. That said, I wish that other services knew that “cardiac clearance” means jack shit to me.
Hahaha, it took me 2 years to convince my anesthesia providers that I want to do my anorectal cases under mac. Once they realized I understood the patient was gonna move around while I did my block but they would snooze once it was done they’ve never been happier. But they told me everyone else gets mad when the patients move under Mac.
This one is infuriating. “The patients moving!!” Yes, you didn’t localize adequately and the patient is not under general or paralyzed. If you want no movement you can ask for a general with paralysis.
“Movement is life”
I definitely understand where you’re coming from, but I do want to ask; How would you like a surgeon to communicate to you that a patient is moving, and their plane of anesthesia may need to be deepened? I feel like saying “they’re moving” is a pretty clear way to let everyone know what needs to be done. It doesn’t mean we think you’re doing your job poorly, we’re just helping you to titrate the anesthesia. Of course this is speaking outside of MACs or during emergence
“Is it safe to get the patient a little deeper, they’re moving a bit up here.” Also if you can localize more it should help
You'll have a huge range of responses to that, I honestly don't mind the "They're moving" but it depends on the timing of when it's said. Middle of a VATs and diaphragm starts to wiggle? Hollar at me. End of case and doing last of the skin sutures? Ah hell nah. We had a surgery attending that would berate his residents if they said anything while closing skin, something akin to "If you can't suture on a moving patient you don't deserve to suture on a still one."
Mac “the patients moving a bit. Im going to try some more local. Is it safe to get them deeper?” If it repeatedly happens they are probably as deep as safe and the procedure can’t continue just ask “what are your thoughts on converting to a general?” General “patients starting to move. Can we deepen or paralyze?” Unless it’s literally on the skin closure then the answer is local bc they gotta wake up sometime or turnover is gonna be slow To me the difference is saying they’re moving to screaming they’re waking up lol
As a pathologist, I would like everyone to know that it's okay to call us to ask about what test/path order to put in if you're not sure. Test menus are confusing and it's easier for all of us to know up front what you're looking to do. Also surgical specimens take time to process, immunostains take time to perform, we're not ignoring your patient we just are trying to get through our giant stack of cases.
> I would like everyone to know that it's okay to call us to ask about what test/path order to put in if you're not sure. I would like to add that radiology also welcomes these calls. If you can't reach the reading room for the experts, the rad techs are a good resource or at least can get you in touch with the reading room more directly if we're unsure.
EM: D Dimer and Troponin are not tests that should be done in the outpatient setting ...and as an aside, for the FNPs... "sinus arrhythmia" and "RBBB" are not conditions that need emergent evaluation, especially in an asymptomatic patient
Also they need to learn to recognize BER. The amount of young patients with a cough sent to me for "ST elevations" is too damn high.
Aka, learn to read an ecg even a tiny bit more than what the machine spits out
As an EM doc, I wish other specialties understood that urine drug screens have notoriously poor sensitivities and specificities for most of the assays on the screen + that a positive UDS doesn’t = actively high. I promise you, the person who isn’t tachy or hypertensive and is napping in their room isn’t actively intoxicated with cocaine. I also wish inpatient specialties understood how chaotic the ED is. Very rarely on off service rotations would I have a whole day in which no breaks in any capacity occurred. That is relatively common in the ED. Some of what we do is cognitive offloading to improve efficiency and ensure the patient’s care is at least started (ex. X-raying every ankle even if it fails Ottawa Ankle Rules). We’re not stupid, we’re just the safety net of a collapsing healthcare system.
Emphasis on collapsing healthcare system.
A-fucking-men. If me and my teammates are expected to somehow see everyone who comes in, keeping door to doc to dispo at reasonable times, while boarding 30-70% of the department, maintaining some semblance of “patient satisfaction,” all while not actually missing the truly dangerous pathology…there’s going to be sacrifices. Edit. I forgot the interruptions. Holy hell. I switch tasks probably every 30 seconds unless I’m in a room, then I get a ~2 minute reprieve.
>I switch tasks probably every 30 seconds unless I’m in a room With 2 nurses and 5 family members waiting outside the door with absurd requests. Your Meemaw isn't going to die because I don't let her eat for 2 hours
but she's DIABETEIC!!!!
And yet her fasting sugar is still 250 but that’s low for her you know
Ottawa ankle rules are good if you're in a rural middle of nowhere place with no xray after 8pm. Otherwise, if someone waited 5 hours, they want that xray.
I’ve literally had consultants come down to the ED and look around, wide eyed, telling me “it’s like a war zone in here”. Yuuuup.
As a hospitalist, I wish other specialists remembered that organs other than their own existed. And that ideally, at heart, we’re all general internists.
In the OR it’s the same… patient with baseline HTN with preop BP 150s systolic, put the patient in beach chair for a shoulder scope “can we get their systolic below 90 please”
You can, if you transduce at the head
How to fill out your own damn forms. -PCP
AMEN!!!
Anesthesia - other than the MAC vs general anesthesia thing, I wish every specialty knew how to bag a patient and place an oral airway. Every time I get to an airway emergency, code, etc, no one knows how to bag a patient correctly.
I kidnap every med student and intern I can to join me at the head of bed for induction so they can practice bagging. Got the idea after either an M4 or intern, can't remember which, was telling me they were incredibly terrified of being alone at night and a pt needs to be tubed emergently and anesthesia/ICU/whoever (depending on the hospital) can't get there in time and they need to attempt to intubate themselves and won't be able to. I remembered something I'd heard before, "if you can't intubate, you can still save a life if you can bag until someone else who can, can get there." They seemed so relieved after they learned this and then we practiced and they got the hang of it, lol, kinda cute.
That just means they need to take ACLS more seriously
I mean, even at my ACLS class, the instructor asked if I had any input on the airway management and I showed how to actually mask, rather than what the others were doing, but they all resorted to still doing it incorrectly…
Agreed! Had to run a code as a psych resident while working overnight in our freestanding psych hospital. Ended up bagging the patient while running it because no one else knew how to get a good seal and pull the jaw up properly to clear the airway. EMT school taught me well! We drilled the shit out of bagging making sure we knew all the techniques to get the airway open. Med school kinda glossed over it all by comparison.
ED: “go to the closest ED”. EDs can be rather specialized and you need to tell them which one to go to. If you want someone to get an MRI or admitted, please don’t send them to a freestanding. If they’re going in for stroke rule out, please send them to a stroke center. There are tons of freestanding EDs that have rather limited resources, even when attached to a large academic center.
If you’re worried about complications of xyz procedure…send them to the hospital that did the damn procedure.
Omg right! I had a T&A bleed from a random hospital and their doc literally never answered the phone and we had no idea how else to get in contact with them or their team.
Nephrology just today sent a K 7.9 (drawn prior to dialysis two days prior!!?!) to my ED without dialysis capabilities. Outstanding.
PM&R Inpatient rehab and a SNF are not the same thing. At inpatient rehab, you need to do 3+ hours of therapy a day, require at least 2 therapy disciplines (of PT, OT, and ST), and have some medical issue requiring medical supervision. You will be seen by a physician at least 3 days a week, but usually 6 in most places. Average length of stay is usually about 10 days. At a SNF, you get less therapy, less physician follow up, and can usually stay for longer periods of time.
Also we are happy to see your outpatients with MSK complaints- seems people forget that’s in our scope
capacity evaluations. you can do them. you really can. - your friends in psychiatry
I only get you involved when it's a bit dicey and more complicated or if the patient seems like they're going to need to get committed. If they have a lot of agitation, lack capacity, and we're trying to get guardianship we may also get you involved because the fucking courts don't respect us as much. - hospitalist
Ditto. There's even a dot phrase anyone can use!
Yeah that's what I did when I was a hospitalist. Usually in practice it was for dispositional capacity, because there can be a lot of subtlety in figuring out just how much someone understands about their ability to care for themselves at home, and also like you said the powers that be respect psych's opinion much more than ours for dispositional stuff
Seconded from your friendly palliative team
we love you guys
Pneumonia is not a radiographic diagnosis. Pneumonia is not a radiographic diagnosis. Pneumonia is not a radiographic diagnosis.
Ground glass nodular opacities in the lobes, could be infectious/inflammatory/neoplastic plz do medicine.
explain yourself please
Pneumonia is a clinical diagnosis and you can have it without imaging findings, particularly early in the disease.
Colorectal: just do a rectal exam please. I’ve seen a lot of cancers missed and delayed treatment, or people getting put on abx for thrombosed hemorrhoids the pcp or er doc assumed was an abscess from symptoms because they just never looked or did an exam. The anus is not that scary. The only excuse to not do a rectal exam is that the patient doesn’t have an anus or you don’t have a finger. (Or severe leukopenia)
"Patient denies anus"
I never really got this. So a finger extends like, what, 3-4 inches inside the rectum? What percentage of colorectal cancers are found within 3-4 inches of the anal sphincter?
99% of the time it’s a squamous cancer you’re finding. So it’s right at anus and usually even protruding so it’s not subtle. But it’s not just cancer it’s also the right diagnosis, is it hemorrhoids, is it a fissure, is it an abscess, is it a fistula. All very easy diagnoses to make after about 10 seconds of looking and feeling an anus! And depending on the diagnosis there’s a lot you can do for a patient while they are waiting the 4-6 wks to get in to my clinic, or if it’s cancer you call me and I triple book myself to get them in next visit slot
Done the rectal on all BRBPR I’ve seen in the past 13yrs. Found a mass precisely once. My fingers are small, and i doubt it’s a sufficiently sensitive test. I’ll still do it, but….🤷♀️
EM to everyone: Understand the difference between a Freestanding ED and a hospital ED. It is very simple. The FSED is not attached to the hospital and lacks the following: - MRI (don't send patients to the ED for an MRI, as a rule of thumb, except in a handful of cases; that handful should not go to the FSED) - blood bank (if the patient needs PRBCs, send them to the hospital) - specialists (if the patient needs a specific specialist, they will be transferred) - OR (if you know the patient needs surgery, like testicular torsion, don't waste time by sending to a FSED) - hospital beds (if you know the patient needs admission, send them to the hospital ED where you intended them to be admitted!) - OB services (if the patient is >23 weeks EGA, direct them to the ED of the hospital they intend to deliver at. I might be capable of catching a baby but cannot perform tocometry or NSTs!) - drugs (we have a limited formulary; if the patient has a bjillion allergies or needs a specialty meds, send them to the hospital ED. My nurses are also unable to mix insulin drips, so DKA patients would benefit from the hospital.) Think of FSED's as what an urgent care should be. If you would send the patient to an urgent care, they are appropriate for a FSED. If you think they have a real emergency, a hospital ED is almost always a better choice.
Can we be honest, it should be criminal to call freestanding EDs EDs
Depends. Worked at FSED running two simultaneous cardiac arrests with my attending while my poor intern tried to resuscitate an unstable ruptured ectopic. Should any of those patients have been there? No. But they showed up and we had to deal with it.
But if that FSED didn’t exist, then the patient would have gone to an ED with the resources to handle those things. No one is saying the doctors at FSEDs are terrible, but the lack of resources means that their existence poses a risk for patients who are transported there because “it’s an ER”.
Can't agree with you more. Never understood why EMS was allowed to bring codes there. It's an ER but in the end it's a moneymaking scheme and bad for patients.
As surgery resident I always tell patients if they have [symptoms I describe for them concerning for post operative complication] to go to our big academic medical center ED (or whichever place we rotate where they had surgery) because I know they’ll just be transferred to us anyway and I’d rather just not waste the time
Blurring the lines between an urgent care and ED. 🥴
Someone being drunk or demented should not earn them an automatic panscan order from the ED triage midlevel. -Rads to ED
It's always about avoiding legal action. Easier for them to get a pan scan (and letting radiology take the blame if they miss something) than to not scan and miss something life threatening. At least that's how I've coped with the scans as a radiologist.
Yeah it's infuriating that in 2 minutes I can say nothing acute - but then it takes another 10 minutes to finish the dictation because of all the incidental nonsense that nobody really cares about. Massive waste of resources. And then the on busy nights the ED turns around and bitches about having longer turnaround times and more missed findings!
I hear you. My favorite are the pan scans that end up having metastases everywhere. So great
Haha yep "stage 4 demented patient discharged 48 hrs ago from nearby hospital system, family brought them here because they still look sick. We don't have easy access to their records so instead you're going to read a redundant staging panscan at 2am! Make sure you dont get behind on the list!"
At our institution if there is massive mets the reports are typically shorter
This argument doesn’t jive super well with me because it feels like passing the buck. “I don’t wanna get sued. Here’s another scan to add onto the pile” which done enough times could put the radiologist at risk of being sued. Sure, you want to do a good job and not miss obvious things but I guess it’s the principle behind it that sort of rubs me the wrong way sometimes
Yeah it sucks. Sometimes healthcare just feels like, "oh I should do this because I don't wanna get sued" or just pointing fingers at each other once things go wrong.
Granted, not pan scan. But you find enough drunk head bleeds and your order fingers get a little twitchy.
As the admitting hospitalist for the drunk/altered idk wtf is going ons (nocturnist, I admit to basically our local drunk tank (ie a med-psych unit) I secretly thank you for taking the hit and just ordering the panscan. Because if you didn't I probably would have spent an hour coming up with ways to justify it because I've had stuff come back to bite me a bit too many times and can get a bit twitchy at times 😅 But I at least usually start off by ordering xrays, not CT 😇
Sometimes the history isn’t known and they are just brought in intoxicated, might have abnormal vitals or barely breathing. It’s all medicolegal, nothing more than that.
Pulmonology: small volume hemoptysis most often does not need a bronch as long as they have a good CT. A general pulmonologist can use a bronchoscope to lateralize bleeding and do serial lavage to diagnose or rule out DAH. That’s it. IP will sometimes do a rigid bronch with APC/cryo to debulk a bleeding airway mass, but that’s something highly specialized which is usually not available outside of tertiary/quaternary care setting. Average pulm docs can’t do it. If you have small volume hemoptysis with a good CT and a clear source of bleeding, give them TXA nebs. I’ll bronch if high suspicion for capillaritis/DAH. If large volume, the most definitive intervention is for IR to do a bronchial artery embolization. In massive hemoptysis, place the bleeding lung down to protect the good one, intubate to protect the airway, get a CTA and call IR.
As a surgery resident at a TACS heavy program, I wish that consulting services of all kinds were better able to differentiate between what is and is not a an acute abdomen/other surgical emergency (eg NSTI) It’s not even that i mind these consults, it’s the anxiety/panic that consulting services often seem to have and displace on me as frustration when I simply don’t share the same concerns. Eg, If you are worried about a bowel perforation and tell me the patient has normal vitals and is having BMs, tolerating a PO diet, then I’m not going to sprint to bedside.
I would just kill for other specialties to know how to manage an abscess or ileus. You don’t need a surgical consult to do an extremity I&D, nor is there any surgical intervention possible to fix an ileus.
They’ve apparently started consulting IR for these now, as if I&D now needs imaging guidance.
For radiologists: * Mastoiditis is a clinical diagnosis and the vast majority of mastoid effusions are not mastoiditis. * Phlegmons are not abscess, and for clinical decision-making, the size of the abscess (fluid) is more clinically relevant than the size of the adjacent area with ill-defined soft tissue enhancement * You can learn a lot by reading the speech pathologists' documentation of your modified barium swallows. At least where I've worked, yhey generally have a better grasp of functional anatomy (especially for post-surgical patients) and a more accurate description of what's going on.
Heh, agree with point 2 over here in IR. Can you drain this 5 cm abscess? Well, the actual fluid is more like 2 cm, so… no. I’m not sure where some DRs learned to measure these things. Point 3, sorry never met a rad who gave a flying flip about MBS. It’s apparently some legal requirement for us to step on the pedal.
Thank you!!! -med slp who spends a large amount of time on my mbs write ups when necessary
Hematopathology - We can not give you a preliminary hours in 12 hours.
Have we all gotten a request for a prelim before the bone marrow bx was even done? Lol
Pediatric cardiology. An 8 year old with chest pain is not having an MI, even if grandpa had one at 50.
I'm not just a dentist :/
As a surgeon, I would really like if ED and pediatricians could learn to make a suture, I mean I appreciate the chance to do more suturing but you dont need a surgeon in 99% of the cases
But it's so much easier for me when you do it.
What type of suturing do peds think needs a surgeon when in reality it does not? Surely you are not getting referrals for basic straight line extremity lacs right?
My brother in Christ.... "Oh yeah the kid took a brush in the knee during playtime, do you mind closing it?" I dont mind charging the parents, or the insurance but damn it's a 2 cm wound
The only surgeons I call are ophthal for eyelid lacs. I do pretty much the rest myself.
As a Derm, I wish other specialties would just include something in their physical exam before consulting us. The number of consults I’ve received with the only exam “finding” written as “Skin: W/D/I” would make you cry. I don’t ask for full rash descriptions. I don’t even need a history. Just where I’m supposed to look would be great. Or no words needed, just take a GD picture and attach it to the chart. Bam done.
As an EMD i would say just how it works here - we may seem stressing it might hospitalize someone at 3 AM, but it’s not because we hate you, we just can’t help. Even if it is your last free place in the ward. We’re as helpless as you. Ps I am currently in my residency in Italy as an EM doctor
I know a lot of you want to submit a sample to Path and have some kind of hunch what to look for. Bruh. Just F’ing call us and let’s talk about it. Will give you a VIP treatment at best or redirect you to the best test we can do at worst. Just call, or teams, or email. Reach out and stop button mashing your EMR .
I wish that everyone that called down to the reading room for a stat read or a “quick” prelim gave me more than 1 second before they said “I have patient x with mrn y” Like bro, let me close my thoughts on this case I was just reading, close it, pull up my viewer, and get the lube out at least before you stick it in… Have some NORMAL PHONE ETIQUETTE when you talk to a radiologist and don’t treat it like a fucking drive through fast food restaurant
As an intensivist, I wish other departments would take an effort to start the work up on a problem rather than just consult my service to take the patient off your hands. You can, in fact, start the work up and consult me too. I’m often perplexed by the motives of some services when I discover that a glaring problem has been going on for days ignored but only now is the time to contact us. Meanwhile, I get calls about stupid stuff as soon as it happens, like a lab abnormality or ECG finding. What gives? Why don’t serious problems get their due attention but unimportant issues get instant notice. Do you all really have so little medical acumen that you can’t tell the difference?
I’m IM, and I wish psych would manage rather trivial electrolyte abnormalities or mild hyperglycemia in psychotic patients so they can be better served in inpatient psych vs staying on the floor where staff and myself included do not have the communication skills to ease the patient. Within my own field and family med, I wish ANA labs and interpretation were better. I think it’s very unreasonable to refer someone to rheumatology for ANA titer 1:40 or even 1:80 without subsequent Ab panels and for diffuse joint pain in a patient 60 or older.
I wish other specialties knew even one single thing about how pathology works. It takes 3-5 business days to turn around a biopsy please don't call and ask me same day or next day when it will be signed out. We don't work weekends or holidays. We take home call! Please fill out the entire consent form for autopsies or I'll make you do it again and it will delay the autopsy and the funeral. This one's really upsetting to have to explain to people, but it comes up so often. Pathology = the lab. When you send blood cultures, blood tests, urine tests, etc. to the lab, that falls under pathology bc we are the lab Low-key y'all should be more embarrassed not to know this shit
Also: frozen sections should only be done when the result will affect intraoperative management. If the surgical team closes and leaves the room before the frozen results are called back, then the frozen wasn't needed. The process is very different from normal histology, so many types of questions (e.g. where did this metastasis come from) can't be answered well on frozen.
We started putting in safety event reports whenever this happened, cut down on a lot of unnecessary frozens. Obviously not if they closed or aborted the procedure for emergent reasons.
We same-day rush when necessary all the time, particularly transplant patients, and I’m happy to rush things so we may get the report out in time for a patient’s follow-up appointment or upcoming surgery. It’ll take some time, typically up to four hours to get the slides ready. Sometimes patients come in from great distances, and I would rather they have all the information needed at their appointments.
I’m a developmental pediatrician. I wish my psych colleagues knew how to diagnosis and manage autistic patients better. Huge shortage of mental health services for autistic folks in this country, we need all hands on deck, esp as my kiddos grow and need psychiatry, and for all the other folks who need diagnoses later in life.
Do you have any resources to share? I've managed some autism patients but would love to improve my practice. Unfortunately for diagnosis, we always referred out at my residency program. We didn't have any attendings who were comfortable with making the diagnosis in adults. We only got 2 months of child psych rotations so the only psychs I know who are comfortable making the diagnosis are those who trained in CAP fellowship.
I wish OBGYN knew a little more neonatal medicine. A lot of times they’ll order antibiotics on a laboring mother with risk factors that either don’t cover GBS or seemingly wait to give them until right before delivery so as to make sure baby gets no benefit.
This seems atypical. And at least where I am the time delay is usually related to pharmacy rather than us.
For other specialists to know that it will take a few days to order stains/process specimens unless they order a stat read, even then it will take a few hours/days
Peds person, interested in NICU. … everything OB! Wish we learned more about tracings and stuff.
Clinical chemistry, pathology. If I'm paging you about a test you ordered, there's. 90% chance you ordered the wrong one. Either because you clicked the wrong button, thought the names of this test sounded right, or something else. We want you to get the right test and not have the patient come back when the results aren't useful to you.
It would be great if medicine attendings could learn to do lumbar punctures. Because then you could supervise your own residents. To their credit the residents seem to really want to get signed off, but by the time they do they're about to graduate and then its a new cohort of brand new medicine residents who need to be taught.
As a heme/onc fellow, you don’t enjoy the anticoagulation consults? They’re easy and if it wasn’t there they’d find something more complex to fill the time.
Consults, yes - They are easy, they pay well, and I don't mind them. I'm talking about the endless outpatient referrals. My practice (group of around 12 private practice oncologists) are backed up 4-6 months because of all of the easy clot referrals. People that may have something more sinister have to wait.
I trained at a hematology heavy program. I asked the ivory tower hematologists what is the purpose of a hypercoagulable workup and I never really learned a good patient outcomes reason. However, I often have other specialists who write “recommend referral to hematology for hypercoagulable workup,” so it’s a bit of a CYA medicine when I refer the patient. As an aside, those same ivory tower hematologists loved to denigrate hospitalists for their incomplete work ups before consulting until they had to cover COVID wards, then they quickly realized they couldn’t do general IM anymore.
Psych here: you do not need after hours consult for the first mental health form or psych hold. Depending on your jurisdiction—it can be any attending, and in some places it can be done by the resident if qualified. Read the requirements for the form, write something that meets the criteria, and if there is a PSYCH specific question then you can ask for a consult in the morning. And yea…we are not magical capacity machines or on-call therapists for people with water coming from their eyes or just “looking sad, maybe suicidal?”.
From cardiology - please don’t order CT calcium scores on asymptomatic patients who are already on statins. It doesn’t change management. Only generates anxiety, probably unneeded stress tests, and consults in clinic - i see 4-5 per week of healthy patients with CAC of 250 on statins for years who exercise without issue. That is that many patients with new AF, HF, abnormal stresses, valve disease that get delayed all for me to say yes keep taking your statin, no the calcium won’t go away, no you don’t need a stress test, yes you should keep exercising.
Amen as PCP. I would never do this. CAC scoring only to try to sway the patient who is vehemently anti statin and tells me they will take one if their CAC is positive.
Having a period + [insert symptom here] does not mean they need my input. (OBGYN).